慢郎中的住院門診大楼(只看性病+已診斷為艾滋病患者)

慢郎中

原帖由 carlchee 于 13-10-2007 12:38 PM 发表
我想问一下。K<5.0就要给KCL了吗？

可以顺便说说要怎样CORRECT POTASIUM 吗？ 我的友族大医生不愿意花时间跟我这给我说个明白。希望你能教我。

做医生的，一定要 foresee 药物将会发生的 hypokalemia.

没错，我的习惯是K<5.0就要给KCL （ 大前题是are you giving those mentioned Rx at the moment ? )

如果 patient's kidney is functionable, 过多的 K 会被自动排出体外，不必担心。

关于如何supply K , oxford handbook 写得非常清楚，请自行查阅。

一般上，如果 K <2.5, 我就会用 IV drip 的方式来补充， 如果2.5 以上， 喝喝mist KCL就可以了。

慢郎中

刚看到一个医学笑话，和大家共享，轻松一下。

Office Sign

Two doctors, a psychiatrist and a proctologist, opened an office in a small town and put up a sign reading: "Dr. Smith and Dr. Jones: Hysterias and Posteriors."

The town council was not happy with the sign, so the doctors changed it to read, "Schizoids and Hemorrhoids."

This was not acceptable either, so in an effort to satisfy the council, they changed the sign to "Catatonics and High Colonics."

No go.

Next, they tried "Manic Depressives and Anal Retentives."

Thumbs down again.

Then came "Minds and Behinds."

Still no good.

Another attempt resulted in "Lost Souls and Butt Holes."

Unacceptable again!

So they tried "Analysis and Anal Cysts."

Not a chance.

"Nuts and Butts?"

No way. "Freaks and Cheeks?"

Still no go.

"Loons and Moons?"

Forget it.

Almost at their wit's end, the doctors finally came up with: "Dr. Smith and Dr. Jones, Odds and Ends."

Everyone loved it.

慢郎中

要解读 ABG 应该是 小case了吧，今天让我来谈谈metabolic acidosis.

很多医生，一看到病人喘个不停，做了ABG，只要是metabolic acidosis， 就不分青红皂白的一律给予sodium bicarbonate infusion 来“中和”掉血酸。

其实，这不是个正确的解决方法，反之，你可能因此错手把病人给杀了。

爱你变成害你，个个替天行道变成了如杀人神医慢郎中般，那可大大的不妙。

先在这里贴上the causes of metabolic acidosis



有没有注意到在病房内,很多的metabolic acidosis病人大多有kidney disease,气喘连连的原因有时候，除了是身体为了compensate而尽量的把CO2排放出去，也可能是因为肾脏坏了而造成fluid overload ( i.e. APO ),所以病人喘个不停。

你如果一律给予sodium bicarbonate infusion，那就糟糕了。

先了解我们一般用的sodium bicarbonate是甚么东东来的。

sodium bicarbonate是一种Hypertonic的液体，它的osmolality 有2,000 mOsm/l那么的高，且含高钠 （ with a high [Na+]）

它的浓度足足是我们人体血液plasma osmolality 的 7 倍那么高，而 3% saline也只不过about 900 mosm/l 的浓度，所以， 你可以想象sodium bicarbonate是多么的Hypertonic。

所以, 如果病人有metabolic acidosis, 加 fluid overload 你这样灌了sodium bicarbonate进入体内，可以想象简直是让病人水分更加滞留于体内，变本加厉，百上加斤呀！！

其实，很多时候，把underlying problem 解决掉了， acidosis自动解决，更本不需动用sodium bicarbonate.

所以，很多时候，其实如果 PH > 7.0，我很少order给予sodium bicarbonate的。

carlchee

对不起，插一下嘴：

有一个资深的老师曾对我说过，给NAHCO3的CRITERIA :

1. PH < 7.21
2. BE/D < -10

EITHER ONE CRITERIA IS MET, THEN, IT'S JUSTIFIABLE TO GIVE NAHCO3.

HOW TO GIVE NAHCO3:

NAHCO3  --- 8.4%,

FORMULA OF DOSAGE:

1/3 x BODY WEIGHT (KG）ｘ　BE
= A mmol/L

To prevent overcorrection, there fore, A is divided into 2 , becoming B mmol/L

Thus, B mmol/L = B cc of 8.4% NaHCO3.

Give B mmol/L in 20min, then, wait another 20 min, repeat ABG again.


PRECAUTION:

1. DON'T GIVE NaHCO3 same line with HARTMANN SOLUTION !!!
2. DON'T GIVE NAHCO3 & inotrope with same line !!!

请多多指教．

慢郎中

有没有过这样子的经验：

你在医院病房值班待命，Emergency department送给病房一个喘气如牛的肥胖老婆婆，你把耳朵靠近她的鼻嘴，听到：hiu…hiu…的wheezing sound.

用听诊器往胸部一听： 果然是generalized rhonchi (++), 再拿起病人的胸部X-ray一看，是AP view, 病人躺着时候照的 ――心脏有点大, 你又不是很肯定是Cardiomegaly。

请问，你要如何的去处理这个病人，讲来听一下。

[ 本帖最后由 慢郎中 于 6-1-2008 10:21 PM 编辑 ]

1st of all, u have to differentiate whether it's a AEBA or COAD. this can be done from histroy.

ask ppl to take 1 ABG stat, r/v, KIV refer aneas for intubation. ( if is a COAD case, then don't intubate, u will need to wait 1000yr to extubate her)

decice how much oxygen she needs, gif her the oxygen respectively..then u neb her. i would prefer to use Neb A:V:N 1/2 hrly x4, 1 hrly x3, 2 hrly x2, then 4hrly  , if COAD then i use Neb Combivant

IV hydrocort 200mg stat,then 100mg QID.

i don't ur patient is so serious that require aminophyline or intubation

others include:

Ix:
FBC, BUSE/CREAT, RBS, Blood C&S etc, get a CXR(erect), ECG

1. Vs, SPO2 monitoring 1/2 hrly till patient stable then 2 hrly x 3 , then 4 hourly
1. Treat the infections (IV augmentin + Doxycicyclin is nice)
2. T. Pred 30mg OD
3. MDI salbutamol 2 PRN
3. MDI Inflamide 2 TDS

usually this kind of fatty aunty will have diabetes or HPT, juz continue her old medication and monitor accordingly. put her on TDS MO r/v.

慢郎中

谢谢你的回复。

各位都同意吗？要补充一些吗？是满意这个答案了，还是有其他答案？

慢郎中

等了两个月，居然没人回答，唉，这个年头，大家宁愿用眼睛去看蔡版DVD， 也不愿用脑子想想这题的differential diagnosis.

为甚么喘气+ wheezing 就一定是 bronchial asthma 呢？

难道不可以是 cardiac asthma 吗？

慢郎中

原帖由 怪杰博士 于 4-11-2007 09:07 AM 发表

IV hydrocort 200mg stat,then 100mg QID.

i don't ur patient is so serious that require aminophyline or intubation

others include:

Ix:
FBC, BUSE/CREAT, RBS, Blood C&S etc, get a CXR(erect), ECG

1. Vs, SPO2 monitoring 1/2 hrly till patient stable then 2 hrly x 3 , then 4 hourly
1. Treat the infections (IV augmentin + Doxycicyclin is nice)
2. T. Pred 30mg OD
3. MDI salbutamol 2 PRN
3. MDI Inflamide 2 TDS ...

如果这个case真的是pure cardiac asthma case,有没有想过类固醇会造成water retention,这会使得cardiac failure 更加严重，百上加斤也。

而salbutamol， aminophylline 也会造成心脏的负担加重 ( by increased heart rate )。

慢郎中

如何分辨 bronchial asthma 或 cardiac asthma ?

两者都造成wheezing,可是前者 wheezing 始于inflammation of bronchial airway 而后者却是因为是水分的囤集于气管旁而造成气管的狭窄而形成（fluid build up causes the airways to narrow and subsequently cause wheezing）.

再问：如何分辨 bronchial asthma 或 cardiac asthma ?

答案是：还是从最基本的医学诊断开始，那就是 History taking & Physical examination:

OK, 先说 Cardiac asthma ( heart failure )

History : ~~
Breathlessness, tiredness and ankle swelling
orthopnoea
paroxysmal nocturnal dyspnoea (PND)

PE: ~~
Raised jugular venous pressure
Displaced apex beat
Gallop rhythm
Basal crackles


Tools :~~
CXR : cardiomegaly (但是也不完全是这样，比如在 restrictive cardiomyopathy的例子，未必看到enlarged heart )

ECHO : 很多医生都用 E.F .来判断是否有left cardiac failure这个也不一定，比如在 diastolic dysfunction的例子中， EF不会低于 50％。

另外，如果病人在扫描的时候有Atrial fibrillation，你也无法 assess得很正确的。

所以，要更进一步的准确判断CCF，好象就是做left ventriculography during coronary angiography.但是我国又有几间医院可以提供这个检查？

For bronchial asthma, history taking 更比其他的步骤重要得多：





好了，讲了，那么多，回到我之前的故事，

原帖由
慢郎中
于 3-11-200705:38 PM 发表
file:///C:/DOCUME%7E1/User/LOCALS%7E1/Temp/msohtml1/01/clip_image001.gif
你在医院病房值班待命，Emergency department送给病房一个喘气如牛的肥胖老婆婆，你把耳朵靠近她的鼻嘴，听到：hiu…hiu…的wheezing sound.

用听诊器往胸部一听：
果然是generalized rhonchi (++), 再拿起病人的胸部X-ray一看，是AP view, 病人躺着时候照的――心脏有点大, 你又不是很肯定是Cardiomegaly。
.

在急诊，或在病房，根据我们上述的那些，好象就可以轻易的区分两者，可惜现实不然，很多原因啦：――医生问诊的功力、医疗器材的缺乏（假设你在小医院或半夜三更接触病人，去那儿找到echo machine 呀）,病人的大数量（告诉我你们医院的 echo appointment 有多长）等等…


在英美先进国,他们的急症室有种rapid test 叫 B-type or brain natriuretic peptide (BNP), 点几滴血在上面，约15 分钟后就可知道有无heart failure, 非常方便而且sensitivity 很高。



可惜价钱太贵，我国负担不起。




好了，下次再谈。。。。。
  



下边是一点补充资料，让你更了解两者的区别：
http://www.mydr.com.au/default.asp?article=2709



[ 本帖最后由 慢郎中 于 12-2-2008 10:17 AM 编辑 ]

慢郎中

原帖由 peying84 于 17-5-2008 03:44 PM 发表
慢大人很久没有教学了哦？

Thanks for yor concern.

I am like a toppled candle now which is going to burnout in anytime（江郎才尽也）.

Obviously my column didn’t successfully grabs the limelight as hitherto , no one bother to leave any comment on it. Felt sorry for that .

Instead of getting something from me, why don’t you guys from realm of Pharmacy teach us something regarding pharmacokinetics as that is considered your forte.

I am always perplexed about how and when should we reckon the half life as well as the concentration of cyclosporine in an uremic patient who has been hemodialysing for years.

Anyone mind to enlighten me ?

[ 本帖最后由 慢郎中 于 25-5-2008 04:10 PM 编辑 ]

peying84

原帖由 慢郎中 于 25-5-2008 04:09 PM 发表

I am always perplexed about how and when should we reckon the half life as well as the concentration of cyclosporine in an uremic patient who has been hemodialysing for years.

i try to look through my book, stated that cyclosporine is eliminated almost completely through hepatic metabolism, not renally.

renal failure does not change CSA pharmacokinetics, and the drug is not significant removed by hemodialysis or peritoneal dialysis..

what i think is since CSA is not eliminated through kidney and through hemodialysis, so the way to calculate the clearance and half-life still remain the same.

when you usually take the blood sample for TDM of CSA?
2 hours after dose? or take pre-dose?

there is another sentence on
the hemofiltration seiving coefficient for CSA is 0.58, which indicates significant removal. replacement doses during hemoperfusion should be determined using CSA concentration.

Hemodialysis=hemoperfusion?

so normally after hemodialysis, no replacement of doses, right? as it is not removed by hemodialysis
so if after hemoperfusion, replacement of doses needed? times by 0.58?


p/s: i need help from yice.....i am not sure about the answer

[ 本帖最后由 peying84 于 28-7-2008 01:11 AM 编辑 ]

yice

cyclosporin is not dialyzed as it is highly protein bound and lipid soluble.

Effects of hemodialysis to cyclosporin's plasma concentration is minimal. Can be neglected.

half life is not much affected too. For anephric pt, cyclosporin's half life is around 16 hr, only about 20-30% increase compared with normal ppl.

For other highly renal excreted drug, their anephric half life is normally 2-5 times more than normal half life.

慢郎中

酱如果要知道 cyclosporin 的 therapeutic level ， 我应该什么时候采血比较准确？

吃药前？
吃药后？
洗肾前？
洗肾后？
（ 如果洗肾是8 am--12 noon的话，吃药时间在 7am  ）

请举个例子，再指点我，谢谢。

peying84

原帖由 慢郎中 于 28-7-2008 02:34 PM 发表
酱如果要知道 cyclosporin 的 therapeutic level ， 我应该什么时候采血比较准确？

吃药前？
吃药后？
洗肾前？
洗肾后？
（ 如果洗肾是8 am--12 noon的话，吃药时间在 7am  ）

请举个例子，再指点我，谢谢 ...

采血时间最好是 2 hours post-dose (吃药后两个小时)
because according to many studies, C2 is the most sensitive predictor for acute rejection.

day (s) after transplant	C2 (ug/L)
1-5 day	1600-2000
6 day until second month	1400-1600
third month	1200-1400
after third month	1000-1200

至于你的case, 有没有可能延迟hemodialysis的时间呢？
因为 2 hours post-dose是在9点（如果病人是在7am吃药）
至于洗肾前还是后，应该没有太大的影响，因为 cyclosporine is not significantly removed by hemodialysis

jinreung

原帖由 peying84 于 28-7-2008 18:07 发表

采血时间最好是 2 hours post-dose (吃药后两个小时)
because according to many studies, C2 is the most sensitive predictor for acute rejection.

day (s) after transplant C2 (ug/L)1-5 day 1600-2000  ...

恕我笨笨，做么从dialysis变成transplant的？

peying84

原帖由 jinreung 于 28-7-2008 08:39 PM 发表

恕我笨笨，做么从dialysis变成transplant的？

因为cyclosprine多数是给transplant patient的

peying84

原帖由 范逍遥 于 28-7-2008 06:13 PM 发表


對了
年輕人做做功課一下

來教我們這些老人
C0 和 C2 的分別

traditionally we use C0 to measure the therapeutic effect of CSA, however it was then understood that C0 level does not correlate well with total drug exposure as measured by AUC (a sensitive predictor of acute rejection) and correlate poorly with clinical events in patients after organ transplantation.

however, AUC monitoing is impractical due to requirement of repeated sampling and cost involved.

Thus, many studies have reported that Cmax plays a role in determine the clinical response of CSA. Unfortunately, Cmax is not a practical monitoring tool because it is a value extrapolated from mutiple measurements.

So, a simple measurement at 2 hours post-dose is used as an effective surrogate marker of Cmax and drug exposure and a predictor of acute rejections. It has been shown repeatedly to be the best single-point predictor of AUC0-4.

adopted from articles below:
http://www.advmolmed.com/issue/20054/pdf/05.pdf
http://medind.nic.in/maa/t04/i4/maat04i4p326.pdf
http://ndt.oxfordjournals.org/cgi/reprint/19/1/215

读到有点blur blur了

yice

以前的guidelines都是使用trough concentration (c0), 现在主要是使用c2measurement.

简单来说，

主要原因有两个， 第一， poor relatioship between C0 concentration and cyclosporin exposure indices (eg. area under curve of the graph   of concentration vs time ).

The C2 concentration has been demonstrated (particularly in kidney and liver transplant recipients) as correlating well with AUC0-4, allowing it to be used as a surrogate index of CsA absorption and exposure.

第二，pharmacodynamically, Cyclosporin exert its effect best at around after 2hr of the dose. It is directly related with the concentration of the drug at that time.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1855625

[ 本帖最后由 yice 于 28-7-2008 09:47 PM 编辑 ]

yice

她给的那个table是当transplantation 过后不同时段里的target C2 level.

dialysis 基本上没有什么影响