[CK] AVF thrombosis.

AVF thrombosis:(HD)
- timing: during or before or after ? 
- possible for doing HD via that AVF? 
- evaluation: thrill, bruit, doppler, and so on. 

HX + P/EX = QRAAA + ASSOCIATED + OPDC + P/EX

- generally: total occlusion, acute occlusion
- if it's not totally occluded
  = no urgent intervention needed(Evaluation on Monday would be good enough)
  = no heparin infusion needed.
- no de-clot over the weekend per IR.


- MOSTLY => EVALUATION on MONDAY(Vascular = no urgent -> IR = Monday !, something like that....)

[CK] Higher dose ASPIRIN in CABG populations !!!? [ Q]

The researchers also found that the majority of coronary artery bypass graft (CABG) patients received low-dose aspirin, even though guidelines call for the use of high-dose aspirin in this population.

Findings from the analysis point to the need for large-scale efforts to educate clinicians and patients about the benefits of low-dose aspirin in the secondary prevention of acute coronary syndrome, the researchers noted.

"Wide variability in the proportional use of high-dose aspirin across centers suggests significant influence from local practice habits and uncertainty about appropriate aspirin dosing," Das and co-authors wrote.

https://www.medpagetoday.com/primarycare/obesity/47185

Daily Basic [CK] JVP and EKG with rhythm(닥터노)

Capillary refill: 5-7secs holding => should be returned 2 sec.

Hepatojugular Reflux (HJR)

Hepatojugular reflux is the distension of the neck veins precipitated by the maneuver of firm pressure over the liver. It is seen in tricuspid regurgitation, heart failure due to other non-valvular causes, and other conditions including constrictive pericarditis, cardia tamponade, and inferior vena cava obstruction. The HJR maneuver may be performed as follows:

1. The patient is positioned supine with elevation of the head at 45 degrees.
2. Look at jugular pulsations during quiet respirations (baseline JVP).
3. Apply gentle pressure (30-40 mm Hg) over the right upper quadrant or middle abdomen for at least 10 seconds (some suggest to 1 minute).
4. Repeat the JVP.
5. An increase in JVP of >3 cm is a positive HJR test.

Note: Normal subjects will have a decrease in JVP with this maneuver since venous return to the heart will be reduced. The jugular venous pressure may transiently rise and then return to normal or decrease within 10 seconds.

Or you can also go to Evidence Base for more data.

https://www.youtube.com/watch?v=fAc0Z6xhQJE
; physical exam

JVP: 8cm = normal(3cm + 5cm)

Hepatojugular reflex = +3cm more. = >6cm = positive sign.

[ ] NEXT _ CARDIAC MURMUR !!!!!

[CK] [ ] Q oxyhemoglobin curve. MVO2 > 70% as our goal !(65% - 70%)

OxyHemoglobin Dissociation Curve 

---

This curve describes the relationship between available oxygen and amount of oxygen carried by hemoglobin.

• The horizontal axis is Pa02, or the amount of oxygen available.
• The vertical axis is SaO2, or the amount of hemoglobin saturated with oxygen.

• Once the PaO2 reaches 60 mm Hg the curve is almost flat, indicating there is little change in saturation above this point.
  • So, PaO2 of 60 or more is usually considered adequate.
  • But, at less than 60 mm Hg the curve is very steep, and small changes in the PaO2 greatly reduce the SaO2.
• The term "affinity" is used to describe oxygen's attraction to hemoglobin binding sites.
  

  • Affinity changes with:
    • variation in pH,
    • temperature,
    • CO2 and,
    • 2,3,-DPG
      • a metabolic by-product which competes with O2 for binding sites.
  • Traditionally the curve starts with:
    • pH at 7.4,
    • temperature at 37 Centigrade, and
    • PaCO2 at 40.
  • Changes from these values are called "shifts".
    
    Click a button to shift the curve.
• A left shift will increase oxygen's affinity for hemoglobin.
  • In a left shift condition (alkalosis, hypothermia, etc.) oxygen will have a higher affinity for hemoglobin.
  • SaO2 will increase at a given PaO2, but more of it will stay on the hemoglobin and ride back through the lungs without being used. This can result in tissue hypoxia even when there is sufficient oxygen in the blood.
• A right shift decreases oxygen's affinity for hemoglobin.
  • In a right shift (acidosis, fever, etc.) oxygen has a lower affinity for hemoglobin. Blood will release oxygen more readily.
• This means more O2 will be released to the cells, but it also means less oxygen will be carried from the lungs in the first place.

ARTERIAL: 90%

MIXED VENOUS: SvO2(pulmonary artery <- including coronary sinus)

                             > 60%(SCVo2 > 70%) 

OXYGEN: ScvO₂ and SvO₂ 

Hemoglobin in arterial blood is highly saturated with oxygen (SaO2).  Normal levels of SaO2 delivered to tissues are 95 - 98%.

Central venous (ScvO2) and mixed venous oxygen saturation (SvO2) are measurements of the relationship between oxygen consumption and oxygen delivery in the body.   Normal values of mixed venous oxygen saturation (SvO2) are 60 - 80%.  Central venous oxygen saturation (ScvO2) values represent regional venous saturations with a normal value of ~70%.  ScvO2 usually measures slightly higher than SvO2 as it has not mixed with the venous blood from the coronary sinus.  Although the values may differ, they trend together.

OXYGEN: BALANCE Oxygen balance is necessary to sustain life. SvO2 is the "watchdog" of this balance and is often called the "fifth vital sign." When monitored, it serves as an early trouble indicator and can help clinicians adjust therapies. It is also a means of interpreting other clinical variables. In a healthy individual, normal SvO2 is between 60 percent and 80 percent. If SvO2 is low (below 60 percent) then the oxygen supply is insufficient or the oxygen demand has increased. If SvO2 is high (above 80 percent) then the oxygen demand has declined or the oxygen supply has increased.

OXYGEN: BALANCING SUPPLY AND DEMAND <=> CARDIOGENIC SHOCK + SEPSIS !!! BOTH CAN DECREASE IT .  When the oxygen supply and demand balance is threatened, the body will compensate in the following three ways: Increased cardiac output and/or heart rate: Initial response to decreasing supply or increasing demand. Increased oxygen extraction: Tissues take more oxygen from arterial blood. This results in lower return of oxygen to the venous system and therefore a lower SvO2 reading. Diverted blood flow: Blood flow is redirected to areas where the oxygen is needed the most.  Redirected blood flow cannot be measured clinically and therefore does not provide early warning signals.

GLOBAL TISSUE HYPOXIA An indicator of serious illness, global tissue hypoxia is a key development preceding multiorgan failure and death.  In cases of circulatory abnormalities, an imbalance between systemic oxygen delivery and oxygen demand, results in global tissue hypoxia.

[CK] Dyspnea method

 fentanyl inhalation: single-dose inhalation of nebulized fentanyl citrate (250 mcg)

fentanyl neb
- 25mcg q 3hr inhalation. 

Intravenous* sedative and analgesic dosing regimens for managing pain, agitation, and delirium in the intensive care unit
https://www.uptodate.com/contents/image?imageKey=PULM%2F79667&topicKey=PULM%2F2888&search=fentanyl%20inhal&rank=2~150&source=see_link

[CK] hematoma = 1-4weeks - resolution(any hemorrhage = 3 weeks at least)

. The swelling and pain of the hematoma will go away. This takes from 1 to 4 weeks, depending on the size of the hematoma

[CK] isolated conjunctival injury without trauma = easy.

Management of isolated conjunctival injuries are as follows (see 'Management' above):

•Spontaneous, nontraumatic causes of subconjunctival hemorrhage self-resolve over two to three weeks without ocular sequelae and require no treatment. In elderly patients, the clinician should perform a complete history to determine if any trauma occurred and measure the blood pressure. Coagulation studies should be performed to assess for a bleeding diathesis or overmedication in patients who are anticoagulated if subconjunctival hemorrhages are recurrent.

•Subconjunctival hemorrhage resulting from trauma (or cases when trauma cannot be ruled out in patients who are poor historians), particularly in the setting of bullous elevation of the conjunctiva, warrants ophthalmology consultation to evaluate for underlying retinal trauma and definitively rule out open globe injury.

•Patients with conjunctival abrasions are treated with antibiotic ointment (eg, erythromycin ophthalmic ointment) and for patients whose symptoms have not fully resolved within one to three days or contact wearers, referral to an ophthalmologist.

•Patients with small (<1 cm) conjunctival lacerations not associated with an open globe should receive an antibiotic ointment (eg, erythromycin ophthalmic ointment) with ophthalmologic follow up arranged for one to three days. Lacerations larger than 1 cm should be promptly referred to an ophthalmologist.

•Superficial conjunctival foreign bodies can be removed at the slit lamp with the aid of a cotton-tipped applicator after the instillation of topical anesthetic (eg, proparacaine). Alternatively, multiple or loose foreign bodies may be removed with normal saline irrigation.

[Q] CHEST TUBE CHECKLIST

? Orange - suction

? Air = leakage or air suction

? Tidling = on the pleural space

[CK] Right Cardiac Cath, Pulmonary vascular resistacne( >3 WU)

The standard definition of pulmonary hypertension is defined by most experts as a mean pulmonary arterial pressure of = 25 mm Hg, with a concomitant pulmonary capillary wedge pressure of = 15 mm Hg, and pulmonary vascular resistance of > 3 Wood units. These criteria are derived from the National Institutes of Health (NIH) registry of patients with primary pulmonary hypertension, now known as idiopathic pulmonary arterial hypertension (IPAH).<sup>3

https://www.uptodate.com/contents/pulmonary-hypertension-in-patients-with-left-heart-failure?search=mixed%20pulmonary%20hypertension&source=search_result&selectedTitle=4~150&usage_type=default&display_rank=4

\
LA(PCWP): 14
LV 120/14

RA: 7
RV: 25 <---6---></sup> PA: (mean 16), 25

^{SVR: 800-1200
PVR: 3WU.
Transpul. gra: <6}

[CK] Pneumothorax - 6L facemask and CXR in AM.

[CK] CP with RECENT AMI(3yo)

Any record of AMI during this 3-year period was categorised as a recent AMI.

[CK] Tube feeding -gradual + Q4HR residual. (250, 500 - residual => hold or stop) . 30cc -> q6hr 30cc/hr without 400 residual to goal.

2. Assess tolerance of tube feedings. A. Check stool amount and frequency daily.5 B. Check gastric residual every 4 hours during the first 48 hours of feeding in gastrically fed patients.

When goal rate is attained, it is possible to reduce gastric residual monitoring to every 6-8 hours in patients who are not critically ill.

Continue to assess gastric residuals in critically ill patients every 4 hours.

High or increasing gastric residuals often are symptoms of problems that are not associated with tube feeding. Therefore, it is important to investigate other causes of high-gastric residual volumes rather than simply holding the tube feeding.

The recommendations of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) regarding gastric residuals are as follows:
 • If the gastric residual volume (GRV) is >250 mL after a second gastric residual check, consider a promotility agent in adult patients. 

 • A GRV >500 mL should result in holding enteral nutrition and reassessing patient tolerance by use of an established algorithm, including physical assessment, GI assessment, evaluation of glycemic control, minimization of sedation, and consideration of promotility agent use, if not already prescribed.

cf) Note signs and symptoms that may indicate GI intolerance, including abdominal distension, vomiting, diarrhea, or constipation; assess non-tube feeding factors that may contribute to gastrointestinal symptoms in patients on tube feeding (see Potential Problems and Preventive Actions, p 14-17) before changing type, amount, or rate of feeding.

UPTODATE:

Amount and rate — The daily amount of enteral nutrition is tailored to the nutritional and fluid needs of each patient. A calorie goal of 18 to 25 kcal/kg/d is a reasonable initial range to use to meet the needs of a critically ill patient of normal weight. In practice, it is generally considered acceptable that enteral feeding be initiated in critically ill patients at a rate of 10 to 30 mL/hour (for standard enteral formulations), so called "trophic" feeding, for six days and then incrementally increased to the target rate. It is our practice to initiate feeds at 25 to 30 percent of estimated goal rate. 

In patients who are subjectively more critically ill, we do not attempt to increase further toward goal until the fifth to seventh day of critical illness. In less critically ill patients, advancement is made toward goal as tolerated, based on gastrointestinal symptoms and physical examination (ie, presence of abdominal distension). 

We do not use gastric residuals, unless greater than 500 mL, as criteria for tolerance, and are working toward cessation of routinely checking gastric volume (see 'Monitoring' below). Provided the enteral nutrition is paused infrequently, for issues such as gastric distension, diarrhea, or vomiting, this suggested approach should result in the patient ultimately reaching a stable target rate within a reasonable period of time. 

START WITH 25cc/hr -> increase 25/hr q6hr unless residual >400. 

Or: low-volume enteral feeding consisted of initiating enteral feeding at approximately 10 to 30 mL per hour (approximately 30 percent of the maintenance target), continuing that rate for six days, and then advancing the infusion rate using the same protocol that was used in the full enteral feeding group. = better outcome with low rate. 

(30cc -> uptitrate 30cc q 6hr for now.)

[CK] Diastolic failure (ASE/EACVI guideline standards.

[normal value]
E' >7(med), >10(lateral)

E/E' <14(Ave), 15(med)

TR velocity < 2.8

LAVI < 34

====================
>1 abnormal = normal
>2 abnormal = intermediate
>3 abnormal = DIASTOLIC DYSFUNCTION. 

Point
1. Abnormal LV relaxation(tau = in cath, e' = tissue doppler) = 1st manifestation of diastolic dysf.
2.E/e' = specific for increased filling pressure. >15 (low e' = impaired relaxation. not eleastic. stiff= slow relax.... delayed relax...) <-> DT: faster shift; +high E = high P. and which affected by preload as well. E ~ related to stiffness(stiff = slow E, but high volume = high E) So It's reliabel

PRESSURE + RELAXATION ! => 2 can be measured with ECHOCARDIOGRAM(reliable like cardiac cath !)

========================
Grade
Normal =====> Smallest size of normal pattern = grade 3. E>A, e'>a'
Grade 1 = abnormal E<A, e'<a' => totally opposite = easy to diagnosis !!! Grade 1 완전반대. 얘만 그렇다!!!!! 
Grade 2 = mixed = pseudonormalization of flow E>A, but still e'<a'
Grade 3 = normali like E>A, e'>a' but too small.

[CK] VBG vs ABG(blood gas)

CORRELATION BETWEEN VBG AND ABG

pH

• Good correlation
• pooled mean difference: +0.035 pH units

pCO2

• good correlation in normocapnia
• non-correlative in severe shock
• 100% sensitive in detecting arterial hypercarbia in COPD exacerbations using cutoff of PaCO2 45 mmHg and laboratory based testing (McCanny et al, 2012), i.e. if VBG PCO2 is normal then hypercapnia ruled out (PaCO2 will be normal), though this conflicts with the meta-analysis by Byrne et al 2014 (see below)
• correlation dissociates in hypercapnia – values correlate poorly with PaCO2 >45mmHg
• Mean difference pCO2 +5.7 mmHg (wide range in 95%CIs among different studies, on the order of +/-20 mmHg)
• A more recent meta-analysis by Byrne et al, 2014 found that the 95% prediction interval of the bias for venous PCO2  was −10.7 mm Hg to +2.4 mm Hg. They note that in some cases the PvCO2 was lower than the PaCO2. The meta-analysis had considerable heterogeneity between studies which limits the reliability of its conclusions.

HCO3

• Good correlation
• Mean difference −1.41 mmol/L (−5.8 to +5.3 mmol/L 95%CI)

Lactate

• Dissociation above 2 mmol/L
• Mean difference 0.08 (-0.27 – 0.42 95%CI)

Base excess

• Good correlation
• Mean difference 0.089 mmol/L (–0.974 to +0.552 95%CI)

PO2

• PO2 values compare poorly
• arterial PO2 is typically 36.9 mm Hg greater than the venous with significant variability (95% confidence interval from 27.2 to 46.6 mm Hg) (Byrne et al, 2014)
• See also: Central venous oxygen saturation (ScvO2) monitoring, mixed venous oxygen saturation (SvO2) and SvO2 vs ScvO2