CVP

8-12mmHg, mmH2O則>17, 有用ventilator既使非Bipap/CPAP,都會增加

不能只從CVP評估fluid，
Intravascular是否水足夠：CVP + Bun/Cre + 尿量（體重）

AF with RVR

老人怕血壓掉太快（尤其中風希望高），且常心較不好而不敢用CCB或BB,故用amiodarone(rhythm + rate control，故須af小於48hr, else　clot打出去．af>48hr沒出血問題包hemorrhagic transformation則先打heparin一陣子才rhythm control--amiodarone或cardioversion;CCB,BB & digoxin無rhythm control,只能rate control)
cardioversion必須要有CR在，才能執行！因有變cardiac arrest或把血栓打出去的問題
amiodarone原IV後PO,突然又須IV時，則重跑一次bolus→maintainance,沒過一天max dose就好，若仍HR>180,則滴amiodarone時又外加個digoxin(老人沒EF<40問題但怕BP掉和心不好而不想用CCB,BB時)
embolism如ischemic stroke若急診(本來)有Af,要用個2天coumadin才可try弄回正常心律(無如用電擊,beta blocker或其它),否則會把心房內的血栓打出去

Af要150以上才會有症狀(有害),否則只要有在滴amiodarone就好,不一定要再加藥到100以下

Amiodarone alone failed →
1. Cordarone 1# QD(not TID) + Digoxin 0.25mgIV Q8H * 3 then 0.125mg PO QD
2. Isoptin(40) 1# TID + Digoxin 0.25mgIV Q8H * 3 then 0.125mg PO QD

INSULIN

RI+NPH BID下：
早ri影嚮中午
早nph影嚮下午／晚上

晚nph影嚮早上

巳進CELL的GLUCOSE不會因藥效過而又再SHIFT出來

早上多打之ＲＩ多少Ｕ要記下來，
改成以後晚上ＮＰＨ的量

PHARMACODYNAMICS / KINETICS — Note: Rate of absorption, onset, and duration of activity may be affected by site of injection, exercise, presence of lipodystrophy, local blood supply, and/or temperature.
Excretion: Urine

RI:Onset 0.5 hours, Peak: 2.5-5 hours
Duration: 4-12 hours (may increase with dose)
Time to peak, plasma: 0.8-2 hours



NPH:Onset 1-2 hours, Peak: 4-12 hours
Duration: 18-24 hours
Time to peak, plasma: 6-12 hours

each increase not ot exceed 3-5U propotional to original dosage

Septic shock with ARF

Intubation: 平常要靠BiPAP, septic shock到用iatrogenic agent，不管ABG如何都可on endo

先charge volume,沒出來才考慮Lasix, albumin
若U/O>1cc/kg/hr, fluid challenge不必急著考慮albumin, FP(not FFP)，光charge volume + Lasix PRN即可

健保albumin之給付：
http://www.nhi.gov.tw/information/bulletin_file/1845_W0960000040-A03.DOC

Relative intravascular hypovolemia is typical and may be severe. As an example, early goal-directed therapy required a mean infusion volume of approximately five liters within the initial six hours of therapy in the trial described above [17]. As a result, rapid, large volume infusions of intravenous fluids are indicated as initial therapy for severe sepsis or septic shock, unless there is coexisting clinical or radiographic evidence of heart failure.
Fluid therapy should be administered in well-defined (eg, 500 mL), rapidly infused boluses [8,9]. Volume status, tissue perfusion, blood pressure, and the presence or absence of pulmonary edema must be assessed before and after each bolus. Intravenous fluid challenges can be repeated until blood pressure is acceptable, tissue perfusion is acceptable, pulmonary edema ensues, or fluid fails to augment perfusion.
Careful monitoring is essential in this approach because patients with sepsis typically develop noncardiogenic pulmonary edema (ie, ALI, ARDS). In patients with ALI or ARDS who are hemodynamically resuscitated, a liberal approach to intravenous fluid administration prolongs the duration of mechanical ventilation, compared to a more restrictive approach that typically requires large doses of furosemide [27]. Thus, while the early, aggressive fluid therapy is appropriate in severe sepsis and septic shock, fluids may be unhelpful or harmful when the circulation is no longer fluid-responsive. (See "Supportive care and oxygenation in acute respiratory distress syndrome", section on Fluid management).

shock後會有利尿期，這時的補多出多並不是身體覺得水夠，而是利尿所致，更要補水以免脫水（注意bun/cre, electrolyte）

gastric ulcer bleeding

free- strocain

cash - Nexium($45,but coffee ground with stroke free for 3 days)/Takepron($40,$80), Pantoloc($311), Ciketin(for old age, young age will cause impotence etc., $2/1# BID)

Plavix只有在aspirin GI bleeding 且primary care自行評估或GI評估不適合胃鏡後才能用

Stroke + Gastric OB only 亦可用Losec

J01398, UTI, suspect pneumonia?

152326, takepron vs nexium pantaloc?

phrase

discharge:
按時依照醫囑服藥.
定期門診追蹤治療.