cirrhosis.md

Cirrhosis - ESLD

Cirrhosis - ESLD (Childs-Pugh ***, MELD ***, Transplant Status***)
? Childs-Pugh: (http://gihep.com/?page_id=43)
? MELD-Na: (http://gihep.com/?page_id=49)
? Cause: Alcoholic, Hepatitis C, NASH, Toxin, AIH, PBC, PSC
? Decompensated: Prior variceal bleed, SBP, medically refractory ascites

- Consult: Hepatology 

Hepatic Encephalopathy

Hx TIPS will make difficult to control

• Lactulose titrated to 3-4BM/day, Rifaximin 550mg PO bid, Zinc SO4 200mg PO daily
• Screen for (infectious) trigger: UA, Blood Cx, paracentesis, r/o dehydration / overdiuresis

Ascites

Hx TIPS? Stable renal function?

• Furosemide 40mg PO : Spironolactone 100mg PO
• Therapeutic paracentesis, replete 25g albumin per 4L removed

SBPeritonitis

Paracentesis with >250 PMN or positive culture

• Ceftriaxone 1g IV daily -> norfloxacin 400mg PO bid or TMP/SMX DS PO bid x1 week
• Albumin 1.5mg/kg day 1 then 1.0mg/kg day 3 may help short-term survival/renal function (Use if high risk: Cr>1, BUN>30, or TBili >4) Gastroenterology 2006;131:1049

SBP Prophylaxis

Hx prior SBP or ascites albumin <1.5 with renal/liver impairment (Cr>1.2, BUN>25, Na<130, Childs-Pugh>9, Bili >3) or ascitic albumin <1.5 and currently hospitalized

• Norfloxacin 400mg PO daily vs. Ciprofloxacin 500mg PO daily vs. TMP/SMX DS 1 tab PO daily? Ciprofloxacin 750mg PO weekly sometimes used (but may select for resistant organisms). VA recommends cefpodoxime given high rates of Cipro resistance

Varices (Bleed)

• Octreotide gtt acutely, transition to Propranolol 20mg PO bid or Nadolol 20mg PO daily after stabilization with goal HR <70
• Antibiotic prophylaxis after bleed x1wk
  • ceftriaxone 1g IV daily while inpatient
  • transition to norfloxacin 400mg or
  • ciprofloxacin 500mg PO bid upon discharge Hepatology 2005;41:572

Hepatorenal? (Type I: Rapidly progressive over days. Type II: "Diuretic refractory ascites")

? 1g/kg/day albumin challenge to confirm not pre-renal

• Midodrine (7.5-12.5mg PO tid) + Octreotide (100-200mcg SubQ tid) + 20-40g/d albumin, goal increase MAP 15mmHg, but really only liver transplant will help at this point Hepatology 1999;29:1690

Coagulopathy / "Chronic DIC"

Elevated INR is actually misleading, patient missing both pro- and anti-coagulant factors, and should receive VTE prophylaxis (heparin) if Plt>50

• For purposes of procedure (i.e., paracentesis), can administer FFP, platelets, cryoprecipitate respectively (goal INR<2, Plt>50, fibrinogen>100), but no data to support. Can't really avoid bleed risks (though minimal for paracentesis anyway). Hepatology 2004;40;484

http://www.thececonsultants.com/images/Burton_Cirrhotic.pdf

Cirrhosis / Outpatient

• q6-12month RUQ ultrasound for HCC monitoring if cirrhosis or Hepatitis B+
• EGD
• Check Hep C genotype + viral load to guide potential therapy
• Hep A/B vaccination series
• Counsel on EtOH cessation

leukemia.md

Summary Line: PCP, Primary Onc Dx, HLA type status, sibling HLA Type, BMT reference, Flow/Cytogenetics, Chemo, Day #1 Date

Acute Leukemia Checklist

Labs

• CBC with diff
• CMP
• Tumor Lysis (BMP, Phosphorus, Uric Acid, LDH)
• DIC Screen (INR, PTT, Fibrinogen, D-Dimer)
• Pregnancy test
• Type & Screen (every third day)
  • Consent patient for transfusions
• HLA Tissue Banking (see "CC BMT" Order Sets)
• Flow Cytometry (might wait for BM biopsy, instead of extra peripheral blood test)
• Specialized Studies for AML
  • AML Prognosis Assay (FLT3, NPM1)
  • (CEBPA, c-Kit)
  • t(15:17) if suspect APL (Chromosome and/or FISH Analysis order)
  • Cancer Somatic Mutation Panel
• Specialized Studies for ALL
  • BCR-ABL Qualitative

Orders

• PICC/CVC
• CXR
• TTEcho
• Allopurinol 300mg PO BID (or appropriate renal dosing) + IVF for TLS Prophylaxis
• Norethindrone 15mg PO daily or Leuprolide 3.75mg monthly (for women, block menstrual bleeding)
• Sperm Banking? (Social Work consult, paper Rx for "Cryopreservation of Sperm")
• Bone Marrow Biopsy plan with fellow
• Tissue Banking for Research
• Bleeding + Neutropenic precautions PRN
• No NSAIDs
• No Anti-Coagulation (as appropriate)

Pre-Bone Marrow Transplant Panel

• Pulmonary function test with spirometry and DLCO
• Cardiac echo with Doppler and LVEF
• EKG
• Hepatitis B Surface Ag
• Hepatitis B Core Total Ab
• Hepatitis C Ab EIA
• Hepatitis C RNA PCR Quantitative
• HIV Quantitative PCR
• HIV (Type 1 and Type 2) ABY
• HTLV-1 Ab Screen
• Syphilis Treponemal Screen
• HSV 1 & 2 IgG
• Varicella Zoster Virus Ab IgG
• CMV Ab Total
• CMV IgM

===============================================

Typical Acute Leukemia Timeline

Admit

• Order diagnostic labs
• Consent for blood transfusions
• Get PICC line
• Pre-chemo TTEcho
• Fellow does BM biopsy for diagnostics
• If clotting evidence or otherwise concern for APLeukemia, fellow will empirically start ATRA (tretinoin)

Day 1-7

â—¾Induction chemotherapy (variable depending on regimen chosen) â—¾Monitor Tumor Lysis labs (K, Cr, Ca, Phos, LDH, Uric Acid)
Mostly just keep hydrated to flush these out, and standing allopurinol 300mg PO bid while at active risk. Only other meaningful intervention is rasburicase if uric acid >10, but requires a call to fellow. Only relevant if very high WBC and early during induction chemotherapy. â—¾Monitor DIC screen first several days, though mostly only looking at fibrinogen for cryoprecipitate repletion

Day 7-21

â—¾Most severe period of pancytopenia â—¾Daily CBC to monitor for blood and platelet transfusion â—¾Neutropenic fever almost inevitably develops, grapple with this daily, as it represents the major threat to your patients' survival

Day 14

Depending on treatment protocol, fellow will often do a repeat bone marrow biopsy. Purpose is to verify an empty "hypocellular" marrow, to verify the chemo was effective at suppressing the leukemia

Day 21-28

â—¾Usually expect to see recovery of normal bone marrow (e.g., ANC>500 and Plt>100k) with reduced transfusion requirements â—¾Once not neutropenic, can start peeling off all antibiotics â—¾May recheck bone marrow biopsy (or defer to clinic follow-up) after count recovery: If no leukemia present (<5% blasts) = disease remission. If leukemia still present = refractory disease, warranting re-induction with different chemo regimen â—¾Arrange outpatient follow-up either with patient's local hematologist or with admitting attending from Hematology service â—¾Make sure expensive discharge meds are approved well in advance (e.g., voriconazole, ATRA, Neupogen). Work with the Case Manager early to ensure these are in order early. The Case Manager matters more for approving discharge than the attending does.

Transfusions

• Keep patients Type & Screened every 3 days (can order standing this way) so will always be ready.
• In general Transfuse 2 units PRBC if Hgb<7 Transfuse 1 unit Platelets if Plt<10 Transfuse 1 unit (10 pooled) Cryoprecipitate if fibrinogen<100

neutropenic_fever.md

EMR A/P

= Neutropenic Fever =
Tmax ***, ANC ***, Last Chemotherapy ***, Expected Nadir***, prior Abx prophylaxis***, prior Neupogen/Neulasta ***
Systolic Heart Function ***
Localizing Sources: Mucositis, line infection, rectal lesions, vesicular lesions***
- Neupogen (filgrastim) 5mcg/kg SubQ daily (until ANC>500) (hold if leukemia with peripheral blasts)
- IVF bolus PRN (Goal CVP 8-12 / JVP 10-15, MAP>65, UOP>0.5mL/kg/hr)
- Neutropenic precautions
- Follow-up blood+urine cultures
- Discharge after confirm negative blood cultures, afebrile >24 hours, ANC>500

Antibiotics

• Cefepime 2g IV q8h
• Zosyn (pip/tazo) if suspect anaerobes
• Add metronidazole if suspect C. Diff
• Vancomycin *** (if mucositis, hypotension, line infection, prior fluoroquinolone prophylaxis, or apparent HCAPneumonia, cellulitis, etc.)
• Acyclovir *** (if vesicular lesions suggestive of HSV/VZV or mucositis and HSV+)
• Fluconazole *** (if oral or other lesions suggestive of candidiasis)

If persistent or recurrent fever >4 days without clear source, consider

• CT Thorax to assess for pulmonary nodules (likely Aspergillus mold)
• CT Sinuses?
• Serum galactomannan (may get false positive if already received Zosyn)
• Empiric anti-fungal (Voriconazole or Caspofungin)

nstemi.md

= NSTEMI / Unstable Angina (dynamic EKG changes with normal cardiac enzymes) =

• TIMI Risk Score (http://www.mdcalc.com/timi-risk-score-for-uanstemi/)

• Cardiology Consult / Interventional Assessment

• ASA 81mg PO daily (initial 162-324mg = 2-4x 81mg chewable tablets) (Consider higher dose >30 days if get BMStent, >3 months if get DEStent, otherwise CURE trial suggests 81mg should be adequate, while higher doses just increase bleeding)

• Clopidogrel 75mg PO daily (initial load 300mg if no cath, 600mg if cath planned) (Hold 5 days if surgery / CABG planned, suggested by diabetes, cardiogenic shock or VA patient since likely multi-vessel disease that will need surgery, probably should ask Cards fellow or attending first) (Continue >30 days if get BMStent, >1 year if DEStent or only planning medical management)

• Atorvastatin 80mg PO daily, check lipid panel (Start high-dose statin prior to discharge regardless as per MIRACL and PROV-IT)

• Consider Beta-blocker: Metoprolol 12.5mg PO bid (titrate to goal HR<70) (Hold if SBP<90 / cardiogenic shock) (Beware may actually worsen near-term mortality from shock, especially if use IV. Start prior to discharge)

• NTG + morphine PRN chest pain or NTG drip if ongoing chest pain (Hold if hypotensive / cardiogenic shock / inferior MI / sildenafil within past 24 hours)

• Anti-coagulation (Heparin drip per ACS protocol) (Enoxaparin if planning medical management only (no cath), slightly superior as per ESSENCE, more appropriate if Low Risk TIMI <=2, but ask Interventional first as they usually prefer reversible and monitorable heparin) (Continue until catheterization or at least 48hrs if only medical management)

(High Risk TIMI >=3) (Favor GP IIb/IIIa and early angiography)

• Consider GP IIb/IIIa inhibitor (e.g., eptifibatide) if ongoing chest pain, elevated troponin on presentation, heart failure, diabetes or otherwise planning early angiography (within 24-48hrs), but only helps if actually getting catheterization and per ACUITY and EARLY, same effect if wait until just prior to PCI, so usually defer to interventional cardiology (Continue until catheterization, then 6-12 hours)

Prior to Discharge (core measures)

• Assess LV Function (i.e., TTEcho)
• ACE-I / ARB if EF<40% (though GISSI-3 indicates can help regardless of EF)
• Eplerenone (or spironolactone) if new EF<40% (as per EPHESUS)
• Beta-blocker

pancreatitis.md

Lipase: *** EtOH: ***

• EtOH Cessation counseling as appropriate

• Check lipid panel to exclude hyper-triglyceridemia

• Consider further imaging (CT abdomen/pelvis w/ contrast) if persistent or unclear symptoms

• Check RUQ ultrasound to exclude gallstones -> Surgery Consult: Indication for Cholecystectomy before discharge Cholecystectomy for acute gallstone pancreatitis: early vs delayed approach. Scand J Surg, PMID: 20679042 IAP Guidelines for the Surgical Management of Acute Pancreatitis, Pancreatology, PMID: 12435871

• NPO advance from clears as tolerated

• IVF maintenance while NPO, bolus PRN until euvolemic

• Morphine IV/PO PRN pain

• Ondansetron or Metoclopramide PRN nausea/vomiting