On Call Survival Kit

THE MOST USED FORMULAS

ACID – BASE

RESPIRATORY ACIDOSIS
ACUTE pH COMPENSATION 7.4 – [ Δ pCO2 X 0.008]
CHRONIC pH COMPENSATION 7.4 – [ Δ pCO2 X 0.003]

RESPIRATORY ALKALOSIS
ACUTE pH COMPENSATION 7.4 + [ Δ pCO2 X 0.008]
CHRONIC pH COMPENSATION 7.4 + [ Δ pCO2 X 0.003]

METABOLIC ACIDOSIS (Hacer ABG’S always)

ANION GAP Na – ( HCO3 + CL)
EXPECTED pCO2 (Winter’s Formula) 1.5 (HCO3) + 8 + 2
Δ ANION GAP ANION GAP –12(Add 3pts for every
1gm
of ↓alb)
Δ/ Δ (DELTA-DELTA) Δ ANION GAP/ (25 – HCO3)
* 1 – 1.5 NO 3rd DISTURB
< 1 NAGMA
> 1.5 METABOLIC ALKALOSIS
∆AG + HCO3 * >24 Met Alk,
<24 NAGMA,
=24 Pure Met Acid

BODY WATER DEFICIT

0.6 X Wt x [(Na/140) -1]

OSMOLAL GAP Calculated Osmolality-Measured

Osmolality
>10 Alcohol Related
Blood Alcohol Level(mg/dl)=4.3 x Osm
Gap

PULMONARY EQUATIONS

IDEAL Po2 (IO2) IO2 = 104 – (AGE x O.4)

O2 NEEDED (FiO2) NEEDED IO2 /(Po2 x FiO2)

A – a GRADIENT (PAtm – pH20) x FiO2 – (pCO2 / 8) - pO2

(760 – 47) – FiO2 – (pCO2 / 8) - pO2

Acute Lung Injury Ratio PaO2/FiO2 <200 ARDS < 300 ALI

>300 NL
NEPHROLOGY EQUATIONS

CORRECTED Na ! [ GLUCOSE – 150 X 1.6 ] + Pt Na

100
→ Na - [(Gluc – 100) x 0.016]
CORRECTED Ca ! [ 4 – (ALBUMIN X 0.8 ] + Ca pt

SERUM OSMOLALITY ! (Na x 2 ) + (glucose/ 18) + BUN/ 2.8

Cr CLEARANCE (Cockcroft-Gault) ! ( 140 – Age) x Kg ideal X (0.85 in females)

72 x Cr

FENa ! [UNa / Plasma Na] / [Ucr / Plasma Cr] X

100
FENA<1=Pre-Renal FENA >1=Renal

WATER DEFICIT ! 0.6 X Kg X 0.05 MILD

0.10 MODERATE
0.15 SEVERE
HEME-ONCO EQUATIONS

Absolute Neutrophil Count !WBC X (POLYS/100 + BANDS/100)

ANC<500 cells/mm3 Neutropenia
CARDIOVASCULAR EQUATIONS
Mean Arterial Pressure (MAP) ! DBP+[1/3(SBP-DBP)]
 Chest Pain
• 1. Ask the nurse?
– Why was the patient admitted?
– Have they tried anything? (SL nitro, MS. . .)
• 2. Orders before getting there
– EKG now!!! Preferably before giving SL nitroglycerin; so, you can
see if there are any ischemic changes.
– Nitro 0.4mg SL q5 minutes x3
– O2 at 2 L via nasal cannula
• 3. Evaluate the Patient:
– Read the EKG
– If there is ST elevation, call for help (resident, attending) - patient
may need urgent intervention
– Is the chest pain getting better with the SL nitro?
– - If not, start a nitro drip.
– - Written: Tridil 50mg in 250 mL of D5W, start at 5cc/hr and titrate
for pain.
• - CALL THE ATTENDING* **
– - If you feel this is unsatble angina, you should ask the attending if
they want the patient on Anticoagulation Protocol, Beta-Blocker,
consult cardiologist.
• If pain does get better with SL nitro, if not already written for, do the
following:
– - CPK with CK-MB and troponin now and q 8 hours x 3
– - ASA 325 mg PO qd
– - Nitro SL 1/150 q5 min x3 for chest pain
– - If not on beta-blocker, may be required
– - Chem Panel and Mg level in the am
• 4. If you think this is GI (and you had better be sure!!):
Try: GI Cocktail
 Shortness of Breath

• Ask the Nurse?

– Vital signs, including a pulse ox. Also ABG if pulse ox < 90.
– Medical history and why the patient was admitted.
• What to do!
– Oxygen is good!!

• How much Oxigen?

– Ideal O2 = 104 - (Agex0.4)
– FiO2 needed = (Ideal O2/ pO2) x FiO2 on ABGs
– Nasal Canula: 1- 6 Lpm
– 1L=24, 3L=32, (Add 4 per liter)
• ** Use low flow for COPD patients, anything high will shut off their
hypoxic drive.
• Venturi-mask: Flow varies (24-50% adjustable)
• Delivers a fixed amount of oxygen, it is not dependent on respiratory
rate.
• High Humidity mask
– 50-80%
• Non-rebreather mask (100% O2)
– One way valve between mask and bag prevents entrapment of
exhaled air.
• Get an ABG’S
• Call Green Code if pt needs intubation
• Is it asthma/COPD?
– Breathing treatment: FFN Proventil/NSS/Atrovent
• Is it CHF?
– Look to see what diuretic the patient is on (if any) and give an extra
dose of what they are normally on.
– Furosemide (Lasix) 40mg usually does the job
 Hypokalemia

• ** If the stomach works, use it!

• *** Be sure to order K level for 2 hours later during your call.
• General rule: 10 meq of KCL should increase the patient’s K by 0.1
meq/L.
• ORAL:
– K-Dur 20-40 mEq PO
– K-lyte (25-mEq) or K-lyte DS (50mEq) - this is a liquid, and great for
the NGT.
• PERIPHERAL LINES:
– KCL 20 mEq-40mEq in 250 mL NS over 2 -4 Hrs
• CENTRAL LINE:
– KCL 40 mEq in 250 mL NS over 1 hour

Hyperkalemia

• Repeat blood draw (?hemolysed)

• Get Stat ECG look peaked T wave
• Treat when K > 5.5 meq/l
• Stop K containing fluids, discontinue any contributing drugs (ACE
inhibitors, NSAIDS, K sparing diuretics)
• Rehydrate
• Correct coexiating low Na, Mg, Ca and acidosis
• Kayaxelate 15-60gm PO/rectal
• If ECG changes of hyperkalemia or K > 7 meq/l; start emergency Rx
immediately
– 10% Ca gluconate: 10Ml over 2-5 min
– Sodium bicarbonate 50ml 0ver 2 -5 min
– Glucose/insulin: 50ml 50% D/W + 10U regular insulin push
– Kayaxelate 15-60g PO/rectal
– Beta agonists- FFN albuterol (arrhythmia risk)
• ECG Changes with hyperkalemia
– Tall peaked T waves
– Flattened P
– Prolonged PR interval
– Widening of QRS
– Sine wave: big trouble
–
 Hyperglycemia

• Ask nurse pt history (cause for admission).

• Is an endocrinologist involved in case?
• Is he on insulin regimen? What type of insulin? How much? Has (s)he
skipped an insulin dose?
• If it is a critical value, was it taken on a dextrostic or Lab value? Did lab
report Ketone presence?
• If blood sugar level was critical and Ketone (+) ask for ABGs
• If not, then proceed to treat
• No sliding scales at SLII!
• General rule:
– One unit of Regular insulin lowers 30mg/dL of blood sugar, so….
– R insulin needed=(Blood sugar-100)/30

Hypoglycemia

• Ask nurse if pt is on insulin, when was the last dose, is he or she

symptomatic?
• If symptomatic, order nurse via telephone to administer IV dextrose
50%DW.
• If pt has an endocrinologist, be sure to contact him and notify about
incident and orders given.
• Ask for a confirmatory lab
• Ask why incident happen?
•
 ELECTROLYTE REPLACEMENTS

• Potassium: NL 3.5-5.0 mEq/L

• Oral: K-dur (tab) 20-40mEq or K-Lyte (liquid) 25meq
• IV: KCL 20-40mEq/100ml-250ml 0.9%NSS IV in 2-4hours
• Replace 10mEq for every 0.1mEq/L below 3.5mEq/L
• (For each 10mEq there is a ↑ of 0.1 mEq/L of K)
• Avoid potassium replacement in renal failure

• Magnesium: NL 1.8-3.0 mg/dl Goal 2mg/dl

• Oral: Magnesium oxide 250mg PO bid or MgCl (Slowmag) 2tabs po D
(watch!! Can cause diarrhea)
• IV: Magnesium sulfate 2gr/100ml 0.45%NSS IV in 1-2hours
• Replace Mg prior to K
• Keep > 2.0mg/dl in cardiac patients
• -For each gram of magnesium given IV, the serum magnesium
should increase by .1 meq/L.
• -In renal insufficiency, the magnesium will increase faster- caution
with replacement

• Phosphate, NL 2.7-5.0mg/dl
• Oral: NeutraPhos 1-2 Packets TID with meals
• IV: 15 or 30 mOsm K3PO4 ml/250 ml 0.9% NSS IV in 4 hours (if K also
Low)
• 30 mmol NaPO4 ml/250 ml 0.9% NSS IV in 4 hours (if only Phosphate
Low)
• Levels < 1mg/dl may cause rhabdomyolysis

• Calcium, NL 8-10.5 mg/dl

• Oral: OsCal 1 tab PO TID
• IV: CaCl 500mg/100ml 0.95NSS IV in 30 min
• Calcium Gluconate 6g/ 250ml D5W in 4-6hrs
•
• NEVER REPLACE IV UNLESS IN OVERT TETANY.
• Correct Calcium for albumin: (4.0- (Pt alb x 0.8) + Ca)
 Hyperkalemia

• For K+ >5.4mEq/L check for hemolysis (increase up to 1mEq/L)

• Do 12-lead EKG if bradycardic or EKG Changes give:

• -1 Ampulle of calcium gluconate (or Chloride)-Use CaCl if pt uses CaChan
blocker and has A-V block
• - 1 Ampulle of D50W and 10 U of Insulin R IV
• -30mg Kayaxelate orally or rectally, followed by cephulac 30min later
• If no EKG Changes or bradycardia
• -Stop all potassium supplements and repeat lab
• -May add inhaled albuterol via nebulizer(FFN albuterol 0.083%)
• -Bicarbonate should be used only in code green situation

Sleepers

• Zolpidem (Ambien 5 mg po) - Can increase to 10 mg

• Temazepam (Restoril) 7.5 - 15 mg po
• Benadryl 12.5 - 25 mg po. Drug of choice in COPD

Poopers
• Dulcolax(bisacodyl)10 mg po
• Colace 100 mg po Surfak 240mg po
• MgCitrate 120 ml PO
• Lactulose(Cephulac) 15-30 ml PO qd
• Fleets enema/Soap suds enema
• Mineral Oil 30ml PO
• Cocktail: cephulac 30ml/mineral oil 30ml/milk mg30ml
•
Nausea/Emesis

• Reglan (metoclopramide) 10 mg IV
• Phenergan (promethazine) 25 mg IM/IV
• Vistaril (hydroxyzine) 25 mg IM(not available in hospital)
• Zofran (ondansteron) 4 mg IV Expensive
•
Falls

• Evaluate the patient x-ray or CT whatever is necessary (if anything).

• Write for fall precautions
 Hypotension
• ** Figure out why!!!
• Sepsis - check temperature, WBC
• Cardiogenic - check for medical history
• Hypovolemic - check hemoglobin
• ** Give FLUID BOLUS of 250 mL or 500 NS and repeat according to
response
• If a patient has had recent surgery or is known to be a GI bleeder. . .
– Get a stat Hgb+Hct
– Open fluids wide
– Type and cross PRBC's
–

Pain Management

• Very Severe
– Morphine 2 mg IV
– Morphine PCA
– Demerol 50 mg IM ***
– Fentanyl patch 25-50
• Severe
– Demerol 25- 50 mg IM ***
– Percocet 1-2 tabs PO q 4-6 PRN
• Moderate
– Percocet 1-2 PO q4 PRN
– Ultracet 2 tabs PO q 6h prn
– Tramadol 50mg po q 6hr prn(ojo con abxs!! Can cause seizure!)
• Mild
– Tylenol 650 mg PO
– Motrin 600-800 mg PO
• *** DO NOT GIVE TO PTS IN RENAL FIALURE OR SEIZURE
DISORDER
 SURVIVING SEPSIS
Resuscitation:
-Keep MAP >65mmHg
-Aggressive IVF (no Difference colloids vs crystalloid) to remain CVP of 12-18
mmHg for patients off MV and mmHg for pt on MV 12-15mmHg
-Keep Mixed venous Oxygen sat >70%
-Keep CVP as above; if not enough then transfuse PRBC to reach Hb
10g/dl if not enough then Dobutamine drip (see IV drips)
-Maintain U/O of 0.5ml/kg/hr
-Measure BP with arterial line
- IVF by two large-bore peripheral lines
-Levophed is vasopressor of choice; may add Intropin, Vasopressin and /or
Phenylephrine.
-Vasopressors by Central venous Lines
-If no response to vasopressors, start hydrocortisone (solucortef) 200-300 mg/
day divided q 6-8hrs for 5 days
-Random cortisol prior to steroids; if <20, needs steroids

Treat Source:
-Panculture prior to abx administration within 1 hour
-Abx given within first hour
-Source control (eg remove infected catheter)
-Xigris (activated protein C) for those with Apache II score 25-49 and no
contraindications
-Lactate Levels

Commorbidities:
- See MV section (PP <30mmH2O)
-Strict Glucose control < 150mg/dl
-No Bicarbonate unless pH <7.15
 HYPERTENSIVE URGENCY
-No Symptoms or target organ affectation
-Oral Medications indicated:
-Clonidine 0.2mg, followed by 0.1mg qh up to 8mg over several hours
(avoid if the pt has never received clonidine)
-Captopril 12.5-25mg po q 8 hrs

HYPERTENSIVE CRISIS

Reduce MAP by no more than 25% within 2hour and then to 160-100 mmHg
over 2-6hrs
-IV medications indicated:
-Nipride 50mg/250mlD5W 0.25-10mcg/kg/min (start 5ml/hr) avoid in the
presence of oliguria or azotemia, requires arterial line
-Labetalol 20mg IV over 2 mins, followed by 40mg IV doses q 10 mins, to
max of 300mg or IV drip
-Vasotec 1.25-5mg IV q 6 hrs, avoid in pt with renal insufficiency or
azotemia
-Tridil 50mg/250ml D5W IV 0.25-5mcg/kg/min (start at 5ml/hr)

ACS
-Oxygen by nasal cannula 2-4 L/min
-Nitroglycerin, sublingual x 3, IV if failure to improve
-Morphine 2-4 mg IV if pain persists
-ASA 325mg to chew
-Plavix 300mg loading, then 75mg PO daily
-Lovenox 1mg/kg SQ every 12 hours (Renal adjustment 1mg/kg Daily)
-12 lead EKG, Cardiac Markers, TIMI score, CXR
-Consider Glycoprotein IIb-IIIa inhibitors (integrillin)
-
 DKA
-Hydrate well. Give 2L of 0.9%NSS over 2hours. If the pt remains in shock,
continue aggressive hydration up to 5L at the rate of 300ml/hr. Always use
0.9%NSS unless Na above 150mEq/L and not Hypotense
-Insulin R 10 U SQ bolus followed by drip to run at 0.1U/kg/hr (7ml/hr for 70kg)
-Obtain DXT stick hourly. Glc should decrease by 50-100mg/dl. If it is corrected
to fast sudden altered mental status. If DXT does not decreases expected, give a
second bolus. If no improvement by second hour, double rate infusion
-When DXT around 250mg/dl add D5W IV at 80-100ml/hr
-If pH <7.0 add bicarbonate drip
-If K is
->5.5, do nothing
- 4.0-5.55, replace orally
- 3.5-4.0 add 20mEq to IVFs
- 3.0-3.5 add 40mEq to IVFs
- 2.5-3.0 add 60mEq to IVFs
< 2.5 add 80mEq to IVFs
-Stop Pump when:
-Anion Gap is NL
-Ph >7.3
-Glc <200mg/dl
-Bicarbonate >18mg/dl
-30min after a 10U dose of insulin R and patient fed

COMA

- ABC, DXT, Toxicology, CBC, CMP, NH3, TSH, ABG

- Thiamine 100mg IV
- Glucose 25-50mg IV
- Naloxone(Narcan) 0.4-2 mg IV q 2-3 min = for opioid overdose
- Romazicon(Flumazenil) 0.2mg IV in 30sec then 0.3-0.5mg in 30 sec up to 3mg-
Benzodiazepines sedation reversal(Ej. Too much versed)
- Brain CT scan

STATUS EPILEPTICUS

-Ensure Airway, Cardiac Monitor, GLC levels, O2 by nasal cannula

-IV lines
-Ativan 0.1mg/kg IV in 2 min
-Dilantin 20mg/kg over 4-5min (1g over 30 min)
-If no response, add Dilantin 5mg/kg and repeat dose
-Phenobarbital 20mg/kg IV @ 100mg/min
-Induced coma with Phenobarbital 5-15mg/kg loading then 0.5-5mg/kg/hr
-Diprivan 1-2 mh/kg loading then IV @ 10 ml.hr
-Verced 0.2mg/kg loading then 0.05-0.5mg/kg drip
 INTRAVENOUS DRIPS

Sedation/Analgesia/Anesthesia:
-Ativan 50mg/50ml 0.9%NSS @2ml/hr
-Verced 50mg/50ml 0.9%NSS @2ml/hr
-Nimbex 200mg/500ml D5W@2-8mcg/kg
-Fentanyl 1mg/80ml 0.95NSS@ 5ml/hr
-Morphine 25mg/250ml 0.9%NSS @ 3ml/hr

Vasopressors:
-Levophed 8mg/500ml D5W or 0.9%NSS @2-12mcg/min
(Max 30mcg/min)
-Vasopressin 100u/100ml 0.9%NSS
@ 3-5 ml/hr for Septic Shock
@ 22ml/hr for Cardiogenic Shock
- Epinephrine 2mg/250ml D5W @ 2-10mcg/min

Inotropics:
- Intropin 400mg/250ml D5W or 0.9% NSS
@1-3mcg/kg/min for D1 action
@ 4-9 mcg/kg/min for ß1 action (inotropic)
@>10mcg/kg/min for α2 action (vasopressor)
(Max 20-50mcg/kg/min)
-Dobutamine 250mg/250ml D5W or 0.9NSS @ 2-10mcg/kg/min
(Max 40mcg/kg/min)
-Milrinone (Primacor) Loading 50mcg/kg in 10 min then 40mg/200ml D5W
@0.375-0.75mcg/kg/min

Antidotes:
- Naloxone 5mg/250ml D5W 0.4-2mg loading then 5mg/250ml D5W @0.4/hr

Heparin Drip:
Heparin 25,000 units/250 ml D5W loading 60-80 Units/kg then 12-18units/kg/hr
and adjust to:

PTT (sec) Adjustment

40. Bolus 5000 units ↑ rate by 3ml/hr
49. Bolus 3000 units ↑ rate by 2ml/hr
59. ↑ rate by 1ml/hr
85. No Change
95. ↓rate by 1ml/hr
95. Hold for 30mins, ↓ rate for 2ml/hr
>105 Hold for 2 hours, ↓rate for 3ml/hr
Vasodilators:
- Tridil 50mg/250 ml D5W or 0.45%NSS @3-12 ml/hr
-Nipride 50mg/250ml D5W @0.5-1mcg/kg/min
With increments by minute, NOT EXCEED 10mcg/kg/min for > than10 min
- Natrecor 1.5mg/250ml D5W loading 2mcg/kg over 1 min, then @ 0.01mcg/kg/
min

Cardiovascular others:
-Normodyne 200mg/250ml D5W @0.5mcg/kg/min
-Lasix 100mg/100ml 0.9%NSS @ 2-20ml/hr
-Cardizem 125mg/100ml D5W @ 5-15ml/hr
-Amiodarone 900mg/500ml D5W Loading 150mg over 10min, then 33.3 ml/hr for
6 hrs then 16.7ml/hr for 18 hours

Gastrointestinal:
- Protonix 80mg/100ml 0.9%NSS @ 11/ml/hr
-Zantac 50mg IV loading then 300mg/500ml D5W @ 10ml/hr
-Sandostatin 50mcg loading, then 1,200 U/250 ml 0.9%NSS @ 11 ml/hr

Pulmonar:
Aminophilline 1gm/500 nss @11ml/hr

Insulin
*For DKA See medical Emergencies
Use Established Protocol of HESL for CABG

General Usage
Insulin R 100U/100ml 0.9%NSS

DXT Drip I Drip II

80-99 0.5 1.0
100-119 1.0 2.0
120-149 1.5 3.0
150-179 2.0 4.0
180-209 3.0 5.0
210-239 4.0 6.0
240-269 5.0 8.0
270-299 6.0 10.0
300-329 7.0 12.0
330-359 8.0 14.0
>360 10.0
 MECHANICAL VENTILATION

Mode:
-CMV or A/C will assit the patient by providing a full volume when he initiates a
ventilatory effort. Use in those with ARDS
-SIMV: will not assit the patient. May add pressure to support to provide some
support
-CPAP: For extubation trials. Perform daily when patient tolerates minimal
paramenters

Tidal Volume:
-Calculate by Ideal Body Weight (see Below)

Tidal Volume in Male

Height IBW 4ml 5ml 6ml 7ml 8ml
(in) (kg)
48 22.4 90 112 134 157 179
49 24.7 99 124 148 173 198
50 27 108 135 162 189 216
51 29.3 117 147 176 205 234
52 31.6 126 158 190 221 253
53 33.9 136 170 203 237 271
54 36.2 145 181 217 253 290
55 38.5 154 193 231 270 308
56 40.8 163 204 245 286 326
57 43.1 172 216 259 302 345
58 45.4 182 227 272 318 363
59 47.7 191 239 286 334 382
60 50 200 250 300 350 400
61 52.3 209 262 314 366 418
62 24.6 218 273 328 382 437
63 56.9 228 285 341 398 455
 64 59.2 237 296 355 414 474
65 61.5 246 308 369 431 492
66 63.8 255 319 383 447 510
67 66.1 264 331 397 463 529
68 68.4 274 342 410 479 547
69 70.7 283 354 424 495 566
70 73 292 365 438 511 584
71 75.3 301 377 452 527 602
72 77.6 310 388 466 543 621

MECHANICAL VENTILATION

FIO2:
-Start with 100% and re-assess with ABG in 1 hour. Decrease below 60% as
soon as possible to decrease loss of vital capacity
Ideal O2=104-(Age x 0.4)
Required FIO2= (Ideal O2 / pO2) x FIO2
Rate:
Usually start 12-14/min. Adjust to decrease pCO2 in respiratory acidosis or
compensate a metabolic acidosis
Rate= (pCO2/desired pCO2) x rate

Tidal Volume for Women

Height IBW 4ml 5ml 6ml 7ml 8ml
(in) (kg)
48 17.9 72 90 107 125 143
49 20.2 81 101 121 141 162
50 22.5 90 113 135 158 180
51 24.8 99 124 149 174 198
52 27.1 108 136 163 190 217
53 29.4 118 147 176 206 235
54 31.7 127 159 190 222 254
 55 34 136 170 204 238 272
56 36.3 145 182 218 254 290
57 38.6 154 193 232 270 309
58 40.9 164 205 245 286 327
59 43.2 173 216 259 302 346
60 45.5 182 228 273 319 364
61 47.8 191 239 287 335 382
62 50.1 200 251 301 351 401
63 52.4 210 262 314 367 419
64 54.7 219 274 328 383 438
65 57 228 285 342 399 456
66 59.3 237 297 356 415 474
67 61.6 246 308 370 431 493
68 63.9 256 320 383 447 511
69 66.2 265 331 397 463 530
70 68.5 274 343 411 480 548
71 70.8 283 354 425 496 566
72 73.1 292 366 439 512 585

MECHANICAL VENTILATION

Peak Flow:
Is the velocity at which the ventilator sends the into the lungs
In COPD patients, use peak flow 80-100 to provide an extended expiratory phase
(what they do physiologically)
In Patients with ARDS, may use low peak flow to provide an inverted I:E ratio,
which results in permissive hypercapnea

ARDS
Criteria
-PaO2/FIO2 ≤ 200, Bilateral (patchy, diffuse, or homogenous)infiltrates consistent
with pulmonary edema, No evidence of Left atria hypertension (PCWP <
18mmHg)

Ventilator Set-up: Lung Protective Measures

-A/C mode
-Set TV to 8ml/kg and reduce by 1ml/kg at intervals ≤ 2hours until=6ml/kg
-Set initial rate to approximate baseline (Max to 35/min)
-Adjust TV and RR to achieve pH and Plateau Pressure goals below
-Set inspiratory floe rate above patient demans (start >80L/min) and may reduce
if iverted I:E ratio required
-Goal oxygenation of pO2 55-80 mmHg or SO2 88-95% with the following

FIO2 0.3 0.4 0.4 0.5 0.5 0.6

PEEP 5 5 8 8 10 10
12-14 14 16 16 18-20 20
FIO2 0.7 0.7 0.7 0.8 0.9 0.9
PEEP 10 12 14 14 14 16
20 20 20 20-22 22 22
FIO2 0.9 1.0 1.0 1.0
PEEP 18 20 22 24
22 22 22 24

Plateau Pressure goal ≤ 30cm H2O

Plateau = _____ TV ____
Static Compliance

Check at least q 4hrs and after each change in PEEP or TV

-If >30mmH2O decrease TV by 1ml?kg minimum 4ml/kg
-If <25 mmH2O and TV<6ml/kg, Increase TV by 1ml/kg (up to 6ml/kg)
-If < 30and breath stacking occurs, may increase TV by 1ml/kg increments by
8ml/kg

MECHANICAL VENTILATION

pH Goal 7.30-7.45
-If pH 7.15-7.30, increase rate until pH>7.30 or pCO2 <25 (max 35/min)
If rate=35 and pCO2<25, may give NaHCO3
-If pH< 7.15 increase rate to 35
If pH remains <7.15 and NaHCO3 is considered or infused,TV may be
increased by 1ml/kg steps until pH>7.15
-If pH>7.45 decrease Ventilator rate
I:E ratio goal of1:1-3
-If FIO2=1.0 and PEEP= 24cmH2O, may adjust I:E to 1:1

Weaning from MV:

Conduct daily CPAP trial when:
-FIO2 ≤0.4 and PEEP <8 or if using the higher PEEP scale and FIO2≤0.3 and
PEEP 12-14, slowly reduce PEEP to 8and increase FIO2 to 0.40 for 30 mins
-PEEP and FIO2 values of previous day
-Patients has acceptable spontaneous breathing effort
-Systolic BP≥90mmHg without vasopressors

Trial:
-Set CPAP=5cmH2O, FIO2 =0.5
-If RR ≤35/min for 5 min advance to Pressure Support weaning below.
-If RR >45in <5 min, may repeat trail after appropriate intervention (eg.
Succtioning, anxiolysis, analgesia). If CPAP trial not tolerated return to previous
settings

Pressure Support weaning:

-Set initial PS based on RR during trial
-If CPAP RR<25, set PS=5cmH2O
_ If CPAP RR = 25-35, set to 20 cmH2O and reduce by 5cmH2O at <5minute
intervals, until rate is 26-35
-If PS=5cmH2O tolerated for ≥2 hours assess for ability to unassited breathing
below

Extubate if by 2hours
-SO2>90% and /or pO2 > 60mmHg
-Spontaneous TV below .4ml/kg
-Rate 35/min
-pH≥ 7.3
-No Distress
-HR<120% of baseline
-Marked accessory muscle use
- Abdominal Paradox
-Diaphoresis
-Marked Dyspnea

Shallow Breathing Index or Respiratory Volume Ratio

 RVR = Frequency / TV
If <105 on CPAP, predictive of successful extubation (the lower the better)

Precautions:
-Risk of VAP 3% daily for the first 7 days, then 1% daily thereafter
-To decrease risk of VAP use Ventilator Bundles
- PUD Prophylaxis: PPI, H2 Blockers or sucralfate
- DVT prophylaxis
- Sedation Vacation
- HOB 30°-45°
- Decubitus ulcer prophylaxis

VAP:
-Treatment of VAP (empiric) Choose three:
- Cefepime, Imipenem or Zosyn +
- Levofloxacin, Cipro or aminoglycoside +
- Linezolid or Vanco
 NUTRITION

Formula Patient Amount KCal Kcal/ml CHO (g) Prot Fat (g)
(g)
Glucerna Diabetes 8oz 237 1 22.2 9.9 13.2
Nepro Renal 8oz 475 2 51.1 16.6 22.7
Nutrihep CLD 8.45 oz 375 1.5 72.5 10 5.3
Nutrivent Pulmonar 8oz 375 1.5 25.2 17 23.7
Oxepa Sepsis 8oz 355 25 14.8 22.2
COPD
ProBalanc Constipa. 8oz 300 1.3 39 13.5 10.2
e
Perative Metabolic 8oz 308 1.3 42 15.8 8.8
Stress
Optimental Malabso 8oz 237 32.9 12.2 6.7
p

-Calculate Ideal Body Weight (IBW)

(See table of IDW under MV)

-Adjusted Body Weight = IBW + 0.2 (BW-IBW)

-For total calories use:
-IBW in Obese and critical patients
-Acute weight in patients with BMI below 18.5
-Total calories
-25-30Kcal/kg in NL pt
-20 Kcal/kg in highly critical PT

-Total proteins (g/kg IBW/d)

-Normal 0.8
-Stress 1.9-1.5
-ARF 0.8-1.0
-HD 1.2-1.4
-Peritoneal Dialysis: 1.3-1.5
-Increase in wounds, burns, protein losing enteropathy
-Decrease in CKD and CLD

-Nitrogen balance:
NB= Protein Intake (gr) – 24hoursUN + 4)
6.25