Numberwang Flashcards
Steroid equivalence (mg) Pred, hydrocort, methylpred, dex
Pred 5
Hydrocort 20
Methylpred 4
Dex 0.75
Cortisol 10-30mg secreted/day endogenously
Opioid equivalence ratios
Morphine, oxycodone, tramadol, codeine
Buprenorphine and fentanyl patches
Oral: Morphine 1 Oxycodone 2 Tramadol 0.15 Codeine 0.1
Transdermal:
Buprenorphine 5mcg/h patch = 12mg Oramorph
Fentanyl 50mcg/h patch = 180mg Oramorph
Incidence of inherited diseases
- Down’s syndrome
- CF
- MD
- CHD
- HCM
- SCD
- Bicuspid AV
- Autism
- RA
- MH
Down’s 1 in 1000 live births
CF 1 in 2500 live births (1 in 25 carrier allele)
MD 1 in 8000 prevalence
CHD 1% live births
HCM 1 in 500 prevalence (25% cases obstructive)
SCD 1 in 2000 live births
Bicuspid aortic valve 0.5-2.5%
Autism 1%
RA 1-2%
MH 1 in 5000-10,000 susceptible; 1 in 40,000-100,000 GAs
Prevalence of acquired diseases
- Diabetes
- Post tonsillectomy bleed
- Asthma
- COPD
- IHD
- HTN
- Obesity
- AF
- PD
- OSA
- Dementia
- AS and aortic sclerosis
- GBS
- MG
- Phaeo
- Latex allergy
- Penicillin allergy
- Anaphylaxis
- Alcohol misuse
- PONV
Diabetes 9% (90% type 2)
Post tonsillectomy bleed 0.5-2%
Asthma 12% (>1400 deaths/y)
COPD 2% (diagnosed; much more undiagnosed)
IHD 4%
HTN 30%
Obesity 27%
AF 5.5% (50% perm, 25% persis, 15% paroxys)
PD 1% of >65s
OSA 5-10%
Dementia 1% (7% of >65s)
AS 3% >65s, aortic sclerosis 25% of >65s (9% progress to AS)
GBS 1-2 in 100,000 (3-5% mortality)
MG 1 in 1000
Phaeo 1 in 100,000
Latex allergy 4.3% (9.7% in healthcare workers)
Penicillin allergy 10% reporting rate (90% of which are not truly allergic)
Anaphylaxis 1/5000-1/20,000, 3:1 female preponderance
Alcohol misuse 9% men, 4% women
PONV 30%
Commonest cancers
Breast 15%
Lung 13%
Prostate 13%
Bowel 11%
Oral bioavailability (%)
- Morphine
- Methadone
- Tramadol
- Pethidine
- Codeine
Morphine 30 Methadone 75 Tramadol 70 Pethidine 50 Codeine 50 (but only 10% metab to morphine)
Oxygen consumption (adult/child)
Adult: 3.5 ml/kg/min (about 250ml/min at BMR)
Child: 6 ml/kg/min
Incidences
- Delirium in ICU pts
- PTSD in relatives of ICU pts
- Proportion of AKI thought to be preventable
- Anaemia in ICU
- Treated cardiac arrests in UK/year
- Hospital discharge post cardiac arrest in pts who went to ICU
- VTE in critical illness
- VAP
- Proportion of line sepsis that occurs >day 5 post CVC insertion
- C.difficile carrier rate
- Stroke aetiology
Delirium: 30% overall but 60-80% in sick, ventilated pts
PTSD in relatives: 33% in one study
Preventable AKI: 20%
Anaemia: 60-80% ICU pts (only 10-15% having been anaemic pre ICU admission)
Cardiac arrests: 50k/y
Hospital discharge: 33% (80% of whom go to usual residence)
VTE: 80% without prophylaxis; 40% with
VAP: 10-20% ICU pts
Line sepsis: 72% occur after day 5
C.diff: 3% general pop but 20% pts on abx
Stroke: 85% ischaemic, of which 35% large artery thromboembolism, 24% cardiac (AF/SBE/thrombus), 18% small vessel disease, remainder vasculitis/dissection/unknown.
Daily nutritional requirements
Calories: 25-35 kCal/kg/day (NICE) or 20-25 initially, rising to 25-30 (ESPEN); much higher in burns/hypermetabolism (e.g. up to 80), lower in obesity (but need high protein), slightly lower in the elderly
Carbohydrate 4g/kg (as 50% dextrose; should provide 60% of non-protein calories)
Protein 1.5g/kg (as 10% amino acid solution)
Fat 1g/kg (as 10% lipid emulsion; up to 40% of non-protein calories)
H2O 30 ml/kg/day (or 2ml/kg/h) + losses
Na+ 1-2 mmol/kg Cl- 1-2 mmol/kg K+ 1 mmol/kg Ca2+ 0.1 mmol/kg Mg2+ 0.1 mmol/kg PO4 0.4 mmol/kg (Electrolytes guided by plasma levels) Nitrogen 14g
Successful feeding = at least 40ml/h with 4h aspirates under 250ml. Aspirates >500ml are considered failure.
Normal blood glucose = 100mg/dL = 5.5mmol/L.
Basal insulin requirement = about 50 units/day.
For every 1C rise in temperature, BMR rises by 5-7%
pH for NGT: <5.5
Sedation/TIVA dosing
Propofol
Induction 1-2.5mg/kg
Maintenance 50-200mcg/kg/min (6-12mg/kg/h)
Effect site conc for GA 2-6mcg/ml
Sedation 25-100mcg/kg/min (max 4mg/kg/h)
Remi
Induction 0.5-1mcg/kg
Maintenance 0.25-0.5mcg/kg/min
Effect site conc as part of GA TIVA 1-8ng/ml (usually 5-8)
All tailored to pt age, clinical response, DoA monitoring etc.
Paeds
Midazolam 60-300 mcg/kg/h
Morphine 10-40 mcg/kg/h
Shelf lives of blood products
RBC: 42d
FFP/cryo: 1y
HAS: 5y
Plt: 5d
pKa
Aspirin 3.0 Midaz and alfentanil 6.5 Remi 7.1 Thio and diamorph 7.6 Prilocaine 7.7 Lidocaine 7.9 Morphine 8.0 Bupivacaine and ropivacaine 8.1 Fentanyl 8.4 Cocaine 8.6 Pethidine 8.7 Propofol 11.0
Cardiac output by organ
Brain - 15% - 750ml/min Heart - 5% - 250ml/min Kidneys - 20% - 1L/min Liver - 25% - 1.5L/min Gravid uterus - 12%
BP targets
Neuro TBI: SBP 110-150, MAP>90 SAH: SBP 110-160 (or SBP<140 preop / SBP<180 postop) SCI: MAP>85 for 7d post injury ICH: SBP<150 Acute ischaemic stroke: - SBP 140-185 if thrombolysing - SBP <220 if not
Other
Burns: MAP>60 (fluid creep)
Permissive hypotension in trauma (no TBI): SBP 80-90/MAP>50 if normal mentation and palpable peripheral pulses
Aortic dissection: SBP 100-120 within 20m
Malignant HTN: reduce by 10-20% in first hour and aim for 25% reduction at 24h
Immediately post ROSC: SBP>100
Post aortic surgery: SCPP>80
Defib energies
Defibrillation (biphasic): 200, 300, 360J
Cardioversion: 100, 200, 360J
ICD: 30-50J
Airway assessment
3/6/12
Thyromental distance: should be >6.5cm; <6cm predicts 75% of difficult larygoscopies
Sternomental distance: <12cm a/w difficulty
Interincisor distance: <3cm a/w difficulty
Transfusion triggers: trials and NHS National Blood Transfusion Committee
70
- General ICU population (TRICC Hb 70 vs. 100)
- Septic shock (TRISS Hb 70 vs. 90)
- Upper GI bleed (Villanueva Hb 70 vs. 90) (but consider 80 in active bleed stage)
- TBI (70-90)
- Stable chronic IHD
80
- ACS (80-90)
- Transfusion dependent anaemia
- Active bleeding
90
- Post elective cardiac surgery (Murphy)
- TBI with cerebral ischaemia
- Ischaemic stroke
- SAH
- Early phase sepsis if clear evidence of reduced O2 delivery (ScvO2<70%)
100
- Sickle crisis
- Chronic renal disease
110
- Radiotherapy (weak evidence)
Ones without citations are guidelines rather than direct evidence-based.
Platelet transfusion triggers/limits
10
- Reversible acute BM failure
20
- Non-bleeding pts with severe sepsis or haemostatic abnormalities
- CVC insertion
30
- Clinically significant bleeding
40
- LP/spinal
50
- DIC with bleeding
- Major haemorrhage
- Liver bx/major surgery
80
- Epidural
100
- Critical site bleeding or surgery
Other indications (no specific target): anti-plt agents, inherited plt disorders. Generally only if severe bleeding or emergency pre-procedure. Avoid in ITP/TTP.
Trache rate in ICU
7-9% pts
90% percutaneous
Complication rate 23% in ICU and 30% on the ward (major ones: displacement, obstruction, PTX, haemorrhage)
Source: NCEPOD report ‘On the right trach’
Body compartment pressures
- Pleural
- Compartment
- Abdominal
- ICP
- Portal venous
Pleural
-5cmH2O at start of inspiration, down to -8cmH2O at end inspiration
Compartment
<30mmHg or <30mmHg difference between compartment pressure and DBP
Abdo
Normal 5-7mmHg
IAH = >12
ACS = >20 with new organ failure
ICP
8-12mmHg
Portal venous
<5mmHg. >5 = HTN, >10 risk of variceal haemorrhage.
Cardiac axis
If I, II and either III or aVF are positive, axis is normal.
Perpendiculars: I and aVF II and aVL III and aVR (On ECG - star shape)
Round clock face: aVL = -30 (normal) I = 0 (normal) II = +60 (normal) aVF = +90 (normal) III = +120 (RAD) aVR = -150 (extreme/north west)
Pleural fluid pH
Normal 7.62
Empyema <7.2
High amylase:
- ca
- pancreatitis
- oesophageal rupture
Cannula flow rates
14 - orange - 270ml/min 16 - grey - 236 (about 4m for 1L) 18 - green - 103 (about 10m for 1L) 20 - pink - 67 22 - blue - 42
PAC variables and normal values
Directly measured CVP 0-8mmHg RAP 0-8mmHg RVP 15-30/0-8mmHg PAP 15-30/4-12mmHg PCWP 6-12mmHg CO 4.5-6 L/m SvO2 75% ScvO2 70% HR 60-100bpm
Derived CI 2.5-4 L/min/m2 SV 60-80ml SVI 35-65ml/m2 SVR 800-1200 dynes/s/cm5 SVRI 1600-2400 dynes/s/cm5/m2 PVR 50-120 dynes/s/cm5 PVRI 250-340 dynes/s/cm5/m2 CaO2 180ml/L CvO2 130ml/L DO2 850-1050ml/min VO2 180-300ml/min
