Using the Information Provided by Your In-Clinic Analyzers
|
|
- Tracey Lane
- 7 years ago
- Views:
Transcription
1 A PUBLICATION OF HESKA S PARTNERADVANTAGE PROGRAM Fall 2010 Decision Making in Critical Care: Using the Information Provided by Your In-Clinic Analyzers Tim B. Hackett, DVM, MS, DACVECC, Colorado State University, Fort Collins, CO Emergency/Critical Care medicine has grown in no small part by the availability of reliable and rapid diagnostics.the availability of accurate, easily calibrated, and easily maintained in-clinic blood analyzers has given practitioners access to timely clinical information. We now wait only hours or even minutes for results. Clinicians are able to move quickly through their diagnostic algorithms to optimize and individualize patient care. However, with new technologies there are also new considerations. Technology for its own sake will only add to a client s bill if that information is not integrated into the care their pet receives. Diagnostic testing should be thoughtfully considered based on patient assessment, the need for baseline knowledge and with the intent that results may change the course of treatment. Nothing can replace a complete physical examination and detailed medical history. Triage skills still rely heavily on our senses to determine a patient s medical status. Patients should be prioritized and treatments rendered based on the lifethreatening nature of their clinical presentation. The dyspneic cyanotic dog should not have to wait on the results of an arterial blood gas before being placed on oxygen and the azotemic, anemic cat should not wait on a creatinine or blood lactate before venous access is secured and fluid therapy begun. Fortunately, most of us work with teams trained for multi-tasking so blood tests are run while we are making our initial assessment. Should we run baseline blood work? The answer is probably yes. The question should also be: What are you going to do with that information? The answer should be: Evaluate it in the context of our physical examination to formulate and adjust our treatment plan for this patient. Blood Gas Analysis One of the most common in-clinic emergency blood tests is the blood gas. In-clinic blood gas analyzers tell us about acidbase and electrolyte balance along with information about the patient s ventilation and oxygenation (provided we re using arterial samples). Two common challenges we are faced with when running blood gases are: continued on page 3 In This Issue FEATURE ARTICLE: Decision Making in Critical Care 1 PartnerAdvantage Profile: The Real Benefits of a Good Partnership 6 CSI Case Challenge: What s Up in the ER? 8 Special Offers 9 5 Things to Make You Smarter About Emergency Medicine 11 Inspiration in Action 12
2 Inspired by Speed. Designed for You. NEW! SEE THE NEW VITALPATH ANALYZER IN ACTION With the newest addition to Heska s Lab Systems, get vital results in just 50 seconds for 35 parameters. The VitalPath Blood Gas & Electrolyte Analyzer also greatly simplifies operations with a color LCD touch screen and flexible sampling options. Learn more about what inspired the new VitalPath analyzer. Call your Heska representative for a demo or visit inspired.heska.com. Not a member yet? Visit partner.heska.com follow Heska
3 FEATURE ARTICLE continued from page 1 1) Failing to get arterial samples in hypoxemic patients. 2) Failing to address abnormal findings (e.g., ignoring a rising PCO 2, keeping a patient on an alkalinizing fluid despite a high ph, not addressing increasingly abnormal electrolyte values). Acid/Base Measurement Metabolic Acidosis Metabolic Alkalosis Respiratory Acidosis Respiratory Alkalosis ph pco 2 HCO 3 - DIFFERENTIAL Normal or decreasing* Normal or increasing* Normal or increasing* Normal or decreasing* Diabetes, Addison s, Renal failure, increased acid production Vomiting from upper GI obstruction, administration of alkaline solutions Obstruction, Pneumonia, Mediastinal Disease Anemia, CHF, Exuberant mechanical ventilation Blood ph, PCO 2, HCO 3 and serum base excess (SBE) are evaluated to assess a patient s acid-base status. The ph of the blood is normally maintained between 7.35 and 7.45 for normal enzymatic functions. Blood ph below 7.35 is referred to as acidemia, while a ph above 7.45 is alkalemia. If an acid-base disturbance is present, the PCO 2, HCO 3 and base excess are evaluated to determine if the problem is primarily respiratory, metabolic or mixed. PCO 2 values below normal are caused by hyperventilation causing a respiratory alkalosis. Retaining CO 2 by hypoventilation causes a respiratory acidosis. Again, an acidosis or alkalosis simply indicates an abnormality exists while the body s many buffering systems may continue to maintain a normal ph. Metabolic acidosis results from a loss of normal buffers. This is seen in the blood gases as a low HCO 3 and negative base excess. Metabolic acidosis is one of the most common findings in the critically ill and implies poor tissue perfusion. Elevated HCO 3 and a positive base excess signal a metabolic alkalosis. Acid-base disorders can be defined as primarily respiratory, metabolic or a mixed disorder. They can then be further categorized as uncompensated, partially compensated or fully compensated. In an uncompensated metabolic acidosis, the ph is low (acidemia), the HCO 3 and base excess are low and there is indication of increased ventilation to blow off excess CO 2. With compensation, the PCO 2 drops as the respiratory system hyperventilates to compensate. With metabolic alkalosis, the HCO 3 and base excess rise. Respiratory compensation will result in an increased CO 2 as more volatile acid is retained through hypoventilation. Respiratory compensation of metabolic acid-base problems occurs very quickly while it may take days for the kidneys to adjust HCO 3 levels in response to a primary respiratory disturbance. Gas Exchange The partial pressure of oxygen while the patient is breathing room air (FIO 2 = 21%) is the most important blood gas variable to assess in patients with respiratory disease. PO 2 levels below normal indicate hypoxemia. Serial arterial blood gas analysis is a great way to monitor changes in pulmonary pathology, changes that may not be obvious on radiographs. Gas exchange is quantitated using the Alveolar-arterial (A-a) gradient which is provided by some blood gas analyzers or can be calculated. Serial measurements of the A-a gradient will give a more objective assessment of change (either better or worse) in pulmonary function. Lactate, Electrolytes and Glucose Blood lactate is an indicator of tissue perfusion. Prior to blood lactate, clinicians had to rely on measures like serum creatinine to indicate inadequate tissue oxygenation. Lactate measurements are superior to measurement of cardiac output with regards to predicting outcome in critically ill humans, and elevated lactate concentrations are linked to increased mortality rates. Measurement of lactate concentration is a minimally invasive technique that can be easily accomplished continued on next page 3
4 FEATURE ARTICLE continued from page 3 using venous blood specimens and inexpensive patient side monitors. Hyperlactatemia indicates poor tissue perfusion and should be quickly followed by an assessment of cardiopulmonary function and fluid balance. Serial lactate readings in the context of the patient s response to therapy are more valuable than a single measurement. Limitations: Lactate should be interpreted along with other clinical findings. A normal lactate in a hypotensive shock patient may not mean normal perfusion. There is a delay between the onset of anaerobic metabolism and elevated blood lactate. Only when the body s lactate clearance is overwhelmed will the measured lactate begin to rise. Conversely an elevated lactate does not always indicate impaired perfusion. An example is a hyperlactatemia that occurs with intracranial neurologic disease. We have seen meningioma patients anesthetized for MRI with normal perfusion parameters and a consistently elevated blood lactate despite aggressive fluid resuscitation. Summary In conclusion, it is important to look at all of your laboratory results and try to explain them. Sodium, potassium, calcium, bicarbonate and glucose are often ignored in patients for whom blood gas tests are being performed. We can all recognize the hyperkalemia and hyponatremia seen with classic Addison s disease. In that context, the electrolyte evaluation is diagnostic. The in-clinic analyzer s value isn t in making an etiologic diagnosis but instead, providing accurate and current information to make adjustments in treatment. This enables us to finely tune the type and composition of fluids used in the hospitalized patient. We need to look at abnormalities in the context of fluid balance and appropriate replacement therapy. Fluid choices can be refined if the clinician knows the patient s Na +, Cl -, and K + status. Days of crystalloid fluid replacement often result in hypernatremia and hypokalemia. By looking at these trends, patients can be switched to lower sodium, potassium-supplemented fluids for ongoing maintenance. There are many hematologic, biochemical and electrolyte disturbances that can be identified using in-clinic analyzers. A complete review is beyond the scope of this article although the importance of following up on abnormal results cannot be overstated. For more on decision making in critical care, see 5 Things to Make You Smarter on page 11. 4
5 Inspired. HemaTrue Hematology Analyzer DRI-CHEM 4000 Chemistry Analyzer DRI-CHEM 7000 Chemistry Analyzer VitalPath Blood Gas & Electrolyte Analyzer To meet the needs of your busy practice, Heska has put inspiration into action. Heska s lab systems offer more than just accuracy and reliability. Whether it s blood gas and electrolytes plus a full CBC in under 1 minute, or sample volumes as small as 20 microliters for sick patients, Heska has brought inspired ideas to life for your in-clinic lab. NOW THROUGH 12/31/10: Take Advantage of the Section 179 Tax Incentive GO HESKA I inspired.heska.com follow Heska
6 The Real Benefits of a Good Partnership Wauconda Animal Hospital Wauconda, Illinois M Staff: 2 doctors, 1 practice manager, 4 technicians, 3 receptionists M Enrolled: April 12, 2010 M Current Products: Solo Step CH Heartworm Tests HemaTrue Hematology Analyzer DRI-CHEM 4000 Chemistry Analyzer Vet/IV Infusion Pump UltraNasal FVRCP Vaccine M Special Offers: Spring and fall promotions on Solo Step Heartworm Tests = $5000 in PartnerAdvantage Points (PA Points) Triple Points offer on hematology and chemistry analyzers Chemistry trade-in incentives M Redemptions: purchased with PA Points Vet/IV Infusion Pump HemaTrue Hematology Analyzer PARTNER Profiles M Total Points Earned Since Enrollment: 11,570 Take a look at your keychain, in your wallet, or in your inbox. There s probably at least one sign of a rewards program. In fact, the average household belongs to at least four rewards or loyalty programs. Often when we think of a rewards program, we think of the free $4 latte at a coffee shop. Rarely, if ever, does a program offer rewards that total in the thousands of dollars. For one clinic, the PartnerAdvantage Program has provided over 10,000 reasons why being a part of this rewards program pays. With a progressive team of highly talented professionals, Dr. Carolyn Nemmers spends her day doing what many clinic owners do multitasking. Everyone in the industry will agree that veterinarians and their staff are not compensated nearly enough for the intensive work they do, so when a rewards program comes around that can offer a clinic well over $10,000 in returns in less than one year, Dr. Nemmers and her staff took notice. Practice manager, Shannon Witt, enrolled in Heska s program during a heartworm test booking period where clinics purchasing Solo Step Heartworm Tests could earn $1000 worth of PartnerAdvantage points (PA Points) for every 14-box order. Now, with a total balance of over $2000 in points to use for any product or service Heska offers, Shannon knew just what to do. With plenty of points left over for future purchases, she redeemed some points for Heska s popular Vet/IV Infusion Pump....You don t have to be a big city practice generating lots of revenue to reap the benefits of the PartnerAdvantage Program. Shannon Witt, Practice Manager As their PA points balance continued growing with every purchase, Dr. Nemmers and her staff knew the time had come to reevaluate their need for analyzers. Until recently, the clinic was sending to a local lab for all hematology and chemistry tests. Dr. Nemmers took advantage of Heska s Triple Points special offer (any points balances worth 3x their value if redeemed toward HESKA hematology and chemistry analyzers). In addition to cost savings for running in-house blood analysis and time savings for staff and clients, this meant that a balance of 2900 points was worth $8, toward a HemaTrue Veterinary Hematology Analyzer! To take care of their chemistry needs, Dr. Nemmers traded in an old VetTest analyzer. This trade-in provided an additional $ off of a DRI-CHEM 4000 Veterinary Chemistry Analyzer. Today, Wauconda Animal Hospital can use their PA Points to generate pure profit by redeeming points for products like ALLERCEPT Testing and Immunotherapy, or Pre-surgical panels. Wauconda s staff have taken advantage of an important opportunity to meet their clinic s needs and maximize returns through the PartnerAdvantage program. Shannon says it best. We just focus on good medicine, client education, great pet care and smart business. You don t have to be a big city practice generating lots of revenue to reap the benefits of Heska s PartnerAdvantage Program. 6
7 Welcome to Working Smarter, Together... Heska. Participation is easy: 1. Register at partner.heska.com and monitor rewards account online. 2. Earn PartnerAdvantage Points for purchasing qualifying HESKA products. 3. Redeem Points to purchase any product or service Heska offers. Call GO HESKA or visit partner.heska.com to get started. 7
8 TM CSI: CASE CHALLENGE In partnership with Clinician s Brief and Educational Concepts, CSI Case Challenges are now featured at two online advanced learning centers Essential Learning in Clinical Pathology and Essential Learning in Allergy Diagnosis & Treatment. Every issue of the PracticePartner newsletter will include a current CSI Case Challenge that can also be taken at one of these online learning centers for free C.E. EARN FREE C.E. IN 3 SIMPLE STEPS: 1. Read these overviews and the associated case challenge questions. 2. Visit or to answer the Case Challenge Questions. 3. Earn RACE Credit for every 6 questions answered. What s up in the ER? CASE OVERVIEW: ESSENTIAL LEARNING IN CLINICAL PATHOLOGY A 3-year-old spayed female terrier mix named Chewie is presented to your ER with a history of inappetence and vomiting for the past 2 weeks. The owners aren t aware of any toxin ingestion or dietary indiscretion. They report that she is depressed. On initial exam she is found to be ambulatory and responsive but subdued in her reactions. Her temperature is Tacky mucous membranes and sluggish skin turgor indicate dehydration and she is tachycardic with a heart rate of 160 beats per minute. Her femoral pulses are slightly weak and the mucous membranes have a gray appearance with a capillary refill time of 3 seconds. Respiration is slow at 15 breaths per minute. She tenses and shows splinting with abdominal palpation. Chewie is hospitalized and per doctor s orders, blood is drawn for a CBC, chemistry panel and venous blood gas. A shock drip of LRS is started. Blood results reveal she has abnormal venous blood gas values: Most notably, she has a severe hypochloremic, metabolic alkalosis with a ph of 7.6 and a chloride of 90 meq/l ( ), She also has a high HCO 3 = 56 mmol/l (25-35), and a high PCO 2 = 65.5 mmhg (35-46) indicating hypoventilation that can cause hypoxia. Since Chewie s ph is elevated, we know the primary problem is the metabolic alkalosis. CASE CHALLENGE QUESTION What are some treatment considerations and appropriate actions for this patient now that you have the lab results? A. Wait for x-rays before modifying the treatment plan or administering any further treatment. B. Put Chewie in an oxygen cage and take care of your other patients. C. Change the LRS drip to a nonbuffered fluid such as 0.9% Sodium Chloride. D. Take the dog to surgery ASAP. Correct answer on page 11. 8
9 Heska Special Offers Purchase Heska s 1-step heartworm tests and receive your choice of the following with qualifying purchases:» 1,000 PartnerAdvantage Program Points (1 point = $1.00)» FREE Vet/IV 2.2 Infusion Pump ($1, value) with qualified purchases of Solo Step Heartworm Tests. While quantities last. Take Advantage of Section 179 Tax Incentive Lease or pay cash by 12/31/10 and you can deduct the full purchase price of your new HESKA analyzers!* Buy 6 boxes E.R.D.-HealthScreen Urine Tests for the Price of 4! Save $196. Get the most sensitive in-clinic measurement for detecting kidney damage and early disease. Please specify canine, feline or combination of your choice. Offer expires 10/31/10. *Consult with your tax advisor for more information on this opportunity. Call GO HESKA ( ), option 1 To take advantage of these promotions, mention promo code PPHB1010SO. 9
10 FOR ALL OF THE RIGHT REASONS... 1 The ONLY 1-step heartworm tests available 2 FREE confirmatory testing on all positive canine results 3 Up to 24 months shelf-life 4 Delayed billing until March 2011 Now is the best time to choose Solo Step Qualifying purchases of Solo Step tests earn you 1000 PartnerAdvantage Points that can be redeemed toward any HESKA product or service (1 point = $1.00).* *As an alternative to points, you may also choose a Vet/IV Infusion Pump. follow Heska
11 Five Things to Make You Smarter About Emergency Medicine Focus on the Big Picture AND the Details: When presented with an urgently ill patient, nothing can replace a complete physical examination and detailed medical history. This is a time when paying attention to the small stuff can really pay off. Veterinarians have multiple mechanisms for gathering information about their patients and no single piece of information holds all of the clues. The best path to initial treatment and accurate diagnosis always starts with good listening and thorough patient assessment. Focusing on one piece of the puzzle can work in some situations but it often leads to missed information and missed opportunities. Baseline and Beyond: Wellness testing is a generally accepted standard of practice these days. Regardless of your protocol, establishing at least a one time hematologic and chemistry snap shot of your healthy patient is a good thing and should be encouraged. In the ER, different considerations come into play. Diagnostic testing should be thoughtfully considered based on patient assessment and history, the need for baseline knowledge, and with the intent that results may change the course of treatment. Choose Your Tests Wisely: With the expanding menu of tests that has become available to veterinary practitioners, it is important to think before testing. Ordering a multitude of procedures and tests to aid in your diagnostic and treatment efforts is necessary in some cases and may be prudent given the established standard of care. However, there are times when careful attention to history, physical examination and results of the minimum data base can be enough to put the clinical puzzle together. The next time you are ready to add on a test, assuming that it is affordable for the client, ask yourself if the results might alter the prognosis or the course of therapy. If the answer is yes, go for it. Put it All Together: Look at all of your test results and try to explain them in relation to the patient presentation and physical examination. If all blood and urine values and other results such as radiology, ECG, etc. are compatible with what the patient s condition is telling you, then move forward with treatment and additional testing, if necessary. If a particular finding doesn t quite fit the picture, step back, listen to your intuition and explore a little further. This reassessment may result in repeating a test, or using other tools to confirm your suspicions. Measure Treatment Success: Veterinary practices, including emergency facilities, always have to be conscious of the client s financial resources. No one wants to run unnecessary tests, but dollars are well spent on serial measurement of abnormal parameters. Important decisions such as changing the electrolyte composition of maintenance IV fluids can only be made when the patient s values are known and sequentially measured. In the long run, customizing your patient s care based on sequential testing will hopefully result in more timely decision making, better response to treatment and shorter hospital stays. CSI Case Challenge Answer: C. The decision to change the fluids to 0.9% Sodium Chloride is a good one. Because metabolic acidosis is much more common than alkalosis with dehydrated patients, the choice of alkalinizing fluids would normally be preferred but in this patient that is not the case. For more information on this case challenge and why C is the correct answer, visit 11
12 INSPIR ATION IN ACTION Winning Ideas Up to $25,000 Voting begins December 1, 2010 Heska asked the veterinary community... How would you use $25,000 to support your profession and inspire the veterinary industry? The competition has begun and the winning ideas will get the chance to bring their inspired ideas to life. Learn more at and follow the progress of the contest on Facebook. follow Heska 2010 Heska Corporation. All Rights Reserved. Clinician s Brief is a registered trademark of Educational Concepts, LLC. DRI-CHEM is a registered trademark of FUJIFILM Corporation. Facebook is a registered trademark of Facebook, Inc. Twitter is a trademark of Twitter, Inc. HESKA, ALLERCEPT, E.R.D.- HealthScreen, Feline UltraNasal, HemaTrue, and Solo Step are registered trademarks and CBC-Diff, PracticePartner, PartnerAdvantage, Smarter, Together, Vet/IV and VitalPath are trademarks and CSI: Clinic Scene Investigation and/or logo are trademarks of Heska Corporation in the U.S. and other countries. Order# Q310
Arterial Blood Gas Case Questions and Answers
Arterial Blood Gas Case Questions and Answers In the space that follows you will find a series of cases that include arterial blood gases. Each case is then followed by an explanation of the acid-base
More informationAcid-Base Balance and the Anion Gap
Acid-Base Balance and the Anion Gap 1. The body strives for electrical neutrality. a. Cations = Anions b. One of the cations is very special, H +, and its concentration is monitored and regulated very
More informationACID- BASE and ELECTROLYTE BALANCE. MGHS School of EMT-Paramedic Program 2011
ACID- BASE and ELECTROLYTE BALANCE MGHS School of EMT-Paramedic Program 2011 ACID- BASE BALANCE Ions balance themselves like a see-saw. Solutions turn into acids when concentration of hydrogen ions rises
More informationDiabetic Ketoacidosis: When Sugar Isn t Sweet!!!
Diabetic Ketoacidosis: When Sugar Isn t Sweet!!! W Ricks Hanna Jr MD Assistant Professor of Pediatrics University of Tennessee Health Science Center LeBonheur Children s Hospital Introduction Diabetes
More informationBLOOD GAS VARIATIONS. Respiratory Values PCO2 35-45 mmhg Normal range. PCO2 ( > 45) ph ( < 7.35) Respiratory Acidosis
BLOOD GAS VARIATIONS 1 BLOOD ph Normal range 7.35 7.45 Think of 7.40 as your new 0 or neutral If the reading is below 7.4 it is acid. Below 7.35 it is acid out of range or Acidosis If the reading is above
More information6 Easy Steps to ABG Analysis
6 Easy Steps to ABG Analysis E-Booklet David W. Woodruff, MSN, RN- BC, CNS, CMSRN, CEN 571 Ledge Road, Macedonia, OH 44056 Telephone (800) 990-2629 Fax (800) 990-2585 1997-2012 Ed4Nurses, Inc. All rights
More informationAcid/Base Homeostasis (Part 4)
Acid/Base Homeostasis (Part 4) Graphics are used with permission of: Pearson Education Inc., publishing as Benjamin Cummings (http://www.aw-bc.com) 5. The newly formed bicarbonate moves into the plasma.
More informationAcid-Base Disorders. Jai Radhakrishnan, MD, MS. Objectives. Diagnostic Considerations. Step 1: Primary Disorder. Formulae. Step 2: Compensation
Objectives Diagnostic approach to acid base disorders Common clinical examples of acidoses and alkaloses Acid-Base Disorders Jai Radhakrishnan 1 2 Diagnostic Considerations Data points required: ABG: ph,
More informationACID-BASE DISORDER. Presenter: NURUL ATIQAH AWANG LAH Preceptor: PN. KHAIRUL BARIAH JOHAN
ACID-BASE DISORDER Presenter: NURUL ATIQAH AWANG LAH Preceptor: PN. KHAIRUL BARIAH JOHAN OBJECTIVES OF PRESENTATION 1. To refresh knowledge of acid-base disorders 2. To evaluate acid-base disorders using
More informationHomeostasis. The body must maintain a delicate balance of acids and bases.
Homeostasis The body must maintain a delicate balance of acids and bases. Metabolic and respiratory processes must work together to keep hydrogen ion (H+) levels normal and stable. ph of Blood The ph of
More informationEileen Whitehead 2010 East Lancashire HC NHS Trust
Eileen Whitehead 2010 East Lancashire HC NHS Trust 1 Introduction: Arterial blood gas analysis is an essential part of diagnosing and managing a patient s oxygenation status and acid-base balance However,
More informationInterpretation of Laboratory Values
Interpretation of Laboratory Values Konrad J. Dias PT, DPT, CCS Overview Electrolyte imbalances Renal Function Tests Complete Blood Count Coagulation Profile Fluid imbalance Sodium Electrolyte Imbalances
More informationDiabetic Ketoacidosis
Princess Margaret Hospital for Children PAEDIATRIC ACUTE CARE GUIDELINE Diabetic Ketoacidosis Scope (Staff): Scope (Area): All Emergency Department Clinicians Emergency Department This document should
More informationThe Initial and 24 h (After the Patient Rehabilitation) Deficit of Arterial Blood Gases as Predictors of Patients Outcome
Biomedical & Pharmacology Journal Vol. 6(2), 259-264 (2013) The Initial and 24 h (After the Patient Rehabilitation) Deficit of Arterial Blood Gases as Predictors of Patients Outcome Vadod Norouzi 1, Ali
More informationACID-BASE BALANCE AND ACID-BASE DISORDERS. I. Concept of Balance A. Determination of Acid-Base status 1. Specimens used - what they represent
ACID-BASE BALANCE AND ACID-BASE DISORDERS I. Concept of Balance A. Determination of Acid-Base status 1. Specimens used - what they represent II. Electrolyte Composition of Body Fluids A. Extracellular
More informationUnderstanding Hypoventilation and Its Treatment by Susan Agrawal
www.complexchild.com Understanding Hypoventilation and Its Treatment by Susan Agrawal Most of us have a general understanding of what the term hyperventilation means, since hyperventilation, also called
More informationLothian Diabetes Handbook MANAGEMENT OF DIABETIC KETOACIDOSIS
MANAGEMENT OF DIABETIC KETOACIDOSIS 90 MANAGEMENT OF DIABETIC KETOACIDOSIS Diagnosis elevated plasma and/or urinary ketones metabolic acidosis (raised H + /low serum bicarbonate) Remember that hyperglycaemia,
More informationMetabolic alkalosis. ICU Fellowship Training Radboudumc
Metabolic alkalosis ICU Fellowship Training Radboudumc Case History 28-year-old male Discovered by roommate at home in bewildering state During transport by EMS possible tonicclonic seizure Arrival in
More informationNICE Pathways bring together all NICE guidance, quality standards and other NICE information on a specific topic.
Diabetic ketoacidosis in children and young people bring together all NICE guidance, quality standards and other NICE information on a specific topic. are interactive and designed to be used online. They
More informationThe Sepsis Puzzle: Identification, Monitoring and Early Goal Directed Therapy
The Sepsis Puzzle: Identification, Monitoring and Early Goal Directed Therapy Cindy Goodrich RN, MS, CCRN Content Description Sepsis is caused by widespread tissue injury and systemic inflammation resulting
More informationIMPAIRED BLOOD-GAS EXCHANGE. Intraoperative blood gas analysis
IMPAIRED BLOOD-GAS EXCHANGE Intraoperative blood gas analysis When do you perform BGA Intraoperatively? Informe actual NEVER Routine:Thoracic Thoracic, Cardiac,Neurosurgery Emergency situation Drop in
More informationApproach to the Patient with Acid-Base Problems. Maintenance of Normal ph. Henderson - Hasselbach Equation. normal ph = 7.40 --> [H + ] = 40 neq / L
Approach to the Patient with Acid-Base Problems Maintenance of Normal ph normal ph = 7.40 --> [H + ] = 40 neq / L H 2 O + CO 2 H 2 CO 3 H + + HCO 3 - dietary breakdown of protein (about 80 meq
More informationOxygenation and Oxygen Therapy Michael Billow, D.O.
Oxygenation and Oxygen Therapy Michael Billow, D.O. The delivery of oxygen to all body tissues is the essence of critical care. Patients in respiratory distress/failure come easily to mind as the ones
More informationAcid/Base Homeostasis (Part 3)
Acid/Base Homeostasis (Part 3) Graphics are used with permission of: Pearson Education Inc., publishing as Benjamin Cummings (http://www.aw-bc.com) 27. Effect of Hypoventilation Now let's look at how the
More informationAcid-Base Disorders. Jai Radhakrishnan, MD, MS
Acid-Base Disorders Jai Radhakrishnan, MD, MS 1 Diagnostic Considerations Data points required: ABG: ph, pco 2, HCO 3 Chem-7 panel: anion gap Step 1: Acidemia/alkalemia (Primary disorder) Step 2: Compensation
More informationFluid, Electrolyte, and Acid-Base Balance
Distribution of Body Fluids Fluid, Electrolyte, and Acid-Base Balance Total body fluids=60% of body weight Extracellular Fluid Comp 20% of Total body wt. Interstitial= 15% of total body wt. Intravascular=5%
More informationVentilation Perfusion Relationships
Ventilation Perfusion Relationships VENTILATION PERFUSION RATIO Ideally, each alveolus in the lungs would receive the same amount of ventilation and pulmonary capillary blood flow (perfusion). In reality,
More informationSuffolk County Community College School of Nursing NUR 133 ADULT NURSING I
Suffolk County Community College School of Nursing NUR 133 ADULT NURSING I Page # 1 Instructions for students: Case study # 1 For this lab, you are planning to provide care to the following client: CB
More informationCHAPTER 1: THE LUNGS AND RESPIRATORY SYSTEM
CHAPTER 1: THE LUNGS AND RESPIRATORY SYSTEM INTRODUCTION Lung cancer affects a life-sustaining system of the body, the respiratory system. The respiratory system is responsible for one of the essential
More informationAdult CCRN/CCRN E/CCRN K Certification Review Course: Endocrine 12/2015. Endocrine 1. Disclosures. Nothing to disclose
Adult CCRN/CCRN E/CCRN K Certification Review Course: Carol Rauen RN BC, MS, PCCN, CCRN, CEN Disclosures Nothing to disclose 1 Body Harmony disorders and emergencies Body Harmony (cont) Introduction Disorders
More informationDAYTON CHILDREN S HOSPITAL CLINICAL PRACTICE GUIDELINES
One Children s Plaza Dayton, OH 45404-1815 www.childrensdayton.org DAYTON CHILDREN S HOSPITAL CLINICAL PRACTICE GUIDELINES DISCLAIMER: This Clinical Practice Guideline (CPG) generally describes a recommended
More informationSepsis: Identification and Treatment
Sepsis: Identification and Treatment Daniel Z. Uslan, MD Associate Clinical Professor Division of Infectious Diseases Medical Director, UCLA Sepsis Task Force Severe Sepsis: A Significant Healthcare Challenge
More informationDiabetic Emergencies. David Hill, D.O.
Diabetic Emergencies David Hill, D.O. Class Outline Diabetic emergency/glucometer training Identify the different signs of insulin shock Diabetic coma, and HHNK Participants will understand the treatment
More informationCore Measures SEPSIS UPDATES
Patricia Walker, RN-BC, BSN Evidence Based Practice Manager Quality Management Services UCLA Health System, Ronald Reagan Medical Center Core Measures SEPSIS UPDATES Sepsis Core Measures Bundle Requirements
More informationBOARD OF PHARMACY SPECIALITIES 2215 Constitution Avenue, NW Washington, DC 20037-2985 202-429-7591 FAX 202-429-6304 info@bpsweb.org www.bpsweb.
BOARD OF PHARMACY SPECIALITIES 2215 Constitution Avenue, NW Washington, DC 20037-2985 202-429-7591 FAX 202-429-6304 info@bpsweb.org www.bpsweb.org Content Outline for the CRITICAL PHARMACY SPECIALTY CERTIFICATION
More informationPet Insurance Fact Sheet
Pet Insurance Fact Sheet What is Pet Insurance? Pet insurance or pet health insurance helps cover the cost of medical expenses should your pet become ill or have an accident. Some pet insurance companies
More informationINTRAVENOUS FLUIDS. Acknowledgement. Background. Starship Children s Health Clinical Guideline
Acknowledgements Background Well child with normal hydration Unwell children (+/- abnormal hydration Maintenance Deficit Ongoing losses (e.g. from drains) Which fluid? Monitoring Special Fluids Post-operative
More informationAcid/Base and ABG Interpretation Made Simple
Acid/Base and ABG Interpretation Made Simple A-a a Gradient FIO2 = PA O2 + (5/4) PaCO2 FIO2 = 713 x O2% A-a a gradient = PA O2 - PaO2 Normal is 0-100 mm Hg 2.5 + 0.21 x age in years With higher inspired
More informationTuberculosis: FAQs. What is the difference between latent TB infection and TB disease?
Tuberculosis: FAQs What is TB disease? Tuberculosis (TB) is a disease caused by bacteria (germs) that are spread from person to person through the air. TB usually affects the lungs, but it can also affect
More informationUpdate on Small Animal Cardiopulmonary Resuscitation (CPR)- is anything new?
Update on Small Animal Cardiopulmonary Resuscitation (CPR)- is anything new? DVM, DACVA Objective: Update on the new Small animal guidelines for CPR and a discussion of the 2012 Reassessment Campaign on
More informationWhat You Need to know about Your Pet s Upcoming Dentistry and Periodontal Treatment
What You Need to know about Your Pet s Upcoming Dentistry and Periodontal Treatment We are sending this packet of information in anticipation of your pet s upcoming dental procedure. Many people have questions
More informationOpen the Flood Gates Urinary Obstruction and Kidney Stones. Dr. Jeffrey Rosenberg Dr. Emilio Lastarria Dr. Richard Kasulke
Open the Flood Gates Urinary Obstruction and Kidney Stones Dr. Jeffrey Rosenberg Dr. Emilio Lastarria Dr. Richard Kasulke Nephrology vs. Urology Nephrologist a physician who has been trained in the diagnosis
More informationUnderstanding Treatment Options for Renal Therapy
Understanding Treatment Options for Renal Therapy Kidney failure happens to many different people for many different reasons 1 What causes kidney failure? Diabetes Chronic infection High blood pressure
More informationCourse outline. Code: MLS211 Title: Medical Biochemistry
Course outline Code: MLS211 Title: Medical Biochemistry Faculty of: Science, Health, Education and Engineering Teaching Session: Semester 2 Year: 2015 Course Coordinator: Dr Mark Holmes Tel: 5430 2844
More informationTerminology and Scripts: what you say will make a difference in your success
Terminology and Scripts: what you say will make a difference in your success Terminology Matters! Here are just three simple terminology suggestions which can help you enhance your ability to make your
More informationHyperosmolar Non-Ketotic Diabetic State (HONK)
Hyperosmolar Non-Ketotic Diabetic State (HONK) University Hospitals of Leicester NHS Trust Guidelines for Management of Acute Medical Emergencies Management is largely the same as for diabetic ketoacidosis
More informationLYMPHOMA IN DOGS. Diagnosis/Initial evaluation. Treatment and Prognosis
LYMPHOMA IN DOGS Lymphoma is a relatively common cancer in dogs. It is a cancer of lymphocytes (a type of white blood cell) and lymphoid tissues. Lymphoid tissue is normally present in many places in the
More informationAcute heart failure may be de novo or it may be a decompensation of chronic heart failure.
Management of Acute Left Ventricular Failure Acute left ventricular failure presents as pulmonary oedema due to increased pressure in the pulmonary capillaries. It is important to realise though that left
More informationSouth Putnam Animal Hospital, Pllc 230b Baldwin Place Road Mahopac, NY 10541 845-628-1834
South Putnam Animal Hospital, Pllc 230b Baldwin Place Road Mahopac, NY 10541 845-628-1834 We are looking forward to seeing you and your dog for his/her surgical appointment. Please arrive between 9 and
More informationUnderstanding Lactate in an Intensive Care Setting. Hilary G. Mulholland
Understanding Lactate in an Intensive Care Setting by Hilary G. Mulholland S.B., Massachusetts Institute of Technology (2014) Submitted to the Department of Electrical Engineering and Computer Science
More informationSmall Animal Emergency VMED 5463
179 Small Animal Emergency VMED 5463 Course Coordinator: Dr. Kirk Ryan (email: kryan@lsu.edu) Orientation: When to show up: 1. For Orientation: All emergency students should attend an orientation meeting
More informationFluid, Electrolyte & ph Balance
, Electrolyte & ph Balance / Electrolyte / AcidBase Balance Body s: Cell function depends not only on continuous nutrient supply / waste removal, but also on the physical / chemical homeostasis of surrounding
More informationBlood Transfusion. Red Blood Cells White Blood Cells Platelets
Blood Transfusion Introduction Blood transfusions are very common. Each year, almost 5 million Americans need a blood transfusion. Blood transfusions are given to replace blood lost during surgery or serious
More informationPHYSICIAN ASSISTANT STUDIES UTMB ESSENTIAL FUNCTIONS AND TECHNICAL STANDARDS Updated 04/10/13
PHYSICIAN ASSISTANT STUDIES UTMB ESSENTIAL FUNCTIONS AND TECHNICAL STANDARDS Updated 04/10/13 This description defines the capabilities that are necessary for an individual to successfully complete the
More informationClinical Aspects of Hyponatremia & Hypernatremia
Clinical Aspects of Hyponatremia & Hypernatremia Case Presentation: History 62 y/o male is admitted to the hospital with a 3 month history of excessive urination (polyuria) and excess water intake up to
More informationHealth Science Career Field Allied Health and Nursing Pathway (JM)
Health Science Career Field Allied Health and Nursing Pathway (JM) ODE Courses Possible Sinclair Courses CTAG Courses for approved programs Health Science and Technology 1 st course in the Career Field
More informationMind the Gap: Navigating the Underground World of DKA. Objectives. Back That Train Up! 9/26/2014
Mind the Gap: Navigating the Underground World of DKA Christina Canfield, MSN, RN, ACNS-BC, CCRN Clinical Nurse Specialist Cleveland Clinic Respiratory Institute Objectives Upon completion of this activity
More informationAcid Base Disorders in Medicine. Case 1. Objectives
Acid Base Disorders in Medicine Jonathan J. Taliercio, DO Department of Nephrology and Hypertension Glickman Urological and Kidney Institute Case 1 A hospitalized 62-year-old woman has a 2 day history
More informationUW MEDICINE PATIENT EDUCATION. Aortic Stenosis. What is heart valve disease? What is aortic stenosis?
UW MEDICINE PATIENT EDUCATION Aortic Stenosis Causes, symptoms, diagnosis, and treatment This handout describes aortic stenosis, a narrowing of the aortic valve in your heart. It also explains how this
More informationThe early symptoms of acute salicylism are the triad of gastrointestinal distress, tinnitus or altered hearing, and hyperventilation.
POISONING SALICYLATES (ASPIRIN) Management Guidelines Emergency Department Princess Margaret Hospital for Children Perth, Western Australia Last reviewed: January 2007 Page 1 of 5 Dr Gary Geelhoed Dr Frank
More informationAdvanced Practice Provider Academy
(+)Corey M. Slovis, MD, FACEP Professor, Emergency Medicine and Medicine; Chairman, Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Medical Director, Metro
More information404 Section 5 Shock and Resuscitation. Scene Size-up. Primary Assessment. History Taking
404 Section 5 and Resuscitation Scene Size-up Scene Safety Mechanism of Injury (MOI)/ Nature of Illness (NOI) Ensure scene safety and address hazards. Standard precautions should include a minimum of gloves
More informationSafe Zone: CV PIP < 26; HFOV: MAP < 16; HFJV: MAP < 16 Dopamine infusion up to 20 mcg/kg/min Epinephrine infusion up to 0.1 mcg /kg/min.
Congenital Diaphragmatic Hernia: Management Guidelines 5-2006 Issued By: Division of Neonatology Reviewed: Effective Date: Categories: Chronicity Document Congenital Diaphragmatic Hernia: Management Guidelines
More informationVirginia. A guide for individuals and families. The health insurance benefits you want, at a cost you can afford
Virginia A guide for individuals and families CoventryOne is an individual product (for individuals and families) offered by Coventry Health Care, an Aetna company. The health insurance benefits you want,
More informationReading Assignment: Tasks for the Veterinary Assistant, pages 467-473, Appendix L, O and P
Patient Monitoring Reading Assignment: Tasks for the Veterinary Assistant, pages 467-473, Appendix L, O and P Patient monitoring during surgery is an extremely important task that is commonly the responsibility
More informationJames F. Kravec, M.D., F.A.C.P
James F. Kravec, M.D., F.A.C.P Chairman, Department of Internal Medicine, St. Elizabeth Health Center Chair, General Internal Medicine, Northeast Ohio Medical University Associate Medical Director, Hospice
More informationSTUDY GUIDE 1.1: NURSING DIAGNOSTIC STATEMENTS AND COMPREHENSIVE PLANS OF CARE
STUDY GUIDE 1.1: NURSING DIAGNOSTIC STATEMENTS AND COMPREHENSIVE PLANS OF CARE WHAT IS A NURSING DIAGNOSIS? A nursing diagnosis is a clinical judgment about individual, family, or community responses to
More informationLAB 12 ENDOCRINE II. Due next lab: Lab Exam 3 covers labs 11 and 12, endocrine chart and endocrine case studies (1-4 and 7).
111 LAB 12 ENDOCRINE II Assignments: Quiz : Endocrine Chart pages 112-114 Due next lab: Lab Exam 3 covers labs 11 and 12, endocrine chart and endocrine case studies (1-4 and 7). Objectives: Review the
More informationSelect the one that is the best answer:
MQ Kidney 1 Select the one that is the best answer: 1) n increase in the concentration of plasma potassium causes increase in: a) release of renin b) secretion of aldosterone c) secretion of H d) release
More informationInterpretation of the Arterial Blood Gas Self-Learning Packet
Interpretation of the Arterial Blood Gas Self-Learning Packet * See SWIFT for list of qualifying boards for continuing education hours. Table of Contents Purpose... 3 Objectives... 3 Instructions... 4
More informationClinical Reasoning Case Study: I. Data Collection Chief complaint/history of Present Illness:
Clinical Reasoning Case Study: I. Data Collection Chief complaint/history of Present Illness: What data is relevant that must be recognized as clinically significant to the nurse? Rationale: Personal/Social
More informationSTAGES OF SHOCK. IRREVERSIBLE SHOCK Heart deteriorates until it can no longer pump and death occurs.
STAGES OF SHOCK SHOCK : A profound disturbance of circulation and metabolism, which leads to inadequate perfusion of all organs which are needed to maintain life. COMPENSATED NONPROGRESSIVE SHOCK 30 sec
More informationPlanning: Patient Goals and Expected Outcomes The patient will: Remain free of unusual bleeding Maintain effective tissue perfusion Implementation
Obtain complete heath history including allergies, drug history and possible drug Assess baseline coagulation studies and CBC Assess for history of bleeding disorders, GI bleeding, cerebral bleed, recent
More informationThe science of medicine. The compassion to heal.
A PATIENT S GUIDE TO ELECTROPHYSIOLOGY STUDIES OF THE HEART The science of medicine. The compassion to heal. This teaching booklet is designed to introduce you to electrophysiology studies of the heart.
More informationThe degree of liver inflammation or damage (grade) Presence and extent of fatty liver or other metabolic liver diseases
ilearning about your health Liver Biopsy www.cpmc.org/learning What is a Liver Biopsy? A liver biopsy is a procedure where a specially trained doctor (typically a hepatologist, radiologist, or gastroenterologist)
More informationJeopardy Topics: THE CLOT STOPS HERE (anticoagulants) SUGAR, SUGAR, HOW D YOU GET SO HIGH (insulins)
Jeopardy Topics: THE CLOT STOPS HERE (anticoagulants) SUGAR, SUGAR, HOW D YOU GET SO HIGH (insulins) I HEAR YA KNOCKING BUT YOU CAN T COME IN (electrolytes) TAKE MY BREATH AWAY (Opiates-morphine) OUT WITH
More informationMEDICATION GUIDE ACTOPLUS MET (ak-tō-plus-met) (pioglitazone hydrochloride and metformin hydrochloride) tablets
MEDICATION GUIDE (ak-tō-plus-met) (pioglitazone hydrochloride and metformin hydrochloride) tablets Read this Medication Guide carefully before you start taking and each time you get a refill. There may
More informationDo you have a. of what you want to be when you grow up? Do you look at your teacher and think you might want to have that job
DREAM BIG Do you look at your teacher and think you might want to have that job when you are bigger, or have you passed the fire station and thought about helping others as a firefighter? What about a
More informationHow To Treat A Heart Attack
13 Resuscitation and preparation for anaesthesia and surgery Key Points 13.1 MANAGEMENT OF EMERGENCIES AND CARDIOPULMONARY RESUSCITATION ESSENTIAL HEALTH TECHNOLOGIES The emergency measures that are familiar
More informationWhat is the overall deductible? Are there other deductibles for specific services?
Small Group Agility MS200 Coverage Period: Beginning on or after 01/01/2015 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or
More informationSeven Steps to Starting Your Own NP Practice
Transcript Details This is a transcript of an educational program accessible on the ReachMD network. Details about the program and additional media formats for the program are accessible by visiting: https://reachmd.com/programs/partners-in-practice/seven-steps-to-starting-your-own-np-practice/6345/
More informationBlue Cross of NEPA: Custom PPO Option 10014 Coverage Period: 03/01/2015-02/29/2016
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bcnepa.com or by calling 1-888-345-2346. Important Questions
More informationP.A. STUDENT COMPETENCIES, TECHNICAL STANDARDS & JOB DESCRIPTION
P.A. STUDENT COMPETENCIES, TECHNICAL STANDARDS & JOB DESCRIPTION TECHNICAL STANDARDS This description defines the capabilities that are necessary for an individual to successfully complete the physician
More informationUnitedHealthcare Insurance Company of the River Valley Attachment D - Schedule of Benefits
UnitedHealthcare Insurance Company of the River Valley Attachment D - Schedule of Benefits Please refer to your Provider Directory for listings of Participating Physicians, Hospitals, and other Providers.
More informationLynda Richardson, RN, BSN Sepsis/Septic Shock Abstractor. No disclosures
Lynda Richardson, RN, BSN Sepsis/Septic Shock Abstractor No disclosures 1 2 3 Discuss data requirements -3 hour bundle -6 hour bundle Challenges and compliance issues Success 4 Based on the Surviving Sepsis
More informationSyllabus for Biology 2402 Human Anatomy & Physiology 2 [This is a generic syllabus. Each instructor will give a syllabus customized for their course.
Syllabus for Biology 2402 Human Anatomy & Physiology 2 [This is a generic syllabus. Each instructor will give a syllabus customized for their course.] Course Description Human Anatomy and Physiology II
More informationOxygenation. Chapter 21. Anatomy and Physiology of Breathing. Anatomy and Physiology of Breathing*
Oxygenation Chapter 21 Anatomy and Physiology of Breathing Inspiration ~ breathing in Expiration ~ breathing out Ventilation ~ Movement of air in & out of the lungs Respiration ~ exchange of O2 & carbon
More informationYour Social Security. Disability Benefits. What You Need to Know to Collect What s Rightfully Yours
Your Social Security Disability Benefits What You Need to Know to Collect What s Rightfully Yours This guide is provided by Berger and Green Attorneys At Law 5850 Ellsworth Avenue Suite 200 Pittsburgh,
More informationAcid Base Problems. Objectives (slide 1)
Acid Base Problems Greg Troll, MD The cases in this will be the substance of the exercise. Answer initially to the best of your ability. Then discuss with you neighbor and I will ask again. If you get
More informationImportant Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com or by calling 1-877-453-5645. Important Questions
More information3% Sodium Chloride Injection, USP 5% Sodium Chloride Injection, USP
PRESCRIBING INFORMATION 3% Sodium Chloride Injection, USP 5% Sodium Chloride Injection, USP IV Fluid and Electrolyte Replenisher Baxter Corporation Mississauga, Ontario L5N 0C2 Canada Date of Revision:
More informationCH CONSCIOUS SEDATION
Summary: CH CONSCIOUS SEDATION It is the policy of Carondelet Health that moderate conscious sedation of patients will be undertaken with appropriate evaluation and monitoring. Effective Date: 9/4/04 Revision
More informationDIABETES. Eyes, Heart, Nerves, Feet, and Kidneys. www.kidney.org
DIABETES Eyes, Heart, Nerves, Feet, and Kidneys www.kidney.org About the Information in this Booklet Did you know that the National Kidney Foundation (NKF) offers guidelines and commentaries that help
More informationHEALTH CAREERS RESOURCE CENTER Health Careers Suitability Inventory
DCCCD Health Careers Resource Center Health Careers Suitability Inventory, page 1 of 8 Dallas County Community College District HEALTH CAREERS RESOURCE CENTER Health Careers Suitability Inventory This
More informationFLUID & ELECTROLYTE THERAPY Lyon Lee DVM PhD DACVA
FLUID & ELECTROLYTE THERAPY Lyon Lee DVM PhD DACVA Purposes of fluid administration during the perianesthetic period Replace insensible fluid losses (evaporation, diffusion) during the anesthetic period
More informationA8b. Resuscitation of a Term Infant with Meconium Staining. Session Summary. Session Objectives. References
A8b Resuscitation of a Term Infant with Meconium Staining Karen Wright, PhD, NNP-BC Assistant Professor and Coordinator, Neonatal Nurse Practitioner Program Dept. of Women, Children, and Family Nursing,
More informationDiabetic nephropathy is detected clinically by the presence of persistent microalbuminuria or proteinuria.
Kidney Complications Diabetic Nephropathy Diabetic nephropathy is detected clinically by the presence of persistent microalbuminuria or proteinuria. The peak incidence of nephropathy is usually 15-25 years
More informationRules on Oxygen Therapy:
Rules on Oxygen Therapy: Physiology: 1. PO 2, SaO 2, CaO 2 are all related but different. 2. PaO2 is a sensitive and non-specific indicator of the lungs ability to exchange gases with the atmosphere. 3.
More informationNICE guideline Published: 9 December 2015 nice.org.uk/guidance/ng29
Intravenous fluid therapy in children and young people in hospital NICE guideline Published: 9 December 2015 nice.org.uk/guidance/ng29 NICE 2015. All rights reserved. Contents Key priorities for implementation...
More informationPreoperative Laboratory and Diagnostic Studies
Preoperative Laboratory and Diagnostic Studies Preoperative Labratorey and Diagnostic Studies The concept of standardized testing in all presurgical patients regardless of age or medical condition is no
More information