HANDBOOK

of
INTERNAL MEDICINE

COC (Medicine)
Hospital Authority
7th Edition
2015

This handbook has been prepared by the COC (Medicine), Hospital

Authority and contains information and materials for reference only.
All information is compiled with every care that should have applied.
This handbook is intended as a general guide and reference only and not
as an authoritative statement of every conceivable step or circumstances
which may or could relate to the diagnosis and management of medical
diseases.
The information in this handbook provides on how certain problems
may be addressed is prepared generally without considering the specific
circumstances and background of each of the patient.
Users of this handbook should check the correct dosage and usage of
medications as appropriate to the context of individual patient,
including any allergic history.
The Hospital Authority and the compilers of this handbook shall not be
held responsible to users of this handbook on any consequential effects,
nor be liable for any loss or damage howsoever caused.

Disclaimer

DISCLAIMER

PREFACE TO 7th EDITION

In this 7th edition, various parts have been revised and in particular, we
have added a section on palliative medicine. Updates of major
guidelines have also been included. I would like to express my heartfelt
thanks to every member of the Editorial Board and all the specialists
who have participated in the review and revision of this new edition.
Without their contributions, this handbook would not have been
materialized. Finally, I have to thank the Coordinating Committee in
Internal Medicine in the support of the publication of this handbook.

Dr LAO Wai Cheung

Chairman
Quality Assurance Subcommittee

Preface

Internal medicine is a rapidly evolving specialty. Over the past 4 years,

there have been changes in some of the guidelines and recommendations
in the management of major medical diseases. This has prompted the
update of this pocket-sized Handbook of Internal Medicine. This
handbook is widely popular among our junior doctors. Many higher
physician trainees also find it useful in the preparation of the interim
assessment and exit examination of Advanced Internal Medicine. As in
the past, this handbook is intended to serve as a quick reference for
interns and clinicians working in the HA setting.

Editorial Board Members

Dr. CHAN Ngai Yin

Dr. LAI Moon Sing

Dr. LAO Wai Cheung
Dr. LEUNG Moon Ho
Dr. TSANG Owen
Dr. WONG Wing Yin Winnie
Dr. YEUNG Hon Ming Jonas

Co-ordinating Committee in Internal Medicine

Hospital Authority

Editorial Board
Members

Dr. CHOI Cheung Hei

CONTENTS
Cardiology

Endocrinology

Diabetic Ketoacidosis (DKA)

Diabetic Hyperosmolar Hyperglycaemic States
Peri-operative Management of Diabetes Mellitus
Insulin Therapy for DM Control
Hypoglycaemia
Thyroid Storm
Myxoedema Coma
Phaeochromocytoma
Addisonian Crisis
Acute Post-operative/Post-traumatic Diabetes Insipidus
Pituitary Apoplexy

Gastroenterology and Hepatology

Acute Liver Failure

Hepatic Encephalopathy
Ascites
Orthotopic Liver Transplantation
Variceal Haemorrhage
Upper Gastrointestinal Bleeding
Peptic Ulcers

C
C
C
C
C
C
C
C
C
C
C

E
E
E
E
E
E
E
E
E
E
E
G
G
G
G
G
G
G

1-3
4-12
13-15
16-24
25
26-28
29-30
31-32
33-34
35
36-42

1-2

3
4-5

6-7
8
9
10
10
11-13
14
15

1-4
5-6
7
8-9
10-11
12-13
14-15

Contents

Cardiopulmonary Resuscitation (CPR)

Arrhythmias
Unstable Angina / Non ST Elevation MI
Acute ST Elevation Myocardial Infarction
Acute Pulmonary Oedema
Hypertensive Crisis
Aortic Dissection
Pulmonary Embolism
Cardiac Tamponade
Antibiotics Prophylaxis for Infective Endocarditis
Perioperative Cardiovascular Evaluation for Noncardiac
Surgery

Management of Gastro-oesophageal Reflux Disease

Inflammatory Bowel Diseases
Crohns Disease
Ulcerative Colitis
Acute Pancreatitis

G
G
G
G
G

16-17
18-20
21-23
24-26
27-30

H
H
H
H
H
H
H

1-2
2-3
3-4
4-5
5-6
6
6

H
H
H
H
H
H

7-8
9-10
11
11
12
12

H
H
H
H
H
H
H

13
13
13-14
14
14-15
15
16-17

Contents

Haematology

Haematological Malignancies
Leukaemia
Lymphoma
Multiple Myeloma
Extravasation of Cytotoxic Drugs
Intrathecal Chemotherapy
Performance Status
Haematologital Toxicity
Non-Malignant Haematological Emergencies/Conditions
Acute Haemolytic Disorders
ImmuneThrombocytopenic Purpura (ITP)
Thrombotic Thrombocytopenic Purpura (TTP)
Pancytopenia
Thrombophilia Screening
Prophylaxis of Venous Thrombosis in Pregnancy
Special Drug Formulary and Blood Products
Anti-emetic Therapy
Haemopoietic Growth Factors
Immunoglobulin Therapy
Anti-thymocyte Globulin (ATG)
rFVIIa (Novoseven)
Novel Oral Anticoagulants (NOACs)
Replacement for Hereditary Coagulation Disorders
Transfusion
Acute Transfusion Reactions
Transfusion Therapy
Actions after Transfusion Incident & Adverse Reactions

H 18-19
H 20-21
H 22

Nephrology

Renal Transplant Donor Recruitment

Electrolyte Disorders
Systematic Approach to the Analysis of Acid-Base Disorders
Peri-operative Management of Uraemic Patients
Renal Failure
Emergencies in Renal Transplant Patient
Drug Dosage Adjustment in Renal Failure
Protocol for Treatment of CAPD Peritonitis
Protocol for Treatment of CAPD Exit Site Infection

Neurology

Respiratory Medicine

Massive Haemoptysis
Spontaneous Pneumothorax
Pleural Effusion
Oxygen Therapy
Adult Acute Asthma
Long Term Management of Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Obstructive Sleep Apnoea
Pre-operative Evaluation of Pulmonary Functions
Mechanical Ventilation
Noninvasive Ventilation (NIV)

1-2
3-13
14-17
18
19-20
21
22-23
24-27
28-29

N
N
N
N
N
N
N
N
N
N
N

1-3
4-5
6-9
10-11
12-14
15-16
17-18
19
20
21-22
23-24

P
P
P
P
P
P
P
P
P
P
P

1-2
3-4
5-6
7-9
10-12
13-16
17-20
21
22-23
24-26
27-28

Contents

Coma
Delirium
Acute Stroke
Subarachnoid Haemorrhage
Tonic-Clonic Status Epilepticus
Guillain-Barre Syndrome
Myasthenia Crisis
Acute Spinal Cord Syndrome
Delirium Tremens
Wernickes Encephalopathy
Peri-operative Management of Patients with Neurological
Diseases

K
K
K
K
K
K
K
K
K

Rheumatology & Immunology

Approach to Inflammatory Arthritis

Gouty Arthritis
Septic Arthritis
Rheumatoid Arthritis
Ankylosing Spondylitis
Psoriatic Arthritis
Systemic Lupus Erythematosus
Rheumatological Emergencies
Non-steroidal Anti-inflammatory Drugs

Contents

Infections

Community-Acquired Pneumonia
Hospital Acquired Pneumonia
Pulmonary Tuberculosis
CNS Infection
Urinary Tract Infections
Enteric Infections
Acute Cholangits
Spontaneous Bacterial Peritonitis
Necrotizing Fasciitis
Skin & Soft Tissue Infection
Septic Shock
Antibiotics for Febrile Neutropenic Patients
Malaria
Chickenpox / Herpes Zoster
HIV / AIDS
Rickettsial Infection
Influenza
Infection Control
Needlestick Injury/Mucosal Contact to HIV, HBV or HCV
Middle East Respiratory Syndrome
Viral Haemorrhagic Fever

R
R
R
R
R
R
R
R
R

1-2
3-4
5-6
7-10
11-12
13-14
15-21
22-24
25-26

In
In
In
In
In
In
In
In
In
In
In
In
In
In
In
In
In
In
In
In
In

1-2
3-4
5-6
7-8
9
10-12
13
14
15
16
17
18-19
20-21
22
23-30
31
32-33
34-36
37-40
41-42
43-44

Palliative Medicine

Anorexia
Nausea and Vomiting
Cancer Pain Management
Guidelines on the Use of Morphine for Chronic Cancer Pain
Dyspnoea
Delirium
Malignant Bowel Obstruction
Palliative Care Emergencies: Massive Haemorrhage
Malignant Hypercalcaemia
Metastatic Spinal Cord Compression
Last Days of Life
Anaphylaxis
Acute Poisoning
General Measures
Specific Drug Poisoning
Non-pharmaceutical Poisoning
Smoke Inhalation
Snake Bite
Accidental Hypothermia
Heat Stroke / Exhaustion
Near Drowning / Electrical Injury
Rhabdomyolysis
Superior Vena Cava Syndrome
Malignancy-related SVCO
Neoplastic Spinal Cord / Cauda Equina Compression
Hypercalcaemia of Malignancy
Tumour Lysis Syndrome
Extravasation of Chemotherapeutic Agents
Brain Death

Procedures

Endotracheal Intubation
Setting CVP Line
Defibrillation
Temporary Pacing
Lumbar Puncture

1-2
3
4
5-6
7-8
9-10
11-12
13
14
15
16

GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM

1
2
2-3
4-9
10-14
15
16-17
18
19-20
21
22
23
24-25
26
27
28
29
30-32

Pr
Pr
Pr
Pr
Pr

1-2
3
4
5
6-7

Contents

General Internal Medicine

PM
PM
PM
PM
PM
PM
PM
PM
PM
PM
PM

Bone Marrow Aspiration and Trephine Biopsy

Care of Hickman Catheter
Renal Biopsy
Intermittent Peritoneal Dialysis
Percutaneous Liver Biopsy
Abdominal Paracentesis
Pleural Aspiration
Pleural Biopsy
Chest Drain Insertion

Contents

Acknowledgement

Pr
Pr
Pr
Pr
Pr
Pr
Pr
Pr
Pr

8-9
10-11
12
13-14
15-16
17
18-19
20-21
22-23

Cardiology
Cardiology

C 1

CARDIOPULMONARY RESUSCITATION (CPR)

1. Determine unresponsiveness
2. Call for Help, Call for Defibrillator
3. Wear PPE: N95/ surgical mask, gown, +/-(gloves, goggles, face
shield for high risk patients)
Primary CDAB Survey (Initiate chest compression before ventilation;
Ref: Field JM et al. Circulation 2010;122[Suppl 3]:S640-656)
C: Circulation Assessment

Check carotid pulse for 5-10 s & assess other signs of

circulation (breathing, coughing, or movement)

Chest compressions 100/min

CPR 30 compressions (depth 2 inches) to 2 breaths

A: Assess the Airway

Clear airway obstruction/secretions

Head tilt-chin lift or jaw-thrust

Insert oropharyngeal airway

B: Assess/Manage Breathing

Ambubag + bacterial/viral filter + 100% O2 at 15L/min

Plastic sheeting between mask and bag

Seal face with mask tightly

Give 2 rescue breaths, each lasting 2-4 s

Cardiology

D: Defibrillate VF or VT as soon as identified

Check pulse and leads

Check all clear

Deliver 360J for monophasic defibrillator, without lifting

paddles successively if no response; or equivalent 200J for
biphasic defibrillator, if defibrillation waveform is unknown

C2
Secondary ABCD Survey
A: Place airway devices; intubation if skilled.
If not experienced in intubation, continue Ambubag and call for
help
B: Confirm & secure airway; maintain ventilation.
Primary confirmation: 5-point auscultation.
Secondary confirmation: End-tidal CO2 detectors,
oesophageal detector devices.
C: Intravenous access; use monitor to identify rhythm.
D: Differential Diagnosis.

Cardiology

Common drugs used in resuscitation

Adrenaline
Vasopressin
Lignocaine
Amiodarone

Atropine
CaCl2
NaHCO3
MgSO4

1 mg (10 ml of 1:10,000 solution) q3-5 min iv

40 international units ivi push
1 mg/kg iv bolus, then 1-4 mg/min infusion
In cardiac arrest due to pulseless VT or VF, 300 mg in
20 ml NS / D5 rapid infusion, further doses of 150 mg
over 10 mins if required, followed by 1 mg/min
infusion for 6 hrs & then 0.5 mg/min, to maximum
total daily dose of 2.2 g
1 mg iv push, repeat q3-5min to max dose of
0.04mg/kg
5-10 ml 10% solution iv slow push for hyperkalaemia
and calcium channel blocker overdose
1 mEq/kg initially (e.g. 50 ml 8.4% solution) in
patients with hyperkalaemia
1-2g in 10ml D5 iv bolus in torsade de pointes

C 3
Tracheal administration of Resuscitation Medications
(if iv line cannot be promptly established):
-

Lignocaine, Epinephrine (adrenaline), Atropine, Narcan (L-E-A-N)

Double dosage
Dilute in 10 ml NS or water
Put catheter beyond tip of ET tube
Inject drug solution quickly down ET tube, followed by several
quick insufflations
Withhold chest compression shortly during these insufflations

Post-resuscitation care:
Correct hypoxia with 100% oxygen
Prevent hypercapnia by mechanical ventilation
Consider maintenance antiarrhythmic drugs
Treat hypotension with volume expander or vasopressor
Treat seizure with anticonvulsant (diazepam or phenytoin)
Maintain blood glucose within normal range
Routine administration of NaHCO3 not necessary

Cardiology

C4

ARRHYTHMIAS
(I)

Ventricular Fibrillation or
Pulseless Ventricular Tachycardia
Primary CDAB Survey
Rapid Defibrillation
DC Shock 360 J (monophasic defibrillation)
or 200J (biphasic shock) if waveform is unknown,
then check pulse

Cardiology

Secondary ABCD Survey

Adrenaline 1 mg iv (10 ml of 1:10,000 solution)
Repeat every 3-5 min
OR
Vasopressin 40 international units IV, single dose, 1 time only
DC Shock 360 J or equivalent biphasic within 30-60s
and check pulse
Consider antiarrhythmics
- Amiodarone 300 mg iv push, can consider a second dose of 150 mg
iv (maximum total dose 2.2 g over 24 hr)
- Lignocaine 1-1.5 mg/kg iv push, can repeat in 3-5 minutes
(maximum total dose 3 mg/kg)
- Procainamide 30 mg/min (maximum total dose 17 mg/kg)

C 5
(II)

Pulseless Electrical Activity

(Electromechanical Dissociation)
Primary CDAB and Secondary ABCD
Consider causes (6Hs and 6Ts) and give specific treatment
Hypovolaemia
Hypoxia
Hydrogen ion (acidosis)
Hyper / hypokalemia
Hypothermia
Hyper/hypoglycaemia

Tablets (drug overdose, accidents)

Tamponade, cardiac
Tension pneumothorax
Thrombosis, coronary (ACS)
Thrombosis, pulmonary (Embolism)
Trauma

Most common causes of PEA

Cardiology

Adrenaline 1 mg iv (10 ml of 1:10,000 solution)

Repeat every 3-5 min

C6
(III)

Asystole

Primary CDAB and Secondary ABCD

Consider causes*
Transcutaneous pacing
If considered, perform immediately
NOT for routine use

Cardiology

Adrenaline 1 mg iv (10 ml of 1:10,000 solution)

Repeat every 3-5 min
Consider to stop CPR for arrest victims who, despite successful
deployment of advanced interventions, continue in asystole for more
than 10 minutes with no potential reversible cause
* Consider causes: hypoxia, hyperkalemia, hypokalemia, acidosis,
drug overdose, hypothermia

C 7
(IV)

Tachycardia
- Assess ABCs & vital signs

- Review Hx and perform P/E

- Secure airway and iv line
- Perform 12-lead ECG
- Administer oxygen
- Portable CXR
- Attach BP, rhythm & O2 Monitors

Unstable?
(chest pain, SOB, decreased conscious state, low BP, shock,
pulmonary congestion, congestive heart failure, acute MI)
Yes

Atrial fibrillation
Atrial flutter

Regular Narrow
Complex Tachycardia

No or
Borderline

Regular Wide
Complex Tachycardia

For immediate cardioversion

Consider sedation
Note possible need to resynchronize after each
cardioversion
If delays in synchronization, go immediately to
unsynchronized shocks

Cardiology

Immediate Synchronized
DC cardioversion 100J/200J/300J/360J
(except sinus tachycardia)

C8

Atrial fibrillation / Atrial flutter

1.

Correct underlying causes

2.

Control of ventricular rate

- hypoxia, electrolyte disorders, sepsis, thyrotoxicosis etc

0.25mg/kg iv bolus over 2 min, then 5-15mg/hr;

oral maintenance 120-360mg daily (ER)
Verapamil* 0.075-0.15mg/kg iv bolus over 2 min, may give
additional 10mg after 30 min if no response, then
0.005mg/kg/min infusion
Risk of hypotension, check BP before 2nd dose
Oral maintenance 180-480mg daily (ER)
Metoprolol* 2.5-5mg iv bolus over 2 min; up to 3 doses; oral
maintenance 25-100mg BD
Amiodarone 300mg iv over 1 hr, then 10-50mg/hr over 24 hr;
oral maintenance 100-200mg daily
Digoxin
0.25mg iv with repeat dosing to a maximum of
1.5mg over 24 hr; oral maintenance 0.125-0.25mg
daily

Cardiology

Diltiazem*

* Contraindicated in WPW Syndrome

- In AF complicating acute illness e.g. thyrotoxicosis, -blockers
and verapamil may be more effective than digoxin
- For impaired cardiac function (EF < 40%, CHF), use digoxin
or amiodarone
3.

Anticoagulation
Prompt anticoagulation can be achieved with unfractionated heparin
with maintenance of aPTT 1.5-2 times control or low molecular
weight heparin. Long-term anticoagulation can be achieved with
warfarin with maintenance of PT 2-3 times control (depends on
general condition and compliance of patient and underlying heart disease)

C 9
or Novel oral anticoagulant like Dabigatran, Rivaroxaban or
Apixaban.
4.

5.

Synchronized DC cardioversion
- Atrial fibrillation 100-200J and up
- Atrial flutter 50-100J and up

Prevention of Recurrence
Class Ia, Ic, sotalol, amiodarone or dronedarone

Cardiology

Termination of Arrhythmia
For persistent AF (> 2 days), anticoagulate for 3 weeks before
conversion and
continue for 4 weeks after (delayed cardioversion approach)
Pharmacological conversion:
Amiodarone 150mg over 10min then 1mg/min for 6 hr then
0.5mg/min for 18 hr or orally 600-800mg daily in
divided doses up to 10g, then 200mg daily as
maintenance dose
Flecainide
200-300mg orally, preferably give betablocker or
nondihydropyridine calcium channel antagonist
30 minutes beforehand
Propafenone 450-600mg orally, preferably give betablocker or
nondihydropyridine calcium channel antagonist
30 minutes beforehand
Procainamide 15 mg/kg iv loading at 20 mg/min (max 1 g), then
2-6 mg/min iv maintenance,
or 250 mg po q4h

C 10
Stable Regular Narrow Complex Tachycardia
Vagal Manoeuvres *
ATP 10 mg rapid iv push

1-2 mins

ATP 20 mg rapid iv push

(may repeat once in 1-2 mins)
Blood pressure

Cardiology

Normal or
Elevated

Verapamil 2.5-5 mg iv
15-30 mins
Verapamil 5-10 mg iv
Consider
- digoxin
- -blocker
- diltiazem
- amiodarone

Low

Synchronized DC
Cardioversion
- start with 50 J
- Increase by 50-100 J increments

* Carotid sinus pressure is C/I in patients with carotid bruits.

Avoid ice water immersion in patients with IHD.
# contraindicated in asthma & warn patient of transient flushing and
chest discomfort

C 11

Stable Wide Complex Tachycardia

Attempt to establish a specific diagnosis

Confirmed SVT

Confirmed VT

Unknown type
ATP 10 mg rapid iv push

1-2 mins
ATP 20 mg rapid iv push
Preserved
cardiac function

EF < 40%,
CHF

Amiodarone
or lignocaine
or
Sotalol or
Procainamide

EF < 40%,
CHF

Amiodarone
or
lignocaine,
then
cardioversion

Amiodarone
then
cardioversion

Dosing:
- Amiodarone 150 mg IV over 10 mins, repeat 150 mg IV over 10
mins if needed. Then infuse 600-1200 mg/d. (Max 2.2 g in 24 hours)
- Procainamide infusion 20-30 mg/min till max. total 17 mg/kg or
hypotension
- Lignocaine 0.5-0.75 mg/kg IV push and repeat every 5 to 10 mins,
then infuse 1 to 4 mg/min (Max. total dose 3 mg/kg)
# contraindicated in asthma & warn patient of transient flushing and
chest discomfort

Cardiology

Amiodarone
or
Sotalol
or
Procainamide

Preserved
cardiac function

C 12
Bradycardia

(V)

- Assess ABCs & vital signs

- Secure airway and iv line
- Administer oxygen
- Attach BP, rhythm & O2 Monitors

- Review Hx and perform P/E

- Perform 12-lead ECG
- Portable CXR
- Watch out for hyperkalaemia

Unstable?
(chest pain, SOB, decreased conscious state, low BP, shock,
pulmonary congestion, congestive heart failure, acute MI)

Cardiology

No
Type II 2nd degree AV block?
Third degree AV block?
No

Observe

Yes
Intervention sequence:
- Atropine 0.5-1 mg *
- Transcutaneous pacing (TCP) #
- Dopamine 5-20 micrograms/kg/min
- Adrenaline 2-10 micrograms/min

Yes

Pacing
(bridge over with TCP)

* - Do not delay TCP while awaiting iv access to give atropine

- Atropine in repeat doses in 3-5 min (shorter in severe condition) up to a
max of 3 mg or 0.04 mg/kg. Caution in AV block at or below
His-Purkinje level (acute MI with third degree heart block and wide
complex QRS; and for Mobitz type II heart block)
Never treat third degree heart block plus ventricular escape with
lignocaine
#
Verify patient tolerance and mechanical capture. Analgesia and sedation
prn.

C 13

UNSTABLE ANGINA / NON-ST ELEVATION

MYOCARDIAL INFARCTION

Specific drug treatment:

Antithrombotic Therapy
a. Aspirin 162-325mg loading, then 81-325mg daily
b. Clopidogrel 300-600mg stat, then 75mg daily OR
Ticagrelor 180mg stat, then 90mg BD OR
Prasugrel 60mg stat, then 10mg daily
c. Low-Molecular-Weight-Heparin e.g
Enoxaparin (Clexane) 1 mg/kg sc q12h.
Nadroparin (Fraxiparine) sc 0.4 ml bd if <50 kgf BW,
0.5 ml bd if 50-59 kgf BW, 0.6 ml bd if >60 kgf BW.

Cardiology

Aims of Treatment: Relieve symptoms, monitor for complications,

improve long-term prognosis
Mx
1. Admit CCU for high risk cases*.
2. Bed rest with continuous ECG monitoring
3. ECG stat and repeat at least daily for 3 days (more frequently in
severe cases to look for evolution to MI).
4. Cardiac enzymes daily for 3 days. Troponin stat (can repeat 6-12
hours later if 1st Troponin is normal)
5. CXR, CBP, R/LFT, lipid profile (within 24 hours), aPTT, INR as
baseline for heparin Rx.
6. Allay anxiety - Explain nature of disease to patient.
7. Morphine IV when symptoms are not immediately relieved by
nitrate e.g. Morphine 2-5 mg iv (monitor BP).
8. Correct any precipitating factors (anaemia, hypoxia,
tachyarrhythmia).
9. Stool softener & supplemental oxygen for respiratory distress.
10. Consult cardiologist to consider GP IIb/IIIa antagonist, IABP,
urgent coronary angiogram/revascularisation if refractory to
medical therapy

C 14

Cardiology

Dalteparin (Fragmin) 120 international units /kg (max 10000

international units) sc q12h.
Anti-Ischemic Therapy
a. Nitrates
reduces preload by venous or capacitance vessel dilatation.
Contraindicated if sildenafil taken in preceding 24 hours.
Sublingual TNG 1 tab/puff Q5min for 3 doses for patients with
ongoing ischemic discomfort
IV TNG indicated in the first 48 h for persistent ischemia, heart
failure, or hypertension
NitroPhol 0.5-1mg/hr (max 8-10 mg/min)
Isosorbide dinitrate (Isoket) 2-10 mg/hr
- Begin with lowest dose, step up till pain is relieved
- Watch BP/P; keep SBP > 100 mmHg
Isosorbide dinitrate - Isordil 10-30 mg tds
Isosorbide mononitrate - Elantan 20-40 mg bd or
Imdur 60-120 mg daily
b. -blockers (if not contraindicated)
reduce HR and BP (titrate to HR<60)
Metoprolol (Betaloc) 25-100 mg bd
Atenolol (Tenormin) 50-100 mg daily
c. Calcium Antagonists (when -blocker is contraindicated in the
absence of clinically significant LV dysfunction)
Diltiazem (Herbesser) 30-60 mg tds
Verapamil 40-120 mg tds
Other Therapies
a. Hydroxymethyl glutaryl-coenzyme A reductase inhibitor (statin)
Should be given regardless of baseline LDL-C level in the
absence of contraindications.
b. Angiotensin- converting enzyme inhibitor (ACEI)
Should be administered within the first 24 hours in the absence of
hypotension or contraindications.

C 15
Angiotensin receptor blocker should be used if patient is
intolerant of ACEI

*High risk features (Consider Early PCI)

Ongoing or recurrent rest pain

Hypotension & APO
Ventricular arrhythmia
ST segment changes 0.1 mV; new bundle branch block
Elevated Troponin > 0.1 mg/mL
High Risk Score (TIMI, GRACE)

Cardiology

(Reference: OGara PT et al. 2013 ACCF/AHA guideline for the

management of ST-elevation myocardial infarction. JACC
2013;61(4):e78-140)

C 16

ACUTE ST ELEVATION
MYOCARDIAL INFARCTION
Ix - Serial ECG for 3 days
Repeat more frequently if only subtle change on 1st ECG; or
when patient complains of chest pain

Cardiology

Area of Infarct
inferior
lateral
anteroseptal
anterolateral
anterior
right ventricular

Leads with ECG changes

II, III, aVF
I, aVL, V6
V1, V2, V3
V4, V5, V6
V1 - V 6
V3R, V4R

Serial cardiac injury markers* for 3 days

CXR, CBP, R/LFT, lipid profile (within 24 hours)
aPTT, INR as baseline for thrombolytic Rx

General Mx
- Arrange CCU bed
- Close monitoring: BP/P, I/O q1h, cardiac monitor
- Complete bed rest (for 12-24 hours if uncomplicated)
- O2 by nasal prongs if hypoxic or in cardiac failure; routine O2 in
the first 6 hours
- Allay anxiety by explanation/sedation (e.g. diazepam 2-5 mg po
tds)
- Stool softener
- Adequate analegics prn e.g. morphine 2-5 mg iv (monitor BP &
RR)
* CK-MB; troponin; myoglobin (depending on availability)

C 17
Specific Rx Protocol
Prolonged ischaemic-type chest discomfort
Aspirin 162-325mg loading, 81-325mg daily
ECG

ST elevation1 or new LBBB

ST depression +/- T inversion

-blocker (if not contraindicated)2

Refer to NSTEMI
+ P2Y12 inhibitors**
+ Anticoagulation with LMWH*** or UFH
12 Hr

12 Hr

Not eligible for

Fibrinolytic

Fibrinolytic 3
(Consider direct
PCI as alternative)

Consider Cath then

PCI or CABG

Not for4
reperfusion Rx

Persistent
Symptoms
No

Other medical therapy

(ACE-I5 +statin Nitrate6)

Consider pharmacological
or catheter-based reperfusion

Persistent / recurrent ischaemia or haemodynamic instability

or recurrent symptomatic arrhythmia
Yes

Consider IABP, angiography

+/- PCI

Yes

No

Continue medical Rx

Cardiology

Eligible for
Fibrinolytic

C 18
1

At least 1mm in 2 or more contiguous leads

e.g. Metoprolol 25 mg bd orally.
Alternatively, metoprolol 5 mg iv slowly stat for 3 doses at 5 min
intervals (Observe BP/P after each bolus, discontinue if pulse <
60/min or systolic BP < 100 mmHg).
3
See Fibrinolytic therapy
4
Not for reperfusion Rx if e.g. too old, poor premorbid state
5
Starting within the first 24 hrs, esp. for anterior infarction or clinical
heart failure. Thereafter, prescribe for those with clinical heart failure
or EF < 40%, (starting doses of ACEI: e.g. acertil
1 mg daily; ramipril 1.25 mg daily; lisinopril 2.5 mg daily)
6
Prescribe if persistent chest pain / heart failure / hypertension
e.g. iv isosorbide dinitrate (Nitropohl/Isoket) 2-10 mg/h. (Titrate
dosage until pain is relieved; monitor BP/P, watch out for
hypotension, bradycardia or excessive tachycardia).
C/I if sildenafil taken in past 24 hours
** For primary PCI, give clopidogrel loading 600mg, 75mg daily
maintenance OR Prasugrel loading 60mg, 10mg daily maintenance
OR Ticagrelor loading 180mg, 90mg BD maintenance
For fibrinolytic therapy, give clopidogrel loading 300mg, 75mg
daily maintenance for age 75; and no loading dose for age>75
*** For age <75, Enoxaparin 30mg iv bolus, followed in 15 min by
1mg/kg sc Q12H; for age 75, no loading dose, 0.75mg/kg sc
Q12H; give up to 8 days or until revascularization

Cardiology

Detection and Treatment of Complications

a. Arrhythmia
Symptomatic sinus bradycardia
- atropine 0.3-0.6 mg iv bolus
- pacing if unresponsive to atropine
AV Block :
1st degree and Mobitz type I 2nd degree: Conservative
Mobitz Type II 2nd degree or 3rd degree: Pacing
(inferior MI, if narrow-QRS escape rhythm &
adequate rate, conservative Rx under careful monitoring

C 19

b.

Pump Failure
RV Dysfunction
Set Swan-Ganz catheter to monitor PCWP. If low or normal,
volume expansion with colloids or crystalloids

Cardiology

is an alternative)
(Other indications for temporary pacing:

Bifascicular block + 1st degree AV block

Alternating BBB or RBBB + alternating LAFB/LPFB)

Tachyarrhythmia
(Always consider cardioversion first if severe haemodynamic
compromise or intractable ischaemia)
PSVT
ATP 10-20 mg iv bolus
Verapamil 5-15 mg iv slowly (C/I if BP low or on
beta-blocker), beware of post-conversion angina
Atrial flutter/fibrillation
Digoxin 0.25 mg iv/po stat, then 0.25 mg po q8H for 2 more
doses as loading, maintenance 0.0625-0.25 mg daily
Diltiazem 10-15 mg iv over 5-10 mins, then 5-15 g/kg/min
Amiodarone 5 mg/kg iv infusion over 60 mins as loading,
maintenance 600-900 mg infusion/24 h
Wide Complex Tachycardia (VT or aberrant conduction)
Treat as VT until proven otherwise
Stable sustained monomorphic VT :
Amiodarone 150 mg infused over 10 minutes, repeat 150 mg iv
over 10 mins if needed, then 600-1200 mg infusion over 24h
Lignocaine 50-100 mg iv bolus, then 1-4 mg/min infusion
Procainamide 20-30 mg/min loading, then 1-4 mg/min infusion
up to 12-17 mg/kg
Synchronized cardioversion starting with 100 J
Sustained polymorphic VT :
Unsynchronized cardioversion starting with 200 J

Cardiology

C 20
LV Dysfunction
Vasodilators (esp. ACEI) if BP OK (+/- PCWP monitoring)
Inotropic agents
- Preferably via a central vein
- Titrate dose against BP/P & clinical state every 15 mins
initially, then hourly if stable
- Start with dopamine 2.5 microgram/kg/min if SBP 90 mmHg,
increase by increments of 0.5 microgram/kg/min
- Consider dobutamine 5-15 microgram/kg/min when high dose
dopamine needed
IABP, with a view for catheterization revascularization
c. Mechanical Complications
- VSD, mitral regurgitation
- Mx depends on clinical and haemodynamic status
Observe if stable (repair later)
Emergency cardiac catheterization and repair if unstable
(IABP for interim support)
d. Pericarditis
High dose aspirin
NSAID e.g. indomethacin 25-50 mg tds for 1-2 days
Others: colchicines, acetaminophen
After Care (For uncomplicated MI)
- Advise on risk factor modification and treatment
(Smoking, HT, DM, hyperlipidaemia, exercise)
- Stress test (Pre-discharge or symptom limited stress 2-3 wks post MI)
- Angiogram if + ve stress test or post-infarct angina or other
high-risk clinical features
- Drugs for Secondary Prevention of MI
-blocker : Metoprolol 25-100 mg bd
Aspirin : 81-325 mg daily

C 21
ACEI (esp for large anterior MI, recurrent MI, impaired LV systolic

function or CHF) :
e.g. Lisinopril 5-20 mg daily; Ramipril 2.5-10 mg daily;
Acertil 2-8 mg daily
Angiotensin receptor blocker should be used in patients intolerant
of ACEI and have heart failure or LVEF<40% or hypertension
Aldosterone blocker should be used in patients without significant
renal dysfunction or hyperkalaemia and who are already on
therapeutic doses of ACEI and beta-blocker, with LVEF<40% +
diabetes or heart failure
Statin should be used in all patients

Cardiology

Cardiology

C 22
Fibrinolytic Therapy
Contraindications
Absolute: - Previous haemorrhagic stroke at any time, other
strokes or CVA within 3 months; except acute ischaemic
stroke within 4.5 hours
- Known malignant intracranial neoplasm (primary or
metastatic)
- Known structural cerebrovascular lesion (e.g. AV
malformation)
- Active bleeding or bleeding diathesis (does not include
menses)
- Suspected aortic dissection
- Significant closed head or facial trauma within 3 months
- Intracranial or intraspinal surgery within 2 months
- Severe uncontrolled hypertension (unresponsive to
emergency therapy)
- For Streptokinase, prior treatment within previous 6
months
Relative: - Severe uncontrolled hypertension on presentation (blood
pressure > 180/110 mm Hg)
- History of chronic, severe, poorly controlled hypertension
- History of prior ischaemic stroke > 3 months or known
intracerebral pathology not covered in absolute
contraindications
- Traumatic or prolonged (>10min) CPR
- Oral anticoagulant therapy
- Major surgery < 3 weeks
- Noncompressible vascular punctures
- Recent (within 2-4 wks) internal bleeding
- Pregnancy
- Active peptic ulcer

Could be an absolute contraindication in low-risk patients with

myocardial infarction.

C 23
Choice of fibrinolytic therapy
TNK-tPA iv bolus, 30mg (<60 kg), 35mg (60-69 kg), 40mg (70-79
kg), 45mg (80-89 kg), 50mg (90 kg)
tPA15 mg iv bolus, then 0.75 mg/kg (max 50 mg) in 30 mins,
then 0.5 mg/kg (max 35 mg) over 1 hr
Streptokinase 1.5 million units iv over 30-60 minutes

Cardiology

C 24
Monitoring
- Use iv catheter with obturator in contralateral arm for blood taking
- Pre-Rx: Full-lead ECG, INR, aPTT, cardiac enzymes
- Repeat ECG 1. when new rhythm detected and
2. when pain subsided
- Monitor BP closely and watch out for bleeding
- Avoid percutaneous puncture and IMI
- If hypotension develops during infusion
withhold infusion
check for cause (treatment-related* vs cardiogenic)
* fluid replacement; resume infusion at rate

Cardiology

Signs of Reperfusion
-

chest pain subsides

early CPK peak
accelerated nodal or idioventricular rhythm
resolution of ST elevation of at least 50% in the worst ECG lead at
60-90 minutes after fibrinolytic

(Reference: Amsterdam EA et al. 2014 AHA/ACC guideline for the

management of patients with non-ST-elevation acute coronary
syndromes. JACC 2014;64(24):e139-228)

C 25

ACUTE PULMONARY OEDEMA

Acute Management :

General measures
1. Complete bed rest, prop up
2. Oxygen (may require high flow
rate / concentration)
3. Low salt diet + fluid restriction
(NPO if very ill)

Identify and treat

precipitating cause
e.g. arrhythmia, IHD,
uncontrolled HT, chest
infection

BP Stable ?
Yes

No
BP
stabilized

Medications (others)
Inotropic agents
- Dopamine
2.5-10 g/kg/min

- Dobutamine
2.5-15 g/kg/min

Unsatisfactory
response
Monitor BP/P, I/O, SaO2,
CVP, RR clinical status
every 30-60 mins

Consider ventilatory support in case of

desaturation, patient exhaustion,
cardiogenic shock
1. Intubation and mechanical ventilation
2. Non-invasive: BIPAP/CPAP

BP not stabilized
or APO refractory
to Rx

Consider:
1. Intra-aortic balloon pump
(IABP)
2. PCI for ischaemic cause
of CHF
3. Intervention for significant
valvular lesion

Cardiology

Medications (commonly considered)

1. Frusemide(Lasix) 40-120 mg iv
2. IV nitrate e.g. nitropohl 1-8 mg/hr
3. Morphine 2-5 mg slow iv

C 26

HYPERTENSIVE CRISIS

Cardiology

Malignant BP 220/120 mmHg + Grade III/IV fundal changes

Emergency Malignant or severe HT + ICH, dissecting aneurysm,
APO, encephalopathy, phaeochromocytoma crisis,
eclampsia (end organ damage due to HT versus risk of
organ hypoperfusion due to rapid BP drop.
Need Immediate reduction of BP to target levels (initial
phase drop in BP by 20-25% of baseline).
Urgency
- Malignant HT without acute target organ damage
- HT associated with bleeding (post-surgery, severe
epistaxis, retinal haemorrhage, CVA etc.)
- Severe HT + pregnancy / AMI / unstable angina
- Catecholamine excess or sympathomimetic overdose
(rebound after withdrawal of clonidine / methyldopa;
LSD, cocaine overdose; interactions with MAOI)
BP reduction within 12-24 hours to target levels

Mx
1.
2.
3.
4.
5.
6.

Always recheck BP yourself at least twice

Look for target organ damage (neurological, cardiac)
Complete bed rest, low salt diet (NPO in HT emergency)
BP/P q1h or more frequently, monitor I/O (Close monitoring
in CCU/ICU with intra-arterial line in HT emergency)
Check CBP, R/LFT, cardiac enzymes, aPTT/PT, CXR, ECG,
urine x RBC and albumin
Aim: Controlled reduction (Rapid drop may ppt CVA / MI)
Target BP (mmHg)
Chronic HT, elderly, acute CVA
170-180 / 100
Previously normotensive, post
cardiac/vascular surgery
140 / 80
Acute aortic dissection
100-120 SBP

C 27
7.

Hypertensive urgency
- Use oral route, BP/P q15 mins for 60 mins
- Patients already on antiHT, reinstitute previous Rx
- No previous Px or failure of control despite reinstituting Rx for
4-6 hrs:
Metoprolol 50-200 mg bd / Labetalol 200 mg po stat, then 200 mg tds
Captopril 12.5-25 mg po stat, then tds po (if phaeo suspected)
Long acting Calcium antagonists (Isradipine 5mg/Felodipine 5mg)
If not volume depleted, lasix 20mg or higher in renal insufficiency

- Aim: Decrease BP to 160/110 over several hours

(Sublingual nifedipine may precipitate ischaemic insult due

to rapid drop of BP)

8.

Cardiology

Malignant HT or Hypertensive emergency

- Labetalol 20 mg iv over 2 mins. Rept 40 mg iv bolus if
uncontrolled by 15 mins, then 0.5-2 mg/min infusion in D5 (max
300 mg/d), followed by 100-400 mg po bd
- Na Nitroprusside 0.25-10 microgram/kg/min iv infusion (50 mg
in 100 ml D5 = 500 microgram/ml, start with 10 ml/hr and titrate
to desired BP)
Check BP every 2 mins till stable, then every 30 mins
Protect from light by wrapping. Discard after every 12 hrs.
Esp good for acute LV failure, rapid onset of action.
Do not give in pregnancy or for > 48 hrs (risk of thiocyanide
intoxication
- Hydralazine 5-10 mg slow iv over 20 mins, repeat q 30 mins or iv
infusion at 200-300 microgram/min and titrate, then 10-100 mg
po qid (avoid in AMI, dissecting aneurysm)
- Phentolamine 5-10 mg iv bolus, repeat 10-20 mins prn (for
catecholamine crisis)

C 28

Cardiology

9.

Notes on specific clinical conditions

- APO -Nitroprusside/nitroglycerin + loop diuretic, avoid
diazoxide/hydralazine (increase cardiac work) or Labetalol &
Beta-blocker in LV dysfunction
- Angina pectoris or AMI - Nitroglycerin, nitroprusside, labetalol,
calcium blocker
(Diazoxide or hydralazine contraindicated)
- Increase in sympathetic activity (clonidine withdrawal,
phaeochromocytoma, autonomic dysfunction (GB Syndrome/post
spinal cord injury), sympathomimetic drugs
(phenylpropanolamine, cocaine, amphetamines, MAOI or
phencyclidine + tyramine containing foods) Phentolamine,
labetalol or nitroprusside
Beta-blocker is contraindicated (further rise in BP due to
nopposed alpha-adrenergic vasoconstriction)
- Aortic dissection - aim: systolic pressure to 100-120mmHg and
cardiac contractility, nitroprusside + labetalol / propanolol IV
- Pregnancy - IV hydralazine (pre-eclampsia or pre-existent HT),
Nicardipine / labetalol , no Nitroprusside (cyanide intoxication)
or ACEI

10. Look for causes of HT crisis, e.g. renal artery stenosis

C 29

AORTIC DISSECTION
Suspect in patients with chest, back or abdominal pain and presence of
unequal pulses (may be absent) or acute AR
Dx

- CXR, ECG, CK, TnI or TnT

- Transthoracic (not sensitive) +/- Transoesophageal echo
- Urgent Dynamic CT scan, MRA & rarely aortogram

Mx
1. NPO, complete bed rest, iv line
2. Oxygen 35-40% or 4-6 L/min
3. Analgesics, e.g. morphine iv 2-5 mg

5. Look for life-threatening complication severe HT, cardiac

tamponade, massive haemorrhage, severe AR, myocardial, CNS or
renal ischaemia
6. Medical Management
- To stabilize the dissection, prevent rupture, and minimize
complication from dissection propagation
- It should be initiated even before the results of confirmatory
imaging studies available
- Therapeutic goals: reduction of systolic blood pressure to
100-120mmHg (mean 60-75mmHg), and target heart rate of
60-70/min

Cardiology

4. Book CCU or ICU bed for intensive monitoring of BP/P

(Arterial line on the arm with higher BP), ECG & I/O

C 30
Intravenous Labetalol
10mg ivi over 2 mins, followed by additional doses of 20-80mg
every 10-15 mins (up to max total dose of 300mg)
Maintenance infusion: 2mg/min, and titrating up to
5-20mg/min.

Cardiology

Intravenous sodium nitroprusside

Starting dose 0.25 microgram/kg/min, increase every 2 mins by
10 g/min, max dose 8 microgram/kg/min
- Diltiazem and verapamil are acceptable alternatives when
beta-blockers are contraindicated (e.g. COAD)
(Avoid hydralazine or diazoxide as they produce reflex
stimulation of ventricle and increase rate of rise of aortic
pressure)
7. Start oral treatment unless surgery is considered
8. Contact cardiothoracic surgeon for all proximal dissection and
complicated distal dissection, e.g. shock, renal artery involvement,
haemoperitoneum, limbs or visceral ischaemia, periaortic or
mediastinal haematoma or haemoperitoneum (endovascular stent
graft is an evolving technique in complicated type B dissection with
high surgical risk).
Intramural hematoma should be managed as a classical case of
dissection.

C 31

PULMONARY EMBOLISM
Investigations
Clotting time, INR, aPTT, ABG, D-dimer
CXR (usu. normal, pleural effusion, focal oligaemia, peripheral wedge)
ECG (sinus tachycardia, S1Q3T3, RBBB, RAD, P pulmonale)
TTE +/- TEE; lower limb Doppler (up to 50% -ve in PE)
CT pulmonary angiography (CTPA) or Spiral CT scan (sensitivity 91%,
specificity 78%)
Ventilation-Perfusion scan (if high probability: sensitivity 41%,
specificity 97%)

Cardiology

Treatment
1. Establish central venous access; oxygen 35-40% or 4-6 L/min.
2. Analgesics e.g. morphine iv 2-5 mg.
3. a) Haemodynamically insignificant
Unfractionated heparin 5000 units iv bolus, then 500-1500
units/hr to keep aPTT 1.5-2.5X control or
Fraxiparine 0.4 ml sc q12h or enoxaparin 1 mg/kg q12h
Start warfarin on Day 2 to 3: - 5 mg daily for 2 days, then 2 mg
daily on 3rd day, adjust dose to keep INR 1.5-2.5 x control.
Discontinue heparin on Day 7-10.
b) Haemodynamically significant or evidence of dilated RV or
dysfunction (no C/I to thrombolytic)
Book ICU/CCU,
Streptokinase 0.25 megaunit iv over 30 mins, then 0.1
megaunit/hr for 24 hrs; or r-tPA 100 mg iv over 2 hours
followed by heparin infusion 500-1500 units/hr to keep aPTT
1.5-2.5 x control
Consider surgical embolectomy if condition continues to
deteriorate, or IVC filter if PE occurred while on warfarin, or
recurrent PE, mechanical ventilation in profound hypoxic
patient.

C 32

Cardiology

Additional notes from Medical Oncology:

For PE in cancer patients, the duration of long term anticoagulation,
if not contraindicated, is at least 6 months AND preferably continued
beyond 6 months for those with active cancer or receiving
chemotherapy (ASCO guideline 2013 update). LMWH is preferred
over warfarin in malignancy-related thrombosis (if CrCl > 30
ml/min) for its lower rate of recurrent thromboembolism and less
drug interaction with systemic therapy. Both have similar bleeding
risks.

C 33

CARDIAC TAMPONADE

Treating tamponade as heart failure with diuretics, ACEI and

vasodilators can be lethal!

Cardiology

Common causes:
- Neoplastic
- Pericarditis (infective or non-infective)
- Uraemia
- Cardiac instrumentation / trauma
- Acute pericarditis treated with anticoagulants
Diagnosis: - High index of suspicion (in acute case as little as 200ml of
effusion can result in tamponade)
Signs & symptoms:
- Tachypnoea, tachycardia, small pulse volume, pulsus paradoxus
- Raised JVP with prominent x descent, Kussmauls sign
- Absent apex impulse, faint heart sound, hypotension, clear chest
Investigation:
1. ECG: Low voltage, tachycardia, electrical alternans
2. CXR: enlarged heart silhouette (when >250ml), clear lung fields
3. Echo: RA, RV or LA collapse, distended IVC, tricuspid flow
increases & mitral flow decreases during inspiration
Management:
1. Expand intravascular volume - D5 or NS or plasma, full rate if in
shock
2. Pericardiocentesis with echo guidance apical or subcostal
approach, risk of damaging epicardial coronary artery or cardiac
perforation
3. Open drainage under LA/GA
- permit pericardial biopsy
(Watch out for recurrent tamponade due to catheter blockage or
reaccumulation)

C 34

Cardiology

Additional notes from Medical Oncology:

For patients with malignant pericardial effusion resulting in cardiac
tamponade stabilized by urgent pericardial drainage, please consult
oncologist to determine whether they could be benefited from surgical
pericardiectomy (pericardial window) and to plan the subsequent
oncological intervention for underlying disease control.

C 35

ANTIBIOTIC PROPHYLAXIS FOR

INFECTIVE ENDOCARDITIS
1. Procedures to dental, oral, respiratory tract or infected skin/skin
structure, musculoskeletal tissue in patients at highest risk or adverse
outcome in case infective endocarditis developed
a) Amoxicillin 2 grams po 1 hr before or
b) Ampicillin 2 grams im/iv within 30 mins before or
c) # Clindamycin 600 mg or *Cephalexin 2 grams or
#Azithromycin/Clarithromycin 500 mg po 1 hr before or
d) # Clindamycin 600 mg im/iv or *Cefazolin 1 gram im/iv within 30
mins before procedure.
# History of allergy to ampicillin/amoxicillin.
*Avoid cephalosporin if allergic to penicillin group of antibiotics.

High risk category:

- Prosthetic valves
- Previous infective endocarditis
- Cardiac transplant patients with valvulopathy
- Unrepaired cyanotic CHD, including palliative shunts and conduits
- Completely repaired CHD with prosthetic material or device,
whether placed by surgery or by catheter intervention, during the
first 6 months after the procedure
Repaired CHD with residual defects at the site or adjacent to the site
of a prosthetic patch or prosthetic device (which inhibit
endothelialization)
(Reference: Wilson W et al. Circulation 2007;116(15):1736-54)

Cardiology

2. Genitourinary/Gastrointestinal Procedure
- Antibiotic prophylaxis solely to prevent infective endocarditis is not
recommended for GU or GI tract procedures.
- Antibiotic treatment to eradicate enterococcal infection or
colonization is indicated in high risk patients for infective
endocarditis undergoing GU or GI procedure.

C 36

PERIOPERATIVE CARDIOVASCULAR
EVALUATION FOR NON-CARDIAC SURGERY

Cardiology

Basic evaluation by hx (assess functional capacity), P/E & review of ECG

Clinical predictors of increased perioperative CV risk (MI, CHF, death)

A) Active cardiac conditions mandate intensive Mx (may delay or
cancel OT unless emergent)
Unstable coronary syndrome recent (<30 days) or AMI with
evidence of important ischaemic risk by symptom or
non-invasive test, Canadian class III or IV angina
Decompensated CHF.
Significant arrhythmias high grade AV block, symptomatic
ventricular arrhythmia in presence of underlying heart disease,
supraventricular arrhythmia with uncontrolled ventricular rate.
Severe valvular disease e.g. severe AS or symptomatic MS.
B) Clinical risk factors (enhanced risk, need careful assessment of
current status)
History of ischaemic heart disease
History of compensated or prior CHF
DM
Renal impairment
C) Minor predictors (not proven to independently increase risk)
Advanced age, abnormal ECG (LVH, LBBB, ST-T abn),
rhythm other than sinus
Low functional capacity, hx of stroke, uncontrolled systemic HT
Cardiac risk stratification for noncardiac surgical procedures (If
the patient has risk factors for stable coronary artery disease,
estimate the perioperative risk for MACE [major adverse cardiac
events] by the combined clinical/surgical risk score
[http://www.surgicalriskcalculator.com])
A) Low risk (<1%)
B) Elevated risk (1%)

C 37
Stepwise approach to preoperative cardiac assessment for patients with
known or risk factors for coronary artery disease

Step 1

Need for emergency

non-cardiac OT

Yes

Clinical risk stratification

and proceed to surgery

No

Step 2

Acute coronary
syndrome

Yes

Evaluate and treat

according to
guideline-directed medical
therapy
Cardiology

No

Step 3

Step 4

Estimate perioperative risk

of MACE based on
combined clinical/surgical
risk socre

Low risk (<1%)

Elevated risk (1%)

Step 5

No further tests
Proceed to surgery

C 38

Moderate or greater (4

Yes

Step 5 METS) functional capacity

No further tests
Proceed to surgery

No

Cardiology

Step 6

Poor or unknown
functional capacity (<4
METS).
Will further testing impact
decision making OR
preoperative care?
No

Step 7

Proceed to surgery
according to
guideline-directed medical
therapy OR alternative
strategies (non-invasive
treatment, palliation)

Yes

normal

Pharmacologic stress
testing

abnormal

Coronary revascularization
according to existing
clinical practice guidelines

C 39
Algorithm for antiplatelet management in patients with coronary
stenting and non-cardiac surgery
Stent implantation
4-6 weeks

Yes

Yes

Elective surgery

Delay surgery until after

optimal period
(BMS: 30d; DES: 365d)

No

Continue DAPT unless

risk of bleeding > risk of
stent thrombosis

No

DES 30d but 365d

Yes

Yes

Does surgery demand

discontinuation of P2Y12
inhibitor?

No
Yes

Proceed to surgery
after 180d

Delay surgery until after

optimal period
(BMS: 30d; DES: 365d)

Continue aspirin and restart

P2Y12 inhibitor ASAP

No

Continue current DAPT

regimen

Cardiology

Risk of surgical delay >

risk of DES thrombosis

No

C 40
Disease-specific approach
1) Hypertension

Control of BP preoperatively reduces perioperative ischaemia

Evaluate severity, chronicity of HT and exclude secondary HT
Mild to mod. HT with no metabolic or CV abn. no evidence that it is
beneficial to delay surgery
Anti-HT drug continued during perioperative period
Avoid withdrawal of beta-blocker
Severe HT (DBP >110 or SBP >180)
elective surgery for better control first
urgent surgery - use rapid-acting drug to control (esp. beta-blocker)

2) Cardiomyopathy & heart failure

Cardiology

Pre-op assessment of LV function to quantify severity of systolic and

diastolic dysfunction (affect peri-op fluid Mx)
HOCM avoid reduction of blood volume, decreasein systemic vascular
resistance or decrease in venous capacitance, avoid catecholamines

3) Valvular heart disease

Antibiotic prophylaxis
AS - postpone elective noncardiac surgery (mortality risk around 10%)
in severe & symptomatic AS. Need AVR or valvuloplasty
AR - careful volume control and afterload reduction (vasodilators),
avoid bradycardia
MS - mild or mod ensure control of HR, severe consider PTMC
or surgery before high risk surgery
MR - afterload reduction & diuretic to stabilize haemodynamics before
high risk surgery

4) Prosthetic valve
Minimal invasive procedures reduce INR to subtherapeutic range (e.g.
INR <1.3), resume normal dose immediately following the procedure
Assess risk & benefit of anticoagulation Vs peri-op heparin (if both
risk of bleeding on anticoagulation & risk of thromboembolism off
anticoagulation are high)

C 41
5) Arrhythmia
Search for cardiopul. Ds., drug toxicity, metabolic derangement
High grade AV block pacing
Intravent. conduction delays and no hx of advanced heart block or
symptoms rarely progress to complete heart block
AF - if on warfarin, may discontinue for few days; give FFP if rapid
reversal of drug effect is necessary
Vent. arrhythmia
Simple or complex PVC or Nonsustained VT usu require no Rx except
myocardial ischaemia or moderate to severe LV dysfunction is present
Sustained or symptomatic VT suppressed preoperatively with lignocaine,
procainamide or amiodarone.

7) ICD or antitachycardia devices

programmed OFF immediately before surgery & ON again post-op
to prevent unwanted discharge
for inappropriate therapy from ICD, suspend ICD function by placing a
ring magnet on the device (may not work for all ICD devices)
VF/unstable VT if inappropriate therapy from ICD & external
cardioversion is required, paddles preferably >12cm from the device.

Cardiology

6) Permanent pacemaker
Determine underlying rhythm, interrogate devices to determine its
threshold, settings and battery status
If the pacemaker in rate-responsive mode inactivated
programmed to AOO, VOO or DOO mode prevents unwanted
inhibition of pacing
electrocautery should be avoided if possible; keep as far as possible
from the pacemaker if used

C 42
Perioperative beta blocker therapy
1. Beta blockers should be continued in patients undergoing surgery who have
been on beta blockers chronically.
2. In patients with intermediate or high risk myocardial ischaemia noted in
preoperative risk stratification tests, it may be reasonable to begin preoperative
beta blockers.

Cardiology

3. In patients with 3 or more risk factors (e.g. DM, HF, coronary artery disease,
renal insufficiency, CVA), it may be reasonable to begin beta blockers before
surgery.
4. In patients in whom beta blocker therapy is initiated, it may be reasonable to
begin the medication long enough in advance to assess safety and tolerability,
preferably > one day before surgery

(Reference : Fleisher LA et al. 2014 ACC/AHA guideline on

perioperative cardiovascular evaluation and management of patients
undergoing noncardiac surgery. JACC 2014;64(22):e77-137.)

Endocrinology

Endocrinology

E 1

DIABETIC KETOACIDOSIS (DKA)

Diagnostic criteria: Plasma glucose > 14 mmol/L, arterial pH < 7.3, plasma
bicarbonate < 15 mmol/L, (high anion gap) and moderate ketonuria or
ketonemia (or high serum beta-hydroxybutyrate BHBA.)
Initial Hour
Ix

Subsequent Hours

Urine & Blood glucose

Hourly urine and blood glucose
Urine + plasma ketones or
BAHA
Na, K, urea, AG ( till blood glucose <14
mmol/L)
Na, K, PO4, Mg,
Repeat ABG if indicated
Anion gap (AG)
(intensive monitoring of electrolytes and
Urea, Creatinine, Hb
acid/base is crucial in the first 24-48 hours)
Arterial blood gas (ABG)

Parameters to Hourly BP/pulse, respiratory rate, conscious level, urine output, central
be monitored venous pressure (CVP)
2-hourly temperature
Ancillary
Measures

Aspirate stomach if patient unconscious or vomiting

(protect airway with cuffed endotracheal tube if necessary)
Catheterize bladder and set CVP as indicated
Give antibiotics if evidence of infection
Treat hypotension and circulatory failure

Endocrinology

N.B. Urine ketone may not be very useful for

If indicated:
monitoring as it fails to measure BAHA
CXR, ECG
Blood & urine culture and
sensitivity
Urine & serum osmolality
PT, APTT
(look for precipitating
causes)

E2
Rx

Initial Hours

Subsequent Hours

1-2 litre 0.9%

saline (NS)

1 litre/hour or 2 hours as appropriate

When serum Na > 150 mmol/L, use 0.45% NS
(modify in patients with impaired renal
function). Fluid in first 12 hrs should not
exceed 10% BW, watch for fluid overload in
elderly. When blood glucose 14 mmol/L,
change to D5

Insulin

Regular human insulin

0.15 unit/kg as IV bolus,
followed by infusion
(preferably via insulin
pump)

Regular human insulin iv infusion 0.1

unit/kg/hr.
Aim at decreasing plasma glucose by 3-4
mmol/L per hour, double insulin dose to
achieve this rate of decrease in blood glucose
if necessary.
When BG 14 mmol/L, change to D5 and
decrease dose of insulin to 0.05-0.1 unit/kg/hr
or give 5-10 units sc q4h, adjusting dose of
insulin to maintain blood glucose between
8-12 mmol/L. monitoring to q2h-q4h
Change to maintenance insulin when AG
normal and normal diet is resumed

10 - 20 mmol/hr

Continue 10-20 mmol/hr, change if

- K < 4 mmol/L, to 30 mmol/hr
- K < 3 mmol/L, to 40 mmol/hr
- K > 5.5 mmol/L, stop K infusion
- K > 5 mmol/L, to 8 mmol/hr
Aim at maintaining serum K between 4-5
mmol/L

NaHCO3

If pH between 6.9-7.0, give 50 mmol NaHCO3 in 1 hr.

If pH < 6.9, give 100 mmol NaHCO3 in 2 hrs.
Recheck ABG after infusion, repeat every 2 hrs until pH > 7.0.
Monitor serum K when giving NaHCO3.

Endocrinology

Hydration

E 3

DIABETIC HYPEROSMOLAR
HYPERGLYCEMIC STATES
Diagnostic criteria: blood glucose > 33 mmol/L (arbitrary), arterial pH >
7.3, serum bicarbonate > 15 mmol/L, effective serum osmolality ((2x
measured Na) + glucose) > 320 mOsm/kg H2O, and mild ketonuria or
ketonemia, usually in association with change in mental state.
1.

Management principles are similar to DKA

2.

Fluid replacement is of paramount importance as patient is usually

very dehydrated

3.

If plasma sodium is high, use hypotonic saline

4.

Watch out for heart failure (CVP usually required for elderly)

5.

Serum urea is the best prognostic factor

6.

Insulin requirement is usually less than that for DKA, watch out for
too rapid fall in blood glucose and overshot hypoglycaemia
Endocrinology

E4

PERIOPERATIVE MANAGEMENT
OF DIABETES MELLITUS
1. Pre-operative Preparation
a. Screen for DM complications, check standing/lying BP and
resting pulse
b. Glucose, HbA1c, electrolytes, RFT, HCO3, urinalysis, ECG
c. Admit 1-2 days before major OT for DM control
d. Aim at blood sugar of 5-11 mmol/L before operation
e. Well controlled patients: omit insulin / OHA on day of OT
f. Poorly controlled patients:
- Stabilise with insulin (+/-dextrose) drip for emergency OT:
Blood glucose (mmol/L) Actrapid HM
Fluid
< 20
1-2 units/hr
D5 q4-6h
> 20
4-10 units/hr
NS q2-4h

Endocrinology

(Crude guide only, monitor hstix q1h and adjust insulin dose, aim to
bring down glucose by 4-5 mmol/L/hr to within 5-10 mmol/L)
* May need to add K in insulin-dextrose drip
* Watch out for electrolyte disorders
* May use sc regular insulin for stabilisation if surgery elective

2. Day of Operation
a. Schedule the case early in the morning
b. Check hstix and blood sugar pre-op, if blood glucose
> 11 mmol/L, postpone for a few hrs till better control if possible
c. For major Surgery
For patients on insulin or high dose of OHA, start
dextrose-insulin-K (DKI) infusion at least 2 hrs
pre-operatively or after fasting:
- 6-8 units Actrapid HM + 10-20 mmoles K in 500 ml D5,
q4-6h (about 1 u insulin for 4 gm of glucose) (Flush iv line
with 40 ml DKI solution before connecting to patient)

- Monitor hstix q1h and adjust insulin, then q4h for 24 hrs
(usual requirement 1-3 units Actrapid/hour)
- Monitor K at 2-4 hours and adjust dose as required to
maintain serum K within normal range

E 5
- Give any other fluid needed as dextrose-free solutions
Patients with mild DM (diet alone or low dose of OHA)
- D5 500 ml q4h alone (usually do not require insulin)
- Monitor hstix and K as above, may need insulin and K
d. For Minor Surgery
May continue usual OHA / diet on day of surgery
Patients exposed to iodinated radiocontrast dyes, withhold
metformin for 48 hours post-op and restart only after
documentation of normal serum creatinine
For well-controlled patients on insulin:
Either:
- Omit morning short-acting insulin
- Give 2/3 of usual dose of intermediate-acting insulin am,
and the remaining 1/3 when patient can eat
Or: (safer)
- Use DKI infusion till diet resumed. Then give 1/3 to 1/2
of usual intermediate-acting insulin
For poorly-controlled patients on insulin:
- Control first, use insulin or DKI infusion for urgent OT
Endocrinology

3. Post-operative Care
a. ECG (serially for 3 days if patient is at high risk of IHD)
b. Monitor electrolytes and glucose q6h
c. Continue DKI infusion till patient is clinically stable, then
resume regular insulin (give first dose of sc insulin 30 minutes
before disconnecting iv insulin) / OHA when patient can eat
normally
d. In case of nasogastric tube feeding, give insulin (infusion or sc)
according to feeding schedule

E6

INSULIN THERAPY FOR DM CONTROL

Common insulin regimes for DM control (Ensure dietary compliance
before dose adjustments):

Endocrinology

1.

For insulin-requiring type 2 DM

(May consider combination therapy (Insulin + OHA) for patients
with insulin reserve)
a. Fasting Glycaemia alone
- Give bed-time intermediate-acting insulin, start with 0.1- 0.2
unit/kg
- Continue metformin and other oral hypoglycemic agents if
appropriate
- Consider adding DPP4 inhibitor as adjunctive to insulin to
optimise control
b. Daytime Glycaemia
- Start with intermediate-acting or pre-mixed insulin 30 mins
before breakfast (AM insulin) and before dinner (PM insulin)
(Daily dose 0.2-0.5 unit/kg in ratio of 2:1 or 1:1)
- Adjust dosage according to fasting and post-meal hstix
- If fasting glucose persistently high, check blood sugar at
mid-night:
- If hypoglycaemic, reduce pre-dinner dose by 5-10%
(Somogyi phenomenon)
- If hyperglycaemic, may need to consider MDI (multiple dose
insulin regimes)

- Consult endocrinologist for insulin analogues in difficult cases with wide

glucose fluctuation. (N.B. Long-acting insulin analogues Glargine and Detemir
are indicated if patients have sub-optimal glycemic control on NPH with
frequent documented hypoglycaemia or sub-optimal glycemic control on NPH
with established CHD/PVD/Stroke or renal (eGFR<60ml/min) complications
with reasonable QoL. Short-acting insulin analogues Aspart, Gluisine and Lispro
are indicated if patients have brittle or poorly control DM despite multi-dose
conventional short acting insulin regimen and good compliance)

E 7
2.

For type 1 DM
- Start with twice daily or multiple daily dose regimes
- Consider use of Pens for convenience and ease of administration
- Start with 0.5 unit/kg/d. Adjust the following day according to
hstix (tds and nocte)

Sliding scale, if employed at all, must be used judiciously:

1. Hstix must be performed as scheduled
2. Dose adjustment should take into consideration factors
that may affect patients insulin resistance
3. It should not be used for more than 1-2 days

Endocrinology

a. For twice daily regimes:

- Give 2/3 or half of total daily insulin dose pre-breakfast
and 1/3 or half pre-dinner in the evening (30 mins before
meals) in the form of pre-mixed insulin
- Advise on multiple small meals to avoid late afternoon
and nocturnal hypoglycaemia
b. For multiple daily dose regimes:
- Give 40-60% total daily dose as intermediate-acting
insulin before bed-time to satisfy basal needs. Adjust
dose according to fasting glucose.
- Give the remaining 40-60% as regular insulin, divided into
3 roughly equal doses pre-prandially (slightly higher AM
dose to cover for Dawn Phenomenon, and slightly higher
dose before main meal of the day)
c. For difficult cases, consult endocrinologist for considering
insulin analogues or continuous subcutaneous insulin
delivered via a pump

E8

Endocrinology

HYPOGLYCAEMIA
1.

Treatment
a. D50 40 cc iv stat, follow with D10 drip
b. Glucagon 1 mg IMI (avoid in suspected phaeochromocytoma)
or oral glucose (after airway protection) if cannot establish iv
line
c. Monitor blood glucose and hstix every 1-2 hrs till stable
d. Duration of observation depends on R/LFT and type of
insulin/drug (in cases of overdose)

2.

Tests for Hypoglycaemia

a. Prolonged OGTT
To document reactive hypoglycaemia, limited use
Overnight fast
Give 75 g anhydrous glucose po
Check plasma glucose and insulin at 60 min intervals for 5
hrs and when symptomatic
b.

Prolonged Fasting Test

Hospitalise patient, place near nurse station
Fast for maximum of 72 hrs
At 72 hrs, vigorous exercise for 20 mins (if still no
hypoglycemia)
Hstix q4h and when symptomatic
Blood sugar, insulin, C-peptide at 0, 24, 48 and 72 hrs and
when symptomatic or hstix < 3.0 mmol/L
Terminate test if blood sugar confirmed to be < 3.0 mmol/L
Consider to check urine hypoglycemic agents level in highly
suspected cases.

E 9

THYROID STORM
Note: The following regimen is also applicable to patients with
uncontrolled thyrotoxicosis undergoing emergency operation.
1.
2.

3.

5.
6.

Endocrinology

4.

Close monitoring: often need CVP, Swan-Ganz, cardiac monitor.

ICU care if possible
Hyperthermia : paracetamol (not salicylate), physical cooling
Dehydration : iv fluid (2-4 L/d)
iv Glucose, iv vitamin (esp. thiamine)
Supportive : O2 , digoxin / diuretics if CHF/AF inotropes
Treat precipitating factors and/or co-existing illness
Propylthiouracil 150-200 mg q46h po / via NG tube.
Hydrocortisone 200 mg stat iv then 100 mg q6-8h
-blockers (exclude asthma / COAD or frank CHF): Propranolol
40-80 mg q4-6h po/NG or Propranolol/Betaloc 1-10 mg iv over 15
min every several hrs
If -blockers contraindicated, consider diltiazem 60-120 mg q8h as
alternative
1 hour later, use iodide to block hormone release
a. 6-8 drops Lugols solution / SSKI po q6-8h (0.2 g/d)
b. NaI continuous iv 0.5-1 g q12h or
c. Ipodate (Oragrafin) po 1-3 g/d
Consider LiCO3 250 mg q6h to achieve Li level 0.6-1.0 mmol/L if
ATD is contraindicated
Consider plasmapheresis and charcoal haemoperfusion for
desperate cases

E 10

MYXOEDEMA COMA
1. Treatment of precipitating causes
2. Correct fluid and electrolytes, correct hypoglycaemia with D10
3. NS 200 - 300 cc/hr vasopressors
4. Maintain body temperature
5. T4 200-500 micrograms po stat, then 100-200 micrograms po or
T3 20-40 micrograms stat, then 20 micrograms q8h po
6. Consider 520 micrograms iv T3 twice daily if oral route not
possible

Endocrinology

7. Hydrocortisone 100 mg q6h iv

PHAEOCHROMOCYTOMA (HT crisis)

1.
2.
3.
4.
5.

Phentolamine 0.5-5 mg iv, then 2-20 micrograms/kg/hr infusion or

Nitroprusside infusion 0.3-8 micrograms/kg/min
Volume repletion
Propranolol if tachycardia (only after adequate -blockade)
Labetalol infusion at 1-2 mg/min (max 200 mg).
ICU monitoring

E 11

ADDISONIAN CRISIS
1. Investigation:
a. RFT, electrolytes, glucose
b. Spot cortisol (during stress) ACTH
c. Normal dose (250 micrograms) short synacthen test (not required
if already in stress)#
d. May consider low dose (1 microgram) short synacthen test if
secondary hypocortisolism is suspected@
e. Look out for the cause(s)

3. Relative Potencies of different Steroids*

Cortisone
Hydrocortisone
Prednisone
Prednisolone
Methylprednisolone
Dexamethasone
Betamethasone

Glucocorticoid
action

0.8
1
4
4
5
25-30
25-30

* Different in different tissues

Mineralocorticoid Equivalent
action
doses

0.8
1
0.6
0.6
0.5
0
0

25 mg
20 mg
5 mg
5 mg
4 mg
0.75 mg
0.75 mg

Endocrinology

2. Treatment
Treat on clinical suspicion, do not wait for cortisol results
a. Hydrocortisone 100 mg iv stat, then q6h (may consider imi or
continuous iv infusion at 200 mg per day if no improvement)
b. 9-fludrocortisone 0.05-0.2 mg daily po, titrate to normalise K
and BP
c. Correct electrolytes
d. 4 litres of D5/NS at 500-1000 ml/hr, then 200-300 ml/hr, watch
out for fluid overload
e. May use dexamethasone 4 mg iv/im q12h (will not interfere with
cortisol assays)

Endocrinology

E 12
4. Steroid cover for surgery / trauma
- Indications:
Any patient given supraphysiological doses of
glucocorticoids (>prednisolone 7.5 mg daily) for >2 wks in
the past year
Patients currently on steroids, whatever the dose
Suspected adrenal or pituitary insufficiency
a. Major Surgery
Hydrocortisone 100 mg iv on call to OT room
Hydrocortisone 50 mg iv in recovery room, then 50 mg iv
q6h + K supplement for 24 hrs or continuous iv infusion of
200 mg hydrocortisone per 24 hours
Post-operative course smooth: Decrease Hydrocortisone to
25 mg iv q6h on D2, then taper to maintenance dose over
3-4 days
Post-operative course complicated by sepsis, hypotension
etc: Maintain Hydrocortisone at 100 mg iv q6h (or 200
mg iv infusion per day) till stable
Ensure adequate fluids and monitor electrolytes
b. Minor Surgery
Hydrocortisone 100 mg iv one dose
Do not interrupt maintenance therapy
#

Normal dose short synacthen test

250 micrograms Synacthen iv/im as bolus
Blood for cortisol at 0, 30, 60 mins. Can perform at any
time of the day
Normal: Peak cortisol level > 550 nmol/L, Abnormal: <
400 nmol/L, Borderline: 400 550 nmol/L (depends on
type of cortisol assay)
Low dose short synacthen test
1 microgram Synacthen (mix 250 g Synacthen into 1 pint
NS and withdraw 2 ml) IV as bolus
Blood for cortisol at 0, 30 mins.. Can perform at any time
of the day.

E 13
Normal: Peak cortisol level > 550 nmol/L, Abnormal: <
400 nmol/L, Borderline: 400 550 nmol/L (depends on
type of cortisol assay)
May need to confirm by other tests (insulin tolerance test
or glucagon test) if borderline results

Endocrinology

E 14

Endocrinology

ACUTE POST-OPERATIVE /
POST-TRAUMATIC DIABETES INSIPIDUS
1.

Remember possibility of a Triphasic pattern:

Phase I : Transient DI, duration hrs to days
Phase II : Antidiuresis, duration 2-14 days
Phase III : Return of DI (may be permanent)

2.

Mx
a. Monitor I/O, BW, serum sodium and urine osmolarity closely
(q4h initially, then daily)
b. Able to drink, thirst sensation intact and fully conscious: Oral
hydration, allow patient to drink as thirst dictates
c. Impaired consciousness and thirst sensation:
Fluid replacement as D5 or : solution (Calculate
volume needed by adding 12.5 ml/kg/d of insensible loss
to volume of urine)
DDAVP 1-4 micrograms (0.5-1.0 ml) q12-24h sc/iv
Allow some polyuria to return before next dose
Give each successive dose only if urine volume > 200
ml/hr in successive hours

3.

Stable cases
Give oral DDAVP 100 - 200 micrograms bd to tds (tablet) or
60-120 micrograms bd to tds (lyophilisate) to maintain urine
output of 1 2 litres/day. Advice drug holiday if appropriate.

E 15

PITUITARY APOPLEXY
1.
2.

Definite diagnosis depends on CT / MRI

Surgical decompression under steroid cover if
- signs of increased intracranial pressure
- change in conscious state
- evidence of compression on neighbouring structures

Endocrinology

Gastroenterology
&
Hepatology

Gastroenterology
and Hepatology

G 1

ACUTE LIVER FAILURE

Definition
A severe liver injury (coagulopathy with INR 1.5)
With onset of hepatic encephalopathy within 8 weeks of the first
symptoms (up to 26 weeks in some definitions)
In the absence of pre-existing liver disease
Classification
Jaundice to
encephalopathy
interval
Prognosis (Survival)
Cerebral oedema
PT
Bilirubin

Hyperacute
0 to 1 week

Acute
>1 to 4
weeks

Subacute
>4 to 26 weeks

Moderate
Common
Prolonged
Least raised

Poor
Common
Prolonged
Raised

Poor
Infrequent
Less Prolonged
Raised

Gastroenterology
and Hepatology

Search for aetiology and assess severity of acute liver failure (ALF)
History medications, herbal medicine, Amanita phylloides intake,
Ecstasy use
CBP/ Clotting/ LRFT/ ABG/ Lactate
Hepatitis (A, B, D, E) serology, HBV DNA
Blood ammonia level (high levels are predictive of complications
and increased mortality)
Autoimmune markers (ANA, ASMA, anti-LKM1)
Metabolic markers (Caeruloplasmin for patients < 50 yrs old)
Toxicology screening especially paracetamol level
Anti-HIV (informed consent) if liver transplant considered
Review herbal formula by Poison Information Centre (Tel:
27722211, Fax: 22051890) or identification of herbal medicine by
Toxic Reference Laboratory (Tel: 29901941, Fax: 29901942)
Transjugular liver biopsy in selected cases

G2
Management
Close monitoring, preferably in ICU
Nutritional support: 1 to 1.5g enteral protein/kg/day (lower level for
patients with worsening hyperammonaemia or at high risk for
intracranial hypertension)
Avoid use of paracetamol
Consider N-acetylcysteine (NAC) for both paracetamol- and
non-paracetamol-related ALF.
Alternative NAC regime for non-paracetamol ALF:
Loading dose: NAC 150mg/kg/hr in D5 over 1 hour,
Then 12.5mg/kg/hr in D5 over 4 hours,
Then 6.25mg/kg/hr in D5 infusion for 67 hours (i.e. 72 hrs in total)
Start nucleos(t)ide analogues for HBV-related ALF, particularly for
transplant candidates
Liaise with QMH Liver Transplantation Centre if indicated

Gastroenterology
and Hepatology

Hepatic encephalopathy
Grade I/II
Consider liver transplantation
CT brain to exclude other causes of altered consciousness
Avoid stimulation/ sedation
Lactulose
Grade III/IV
Early endotracheal intubation and mechanical ventilation
Choice of sedation: Propofol (small dose adequate; long T in
patient with hepatic failure). Avoid neuromuscular blockade as it
may mask clinical evidence of seizure activity
Elevate head of patient ~ 30, limit neck rotation or flexion
Prophylactic anti-convulsant not recommended. Immediate control
of seizure with minimal doses of benzodiazepine. Control seizure
activity with phenytoin
Consider ICP monitoring especially if patient listed for liver
transplant with high risk of cerebral oedema

G 3
Intracranial hypertension
1. Mannitol
Dose: 0.5-1g/kg IV bolus, can repeat once / twice Q4H if needed
Stop if serum osmolality > 320 mosm/L
Risk of volume overload in renal impairment and hypernatraemia
Prophylactic use not recommended
Use in conjunction with RRT in renal failure
2.

Hyperventilation
Indicated when increased ICP not controlled with mannitol
Keep PaCO2 at 4 to 6 kPa
Sustained hyperventilation should be avoided

3.

Others (ICU setting preferred if available)

Hypertonic saline solution and barbiturate for refractory intracranial
hypertension
Therapeutic hypothermia (cooling to a core temperature of 32 to
34C)

Infection
Screening for sepsis to detect bacterial and fungal infection
Low threshold to start appropriate wide-spectrum anti-bacterial/
antifungal therapy as usual clinical signs of infection may be absent
Gastroenterology
and Hepatology

Coagulopathy and bleeding

Spontaneous and clinically overt bleeding uncommon in ALF
Variceal bleeding in the setting of ALF should raise suspicion of
Budd-Chiari syndrome
Give prophylactic Pepcidine or PPI to reduced stress-related GIB
Give Vitamin K1 10mg IV Q24H
Replacement therapy for thrombocytopenia (< 50,000 700,000/
mm3) and/ or prolonged prothrombin time (INR 1.5) only in the
setting of haemorrhage or before invasive procedures

G4
Haemodynamic/ Renal failure
Fluid replacement for intravascular volume deficits (colloids
preferred)
All solutions should contain dextrose to maintain euglycaemia
Maintain mean arterial pressure (MAP) > 75 mmHg
Use vasopressor (adrenaline/noradrenaline/dopamine) when fluid
replacement fails to maintain adequate MAP
Assess adrenal function in patient requiring vasopressors
Consider pulmonary artery catheterization in haemodynamically
unstable patient to ensure adequate volume replacement
CVVH preferred for acute renal failure requiring dialysis

Gastroenterology
and Hepatology

Considerations for liver transplantation

Kings College Hospital prognostic criteria
Paracetamol
Non-paracetamol
pH < 7.3, or
PT > 100 (INR > 6.5), or
Three out of 5 criteria:
All 3 criteria:
1. Age < 10 or > 40
1. PT > 100s
2. Aetiology: Drug-induced,
(INR > 6.5)
indeterminate
2. Cr > 300 mol/L
3. Grade III/ IV hepatic 3. Bilirubin > 300 mol/L
4. Jaundice to coma interval > 7 days
encephalopathy
5. PT > 50 (INR 3.5)
Calculate MELD score for reference
Contraindications for liver transplantation
HIV infection
Active alcohol or substance abuse
Systemic infections
Life-limiting co-existing medical conditions: advanced heart, lung
or neurologic conditions.
Uncontrolled psychiatric disorder
Inability to comply with pre- and post-transplant regimens

G 5

HEPATIC ENCEPHALOPATHY
Child-Pugh Grading of Severity of Chronic Liver Disease
Points:
1
2
3
Parameters:
Encephalopathy
None
I and II
III and IV
Ascites
Absent
Mild
Moderate
Bilirubin (umol/l)
<35
35 50
>50
for PBC (umol/l)
<70
70 170
>170
Albumin (g/l)
>35
28 35
<28
Prothrombin time
1-3
4-6
>6
(sec prolonged)
Grades: A: 5-6 points,
B: 7-9 points, C: 10-15 points

Management of hepatic encephalopathy in cirrhotic patients

Initiate care for patients with altered consciousness
Look for other causes of altered mental state

A. Identify and correct precipitating factors

Watch out for infection, constipation, gastrointestinal bleeding,
diuretic overdose, electrolyte disorder. (other possible
precipitating factors: excess dietary intake of protein, vomiting,

Gastroenterology
and Hepatology

Grading (Grade 0-I: Covert HE; Grade II-IV: Overt HE)

0 Psychometric or neuropsychological alteration of tests
(psychometric, psychomotor or neurophysiological) without
clinical evidence of mental change
I Euphoria, mild confusion, mental slowness, shortened attention
span, slurred speech, disordered sleep
II Lethargy or apathy, disorientation, moderate confusion,
inappropriate behaviour, drowsiness
III Marked confusion, incoherent speech, somnolence or
semi-stupor, response to stimuli, bizarre behaviour
IV Coma, initially responsive to noxious stimuli, later unresponsive

G6

Gastroenterology
and Hepatology

large volume paracentesis, recent alcohol binge, vascular

occlusion and primary HCC)
Avoid sedatives, alcohol, diuretic, hepatotoxic and nephrotoxic
drugs
Correct electrolyte imbalance (azotaemia, hyponatraemia,
hypokalaemia, metabolic alkalosis/acidosis)

B. Treatment
Tracheal intubation should be considered in patient with deep
encephalopathy
Nutrition: In case of deep encephalopathy, oral intake should be
withheld 24-48hr and i.v. glucose should be provided until
improvement. Enteral nutrition by gastric tube can be started if
patients are unable to eat after this period. Protein intake begins
at a dose of 0.5g/kg/day, with progressive increase to
1.2-1.5g/kg/day. Vegetable and dairy sources are preferable to
animal protein. Liaise with dietitian if necessary.
Oral formulation of branched chain amino acids (BCAA) may
provide better tolerated source of protein in patients with chronic
encephalopathy and dietary protein intolerance
Lactulose ( oral / via nasogastric tube) 30-40 ml q8h and titrate
until 2-3 soft stools/day
Antibiotics in suspected sepsis
Consider referral for liver transplantation in selected cases
recurrent intractable overt HE

G 7

ASCITES

Gastroenterology
and Hepatology

A. Investigations
- Diagnostic paracentesis, USG abdomen, alpha-fetoprotein
B. Conservative Treatment (aim to reduce BW by 0.5 kg/day)
1. Low salt diet (2g/day)
2. Fluid restriction (1-1.5L/day) if dilutional hyponatremia Na
<120-125 mmol/L
3. Monitor input/output, body weight, urine sodium
4. Spironolactone starting at 50 mg daily (single morning dose)
alone or with Lasix 20 mg daily as combination therapy.
5. Increase the dose stepwise (maintaining the 100mg:40mg
ratio) every 5-7days to the maximum spironolactone
400mg/day and Lasix 160mg/day if no response (if weight
loss and natriuresis are inadequate)
6. Amiloride (10-40mg/day) can be substituted for
spironolactone in patients with tender gynaecomastia
7. Once ascites has largely resolved, dose of diuretics should be
reduced and discontinued later whatever possible.
8. All diuretics should be discontinued if there is severe
hyponatraemia <120 mmol/L, progressive renal failure,
worsening hepatic encephalopathy, or incapacitating muscle
cramps
- Lasix should be stopped if there is severe hypokalemia
(<3 mmol/L)
- Spironolactone should be stopped if there is severe
hyperkalaemia (>6 mmol/L)
C. Therapeutic paracentesis can be used in refractory ascites
- Exclude spontaneous bacterial peritonitis before paracentesis
- Caution in patients with hypotension and raised serum
creatinine, monitor vital signs during paracentesis
- If >5L fluid removed, give IV albumin 6-8g per litre tapped
D. Consider TIPS in refractory ascites
E. Referral to liver transplant centre for potential candidate

G8

Gastroenterology
and Hepatology

GENERAL GUIDELINES FOR

CONSIDERATION OF ORTHOTOPIC LIVER
TRANSPLANTATION (OLT) IN CHRONIC
LIVER DISEASE OR HEPATOCELLULAR
CARCINOMA
Chronic liver disease and hepatocellular carcinoma
Patients who have an estimated survival of less than 80% chance after 1
year as a result of liver cirrhosis should be referred for consideration of
liver transplantation. If any of the following are present, it may be
appropriate to refer the patient:
A. Child-Pugh score 8 or above
B. Complications of cirrhosis
a. Refractory ascites or hydrothorax
b. Spontaneous bacterial peritonitis
c. Encephalopathy
d. Very poor cirrhosis related quality of life
e. Hepatorenal syndrome, hepatopulmonary syndrome, or
portopulmonary hypertension
f. Portal hypertensive bleeding not controlled by endoscopic
therapy or transjugular intra-hepatic porto-systemic shunt
C. For patients with unresectable hepatocellular carcinoma and those
with hepatocellular carcinoma and underlying cirrhosis
a. Solitary tumour of less than 5cm in diameter or those with
up to 3 tumours (each of which should be < 3 cm)
b. For tumours beyond the above criteria, patients may still be
eligible for liver transplantation if
i. There is a potential living-related donor and

G 9
ii. Single tumour not exceeding 6.5cm, or 2-3 lesions none
exceeding 4.5cm, with the total tumour diameter less
than 8cm
Acute liver failure/acute on chronic liver failure
These patients should be referred early to avoid delay in work-up
for potential liver transplantation if they have any of the
following criteria
Those with rising INR (>2.0)
Evidence of early hepatic encephalopathy
Relative contra-indications to liver transplantation
Alcoholic patients with less than 6 months abstinence
Extra-hepatic malignancy
Severe/uncontrolled extra-hepatic infection
Multi-system organ failure
Significant cardiovascular, cerebrovascular, or pulmonary
disease
Advanced age

If in doubt, discuss with the liver transplant team

Gastroenterology
and Hepatology

G 10

Gastroenterology
and Hepatology

VARICEAL HAEMORRHAGE
A.

Initial Management (as in upper GI bleeding)

maintain systolic BP at 90-100mmHg but avoid excessive volume
restitution (increase portal pressure early rebleeding)
restrictive blood transfusion, aim at Hb 7-8g/dl, haematocrit 21-24%
correction of significant coagulopathy and thrombocytopenia may be
considered
Routine use of NG tube is not recommended but it may be used in
cases of hepatic encephalopathy

B.

Vasoactive agents should be initiated before endoscopy to patient with

suspected variceal bleeding and maintained for 2-5 days after
endoscopic treatment.
Terlipressin* 2 mg IV bolus Q4H
Octreotide 50 micrograms iv bolus, then 50 micrograms/hour IV
infusion
Somatostatin 250 micrograms iv bolus, then 250 microgram/hour IV
infusion
* Beware of side-effects related to vasoconstriction such as bowel
ischaemia, hypertension, myocardial ischemia, peripheral
vascular ischaemia

C.

IV thiamine for those with alcohol excess

D.

Anti-encephalopathy regimen
Correct fluid and electrolyte imbalances
Lactulose 10-20 ml q4-8H PO or via NG tube aims at 2-3 bowel
motions per day. It can be given as enema (300ml in 1L water)
retained for 1 hr with patient in Trendelenburg position

E.

Prevention of sepsis
Short-term (7d) prophylactic antibiotic: IV ciprofloxacin 400-500mg
bd (patients with preserved liver function), or IV ceftriaxone 1g/day
(patients with advanced cirrhosis or known quinolone-resistance), or
IV ertapenem 1g/day (patients with recent ESBL-Enterobacteriaceae
infection)

G 11
F.

Endoscopic treatment
Upper endoscopy should be arranged as soon as possible after
admission once haemodynamic condition is stabilised (sBP
>70mmHg)
Patients with altered mental state or massive bleeding should
undergo endotracheal intubation and mechanical ventilation prior to
endoscopy
Esophageal variceal ligation (EVL) / sclerotherapy for oesophageal
varices; Tissue glue like N-butyl-cyanoacrylate injection for gastric
varices
Vasoactive agents should be initated within 30 min after
confirmation of variceal bleeding if not given prior to endoscopy
Proton-pump inhibitor (PPI) or sucralfate should be given for 2
weeks
Uncontrolled/recurrent variceal bleeding
Recurrent bleeding should be managed by repeated endoscopy
Refer to emergency surgery (port-systemic shunting,
devascularisation) or TIPS as salvage therapies for uncontrolled
bleeding
Balloon tamponade should only be used as temporary measure (max
12-24 hr) until definite therapy is planned. If haemostasis is not
achieved, other therapeutic options should be considered

H.

Prevention of rebleeding
EVL combined with a non-selective beta-blocker* (NSBB) is
recommended as secondary prevention
Combined NSBB and isosorbide 5-mononitrate# are recommended if
patient is unsuitable for EVL

NSBB (non-selective beta-blocker): propranolol, nadolol or carvedilol should start at

low dose and titrate up till 25% reduction in resting heart rate but not lower that 55
beats/min.

Nitrate may have adverse effect on kidney function especially in patients aged over 50.

Gastroenterology
and Hepatology

G.

G 12

UPPER GASTROINTESTINAL BLEEDING

A.

Gastroenterology
and Hepatology

B.

C.
D.

E.

Initial Management (Consider ICU if severe bleeding)

Nil by mouth

Insert large bore IV cannula

Closely monitor BP, Pulse, I/O

Risk stratification applying Blatchford score or Rockall score

Blood transfusion when Hb<7g/dL (except for massive bleeding) and

fluid replacement as required

Withhold anticoagulants and antiplatelet if possible. Weight against

the thrombotic risk of an individual patient before REVERSAL of
anticoagulation

Cuffed ET tube to prevent aspiration if massive haematemesis or

suspected compromised respiratory or airway condition

Nasogastric tube if massive haematemesis or signs suggestive of GI

obstruction

Tranexamic acid is not recommended as insufficient evidence

Pre-endoscopy IV proton-pump inhibitor (PPI) treatment is

recommended if early endoscopy (within 24 hours) cannot be arranged

IV antibiotics in all cirrhotic patients with GI bleeding: IV Augmentin

1.2g Q8H/ IV levofloxacin 500mg Q24H (max 7d)

Arrange early (within 24 hours) upper endoscopy after initial

stabilization
Indications for Emergency Endoscopy

Haemodynamic shock

Massive haematemesis/bloody NG aspirate

Suspected gastroesophageal variceal bleeding

Contraindications for Endoscopy

Suspected intestinal perforation

Unstable cardiac or pulmonary status

Post-endoscopy Management

After endoscopic treatment of patients with actively bleeding ulcer,

ulcer with visible vessel or ulcers with adherent clot resistant to
vigorous irrigation, IV PPI infusion should be given for 72 hours

IV PPI Infusion: pantoprazole/esomeprazole 80mg IV bolus stat

followed by 8mg/hr infusion
Recurrent bleeding
Repeated endoscopy should be attempted

G 13

If bleeding cannot be controlled or recurs, surgical intervention

becomes necessary
Interventional radiology may be considered as an alternative if
expertise is available

0
<60

1
60-79

2
>80

Pre-endoscopic

Blood pressure

No shock
sBP >100
P <100

Tachycardia
sBP>100
P>100

Hypotension
sBP<100

Co-morbidity

No

Endoscopic

Rockall Score (ABCDE)

Dx at time of
OGD

Mallory-Weiss,
no SRH

Variables
Age

Evidence of
No, or dark spot
bleeding
only
Pre-endoscopy score
0:
Early discharge or non-admission
0-1: Low risk
2-3: Moderate risk
>4:
High risk of death

CHF, IHD, major

diseases
All other Dx
except
malignancy

Glasgow-Blatchford Score (GBS)

Blood Urea

Systolic BP
Pulse
Melena
Syncope
Hepatic disease
Cardiac failure

Male
Female
12-<13
10-<12
10-<12
<10
<10
100-109
90-99
<90
>100
Yes
Yes
Yes
Yes

Renal failure,
liver failure,
metastatic ca

GI malignancy

Blood, adherent
clot, spurter
Full score (Pre-endoscopic + endoscopic)
0-3: excellent, consider early discharge
>8: high risk of death and rebleeding

Score
2
3
4
6
1
3
6
1
2
3
1
1
2
2
2

0:

can be safely managed as

outpatient without early
endoscopy
>0: increased risk for
intervention and inpatient
management is
recommended
>6: > 50% risk of needing an
intervention

Gastroenterology
and Hepatology

Hb

6.5-<8
8-<10
10-<25
>25

G 14

PEPTIC ULCERS

Gastroenterology
and Hepatology

A.

Ulcer-healing drugs
H2-antagonists for 8 weeks
Famotidine 20 mg bd or 40 mg nocte
Proton-pump inhibitors (PPI)* for 4 - 6 weeks
Omeprazole/ Esomeprazole 20 mg om
Rabeprazole 20mg om
Lansoprazole 30 mg om
Pantoprazole 40 mg om
*PPI should be taken 30-60 min before meals
B. Anti-Helicobacter pylori therapy
1. First line therapy
Standard triple
PPI (bd) + clarithromycin (500mg bd) +
therapy
amoxicillin (1g bd) for 7 days
(substitute amoxicillin with metronidazole 500mg
bd in case of penicillin allergy)
2. Salvage therapy
Levofloxacin-based
PPI (bd) + levofloxacin (500mg daily) +
triple therapy
amoxicillin (1g BD) for 10 days
Bismuth-containing
PPI (bd) + bismuth subsalicylate (524mg qid) +
quadruple therapy
tetracycline (500mg qid) + metronidazole (500mg
qid) for 10-14 days
Rifabutin-based
PPI (bd) + rifabutin (150mg bd) + amoxicillin (1g
triple therapy
bd) for 14 days
C. NSAID/ aspirin user with active peptic ulcer
NSAID user: discontinue NSAID during PPI treatment
Aspirin user with non-bleeding peptic ulcer: continue aspirin with PPI
treatment
Aspirin user with bleeding peptic ulcer: resume aspirin with PPI
treatment once hemostasis is secured in order to minimize
cardiovascular risk
D. Ulcer prevention
H pylori ulcer:
- maintenance acid suppression therapy not neccessary after H pylori
eradication

G 15
NSAID ulcer:
- avoid NSAID if high GI risk^ or prior complicated peptic ulcer
- add PPI or misoprostol (200 micrograms bd) as prophylaxis with
NSAID or COX-2 inhibitor use
Aspirin ulcer:
- review the need for aspirin
- add PPI as prophylaxis when resume aspirin
Idiopathic ulcer:
- consider long-term maintenance PPI
^High GI risk = more than 2 of the followings: age>65, high dose NSAID,
previous history of peptic ulcer, concomitant use of aspirin, corticosteroids
or anti-coagulants
Follow-up Endoscopy
Uncomplicated DU => Unnecessary if asymptomatic
GU or complicated (bleeding/ obstruction) or giant DU (>2cm) =>
Necessary till complete healing confirmed

E.

Gastroenterology
and Hepatology

G 16

MANAGEMENT OF GASTRO-OESOPHAGEAL
REFLUX DISEASE (GERD)
A. Empirical PPI (Proton-pump inhibitor) trial [bd dose PPI for 4 weeks]:

For patients with typical GERD symptoms (heartburn and

regurgitation), an initial trial of empirical PPI is appropriate

Patients with chest pain suspected due to GERD should have IHD
excluded before empirical PPI trial.
B. Indications for endoscopy in GERD

Not for diagnosis of GERD with typical symptom.

presence of alarm features (dysphagia, odynophagia, unintentional weight

Gastroenterology
and Hepatology

loss, anaemia, haematemesis and/or melaena, recurrent vomiting, family

history of gastric and/or esophageal cancer, chronic non-steroidal
anti-inflammatory drug use, age >40 years in areas of a high prevalence of
gastric cancer).

persistent symptom after empirical PPI trial (need to stop PPI for at
least 1 week prior to endoscopy).
diagnosis of complications of GERD including oesophagitis,
Barretts esophagus.
severe esophagitis (LA Grade C-D*) after 8-week PPI treatment to
assess healing and exclude Barretts esophagus.
history of oesophageal stricture who have recurrent dysphagia.
evaluation before anti-reflux surgery.

C. Indications for oesophageal pH monitoring

when diagnosis of GERD is in doubt (off PPI before test).

when treatment is ineffective (keep PPI before test) to define those

with or without continued abnormal acid exposure times.

evaluation before endoscopic or surgical therapy (off PPI before test).

persistent/recurrent symptoms after reflux surgery.

D. Indications for esophageal manometry

Not indicated for uncomplicated GERD.

Pre-operative assessment to exclude severe oesophageal motility

disorders before antireflux surgery.

G 17
E. Indications for oesophageal impedance testing

To detect non-acid reflux when oral PPI therapy is ineffective

F. Management

Lifestyle modification: body position, food, weight reduction,

behaviour.

Severe oesophagitis (LA Grade C-D): standard PPI dose# for 8

weeks. Doubling the dose to bd daily may be necessary in some
patients when symptoms or oesophagitis are not well controlled.
Maintenance therapy is required in severe oesophagitis/Barretts
esophagus and lowest PPI dose should be used to minimize long
term adverse effects.

Non-erosive GERD (NERD)/ mild oesophagitis (LA Grade A-B):

standard dose H2 antagonists (H2RA) or PPI# for 8 weeks.
On-demand/intermittent H2RA can be used as maintanence
treatment.
G.Indications for anti-reflux surgery

Unresponsive or intolerant to medical treatment

Complications of GERD unresponsive to medical therapy

Standard dose acid suppressants for GERD:

omeprazole 20mg, lansoprazole 30mg, pantoprazole 40mg, rabeprazole 20mg,
esomeprazole 40mg, dexlansoprazole 30mg, famotidine 20mg bd.
All PPIs except dexlansoprazole should be administered 30-60min before meals to
assure maximal efficacy.

Gastroenterology
and Hepatology

*Los Angeles classification of reflux oesophagitis

A
mucosal break(s) <5mm, no extension between tops of mucosal folds
B
mucosal break >5mm, no extension between tops of mucosal folds
C
mucosal breaks continuous between tops of mucosal folds, but not
circumferential
D
mucosal break(s) involving >75% of circumference

G 18

INFLAMMATORY BOWEL DISEASES: OVERVIEW

DIAGNOSIS = clinical + haematologic + endoscopic
+ histologic + imaging evaluation

A. History:
recent travel, medication (antibiotics, NSAID), sexual and vaccination
smoking, prior appendicectomy, family history, recent episodes of infectious
GE
bowel habit: stool frequency and consistency (nocturnal, usually >6wk
duration), urgency, tenesmus, per rectal passage of blood and mucus
abdominal pain, malaise, fever, wt loss
perianal abscess / fistulae: current or in the past
EIM: joint, eye, skin, oral ulcer

Gastroenterology
and Hepatology

B. Physical Examination:
G/C, hydration, Temp, wt, BMI, nutritional assessment, BP/P, pallor, oral
ulcer
abdominal distension or tenderness, palpable masses, perianal inspection and
PR
C. Endoscopy and Bx for histological evaluation
1. Sigmoidoscopy: in acute severe colitis, take 2 Bx samples
2. Ileocolonoscopy:
a. Crohns disease
patchy distribution of inflammation with skip lesions, rectal sparing is often
deep, stellate, linear ulcers, multiple aphthous ulcers, cobblestoning mucosa
a minimum of 2 Bx from each of the 6 segments (TI, asc, trans, desc,
sigmoid and rectum) including macroscopically normal segments
ulcer: Bx taken from the edges (increase yield of granuloma)
b. Ulcerative colitis
rectal involvement, extend proximally in a continuous, confluent and
concentric fashion; clear and abrupt demarcation between inflamed and
normal mucosa;
caecal patch: patchy inflammation in caecum, observed in L-sided colitis

G 19
backwash ileitis: continuous extension of macroscopic or microscopic
inflammation from caecum to distal ileum, observed in up to 20% of patients
with pancolitis; associated with a more refractory course
severity:
mild: mucosal erythema, decreased vascular pattern, mild friability
moderate: marked erythema, absent vascular pattern, friability, erosions
severe: spontaneous bleeding, ulceration
3. Anorectal ultrasound: for assessment of perianal CD
4. Small bowel capsule endoscopy: high clinical suspicion of CD but -ve
endoscopic/radiologic findings
D. Radiology
1. AXR: small bowel or colonic dilatation (toxic megacolon: transverse colon
diameter >5cm), assess disease extent (ulcerated colon contains no solid
faeces), mass in right iliac fossa, calcified calculi, sacroiliitis
2. CT/MR abd/pelvis /small bowel: dis extent and activity, inflammatory vs
fibrotic stricture, extraluminal Cx, internal fistulization, perianal disease
3. Barium fluoroscopy: superior sensitivity for subtle early mucosal disease
E.
1.

2.

3.

Gastroenterology
and Hepatology

Laboratory Ix:
CBP and ESR: anaemia, thrombocytosis
LFT, electrolytes, RFT, Mg, CRP: active disease, infective Cx, ~ risk of
relapse
Iron studies, vit B12 and folate level
Antibodies: adjunct to diagnosis
Anti-Saccharomyces cerevisiae antibody (ASCA): Crohns disease
p-Anti-neutrophil cytoplasmic antibody (p-ANCA): Ulcerative colitis
Stool
R/M: presence of WBC indicates mucosal inflammation
Culture to rule out infective cause e.g. Clostridium difficile (high
prevalence in IBD), Campylobacter spp., E.coli 0157:H7, amoebae and
other parasites
Cytomegalovirus: in severe or refractory colitis

G 20
4.

Faecal markers: calprotectin

marker of colonic inflammation
useful to differentiate IBD from functional diarrhoea, assessing disease
activity
not available in HK

Gastroenterology
and Hepatology

MANAGEMENT
1. Nutrition:
an adjunct to treatment
dairy free diet in case of active colitis
calcium, vitamin D, fat soluble vitamin, zinc, iron, vit B12 status
2. Fluid and electrolyte correction: hypoK and hypoMg can exacerbate toxic
dilatation
3. Smoking cessation:
a risk factor of CD: higher operative risk and anastomosis recurrence
4. An alternative explanation for symptom should be considered e.g.
infection, bacterial overgrowth, bile salt malabsorption, dysmotility,
gallstones
5. Objective evidence of disease activity should be obtained before starting
or changing medical therapy
6. Avoid NSAID, anticholinergic, antidiarrhoeal, opioids (ppt colonic
dilatation)

G 21

CROHNS DISEASE
Risk factors: smoking, prior appendicectomy, family history of IBD, hx of
infectious GE in the prior one year
Montral phenotypic classification
A. Age of onset:
A1 <16 yrs
A2 17 40 yrs
A3 >40 yrs
B. Disease location:
L1
Ileal
L2
Colonic
L3
Ileocolonic
L4
Isolated upper GI (a modifier that can be added
to L1-L3 when concomitant UGI disease is
present)
C. Disease behavior:
B1
Non-stricturing, non-penetrating
B2
Stricturing
B3
Penetrating
p
Perianal fistulae / abscess (added to B1-B3
when concomitant perianal disease is present)
Medical Management: to induce and maintenance remission, taking into
account on activity, site, disease behaviour and patient preference
Disease activity
CDAI
General

Treatment

CRP

Usually > ULN

Moderate
220 450
Intermittent vomiting

Severe
>450

loss >10%
Tenderness mass
No overt obstruction
Ineffective for mild disease

Cachexia, BMI <18

Abscess
Obstruction
Persistent symptom despite
intensive treatment
Increased

>ULN

a trend towards early introduction of immunomodulator and biologics in

patients with adverse prognostic factors:
1. young age <40
2. extensive small bowel disease
3. requiring steroid in initial treatment
4. perianal disease
5. stricturing disease
6. deep colonic ulcers

Gastroenterology
and Hepatology

Weight
Examination

Mild
150 220
Ambulatory
Eating and drinking
loss <10%

G 22

Gastroenterology
and Hepatology

A.

B.

C.

Aminosalicylates:
no consistent evidence that it is effective in maintenance of remission
monitor CBP and RFT
Sulphalazine: 3-6g/day is modestly effective in colonic disease
Mesalazine: limited efficacy for ileal or colonic disease
Antibiotics:
septic Cx, symptom attributed to bacterial overgrowth, perianal disease
Corticosteroid:
effective to induce remission, ineffective in maintenance of remission
Ca and vit D supplements, +/- osteoprotective therapy if given >12 wks
Systemic steroid: no evidence to support use of a particular regimen but a
standard tapering strategy is recommended
e.g. prednisolone 40mg/day, reducing by 5mg/day at weekly intervals
20mg/day x 4 wks, then reduce by 5mg/day at weekly
intervals
Budesonide: 9mg daily, for TI or ileocaecal disease, less effective
D. Immunomodulator

Thiopurines: to maintain remission, steroid-sparing effect

check thiopurine methyl-transferase (TPMT) level if available
Azathioprine 1.5-2.5mg/kg/day or Mercaptopurine 0.75-1.5mg/kg/day
delay onset of action, takes 8-12 wks, monitor CBP and LFT

Methrotrexate: active or relapsing CD refractory to/intolerant of

thiopurines or anti-TNF, monitor CBP and LFT
Induction: 25mg/wk x 16 wks, maintenance: 15mg/wk, IM or SC
folic acid 5mg weekly, given po 3 days after methotrexate
E. Biologics (anti-TNF):

contraindications: latent untreated or active TB, NYHA Class III- IV heart

failure, hx of demyelinating disease, optic neuritis, history of lymphoma.

Infliximab: chimeric anti-TNF antibody, 75% human IgG and 25% murine
loading with 5mg/kg at 0, 2 and 6 wk, then at 8-weekly intervals IV
infusion

Adalimumab: humanised anti-TNF

loading with 80mg/40mg or 160mg/80mg at 0 and 2 wk, then 40mg
every other week, sc

similar efficacy, choice depends on patients preference, cost, route of

delivery

G 23
covered by Samaritan fund for 1) fistulizing CD, 2) CDAI 300, check
HA intranet for updates (ha.home > Guidelines > Non-clinical Manual /
Guidelines > Samaritan Fund)
F. Proton pump inhibitors: for upper GI involvement
Surgical Management: aim at bowel conservation

an option in localized dis, septic Cx, non-inflammatory obstructive

symptom (stricturoplasty for small bowel, endoscopic dilatation for large
bowel)

perianal disease: examination under anaesthesia (EUA) to assess extent of

disease, drain collections, seton drainage, advancement flaps, fistula plugs

Gastroenterology
and Hepatology

G 24

ULCERATIVE COLITIS
A chronic relapsing and remitting inflammatory condition leading to continuous
colonic mucosal inflammation, affecting the rectum and to a variable extent of
the colon.
Protective factors: appendicectomy (for genuine appendicitis), smoking
Risk factors: family history of IBD, non-selective NSAID in exacerbation of UC
Montral phenotypic classification: according to the maximal extent of
inflammation observed at colonoscopy

influences treatment modality, oral and / or topical

influences timing of starting surveillance and its frequency

E1 Proctitis
involvement limited to the rectum
E2 Left-sided (distal UC)
involvement extending up to splenic flexure
E3 Extensive (pancolitis)
involvement extends proximal to the splenic
flexure
Medical Management

depends on disease activity, extent and pattern of disease, taking patient

preference into account

Gastroenterology
and Hepatology

Disease activity
Bloody stools / day
Pulse
Temperature
Haemoglobin
ESR
or CRP

Modified Truelove and Witts criteria for clinical practice

Mild
<4
< 90 bpm
<37.5 oC
>11.5g/dL
<20 mm/h
Normal

Moderate
4
90 bpm
37.8 oC
10.5g/dL
30 mm/h
30mg/L

Severe
6
>90 bpm
>37.8 oC
<10.5g/dL
>30 mm/h
>30mg/L

immediate admission warranted in severe disease

toxic megacolon: total or segmental non-obstructive dilatation of colon
>5.5cm or caecum >9cm, associated with systemic toxicity

Prognostic indicators:
1. patients diagnosed before the age of 16 have a more aggressive initial
course
2. older age of diagnosis is associated with a lower risk of colectomy

G 25
3.
4.
5.

CRP >45mg/dL on D3 of hospital admission and 3 8 stools/day as

predictor of colectomy
CRP >10mg/dL after a year of extensive colitis predicts an increased rate
of surgery
Presence of sclerosing cholangitis increases risk for colorectal cancer

Mild to Moderate Disease

Dose/day

Oral

IV

Aminosalicylate
Sulphasalazine
Mesalazine tab
Mesalazine granules
Steroid
Prednisolone
Budesonide
Thiopurine
Azathioprine
Mercaptopurine
Steroid
Hydrocortisone

Anti-TNF
Infliximab (IV)
Adalimumab (sc)
Rescue Calcineurin inhibitor
Cyclosporin (IV)
Tacrolimus (po)

Maintenance

500mg bd / 1gm
1-4 gm

0.5 1 gm
1 4 gm

20mg
2gm

4 6 gm
2 4 gm
1.5 4 gm

2 4 gm
2gm
1.5 2 gm

20 40 mg
9mg
1.5 2.5mg / kg
0.75 1.5 mg / kg
100mg Q 6 8H
5mg / kg at wk 0, 2, 6
5mg / kg every 8 wks
160mg / 40mg at wk 0 and 2 40mg every other
week, from wk 4
2mg / kg
0.05mg / kg to keep trough
conc of 10-15ng/mL

Surgery: no response to rescue therapy in 4 7 days

Mild L sided disease: start with topical treatment

Extensive disease: oral therapy
Combination therapy (oral and topical) is more effective in inducing remission
than either modality alone

Gastroenterology
and Hepatology

Severe Disease

Induction

Mesalazine
Suppository: distal
10cm
Enema: to splenic
Topical
flexure
Steroid enema
Prednisolone
Budesonide

G 26
Severe disease: consider rescue therapy early in steroid-refractory disease (~D3)

early surgical input, consider colectomy if no improvement within 4-7

days of salvage therapy

predictors of colectomy:
Colectomy
rate

Gastroenterology
and Hepatology

1.
2.
3.
4.
5.
6.

BO >12/day on D2 of IV steroid
BO >8/day or BO 3-8/day + CRP >45 on D3 IV steroid
Stool frequency x 0.14 CRP on D3 IV steroid 8
High CRP, low albumin and pH, ESR >75, temp >38o on admission
Colonic dilatation >5.5cm
Ileus with 3 small bowel loops of gas

55%
85%
75%
59x
75%
73%

G 27

ACUTE PANCREATITIS
High index of suspicion is needed. Suspect acute pancreatitis in
any patient with upper abdominal pain (esp. with vomiting),
unexplained shock or elevated serum amylase (at least 3 x ULN,
excluding other causes of acute abdomen is of paramount
importance).
A. Assessment of severity and prognosis
Risk factors of severity at admission include age >55, obesity
(BMI >30), altered mental state, and co-morbid disease
Clinical Parameters
Variable

Ranson
At
0 hrs

At
48 hrs

Glasgow
within first
48 hrs

APACHE II
admission,
then daily

Age (years)

>55

>55

WBC count (x109/l)

>16

>15

Blood glucose
(mmol/l)

>11.1

>10

AST (U/l)

>250

LDH (U/l)

>350

>600

>16

creatinine

Serum urea (mmol/l)

>1.8
<2

<2

<32

PaO2 (kPa)

<8

<8

Base deficit

>4

Arterial pH

Serum Alb (g/l)

Fluid sequestration
Haematocrit (%)

>6 L

10%

Serum Na

Serum K

Temperature

Mean arterial BP

Gastroenterology
and Hepatology

Serum Ca (mmol/l)

G 28
Heart rate

Respiratory rate

Glasgow coma scale

(15 - actual
score)

Chronic health score

Suggested cut off

number

11 criteria: <3
8 criteria:
criteria indicate mild 3 criteria
AP
indicate
severe AP

14 criteria: 8
points*
indicate severe
AP

* Points system per variable: from 0 (normal) to +4 (very abnormal).

Minimal score: 0, maximum score: 71.
C-reactive Protein: 150mg/l at 48hrs predicts a severe attack
Contrast-enhanced CT pancreas: to diagnose severity of AP and to
identify complications, especially pancreatic necrosis, full extent
of which cannot be appreciated until at least 3 days after symptom
onset. Best done on D6-D10 after admission.
Balthazar CT severity index = grade of AP (0-4) + percentage of
necrosis (0-6). Score of 7-10 associated with morbidity of 92%,
mortality 17%.
Grade of Pancreatitis

Gastroenterology
and Hepatology

Normal pancreas

Points
0

Percentage of
Necrosis
0%

Points
0

Focal or diffuse enlargement

<30%

Pancreatic or peripancreatic
inflammation

30-50%

Single peripancreatic fluid

collection

>50%

Multiple fluid collection and/or

retroperitoneal air

G 29
B. Watch out for biliary pancreatitis
ALT > 3 ULN in a non-alcoholic patient would highly
suggestive of gallstone aetiology
USG hepatobiliary system for detection of gallstone and
dilated bile ducts; pancreas can only be visualized in 50% of
cases
EUS is the most accurate test for diagnosing or ruling out
biliary etiology
Arrange early ERCP and sphincterotomy within 24 to 72
hours after admission, if there is acute cholangitis or
evidence of persistent CBD stones

Gastroenterology
and Hepatology

C. Management (ICU care for severe cases)

Laboratory Ix for assessment of severity (see above)
CXR, AXR (erect and supine films for excluding other
causes of acute abdomen, serially for monitoring), ECG
Closely monitor vital signs, I/O, RFT, Ca, glucose ABG
Adequate intravenous hydration is crucial (to produce urine
output of 0.5ml/kg/hr in the absence of renal failure) and
supplemental oxygen
Correct electrolyte and glucose abnormalities
Cardiovascular, respiratory and renal support as required
Analgesics - Pethidine for pain control
Nil by mouth till nausea and vomiting settle. Nasogastric
suction if ileus or protracted vomiting
Early oral feeding is encouraged in mild acute pancreatitis
Nutritional support via enteral route is preferred to parenteral
route. Nasogastric or nasojejunal feeding appear comparable
in efficacy and safety.
Parenteral nutrition should be considered if the enteral route
is not available, not tolerated, or not meeting caloric
requirements.

G 30
Recommended nutrient requirements in acute severe pancreatitis
Energy

25-35
kcal/kg/day

Protein

1.2-1.5
g/kg/day

Carbohydrates

3-6 g/kg/day

Lipids

2 g/kg/day

Gastroenterology
and Hepatology

Fat administration is safe provided hypertriglyceridaemia (>12

mmol/l) is avoided
Antibiotics
- Given on demand: biliary sepsis, newly developed sepsis or
systemic inflammatory response syndrome, infected pancreatic
necrosis, an increase in CRP in combination with other
evidence supporting the possibility of infection.
- Prophylactic antibiotic treatment generally not recommended
but may be considered in patients with pancreatic necrosis of
>30% involvement by CT. It should be active against enteric
organisms (e.g. imipenem) and be given for one to two weeks.
Look out for complications e.g. pseudocyst or pancreatic sepsis.
CT-guided FNA of pancreas for Gram stain and culture if
suspected infection of pancreatic necrosis with ongoing fever,
leucocytosis and worsening abdominal pain
Consult surgeon in severe cases or when complication arise.

Haematology

Haematology

H 1

HAEMATOLOGICAL MALIGNANCIES
(1) LEUKAEMIA

Haematology

1. Investigations at diagnosis
a. Blood tests
CBP, PT/APTT
D-dimer, fibrinogen (if suspicious of APL or DIC)
G6PD, HBsAg, antiHBc, antiHBs
RFT, LFT, Ca/P, Urate, Glucose, LDH, Type&Screen
HCV Ab, HIV Ab, HBV DNA for HBV carrier
Serum lysozyme for AML M4/M5/CMML
Flow cytometry, Coombs test and serum protein IEP,
Fluorescence in situ hybridization (FISH) for CLL
Tartrate resistant acid phosphatase (TRAP) for HCL
b. Bone marrow aspiration and trephine
Contact haematologist for cytogenetic and molecular studies
before BM biopsy
2. Initial management
a. Start allopurinol or febuxostat
b. Ensure adequate hydration
c. Blood product support:
RBC/blood transfusion if symptoms of anaemia are present
Platelet transfusion if platelet count 10 x 109/L or 20x109/L if
fever or bleeding
Give FFP if there is evidence of bleeding due to DIC
d. Do sepsis workup if patient has fever
e. Antibiotic therapy:
Give appropriate antibiotic if there is evidence of infection
PCP prophylaxis for patients with acute lymphoblastic leukaemia:
i. Septrin tab 2 daily three days per week, or
ii. Pentamidine inhalation 300mg/dose (or 5mg/kg) once every
4 weeks.
f. Record patients performance status (PS)

H2
3. Inform haematologist the following medical emergencies
a. Hyperleucocytosis (e.g. WBC 100x109/L) for chemotherapy
leucopheresis. Avoid blood transfusion till WBC is lowered
b. APL (acute promyelocytic leukaemia) for early use of
all-trans-retinoic acid (ATRA)
4. Subsequent management
a. Consult haematologist for long-term treatment plan
b. Arrange Hickman line insertion if indicated
c. Arrange HLA typing for patients siblings if HSCT is
anticipated
d. CMV negative blood product for potential HSCT recipient if
patient is CMV seronegative.

Haematology

(2) LYMPHOMA

1. Investigations at diagnosis
a. Blood tests
CBP, ESR, PT/APTT, G6PD
RFT, LFT, Ca/P, LDH, Urate, Glucose, Direct Coombs test
Serum IgG/IgA/IgM levels, serum IEP
HBsAg, anti-HBc, anti-HBs, HBV DNA (optional)
b. Biopsy
Excisional biopsy of lymph node or other tissue (send fresh
specimen, no formalin)
Send fresh specimen for study (immune markers, EM, DNA)
c. Bilateral iliac crest aspiration and trephine
d. Radiology
PET/CT scan (preferred, especially in diffuse large B cell
lymphoma, Hodgkins lymphoma) or CT scan of thorax,
abdomen and pelvis or other sites of involvement
e. Other investigations
Endoscopic and Waldeyers ring exam for GI lymphoma
LP with cytospin for patients with high risk of CNS lymphoma
(high grade lymphoma, nasal/ testicular/ marrow lymphoma)
Cardiopulmonary assessment optional

H 3
2. Initial management
a. Start allopurinol or febuxostat and ensure adequate hydration
b. Record patients performance status (PS)
3. Note the following medical emergencies
a. SVC obstruction due to huge mediastinal lymphoma
b. Hypercalcaemia
c. Tumour lysis syndrome
d. Spinal cord compression
4. Subsequent management
- Consult haematologist for long-term treatment plan

(3) MULTIPLE MYELOMA

1. Investigations at diagnosis
a. Blood tests
CBP, ESR, RFT, LFT, Ca/P, LDH, Urate, Glucose
Serum Immunoelectropheresis (IEP) and paraprotein level
Serum IgG/IgA/IgM level, Serum free light chain level
2 M, CRP, HBsAg, anti-HBc, anti-HBs, G6PD
b. Urinalysis - Bence Jones Protein (BJP) and free light chains
c. Radiology skeletal survey or Total Body MRI or PET/CT
d. Bone marrow aspiration and trephine (+/- FISH)
2. Staging

a. International Staging System (ISS)

Serum Albumin (g/l)

I
II
III

> 35
Neither stage I or III
--

(JCO 23:3412, 2005)

Serum
2-microglobulin
(mg/l)
<3.5
>5.5

Median survival
( months )
62
45
29

Haematology

Stage

H4
b. Symptomatic Vs asymptomatic myeloma

Symptomatic: presence of end-organ damage: CRAB:

Calcium elevation: (>2.9 mmol/L)
Renal insufficiency: (creatinine >176.8mol/L)
Anaemia (Hb <10 or 2g < normal)
Bone disease (lytic or osteopenic)

3. Initial management
a. Ensure adequate hydration and start allopurinol 300 mg daily or
febuxostat
Correct hypercalcaemia pamidronate or Zometa.
c. Renal dialysis plasmapheresis for patients with renal failure
d. Record patients performance status (PS)
e. Consult Radiotherapy or Orthopaedic Team for patients
presenting with skeletal complications (pathologic fracture or
spinal cord compression)

Haematology

4. Subsequent management
Consult haematologist for long-term treatment plan
(4) EXTRAVASATION OF CYTOTOXICS (also see page GM 29
Oncological Emergency)
1. Prevention
a. Extreme care and never give it in a hurry
b. Choose appropriate veins
c. Confirm patency of iv site with NS before injection of cytotoxics
d. Flush with NS on completion of infusion/injection of cytotoxic
drugs
e. Stop when patient complains of discomfort, swelling, redness
f. Use central line if indicated e.g. Hickman line

H 5
2. Extravasation suspected
a. Leave iv needle in place and suck out any residual drug
b. If there is a bleb, aspirate it with a 25-gauge needle
Anthracycline apply ice pack
Vinca alkaloid apply heat
c. Potential antidotes
Anthracycline- DMSO or hydrocortisone or NaHCO3 locally
Vinca alkaloid- apply hydrocortisone locally
Cisplatinum- sodium thiosulphate
d. Record the event in clinical notes and inform seniors

Haematology

(5) INTRATHECAL CHEMOTHERAPY

1. Prescription
a. All intrathecal chemotherapy should be prescribed in a separate
prescription form.
b. Methotrexate, cytarabine and hydrocortisone are the only THREE
drugs that can be prescribed for intrathecal chemotherapy
administration.
c. The route of administration Intrathecal must be written in full in
the prescription.
d. Platelet count and clothing profile should be checked beforehand.
2. Dispensing
a. All dispensed intrathecal drugs must be labeled with a warning
message For Intrathecal Use Only.
b. All dispensed intrathecal chemotherapy must be dispatched
separately in a designated container or in a sealed envelope/bag
(marked Intrathecal drug).
3. Consent
a. Prior to intrathecal chemotherapy administration, the medical staff
who is responsible for the procedure, must obtain an informed
written consent from the patient.
4. Administration
a. Parenteral drug(s) and intrathecal drug must be administered as
separate procedures, i.e. separated in time in setting up and
initiating the administration.

H6
b. The staff responsible for the drug administration must verify the 5
Rights (Right patient, right time, right drug, right dose and right
route) against the prescription. A second trained staff is required to
independently verify the patient identification and drug checking
process.
c. Both staff must sign the medication administration (MAR) record.
(6) PERFORMANCE STATUS
WHO/ECOG Performance Status
Score

Activities

Fully active; able to carry on all pre-disease performance without restriction.

Restricted in physically strenous activity, but ambulatory and able to carry out
work of a light or sedentary nature, e.g. light housework, office work.

Ambulatory and capable of all self-care but unable to carry out any work
activities; up and about more than 50% of waking hours.

Capable of only limited self-care, confined to bed or chair more than 50% of
waking hours.

Completely disabled; cannot carry on any self-care; totally confined to bed or

chair.

(7) HAEMATOLOGICAL TOXICITY

Haematology

WHO Haematological Toxicity Scale

Parameter

Grade 0

Grade 1

Grade 2

Grade 3

Grade 4

Haemoglobin
(g/dL)

11

9.5-10.9

8-9.4

6.5-7.9

<6.5

Leucocytes
(x109/L)

3-3.9

2-2.9

1-1.9

<1

Neutrophils
(x109/L)

1.5-1.9

1-1.4

0.5-0.9

<0.5

Platelets
(x109/L)

100

75-99

50-74

25-49

<25

Haemorrhage

None

Petechiae

Mild blood
loss

Gross blood
loss

Debilitating
blood loss

H 7

NON-MALIGNANT HAEMATOLOGICAL
EMERGENCIES/CONDITIONS
(1) ACUTE HAEMOLYTIC DISORDERS

1. Approaches
a. Collect evidence of haemolysis
- evidence of increased Hb break down
indirect bilirubin, haptoglobin, LDH
Methaemalbuminaemia*, Haemoglobinaemia*,
urinary and faecal urobilinogen, Haemoglobinuria*
Haemosiderinuria*
(* :evidence of intravascular haemolysis)

- evidence of compensatory erythroid hyperplasia

Reticulocytosis, erythroid hyperplasia of bone marrow
- evidence of damage to red cells
Spherocytosis, RBC fragility, Fragmented RBC, Heinz bodies
- evidence of shortened red cell life span
Chromium51 labelled red cell study
b. Document the cause and nature of haemolysis
- Intracorpuscular/Extracorpuscular defect - Congenital/Acquired
- Intravascular/Extravascular haemolysis - Acute/Chronic

3. Management
a. Must identify cause of haemolysis, then treat accordingly

Haematology

2. Investigations
a. Blood tests
CBP, Reticulocyte count, Peripheral smear, Hb pattern
RFT, LFT, Bilirubin(direct/indirect), LDH, Haptoglobin
Direct Coombs test, ANF, Viral study, Screening for malaria
Cold agglutinins (arrange with laboratory)
Sucrose lysis test / PNH screening test(arrange with laboratory)
G6PD assay (may be normal during acute haemolysis, consider
repeating test a few weeks after recovery)
b. Urine test
Urobilinogen, Haemoglobin, Haemosiderin

H8
b. Consult haematologist

Haematology

4. Common agents reported to induce haemolytic anaemia in

subjects with G6PD deficiency
Unsafe for class I, II, & III variants

Safe for class II & III variants*

Acetanilid
Dapsone
Furazolidone
Methylene blue
Nalidixic acid
Naphthalene (mothballs, henna)
Niridazole
Nitrofurantoin
Phenazopyridine
Phenylhydrazine
Primaquine
Sulfacetamide
Sulfamethoxazole
Sulfanilamide
Sulfapyridine
Thiazosulfone
Toluidine blue
Trinitrotoluene
Chinese Herbs:
plum flower ()
chuan lianzi ()
zhen zhu ()
jin yin hua ()
niu huang ()

Acetaminophen (paracetamol)
Aminopyrine
Ascorbic acid except very high dose
Aspirin
Chloramphenicol
Chloroquine
Colchicine
Diphenhydramine
Isoniazid
L-DOPA
Menadione
Para-aminobenzoic acid
Phenacetin
Phenytoin
Probenecid
Procainamide
Pyrimethamine
Quinidine
Quinine
Streptomycin
Sulfamethoxpyridazine
Sulfisoxazole
Trimethoprim
Tripelennamine
Vitamin K

5. Safety for class I variants is usually not known.

Data from Beutler, E, Blood 1994; 84:3613.

Class 1 (severe deficiency with nonspherocytic hemolytic anaemia),

Class II (severe deficiency with intermittent hemolysis), and
Class III (moderate to mild deficiency). Beutler, E, Blood 1994; 84:3613

H 9

(2) IMMUNE THROMBOCYTOPENIC

PURPURA (ITP)

1. Definition
Isolated thrombocytopenia due to peripheral destruction with no
clinically apparent causes but of presumed autoimmune aetiology
Secondary causes:
- SLE
- MDS
- TTP
- HIV infection
- Gestational thrombocytopenia - Alloimmune thrombocytopenia
- Lymphoproliferative disorders - 1oanti-phospholipid syndrome
- Infection (eg. viral, malaria)
- Drugs e.g. heparin induced thrombocytopenia (HIT)
The 4Ts: A clinical probability scoring system for diagnosis of HIT
4Ts
2 Points
Thrombocytopenia Platelet count fall
>50% and platelet
nadir 20 x109/L
Timing of platelet Clear onset
count fall
between days 5-14
or platelet fall 1
day (prior heparin
exposure within 30
days)

New thrombosis
(confirmed); skin
necrosis at heparin
injection sites;
anaphylactoid
reacton after IV
heparin bolous

OTher causes of
thrombocytopenia

None apparent

0 Point
Platelet count fall
<30% or platelet
nadir <10 x109/L
Platelet count fall
4 day without
recent exposure

None

Definite

High probability (6-8 points), intermedicate probability (4-5 points), low probability (3 points).
Adapted from Lo et al., J Thromb Haemost 2006;4:759

Haematology

Thrombosis or
other sequelae

1 Point
Platelet count fall
30-50% or platelet
nadir 10-19 x109/L
Consistent with
days 5-14 fall, but
not clear (e.g.
missing platelet
counts) or onset
after day 14 or fall
1 day (prior
heparin exposure
30-100 days)
Progressive or
recurrent
thrombosis;
Non-necrotizing
(erythematous)
skin lesion;
Supected
thrombosis (not
confirmed)
Possibile

H 10

Haematology

2. Investigations
a. CBP and blood film (to ensure no red cell fragments, leukaemia)
b. Bone marrow examination not mandatory, indicated if
i. the diagnosis of ITP is not certain
ii. in patients age over 60 years to rule out myelodysplasia
iii. prior to splenectomy
iv. if response to treatment is poor
c. Autoimmune profile and APTT
d. anti-HIV serology in patients at risk
3. Management
a. Consult haematologist
b. Initial treatment: Prednisolone 1 mg/kg/day, or
Pulse dexamethasone 20- 40mg/day for 4 days
c. For acute life-threatening bleeding
- IVIg 0.4 g/kg/day for 5 days or 1.0 g/kg/day for 2 days
(80% effective, lasts 2-3 weeks)
- or Methylprednisolone 1 g iv in 1 hour daily for 3 days
- or Pulse dexamethasone 40 mg po daily for 4 days
- or Intravenous anti-Rh0 (D)
d. Second line therapy: thrombopoietin mimetics (Eltrombopag,
Romiplostim), splenectomy, Rituximab, other immunomodulatory
agents
e. Avoid aspirin and other antiplatelet agents and im injection
f. Platelet transfusion only for life-threatening bleeding
4. Management of ITP in Pregnant Women
a. Consult haematologist
b. During pregnancy
Platelet count > 50 x109/L and no bleeding no treatment
Platelet count <50 x109/L- consider steroid or IVIg
Be cautious with use of steroid in first trimester
c. At delivery
- Mode of delivery according to obstetrical indication. Maternal
platelet count 50 x 109 /L is sufficient to prevent complications
due to vaginal delivery or cesarean section.
- Avoid epidural or spinal anaesthesia if platelet count < 80 x 109 /L.
- Check infants platelet count at delivery

H 11

(3) THROMBOTIC THROMBOCYTOPENIC

PURPURA (TTP)
1. Diagnosis
a. Classical pentad microangiopathic anaemia, thrombocytopenia,
fever,
renal impairment, neurologic symptoms and signs
b. Redefined as a syndrome of Coombs-negative haemolytic
anaemia and thrombocytopenia in the absence of other
possible causes of these manifestations
c. Important to examine blood film for micro-angiopathic features
2. Investigations
CBP, Peripheral smear (for features of micro-angiopathic
haemolytic anaemia), retic, RFT, LFT, LDH, Haptoglobin,
Direct Coombs test, Coagulation profile (relatively normal)
3. Treatment
a. Consult haematologist
b. Daily plasma exchange should be commenced immediately with
exchange for FFP or cryosupernatant

c. Platelet transfusion is contraindicated

(4) PANCYTOPENIA

Haematology

1. Approaches to determine the cause of pancytopenia

a. Bone Marrow disorder (defective synthesis)
- Aplastic anaemia
- Reactive haemophagocytosis
- Subleukaemic leukaemia
- Megaloblastic anaemia
- MDS
- Disseminated tuberculosis
- Marrow infiltration: lymphoma, myeloma, marrow fibrosis,
carcinoma
b. Peripheral destruction
- SLE
- DIC
- Hypersplenism
- Paroxysmal nocturnal haemoglobinuria (PNH)
2. Investigations
CBP, Peripheral smear, Bone marrow aspiration and trephine

H 12

(5) THROMBOPHILIA SCREENING

1. Screening Tests
a. Lupus anticoagulant(LA) Anti-cardiolipin Ab
ANF
b. Protein C (PC), Protein S (PS), Antithrombin (AT),
Activated Protein C Resistance (APCR), Factor V Leiden
2. Indications
a. Young patients with idiopathic venous thrombosis
b. Recurrent venous thrombosis or superficial thrombophlebitis
c. Unusual sites of thrombosis (mesenteric, renal, portal veins,
cerebral venous sinus)
d. Warfarin induced skin necrosis
e. Arterial thrombosis with age < 40
f. Recurrent miscarriage

(6) PROPHYLAXIS OF VENOUS THROMBOSIS IN

PREGNANCY

Haematology

1. Pre-delivery and delivery

a. Consult haematologist for dosage of LMWH and monitoring
b. Monitoring of plasma anti-Xa activity may be required
c. If need epidural/spinal anesthesia, withhold LMWH 12-24h before
the procedure.
2. Post-delivery
a. Same dose of LMWH is continued until INR on warfarin is
2.0 to 3.0
b. Warfarin is continued for 6-8 weeks

H 13

DRUGS AND
BLOOD PRODUCTS
(1) ANTI-EMETIC THERAPY

1. 5-HT3 antagonists (for patients on cytotoxic chemotherapy)

a. Zofran (ondansetron) 8 mg iv Q8H/Q12H or 8 mg po tds
b. Kytril (granisetron) 3-6 mg iv once daily or transdermal patch
c. Navoban (tropisetron) 5 mg iv/po once daily
2. Maxolon 10 mg iv Q6H prn
3. Emend ( Aprepitant )
use in combination with corticosteroid or other 5-HT3 antagonist :
125mg po on day 1, 80mg po daily on day 2-3

(2) HAEMOPOIETIC GROWTH FACTORS

Granulocyte Colony Stimulating Factor (G-CSF)

Indications
- Mobilization of haemopoietic stem cells for transplantation
- Shortening of neutropenia after chemotherapy given when
absolute neutrophil 1x109/L
- Drug-induced agranulocytosis
- Other conditions of severe neutropenia associated with
infection e.g. cyclical neutropenia
2. Dosage (usage endorsed by haematologist)
G-CSF: 5 micrograms/kg/day sc/iv (1 vial contains 300 micrograms)
1.

(3) IMMUNOGLOBULIN THERAPY

Haematology

1. Indications
a. As replacement
Primary immunodeficiencies with significant past infections
Secondary Ab deficiencies: CLL, multiple myeloma, post HSCT
patients with chronic GvHD and significant past infections
b. As an immunomodulator (haematology)
Proven benefit-ITP with life threatening bleeding or pregnancy

H 14
Probable benefit autoimmune haemolytic anaemia
post infectious thrombocytopenia
Possible benefit coagulopathy with factor VIII inhibitor
2. Dosage
a. Replacement 0.2 g/kg Q3weeks
b. Immunomodulator e.g. ITP 0.4 g/kg/day for 5 days or 1g/kg/day
for 2 days
3. Contraindications
a. Previous history of allergy to IVIg
b. IgA deficiency

(4) ANTITHYMOCYTE GLOBULIN (ATG)

1. Indication

Very severe AA

Bone marrow cellularity <25% and

Neutrophils <0.2 x109/L and
Platelets <20 x109/L or reticulocytes <20 x109/L

Severe AA

Bone marrow cellularity <25% and two of the following three

Neutrophils 0.2- <0.5 x109/L
Platelets <20 x109/L
Reticulocytes <20 x109/L

Haematology

2. Premedication (1 hour before ATG)

a. Paracetamol 1gm and chlorpheniramine (piriton) 4mg po
Methylprednisolone 2-3 mg/kg in 100ml normal saline iv in 1 hour
3. Test dose: 10mg ATG in 100ml normal saline iv in 1 hour
Physician in attendance, anaphylaxis 1 in 50
4. Daily dose: ATG 40mg/kg iv in 4 hours for 4 days

(5) rFVIIa (NOVOSEVEN)

Dosage:
90-120 micrograms/kg/dose
may be repeated every 2-4 hours
Indications: (Please refer to latest HA drug formulary)
- haemophilc patients with inhibitor activity and active bleeding

H 15
- factor VII deficiency
- patients with acquired inhibitors and active bleeding

(6) NOVEL ORAL ANTICOAGULANTS (NOACs)

Clinical setting
Prevention of venous
thromboembolism post total
hip/knee replacement

Non-valvular Atrial
fibrillation

DVT treatment
PE treatment

Prevention of recurrent VTE

Dabigatran
Knee: 110mg once
within 1-4 hours of
completed surgery, then
220mg daily for 10 days

Rivaroxaban
Knee:10mg daily for 12
days with or without food

Apixaban
Knee: 2.5mg BD
for 12 days

Hip: 110mg once within

1-4 hours of completed
surgery, then 220mg
daily for 28-35 days
CrCl>30mL/min: 150mg
BD; CrCl 15-30mL/min:
75mg BD

Hip: 10mg daily for 35

days with or without food

Hip: 2.5mg BD for

35 days

CrCl>50mL/min:20mg
daily with evening meal;
CrCl 15-50mL/min: 15mg
daily with evening meal

CrCl>30mL/min: 150mg
BD; CrCl30mL/min or
on dialysis: Dosing
recommendation cannot
be provided
CrCl>30mL/min: 150mg
BD; CrCl30mL/min or
on dialysis: Dosing
recommendation cannot
be provided

15mg BD for 21days with

food, then 20mg QD for 6
months, for remaining
treatment

5mg BD (2.5mg
BD with any 2 of
the followings:
80 years old;
BW60kg, serum
Cr 132.6mol/L
10mg BD for 7
days, then 5mg BD

20mg daily with food

The table shows the doses of each OAC in different clinical settings.
be adjustecd if the patient has underlying renal impairment.

2.5mg BD after at
least 6 months of
treatment of
DVT/PE

However, the dose has to

Haematology

Reversal of NOACs:
At the time of writing, there is no specific antidote (only available in
clinical trial). Management of bleeding should be through cessation
of treatment and general haemostatic measures.
Dabigatran: oral activated charcoal may
decrease further
absorption if intake is less than 2 hours. Haemodialysis offers the
possibility of enhanced clearance of the active drug.
Rivaroxaban/Apixaban: Oral activated charcoal may decrease further
absorption while haemodysis does not help.
In life-threatening bleeding condition, prothrombin complex
concentrates (PCC) 25-50 unit/kg can be given while the effect of
rFVIIa is unpredictable

H 16

(7) REPLACEMENT FOR HEREDITARY

COAGULATION DISORDERS

General information for therapy in hereditary coagulation disorders

Factors
VIII
IX
VWF

half life
10 hrs
25 hrs
-

Fibrinogen
90 hrs
V
36-80 hrs
VII
5 hrs
X
40 hrs
XI
45 hrs

replacement material
VIII conc1
DDAVP3 cryoprecipitate*
2
IX conc FFP*
DDAVP
FVIII/VWF containing conc
Cryoprecipitate
FFP
Cryoprecipitate
FFP
FFP
FVIIa FFP
prothrombin complex concentrates
FFP
FFP

Haematology

For Factor VIII and Factor IX deficiencies, use cryoprecipitate / FFP

only when specific factor concentrate is not available
1
1 unit/kg BW of infused Factor VIII raises plasma level by 2%
2
1 unit/kg BW of infused Factor IX raises plasma level by 1%
3
DDAVP is useful for mild haemophilia A if a 3x increase in Factor
VIII suffices. Each patients response should be tested prior to
therapeutic use as there are individual variations. 0.3 microgram/kg in
50 ml normal saline iv in 20 minutes causes a peak in Factor VIII level
at 30 minutes. Intranasal DDAVP may be used. As DDAVP stimulates
fibrinolysis, tranexamic acid 500 mg Q8H is used concomitantly for
dental procedures. Prolonged use of DDAVP causes tachyphylaxis
Suggested Plasma Factor Peak Level and Duration of
Administration for Haemophilia A and B
(WFH Guidelines for the Management of Hemophilia 2012.
www.wfh.org)

H 17

Haematology

H 18

TRANSFUSION

Haematology

Please refer to latest version of HAHO Transfusion Guidelines at

HA webpage (version 2.0, effective date: 13 Dec 2013)
Acute Transfusion
Reaction
(Estimated risk)

Cause

Signs & Symptoms

Management

Allergic reaction
(1:100 to 1:300)

Sensitivity to plasma
protein or donor antibody

1.Flushing
2.Itching, rash
3.Urticaria, hives
4.Shortness of breath,
wheezing
5.Laryngeal oedema
6.Anaphyxis

1. Stop transfusion immediately and

keep vein open
2. Give antihistamine as directed
3. Observe for anaphylaxis
4. If hives are the only sign, the
transfusion may sometimes continue
at a slower rate
5. For anaphylaxis, adrenaline
injection may be required.

Febrile,
non-haemolytic
transfusion
reaction(FNHTR)
(1:100 with
non-leukoreduced
blood components)

Immunological reactions
between recipient HLA or
granulocyte specific
antibodies with donor
leukocytes or reaction to
the pyrogenic cytokines
released from donor
leukocytes during storage

1. Flushing
2. Fever
3. Tachycardia
4. Sometimes rigors

1. Stop transfusion immediately, keep

vein open and inform clinician for
assessment
2. Clerical check for compatibility
between recipient and blood unit(s)
given
3. Antipyretic e.g. paracetamol can be
given
4. For mild febrile reaction and rapidly
resolving symptoms, transfusion
may be resumed slowly.
5. For severe febrile reaction (e.g. rise
in temperature > 1.5 C), the same
unit should not be restarted.
6. Haemolytic transfusion reaction
and septic reaction should always
be suspected,investigated and
managed

Septic reaction
(Red cell 1 :
500,000
Platelet 1 : 10,000)

Transfusion of bacterial
contaminated whole blood
/ blood components

1. Rapid onset of chills

and rigors
2. High fever usually > 2
C
3. Nausea, vomiting,
diarrhoea
4. Hypotension
5. DIC
6. Intravascular
haemolysis
7. Renal failure

Symptoms usually occur

about 30 mins.to 2
hrs.after starting a red
cell transfusion. Even
earlier after a platelet
transfusion

1. Stop transfusion immediately, keep

vein open and inform clinician for
assessment
2. Monitor patient closely for
septicaemic shock
3. Clerical check for compatibility
between recipient and blood unit(s)
given and exclude haemolytic
transfusion reaction accordingly
4. Obtain patients blood for septic
workup and send blood bags and
administration set for culture
5. Treat septicaemia with intravenous
broad spectrum antibiotics with
adequate anti-pseudomonas
coverage
6. Report through hospital blood bank
to HKRCBTS forfurther
investigation

H 19
Circulatory
overload
(1 : 10,000)

Whole blood / blood

component(s) was
administered at a rate or
volume more than the
recipient circulatory
system can accommodate.

1. Rise in jugular venous

pressure with
distended neck veins
2. Dyspnoea
3. Cough
4. Crackles in bases of
lung

1. Withhold transfusion immediately

and exclude other causes
2. Support treatment e.g. place patient
upright with feet in dependent
position; give diuretics, oxygen
supplement, etc.
3. May require intubation if severe
dyspnoea

Haemolytic
transfusion reaction
(1 in 250,000
1,000,000)

Infusion of incompatible
whole blood / blood
components

1. Fever, chills and

rigors or both
2. Pain at the infusion
site or localized to the
loins, abdomen, chest
or head
3. Hypotension,
tachycardia or both
4. Agitation, distress and
confusion; particularly
in the elderly
5. Nausea or vomiting
6. Dyspnoea
7. Flushing
8. Haemoglobinuria

1. Stop transfusion immediately and

spigot off the unit. (save the blood
units and blood giving set for
investigation)
2. Use a new giving set and keep vein
open with normal saline
3. Inform clinician for urgent
assessment
4. Clerical check for compatibility
between recipient and blood unit(s)
given
5. Inform blood bank to return blood
units for investigations and collect
additional blood samples
6. Treat shock if present
7. Collect urine samples
8. Maintain BP with IV colloid
solutions. Give diuretics as
prescribed to maintain adequate
urine output
9. Insert indwelling catheter to monitor
hourly urine output. Patient may
require dialysis if renal failure
occurs

Transfusion related
acute lung injury
(TRALI)
(1 in 50,000
200,000 reported
in the literature)

? due to the presence of

antibodies
(anti-granulocyte-specific,
anti-HLA class I,
anti-HLA class II,
anti-IgA, other ?) from
donors to cause immune
reaction in the recipient
resulting in the clinical
manifestation in the lung.

1. Acute respiratory
distress occurring
within 6 hour of
starting a transfusion
2. Severe bilateral
pulmonary edema
3. Severe hypoxia
4. Fever
5. Chest X ray shows
peri-hilar and nodular
shadowing in themid
and lower zone

1. Withhold transfusion immediately

and exclude other causes of
shortness of breath e.g. circulatory
overload
2. Prompt and full respiratory support
3. If properly treated, reversible and
recovered without sequelae
(pulmonary edema can clear usually
in72 hr)
4. Report through hospital blood bank
to HKRCBTS for further
investigation

Haematology

H 20
Whole blood / Blood
components

Dosage

Indications

Fresh whole blood (

5 days from donation)

1 -2 units

Exchange transfusion or massive blood loss in neonates

Whole blood / Red

cells

Dosage depends on clinical

situations
One standard unit (derived
from 450 ml whole blood
donation) should raise Hb level
by up to 1.2 g/dL in a 70 kg
adult.
One small unit (derived from
350 ml whole blood donation)
should raise Hb level by about
0.85 g/dL in a 70 kg adult.
For children, 4 ml/kg should
raise Hb
level by 1 g/dL

There is no single haemoglobin value that must be taken as

the transfusion trigger. However, a trend towards cautious
blood transfusion trigger has been observed but patients
condition may affect clinical decision. The initiation of
transfusion is a clinical decision by the attending clinician.
Ingeneral, the following principles are considered:
1. Haemoglobin concentration <7g/dL and assessment on
the rate of ongoing red cell loss.
2. For haemoglobin concentration between 7 and 10 g/dL,
transfusion strategy is less clear but general view is that
transfusion is often not justified purely based on
haemoglobin concentration.
3. A higher haemoglobin concentration may be required in
patients who may tolerate anaemia poorly, e.g. patients
over the age of 65 years and patients with cardiovascular
or respiratory disease.

Haematology

Platelet concentrates
4 random donor units (each
(either prophylactic or derived from 350 ml or 450 ml
therapeutic)
whole blood donation) for
adults up to 70 kg;
each unit should raise platelet
count by 7-10 x109/L
5 units/M2 for paediatric
patients
1 unit of apheresis platelet
concentrate is equivalent to one
standard adult dose (for adults
up to 70 kg)

1. Platelet <10 x109/L in stable patients (usually NOT

indicated in idiopathic thrombocytopenia, systemic lupus
erythromatosis, thrombotic thrombocytopenia and
hemolytic-uraemic syndrome).
2. Platelet <20 x109/L in patients with fever or sepsis.
3. Platelet <50 x109/L with diffuse microvascular/mucosal
bleeding, major bleeding or before invasive procedures.
4. Platelet <100 x109/L with retinal or central nervous
system bleeding/ surgery, or with active bleeding in
postcardiopulmonary bypass.
5. Platelet <50 x109/L in stable premature neonates or
platelet <100. x109/L in sick premature neonates
6. Suspected platelet dysfunction with active bleeding or
before invasive procedures.
7. Suspected platelet deficiency with severe active
bleeding or following massive transfusion.

Buffy coat/
granulocytes (must be
irradiated)
(Require special
arrangement with the
HKRCBTS)

10 units/day for 4 days or until

fever subsides

Neutropenia (<0.5 x109/L) with documented infection

unresponsive to broad spectrum antibiotics including
antifungal agents for at least 48 hours.

Fresh frozen plasma

(FFP)

Typical dosage:
2 -4 units for adults
12 -15 ml/kg for paediatric
patients
** always reassess for clinical
and laboratory responses

1. Thrombotic thrombocytopenic purpura.

2. When clotting factors deficiency is suspected or
anticipated with active bleeding during operation or
following massive transfusion,
3. Immediate reversal of warfarin overdose (bleeding or
impending surgery).
4. Prothrombin time/ activated partial thromboplastin time
(PT/APTT) >1.5x control values with active bleeding or
before invasive procedure in the following situations:
Single or multiple clotting factor deficiency (other than
haemophilia A/B).

H 21
Disseminated intravascular coagulopathy).
Hepatic failure.
Methylene Blue
treated FFP

Supply for pediatric patients

only.

As for fresh frozen plasma, with lower residual infectious

risk

Cryoprecipitate

Depends on the target factor

levels in particular diseases and
clinical situations, ranging from
6 -30 units/dose; 10 units per
dose for adults up to 70 kg

1. von Willebrand disease (if desmopressin or factor

concentrate is inappropriate).
2. Documented fibrinogen deficiency (<100 mg/dL) or
dysfunction.
3. Documented factor XIII deficiency.

Leucodepleted
(filtered) red cells

Same as other red cell

preparations

As indicated for whole blood/red cells, but especially

indicated for:
1. All thalassaemia patients on regular transfusion
regimens;
2. Haematological diseases;
3. Documented severe febrile non-haemolytic transfusion
reaction ( 2 episodes);
4. Paediatric oncology patients.

Irradiated cellular
blood components

Same as non-irradiated
counterparts

For prevention of transfusion-related graft versus host

disease in circumstances such as:
1. Foetuses requiring intrauterine transfusion.
2. Patients with severe congenital cellular
immunodeficiency.
3. Haemopoeitic stem cell transplantation patients.
4. Patients receiving transfusion from close relatives.

Cytomegalovirus
(CMV) negative
cellular blood
components

Dosage according to individual

cellular blood components

1. CMV-antibody-negative pregnant women

2. CMV-antibody-negative recipients of allogeneic stem
cell grafts
3. Intrauterine transfusions
4. Patients with human immunodeficiency virus (HIV)
disease

Rhesus D (Rh(D))
negative red cells

Same as Rh(D) positive red

cells

In this order of priority:

1. Haemolytic disease of newborn due to anti-D.
2. Rh(D) negative individuals with anti-D.
3. Rh(D) negative females prior to menopause.
4. Emergency resuscitation of Caucasian females in
reproductive age with unknown Rh(D) status.
5. Other Rh(D) negative individuals

Haematology

Haematology

H 22

Nephrology

Nephrology

K 1

RENAL TRANSPLANT
DONOR RECRUITMENT
Protocol for preparation and management of potential organ donor:
Identification of potential organ donor:
a. definite diagnosis, irreversible CNS damage;
b. brain death is imminent;
c. put on mechanical ventilation;
d. GCS 3-5 / 15, both pupils fixed to light
Exclusion criteria:

Age 71 (for kidney donors);

Uncontrolled fulminant infection;

Risk of transmission of disease caused by prions, including

Creutzfeldt-Jakob disease, rapid progressive dementia or
degenerative neurological disease;

History of IV drug abuse;

HIV +ve cases or has risk factors for HIV infection;

Presence or previous history of malignant disease (except

primary basal cell carcinoma, carcinoma in-situ of uterine
cervix and some primary tumour of CNS)
Maintenance of organ perfusion of potential donor:
Aim:
Maintain SBP 100 - 140mmHg, AR 60-120 bpm
Maintain Mean BP > 80mmHg
Maintain CVP of 8-12cm H2O
Maintain hourly urine output ~100ml
Maintain intake and output balance and cover insensible loss
Maintain SaO2 >= 95%
Maintain body temperature> 36oC
Nephrology

K2

Nephrology

a. Monitor BP, P, CVP, urine output, SaO2, ventilator status q1h,

body temperature q2h
b. Monitor electrolytes, RLFT, Ca/PO4 q6-8h, Hstix q2-4h
c. Set two good IV lines, preferably one central line
d. Monitor BP:
- If persistently hypertensive (MBP > 120mmHg), start
labetalol 5mg IV over 1 min and repeat at 5 min intervals if
necessary
- If persistently hypotensive (SBP 100mmHg)
: Start fluid replacement by infusing crystalloid or colloid
: Add dopamine 2.5 10 micrograms/kg/min if BP
persistently low despite adequate fluid replacement
: Add adrenaline 0.1 10 micrograms/kg/min
- If BP persistently low: start hydrocortisone 100mg stat &
100 mg q8h
e. Monitor urine output: If massive urine output ( > 200ml /hour )
: Control hyperglycaemia ( Hstix > 12mmol/L persistently) by
Actrapid HM hourly infusion at 2 6 units
: Control diabetes insipidus (serum Na 150mmol/L) by
dDAVP 2-6g IV q6-8h
: Control hypothermia (body temperature 35oC) by apply
patient warming system
If oliguric (hourly urine < 30ml)
: check Foley patency
: oliguria with low or normal CVP, start fluid replacement
: oliguria with high CVP, start lasix 20 250mg IVI
f. Add prophylactic antibiotics after blood culture if fever > 38oC.
Routine arrangement:
a. Inform transplant coordinator via hospital operator at any time
b. Interview family for grave prognosis, do not discuss organ
donation with family until patient is confirmed brain death
c. Once the patient meets brain death criteria, arrange qualified
personnel to perform brain stem death test

K 3

ELECTROLYTE DISORDERS
Hypokalaemia
Hints Ix:

Mx:

Check drug history, most likely attributed to diuretic therapy;

Usually associated with metabolic alkalosis;
Start intravenous therapy if serum K < 2.5 mM;
Consider magnesium depletion if hypoK is resistant to
treatment;
Dont give potassium replacement therapy in dextrose solution.
serum RFT, total CO2 content, chloride, magnesium;
simultaneous blood and urine x TTKG (trans-tubular potassium
gradient)
check baseline ECG (esp. those patients on digoxin therapy)
If serum K > 2.5 mM & ECG changes are absent:
KCl 20-30 mmol/hour in saline infusion (up to 60-80 mmol/L)
as continuous IV infusion; may combine with oral KCl 30-40
mmoles (3-4 gm syr KCl) Q4H; maximum total treatment dose:
100 200 mmoles per day (~ 3 mmoles/kg/day).
If serum K < 2.5 mM &/or ECG changes present:
Consult ICU / cardiac monitor;
KCl 30-40 mmol/hour in saline infusion (concentration up to 80
mmol/L); may combine with oral KCl 30-40 mmoles (3-4 gm
syr KCl) Q4H; maximum total treatment dose: 100 200
mmoles per day (~ 3 mmoles/kg/day).
Hypokalaemia associated with metabolic acidosis
Give potassium citrate solution (1 mmole/mL) 15-30 mL QID
in juice after meals; start K replacement before bicarbonate
therapy in separate IV line if indicated.

Nephrology

K4
Dosage form:
Syrup KCl ( 1 gram = 13.5 mmoles K );
Slow K ( 8 mmoles K / 600 mg tablet );
Potassium citrate ( 1 mL = 1 mmole K );
Phosphate-sandoz ( 3 mmoles K, 16 mmoles phosphate /
tablet ).

Nephrology

Pre-mixed K-containing solution for maintenance IV infusion

for HA Hospitals
0.9% NS with 10 mmoles K / 500 mL ( K conc: 20 mM)
0.9% NS with 20 mmoles K / 500 mL ( K conc: 40 mM)
5% D5 with 10 mmoles K / 500 mL ( K conc: 20 mM)
5% D5 with 20 mmoles K / 500 mL ( K conc: 40 mM)
Lactated Ringers with 2 mmoles K /500 mL (K conc: 4 mM)

K 5
Hyperkalaemia
Hints: Exclude pseudohyerK e.g. haemolysis, esp. in those with
relatively normal renal function;
discontinue K supplement, NSAID, ACEI, K-sparing diuretic.
Ix:
Repeat RFT CO2 chloride, ECG
Rx:
For urgent cases ( serum K > 6 mM &/or ECG changes of
hyperK )
1. 10% Calcium gluconate 10 mL IV over 2-3 minutes with
cardiac monitoring; repeat if no effect in 5 minutes
(onset:1-3 min; duration: 30-60 min ). If digoxin toxicity is
suspected, omit calcium gluconate infusion.
2. Dextrose-insulin infusion: give 250 mL D10 or 50 mL D50
with 8-10 units Actrapid HM over 30 minutes; repeat every
4-6 hrs if necessary (onset: 30 minutes; duration: 4-6 hrs ).
3. Sodium bicarbonate 8.4% 100-150 mL over 30-60 min; to
be given after calcium infusion in separate IV line; watch
out for fluid overload (onset: 5-10 minutes; duration: 2 hrs).
4. Resonium C / A: 15-50 g orally Q 4-6 hrs or as retention
enema; may be given in 100-200 mL 10% mannitol as
laxative; one gm resonium will bind 1 mmole of K. (onset:
1-2 hrs; duration: 4-6 hrs).
5. Salbutamol 10-20 mg in 3 mL NS by nebulizer (onset:
15-30 minutes; duration: 2-3 hrs).
6. Diuretics: furosemide 40-80 mg IV bolus.
7. Emergency haemodialysis or peritoneal dialysis.
For chronic cases:
1. Low K diet (< 2 g/ day).
2. Diuretics: furosemide / thiazide
3. Correct acidosis with sodium bicarbonate 300-900 mg tds
(~10-30 mmoles/day).
4. Fludrocortisone 0.1-0.2 mg daily (for Type IV RTA).
Nephrology

K6
Hypercalcaemia (Also see page PM 14 and GM 27)

Nephrology

Hints: calculated corrected serum calcium level based on serum albumin

concentration
Corrected calcium = 0.02 * (40 g/L patients albumin (g/L)) + serum
Ca; commonly associated with dehydration.
Ix:
check ionized calcium, PO4, RFT, ECG
Rx:
1. Off calcium / vitamin D supplement if any.
2. Volume repletion with NS at 100-500 mL/hr infusion ( guided by
CVP / urine output ); start furosemide after rehydration 20-40 mg
IV Q 2-12 H; aim at a urine output of ~ 200 mL/Hr; close
monitoring of Na K Ca Mg level.
3. Pamidronate 30-90 mg in 250-500 mL NS infused over 4-6 hrs;
maximum effect is not seen for several days; repeat another dose
after a minimum of 7 days if necessary.
4. Salmon calcitonin 4 units/kg IMI / SC Q 12 H; Ca level begins to
fall within 2-3 hrs; tachyphylaxis occurred within 2-3 days.
5. Mithramycin: 25 micrograms/kg IV in 500 mL D5 over 3-6 hrs
infusion; Ca begins to decrease in 12 hrs; peak action at 48 hrs;
repeat dose at 3-7 days interval if necessary (usually reserve for
malignancy-related hypercalcaemia ).
6. Hydrocortisone 5 mg/kg IV Q 8 H then prednisolone 40-100 mg
daily ( onset: 3-5 days; useful in haematological malignancy,
vitamin D intoxication, some CA breast).
7. Sandoz-phosphate 2-8 tablets per day; avoid if severe
hypercalcaemia or hyperphosphataemia.
8. Haemodialysis with zero or low Ca dialysate.

K 7
Hypocalcaemia
Hints:
Ix:
ECG.
Rx:

usually due to chronic renal failure;

check ionized Ca level, PO4, ALP, Mg, RFT, amylase, CK,

Symptomatic hypocalcaemia: 10% Calcium gluconate 20 mL

IV over 10-15 minutes then
30 mL 10% Ca gluconate in
500 mL NS/D5 Q 4-6 H /pint; monitor Ca level.
Chronic cases: ( add Vit D if no response after 2-4 gm
elemental Calcium )
1. Ca supplement: Caltrate=600 mg elemental Ca / tablet
Oscal=250 mg elemental Ca / tablet
Titralac=168 mg elemental Ca / tablet
Ca gluconate=27mg elemental Ca / tablet
2. Vit D: Calcitriol/1-hydroxycholecalciferol: 0.25-2ug daily

Nephrology

K8
Hypomagnesaemia

Nephrology

Hints: may be associated with hypoK, hypoCa, arrhythmia.

Ix: check RFT, K, Ca, ECG.
Fractional excretion (FE) of Mg
= 100 x (UMg x PCr) / (0.7 x PMg x UCr)
( if HypoMg, FE > 2.5% indicates renal loss of Mg).
Rx: Emergency:
4 mL 50% MgSO4 ( 8 mmoles ) solution IV in 20 mL NS/D5
infused over 15 minutes then 10 mL 50% MgSO4 ( 20 mmoles )
in 500 mL NS/D5 over 6 hrs.
Less urgent cases:
4 mL 50% MgSO4 ( 8 mmoles ) solution 500 mL NS/D5 Q 8
H/pint for 1 day ( up to 50% of the infused Mg will be excreted
in urine; slow and sustained correction of hypoMg is preferred)
Chronic cases:
Normal average daily intake of Mg ~ 15 mmoles ( ~ 1/3 is
absorbed )
1. Mg supplement : Mylanta / Gelusil : 3.5 mmoles/tablet
2. Amiloride: 5 10 mg daily PO ( decrease urinary loss of
Mg )

K 9
Hypermagnesaemia
Hints: Uncommon in the absence of Mg administration or renal failure;
Mild cases ( < 1.5 mM ) usually require no treatment.
Rx:

Take off Mg supplement if any;

Saline diuresis: NS 300 500 mL / hr infusion;
10% Calcium gluconate 10 20 mL in 100 mL NS over 15
minutes;
Furosemide 20 40 mg Q2-4 Hr ( aim at urine output ~ 200
mL/hr );
Haemodialysis if necessary.

Nephrology

K 10
Hyperphosphataemia
Hints:

Nephrology

Ix:
Rx:

Usually attributed to chronic renal failure;

Usually resolved in 6-12 hrs if RFT normal;
Aim at a serum phosphate level of ~ 1.4 mM for uraemic
patients.
RFT Ca PO4 CO2 ALP
1. Low phosphate diet ( < 1 gm / 30 mmoles per day ).
2. Start phosphate-binder:
If serum phosphate < 2 mM:
Caltrate tab 1-2 tds with meal
Titralac tab 1-2 tds with meal
Ca acetate tab 1-2 tds with meal
If serum phosphate > 2 mM:
Alusorb tab 1-3 tds with meal
Alutab tab 1-3 tds with meal
3. Arrange dialysis if necessary.

K 11
Hypophosphataemia
Hints:

usually required no treatment if serum PO4 > 0.5 mM;

Replacement rate < 2 mg (0.067 mmoles)/kg per 6 hrs,
otherwise may be associated with metastatic
calcification.
Ix: check RFT serum Ca / PO4 ALP;
Fractional excretion (FE) of phosphate
FE = 100 x (Up x PCr) / (UCr x Pp)
(In the presence of hypoPO4, FE >5% indicates urinary loss)
Rx: IF serum PO4 < 0.5 mM with symptoms:
6 mL potassium di-phosphate solution in 500 mL D5 Q 12 H
infusion
(Potassium di-phosphate solution : 14.5 mmoles PO4 + 25
mmoles K per 10 mL solution)
Chronic therapy:
Sandoz-phosphate tab 1 QID PO (16 mmoles PO4; 20 mmoles Na; 3
mmoles K / per tablet)

Nephrology

K 12
Hyponatraemia
Ix: RFT, serum / urine osmolarity, spot urine x Na.
1. Isovolaemia:
(urine Na > 20 mM: SIADH, hypothyroid, Addisons disease;
urine Na < 10 mM: water intoxication )
Rx: restrict water intake < 1000 mL per day;
High salt diet (> 8 gm/day) sodium supplement:
Syr NaCl 2 gm tds (100 mmoles);
demeclocycline 600-1200 mg daily;
For symptomatic hypoNa: 100 mL 5.85% NaCl (1
mmole/mL) over 4-6 hrs + furosemide 40 mg IV; repeat if
necessary until serum Na > 120 mM or patient is
asymptomatic (rapid collection > 0.5 mM / Hr elevation in
serum Na may lead to central pontine myelinosis ).
2. Hypovolaemia:
(urine Na < 10 mM: fluid loss, hypotension, dehydration; urine Na
> 20 mM: diuretics, adrenal insufficiency, salt wasting)
NS 500 mL/hr till BP normal, then replace Na deficit with NS;
Sodium deficit = BW (kg) x 0.6 x (desired [Na] measured [Na]);
replace first 50% of deficit over 4-6 hrs and the other 50% over
next 18-20 hrs till serum Na level reaches 120 mM or increase by
10-12 mM over 24 hrs.

Nephrology

3. Hypervolaemia:
( urine Na < 10 mM: CHF, cirrhosis; urine Na > 20 mM: acute /
CRF )
Rx: restrict water intake < 1000 mL per day;
Furosemide 40-80 mg IV / 20 500 mg PO daily.

K 13
Hypernatraemia
Ix: serum / urine x osmolality.
Rx: Hypervolaemia:
(Primary Hyperaldosteronism, Cushings syndrome, acute salt
overload)
Start D5 infusion to correct water deficit;
Add furosemide 40-80 mg IV or PO Q12-24 H
Isovolaemia or Hypovolaemia:
(Diabetes insipidus, large insensible water loss, renal / GI loss )
If volume is depleted, give NS 500 mL/hr infusion till no
orthostatic hypotension, then replace water:
Serum Na < 160 mM: give water PO
Serum Na > 160 mM: replace fluid with D5 or half half saline;
body water deficit (L) = {0.6 x BW(kg) x (measured [Na] 140)}
/ 140;
replace half of the body water deficit over first 24 hrs, then
remaining deficit over next 1-2 days ( correct Na at a rate < 0.5
1 mM/hr; rapid correction may lead to cerebral edema );
For acute DI: give DDAVP 4-8 g Q 3-4 H prn;
For chronic central DI: DDAVP 10-40g daily intranasally (in
one to two divided dose)
For chronic nephrogenic DI: thiazide diuretic, e.g.
hydrochlorothiazide 25 mg daily, indapamide 2.5 mg daily,
amiloride 5 mg daily

Nephrology

K 14

SYSTEMATIC APPROACH TO THE ANALYSIS OF

ACID-BASE DISORDERS
1. Hx and PE for causes of acid-base disturbance.
2. Identify the primary acid-base disturbance.
3. Assess adaptive response to primary acid-base disorder.
1o response
Adaptive response
Metabolic
Acidosis
HCO3
pCO2: 1.6 kPa per 10 mM in HCO3
pCO2 =(1.5 x HCO3) +8 2 mmHg
Alkalosis
HCO3
pCO2: 0.9 kPa per 10 mM in HCO3
Respiratory
Acidosis
pCO2 acute: 0.77 mM HCO3 per 1 kPapCO2
chronic: 2.7 mMHCO3 per 1 kPapCO2
Alkalosis
pCO2 acute: 1.5 mM HCO3 per 1 kPapCO2
chronic: 3 mM HCO3 per 1 kPapCO2
Suspect mixed metabolic / respiratory acid-base disorder if
compensation is not appropriate (common in clinical practice!).
4. Calculate serum anion gap ( Na Cl HCO3; normal 10 4 )
High AG metabolic acidosis:
- Treat underlying disorder, consider HCO3 therapy if serum HCO3 <
10.
Normal AG metabolic acidosis:
- Use IV NaHCO3 (1 mL = 1 mmoles of HCO3) if serum HCO3 < 10 (To
be given in large vein over 1-2 hrs, watch out for fluid / salt overload ).
- IV NaHCO3 required = (15 measured HCO3) x BW (kg) x 0.5
(Correct to HCO3 > 15 mM is usually sufficient)
5. For patients with acidosis:
Compare AG with serum HCO3 (abnormal if discrepancy > 5):

Nephrology

AG > serum HCO3: mixed metabolic acidosis / alkalosis

AG < serum HCO3: mixed normal AG /AG metabolic acidosis

K 15
6. Measure urine electrolytes / pH:
a) For patients with metabolic alkalosis
urine Cl < 15 mM Cl responsive metabolic alkalosis, e.g.
vomiting
urine Cl > 15 mM Cl resistant metabolic alkalosis, e.g.
mineralocorticol excess, during diuretic therapy.
b) For suspected renal tubular acidosis
urine anion gap : Na + K Cl ( normal: negative )
urine osmolar gap: [urine osmolarity 2(Na + K) urea] / 2
(normal: >30)
abnormal value indicates low ammonium excretion, e.g. distal
RTA
*false positive conditions: - present of an unusual anion in urine,
e.g. ketone; excessive bicarbonaturia, urine pH > 6.5
Causes for high anion gap metabolic acidosis (MULEPAK)
M = methanol , U = uraemia,L = lactic acidosis,
E = ethylene glycol P = paraldehyde, A = aspirin,K = ketosis
Causes for normal anion gap metabolic acidosis (USEDCAR)
U = ureteroenterostomy, S = saline infusion, E = endocrinology
e.g.: Addison, D = diarrhoea, C = carbonic anhydrase inhibitor,
A = ammonium chloride R = renal tubular acidosis

Nephrology

K 16
Therapeutic Options in patient with metabolic acidosis:
Hints:
In order to avoid being misled by acute hyperventilation or
hypoventilation, plasma [HCO3] is, in general, a better guide
to the need of NaHCO3 therapy than systemic pH.

Nephrology

1. Correction of metabolic acidosis with HCO3

- Oral NaHCO3 : 300 mg ( 3.6 mmoles ) per tablet
- NaHCO3 required (mmoles) = (desired measured HCO3 ) x
BW(kg) x 0.5
- Give over 1 2 hours as 8.4% NaHCO3 IVI ( 1 mL = 1 mmole
HCO3 )
- Overcorrection may increase CO2 production, which can
aggravate respiratory acidosis in a poorly ventilated patient.
Watch our for hypercapnia which may cause paradoxical increase
in acidaemia after NaHCO3 therapy
- Can worsen or precipitate hypokalaemia.
2. Hyperventilation:
If the patient with severe metabolic / respiratory acidosis is in
pulmonary oedema, one should consider ventilating the patient to
lower PCO2 appropriately to treat acidaemia.
Acidaemia responses much faster to lowering the PCO2 than to IV
NaHCO3 therapy.
3. Dialysis:
- Especially in those patients with volume overload;
- Use HCO3 bath for haemodialysis.

K 17
Therapeutic options in patients with metabolic alkalosis:
Hints: Metabolic alkalosis is a disorder caused by mechanisms
whereby [HCO3] is elevated; and a renal basis, e.g.
hypovolaemia, to maintain an elevated [HCO3] level. Both
processes must be corrected if possible for an optimal response
to therapy.
Chloride-responsive metabolic alkalosis ( urine chloride < 15 mM ):
- give NS KCl to correct ECF volume;
- give H2 antagonist if alkalosis due to NG suction;
- acetazolamide 250 mg QID PO / IV ( may promote K loss ).
Chloride-resistant metabolic alkalosis ( urine chloride > 15 mM ):
- Block mineralocorticoid effect with spironolactone 100 400
mg daily PO.

Nephrology

K 18

PERI-OPERATIVE MANAGEMENT IN
URAEMIC PATIENTS
1.
2.
3.

4.
5.
A)
B)

Assess fluid status, BP control.

Check Na, K, urea, Creatinine, Ca/PO4, CBP, arterial blood gases,
CXR, ECG.
Consult renal team for need of peri-operative dialytic support.
HD: preferably 1 day before operation (pre-dilution / tight
heparin).
PD: continue CAPD. Cap off Tenckhoff catheter and drained out
PDF for abdominal operation.
Transplant recipient: continue usual dose of immunosuppressive
agents
Steroid cover for those patients on oral steroid.
Treatment of bleeding tendency: (arrange dialysis if available)
Dosage
Onset time Remark
Blood
-------Hb > 8 g/dL,
Transfusion
Hct >0.26.
fluid overload.
dDAVP
0.3 microgram/kg SC 1 hour
for 2 days then off.

Nephrology

C) Cryoppt
D) FFP
E) Premarin

(Octostim: 15 micrograms/ml)
or 40 micrograms intranasally
BD

10 bags
5 units

1 hour
1 hour
0.6 mg/kg IV daily x 5/7 > 6 hour

Major bleeding
Major bleeding
For major
surgery or long
lasting effect.

K 19

RENAL FAILURE
Hints: Exclude pre-renal failure: Orthostatic hypotension,
congestive heart failure, cirrhosis
Exclude post-renal failure: PR exam, feel for bladder, bedside
USG
Ix:
CBP, RLFT, CO2, Cl, Ca, PO4, amylase, urate, arterial blood
gases, CXR, ECG;
24 hr urine x Na K P Cr Cr Clearance;
MSU x RM C/ST, urine x dysmorphic RBC;
Autoimmune markers : ANF, DsDNA, C3/4, ANCA, anti-GBM,
etc ;
HBsAg/Ab, anti-HCV (urgent HBsAg if haemodialysis is
anticipated);
Urgent USG kidneys, KUB.

Nephrology

Treatment of suspected acute renal failure:

1. Fluid intake = 500 mL + urine output;
Fluid challenge: NS 500-1000 mL over 1-2 hrs for hypovolaemia;
Add frusemide 10 mg/hr IV infusion for fluid overload; metolazone
5-10 mg daily PO;
Dopamine 2.5 microgram/kg/min to improve renal blood flow.
2. Correct electrolyte disturbances: hyperkalaemia, metabolic acidosis.
3. Low salt diet (< 100 mmoles per day), low K (<20 mmoles/day),
low phosphorus diet (<800 mg day), low protein diet (40 g HBV).
4. Strict I/O chart, daily BW (< 1 kg increase in BW per day)
5. Emergency indications for dialysis: uncontrolled hyperkalaemia (>6
mmol/L); uncontrolled metabolic acidosis (HCO3 <10 mmol/L);
uncontrolled pulmonary oedema.
6. Less urgent indications for dialysis: uraemic pericarditis, uraemic
encephalopathy, intractable uraemic symptoms.
7. Inform on-call renal physician for acute HD support if indicated.
8. Avoid nephrotoxic drugs if possible, e.g. NSAID, aminoglycoside,
etc.

K 20

Nephrology

Treatment of chronic renal failure:

1.
Consult nephrologist for assessment of feasibility of long-term
renal replacement therapy.
2.
No blood taking / BP measurement from AV fistula arm.
3.
Monitor AV fistula daily / exit site dressing daily for CAPD
patients.
4.
Strict I/O chart, daily BW ( < 1 kg increase in BW per day ).
5.
Diet ( consult dietitian ):
Calorie 30-35 kcal/kg/day ( 500-700 kcal from PD already for
CAPD patients );
Protein: 0.6-0.75 gm/kg/day for CRF patients
1.2-1.3 gm/kg/day for CAPD patients
1-1.2 gm/kg/day for HD patients.
Na: < 100 mmoles per day for CRF / HD patients (except
salt-loser )
No restriction for euvolaemic CAPD patients.
K: < 1 mmole/kg/day.
PO4: <800 mg/day.
Vitamin: Ascorbic acid 100 mg/day (optional)
Folic acid 5 mg/day (optional)
Rocaltrol / Alfacalcidol: 0.25-2 g /day ( For renal
osteodystrophy).
6.
Control hypertension (<140/90 mmHg): long-acting calcium
channel blocker, beta-blocker, ACEI (monitor RFT, K ).
7.
Correct metabolic acidosis, hyperK, hypocalcaemia.
8.
Symptomatic anaemia: transfusion ( preferably during dialysis
using pack cell); give Lasix 20-80 mg IV before transfusion;
sustanon 250 mg IMI Q 3-4 week; consider EPO therapy for
refractory anaemia.

K 21

EMERGENCIES IN
RENAL TRANSPLANT PATIENTS
Fever:

Both infection and acute graft rejection can present as fever;

a. Infection:
- Consider opportunistic infection if < 6 months post-transplant;
- Usual pattern of infection if > 6 months post-transplant;
- Search for infection: Hx, PE, culture from wound, urine, IV lines,
sputum, blood, viral culture & serology, CMV pp-65 Ag, CXR;
- Check CBP D/C, RLFT, CsA / Tacrolimus trough level, 24 hr urine x P
& Cr;
- Avoid macrolide antibiotics / fluconazole (may increase CsA /
Tacrolimus level)
b. Acute graft rejection:
- Acute increase in serum creatinine > 20% after excluding other causes;
- May present as oliguria, graft tenderness, fever, ankle edema,
hypertension;
- Check CBP, RLFT, CsA / tacrolimus trough level, 24 hr urine x P & Cr,
MSU;
- Arrange urgent USG kidney + Doppler study;
- Consider renal biopsy

Oligouria / Anuria:
- DDx:

Nephrology

acute graft rejection

acute CsA, tacrolimus toxicity
obstructive uropathy
urinary leakage
acute tubular necrosis
acute vascular ( arterial or venous ) thrombosis.
Treatment according to the cause
Check CBP, RLFT, CsA / tacrolimus trough level, MSU RM C/ST, 24 hr
urine x P Cr
Monitor I/O chart, hourly urine output
Urgent USG graft kidney + Doppler study
Arrange standby MAG-3 / DTPA scan
Renal biopsy.

K 22

DRUG DOSAGE ADJUSTMENT IN RENAL FAILURE

(D: reduce dose (in %), same interval as in normal; I: same dose as
normal, increase interval between 2 dose (in hrs))
Name
Adriamycin
Allopurinol
Amiloride
Atenolol
Azathioprine
Captopril
Carbamazepine
Chlorpropamide
Cimetidine
Colchicine
Cyclophosphamide

Nephrology

Digoxin
Disopyramide
Gemfibrozil
Hydralazine
Insulin
Methyldopa
Nadolol
Neostigmine
Penicillamine
Probenecid
Procainamide
Spironolactone
Sulindac

D/I
D
D
I
D
D
I
D
D
D
I
D
D
D
I
D
I
D
I
D
I
D
D
D
D
I
D
I
D

Adjustment for Renal Failure

GFR (ml/min)
>50
10-50 <10 or ESRF
100
100
75
100
75
50
8
8-12
12-24
100
50
avoid
100
50
25
24
48
96
100
100
75
100
75
50
100
100
75
avoid
avoid
24
100
50
25
100
100
50
100
100
50-75
24
24
36
100
25-75
10-25
none
12-24
24-40
100
50
25
8
8
8-16
100
75
50
6
8-12
12-24
100
50
25
100
50
25
avoid
avoid
100
avoid
avoid
100
4
6-12
8-24
avoid
100
50
avoid
6-12
12-24
100
100
50

Supplement
for Dialysis

HD
?
?

PD
?
?

?
+

?
-

+
+

+
?
?
+
+
?
?
+
?

?
?
?
?
?

K 23
Common Drugs not requiring dosage adjustment in Renal Failure
Barbiturates
Ceftriaxone
Erythromycin
Levodopa
Nitrates
Na valproate
Tolbutamide

Benzodiazepines
Cholestyramine
Furosemide
Lignocaine
Prazosin
Steroids
Verapamil

Bromocriptine
Cloxacillin
Heparin
Minoxidil
Propylthiouracil
Streptokinase
Warfarin

Cefoperazone
Diltiazem
Ketoconazole
Nifedipine
Quinidine
Theophylline

Drug interaction with calcineurin inhibitor (tacrolimus,

cyclosporine)
Increase drug level:
Imidazole:
ketoconazole, fluconazole
Macrolide:
erythromycin, clarithromycin
Calcium channel blocker:
verapamil, diltiazam
Antidepressant:
fluoxetine (Prozac)
Grapefruit juice
Decrease drug level:
Anti-TB drug:
isonazid, rifampicin, ethambutol
Anti-convulsant:
phenytoin
Lipid-lowering agent:
cholestyramine
Sulfamethoxazole
Ethanol
Additive nephrotoxicity:
Aminoglycoside
Amphotericin B
Sulphonamide / Trimethoprim
Colchicine
NSAID
Others:
Hyperkalaemia with ACEI, K-sparing diuretics, NSAID
Myopathy / rhabdomyolysis with HMG-CoA reductase inhibitor

** value x 0.85 for women

Nephrology

Estimation of Creatinine Clearance

Cr Cl (ml/min) = [(140-Age) x BW (kg)] / [0.82 x Cr (M)]

K 24

PROTOCOL FOR TREATMENT OF CAPD

PERITONITIS
(BASED ON RECOMMENDATION OF ISPD, 2010)

1. Treatment of peritonitis in CAPD patients

When patient have signs and symptoms of peritonitis S/S:

Turbid fluid

Abdominal pain

Fever

Nephrology

a. Ask patient to come back immediately to dialysis unit for collection

of PDF
b. Send PDF :
White cell count with differential, gram smear
Culture
c. Rapid flushing of 3 bags of PDF with heparin 500 units per litre for
symptomatic relief
d. Adequate analgesia
e. Increase to 4 exchanges per day to improve ultrafiltration
f. Heparin: 500-1000 units/ L until signs and symptoms subsided or
until fibrin clots no longer visible
g. Preliminary antibiotics regime:
Empiric antibiotics must cover both gram-positive and
gram-negative organisms.
Gram-positive organisms may be covered by vancomycin or a
cephalosporin, and gram-negative organisms by a
third/forth-generation cephalosporin (ceftazidime, cefepime),
aminoglycoside or carbapenam.

K 25
Suggested protocol
A. CAPD (intermittent dosing method)
Daily urine output > 100 ml per day or deafness or recent
history of aminoglycoside in recent 3 months:
Protocol 1
Loading dose:
Cefazolin 1 gram and Cefepime 1gram loading IP,
allow to dwell for at least 6 hours
Maintenance dose:
Cefazolin 1 gram + Cefepime 1gram into last bag
daily (at least 6 hours dwell) x 13 days
Daily urine output < 100 ml per day and no recent history of
or contraindication to aminoglycosides:
Cefazolin 1 gram and Gentamicin 80 mg IP as loading
dose, then Cefazolin 1 gram and Gentamicin 40 mg IP into
last bag x 13 days.
Substitute vancomycin (1gram iv or IP every 5-7 days) for
cefazolin if MRSE or MRSA suspected; no routine use of
Vancomycin to avoid emergence of VRE
Change antibiotics regime once culture and sensitivity result
available
For St. aureus or pseudomonas peritonitis, antibiotics should
be given x 21 days; otherwise 14 days of antibiotics are
adequate
For refractory, recurrent or relapsing peritonitis, add Nystatin
oral suspension to prevent Candida peritonitis
B. CCPD (intermittent dosing method)
Can convert to CAPD temporarily
Intermittent dosing not recommended for severe cases
Mild to moderate case: Cefazolin with Cefepime 1 gram into
long daytime dwell
Nephrology

K 26
h. If patient has evidence of septicemia, admit patient and give
parenteral antibiotics

Cefazolin 500 mg i.v.i. Q12Hr + Cefepime 1 Gm i.v.i. Q24H (if daily

urine > 100 ml per day)
Cefazolin 500 mg i.v.i. Q12Hr + Gentamicin 100 mg Q48Hr (if anuria
and no recent aminoglycosides in 3 months)

i. Change antibiotics later according to culture and sensitivity result

and give adequate duration of antibiotics (14 21 days)
j. Repeat PDF x WCC and gram smear, culture on D4, reassess the S/S
k. Consider removal of Tenckhoff catheter if peritonitis fails to respond
to appropriate antibiotic within 5 days
l. Change transfer set after completion of antibiotics if patient
recovered

Nephrology

2. Treatment of fungal peritonitis

Arrange removal of Tenckhoff catheter
Arrange insertion of triple-lumen central venous catheter for
amphotericin B infusion and haemodialysis
Continue CAPD until on call to OT, drain out the PDF before
going to OT
Amphotericin B:
Test dose 1 mg in 100 ml D5 over 1 hr
then 10 mg / 200 ml D5 over 6 hr on D1, 20 mg / 200 ml D5 over 6
hr from D2-21
alternative: Fluconazole: 200 mg loading and then 100 mg daily p.o.
x 3 weeks

K 27
3. Antibiotic prophylaxis for procedure:
For dental procedure, a single oral dose of amoxicillin (2 g) 2
hours before extensive dental procedures
For patients undergoing colonoscopy with polypectomy
Ampicillin (1 g) plus a single dose of an aminoglycoside (1.5
mg/kg, max 80 mg), with or without metronidazole, given IV just
prior to the procedure
The abdomen should be emptied of fluid prior to all procedures
involving the abdomen or pelvis (such as colonoscopy, renal
transplantation, and endometrial biopsy)

Nephrology

K 28

PROTOCOL FOR TREATMENT OF CAPD EXIT

SITE INFECTIONS
(BASED ON RECOMMENDATION OF ISPD, 2010)

Exit site infection:

1. Purulent discharge from exit site
Treatment:
1. Equivocal exit site infection
Hibitane dressing TDS
Local treatment: 0.1% Gentamycin cream, 2% mupirocin
cream or otosporin ear drops to exit wound TDS

Nephrology

2.

Exit site infection

Take exit site swab for microscopy and culture
Empirical treatment depends on clinical appearance of the
exit site
Oral penicillinase-resistant penicillin (Cloxacillin 500 mg
qid) or a first generation cephalosporin (Cephalexin 500 mg
bd to tds) x 14 days if gram positive organism was suspected
Oral fluoroquinolones e.g. Ciprofloxacin 250 mg BD p.o. x
14 days if gram negative organism was suspected (avoids
medication contains multi-valent cations including
Sevelamer, Ca or Fe supplements , Mg-Al containing
antacids, sucralfate, milk; a minimal spacing of 2 hours from
ciprofloxacin if cannot discontinue). Treatment for 3 weeks
is probably necessary for exit site infection caused by P.
aeruginosa.
Change antibiotics regime according to culture and
sensitivity result once available
For slowly resolving or severe S. aureus exit site infection,
add Rifampicin 450 mg daily
For Gram-ve organisms, if no improvement, parental
antibiotics may be needed
If ESI + peritonitis: arrange early removal of Tenckhoff
catheter

K 29

Consult nephrologist for assessment if ESI is persistent

before further courses of antibiotics

Refractory ESI:
- For double-cuffed Tenckhoff catheter, consider shaving
of external cuff if external cuff is eroded and extruded

Recurrent ESI:
- Counsel on personal hygiene, review exit site care,
avoid excessive traction on TC
- Take nasal swab x R/M, c/st. If repeatedly grow S.
aureus, give mupirocin cream LA TDS x 1 wk to
eradicate nasal carriage

Nephrology

Neurology

Neurology

N1

A medical emergency characterized by the absence of arousal and

awareness.
Timely identification and treatment of reversible cause can be
life-saving.
Mechanisms:
Structural brain lesion.
Diffuse neuronal dysfunction.
Psychiatric (rare).
Approach:
Please refer to the flow chart.

Neurology

Coma

Neurology

N2

N3
Neurology

N.B. "head of bed": 30 degree for raised ICP; Flat for posterior circulation stroke

Supportive Care
a)
Close monitoring of vital signs and neurological status
b)
Proper positioning and turning to avoid aspiration, pressure nerve palsy,
contracture, pressure sore
c)
Bladder catheterization
d)
Adequate hydration, oxygenation and nutrition
e)
Chest and limb physiotherapy
f)
Hypromellose eyedrops and secure eyelids if no spontaneous blinking

Neurology

N4

DELIRIUM

(Also refer to page PM 9-10 in Palliative Medicine)

An acute neuropsychiatric syndrome characterized by global cognitive

dysfunction and inattention. The diagnosis is clinical, based on bedside
observation. In the elderly, delirium is a common (and often sole)
manifestation of acute illness. It is not always transient and reversible
and can lead to long-term cognitive changes and mortality.
DSM V Diagnostic Criteria

Disturbance in attention (i.e., reduced ability to direct, focus,

sustain, and shift attention) and awareness.
Disturbance in cognition (e.g., memory deficit, disorientation,
language, visuospatial ability, perception)
The disturbance develops over a short period (usually hours to
days) and tends to fluctuate during the course of the day
Not better accounted for by another preexisting, established, or
evolving neurocognitive disorder and do not occur in the
context of a severely reduced level of arousal, e.g. coma
There is evidence from the history, physical examination, or
laboratory findings that the disturbance is caused by a direct
physiologic consequence of another medical condition,
substance intoxication or withdrawal, exposure to a toxin, or
multiple etiologies

Other Associated Features: psychomotor disturbances (hyperactive,

hypoactive and mixed), altered sleep-wake cycle, emotional
disturbances
Choice of Ix according to the clinical presentation
a) CBP, ESR, RFT, LFT, Ca2+, thyroid function test, blood glucose,
ABG, urine analysis and culture, blood culture, ECG, CXR
b) in selected cases: CRP, troponin, serum B12, folate, syphilis
serology, HIV, autoantibodies, Mg, ammonia, cortisol, lumbar
puncture, toxicology screen, urinary porphyrins, EEG, CT brain

N5
Neurology

Management
a) Prevention: orientation, early mobilization, visual and hearing
aids, avoid dehydration, psychoactive drugs and sleep deprivation
b) Identify and treat underlying causes (often multifactorial)
c) Review medications and remove potential harmful drugs
d) Protect airway, fluid and electrolytes balance, adequate nutrition
and vitamins, mobilization to prevent VTE, skin and bedsore
care, avoid physical restraints and Foley catheters.
e) Reassuring supportive nursing care in well illuminated, quiet
place. Normalize sleep-wake cycle.
f) Reserve pharmacologic management to agitated patients at risk
of causing harm to themselves or others
- Low dose haloperidol 1-3 mg daily in divided dose
- Atypical antipsychotics (risperidone, olanzapine, quetiapine) as
alternatives
- Lorazepam (second line agent): for withdrawal from
alcohol/sedatives

Neurology

N6

ACUTE STROKE
It is essential to identify site, subtype, cause and risk factors of stroke.
1. Admit to designated acute stroke unit.
2. Initial assessment: vital signs including airway, respiration,
haemodynamics, conscious level & neurological impairment.
3. Ix : Urgent non-contrast CT brain, CBP, R/LFT, PT, aPTT, blood
glucose, lipid, CXR, ECG.
4. Special Ix (in selected cases): Magnetic resonance imaging (MRI),
magnetic resonance angiography (MRA), computer tomography
angiography (CTA), Echocardiography, Duplex study of carotid
arteries, Transcranial Doppler (TCD), cerebral angiography, VDRL,
hyper-coagulopathy assessment and autoimmune screening.
5. Supportive management:
a) Regular monitoring of neurological and vital signs
b) Swallowing assessment before feeding, positioning splinting to
avoid aspiration, contractures, pressure nerve palsy, shoulder
subluxation, pressure sores, etc
c) Ensure good hydration, nutrition and oxygenation
d) Meticulous control of blood sugar & pyrexia
e) Cautious and gradual lowering of elevated blood pressure
In ischaemic stroke, lowering of blood pressure is considered:
in case of hypertensive emergencies (eg: hypertensive
encephalopathy, aortic dissection, acute renal failure, acute
pulmonary edema or acute myocardial infarction)
when the systolic blood pressure >220 mmHg, or the diastolic
blood pressure is >120 mmHg, according to repeated
measurements 20 minutes apart.
when thrombolytic therapy is considered/given
In hemorrhagic stroke, lowering of blood pressure is considered:
if systolic blood pressure >200 mmHg or the mean blood
pressure is >150mmHg

N7

6. Specific therapy:
Ischaemic Stroke
a) Aspirin 75mg to 325 mg stat dose within 24 to 48 hours of onset of
acute ischaemic stroke. It should be withheld for the first 24 hrs if
thrombolytic therapy was given.
b) Thrombolytic therapy: in hospitals with stroke thrombolysis
program implemented, inform the thrombolysis team immediately
for urgent evaluation if a potential candidate is identified. (see
protocol for individual hospital for details)
Usual indication:
Ischaemic stroke onset within 3 to 4.5 hr
Good premorbid function
Usual contraindication for intravenous thrombolysis:
Presence of extensive early infarct changes in CT
Active internal bleeding
Use of warfarin with INR > 1.7
Prior intracranial haemorrhage
Any intracranial surgery, serious head injury or previous
ischaemic stroke within 3 months
Known intracranial AVM or aneurysm
Clinical presentation suggestive of SAH
c) Immediate anticoagulation may be considered for acute ischaemic
stroke in:
- Arterial dissection
- Documented cardiac source of embolism

Neurology

if systolic blood pressure >180 mmHg or the mean blood

pressure is >130mmHg when there is no clinical evidence of
elevated ICP
recent studies suggested that acute lowering of systolic BP to
less than 140mmHg is probably safe and associated with mild
improvement in functional outcome
f) Seizure should be treated promptly but prophylactic anticonvulsant
is not indicated for ischaemic or haemorrhagic stroke.
g) Early allied health therapists referral and assessment.

Neurology

N8
- Cerebral venous thrombosis
Contraindications and precautions
e.g. BP > 180/110 mmHg, large infarct.

The use of anti-coagulation in acute stroke due to large artery thrombosis is

controversial.
d) Decompressive Hemicraniectomy: urgently consult neurosurgeon to
consider decompressive surgery in patient with malignant MCA syndrome
(massive middle cerebral artery territory infarct with eye deviation, dense
hemiplegia and progressive drowsiness +/- unequal pupil size. Serial CT
will show significant infarct with swelling and midline shift).

Intracerebral Haemorrhage
a) Urgent reversal of warfarin effect: for patients with elevated INR
due to warfarin:
Give vitamin K1 5 to 10mg iv
Give prothrombin complex concentrate (PCC) 25 to 50 units/kg
+/- FFP (PCC have shorter preparation/infusion time and much
less fluid volume. It is reasonable to consider as an alternative
to FFP since PCC can reverse warfarin effect much faster than
FFP. Fluid overload is not a concern for PCC). However, PCC
treatment is associated with 1% risk of thrombosis e.g. DVT,
PE, MI and ischeamic stroke. So it is contraindicated in
patients with active thrombosis or DIC and Transamine
(tranexamic acid) should not be given together with PCC.
Give FFP as soon as possible if PCC is not available
b) Neurosurgical consultation:
Cerebellar haematoma or large cerebellar infarct with
significant mass effect
Large cerebral haematoma (> 30ml) with mass effect
Impending or established hydrocephalus/ intraventricular
haemorrhage
Subarachnoid haemorrhage
7. Rehabilitation:
All acute stroke patients should be assessed for rehabilitation
potential and admission to organized rehabilitation programmes

N9
Neurology

8. Secondary prevention:
a) Risk factor modification for all types of stroke
b) Oral anticoagulation in cardioembolic stroke (including non-valvular
AF) and anti-phospholipid antibody syndrome
c) Aspirin 80-300mg daily for ischaemic stroke if anti-coagulation not
indicated. Aspirin + controlled release dipyridamole or clopidogrel
are other options for first line anti-platelet agents. Dual anti-platelet
agents may be considered in high risk TIA or minor stroke patients
on individual basis, preferably for a short course of 3 weeks.
d) Carotid Endarterectomy (CEA) or carotid stenting is indicated for
symptomatic extracranial carotid stenosis of 70-99%, depending on
the availability of expertise and their own track record of
peri-interventional complication. Intervention for symptomatic
stenosis of 50-69% can only be considered in centre with very low
complication rate (less than 3%). Carotid stenting will be preferable
in case of: (i) difficult surgical assess, (ii) medical co-morbidities
with high risk of surgery eg: IHD, (iii) radiation induced
arteriopathy, (iv) re-stenosis after CEA. (Please refer to individual
hospital logistic for referral of those patients for carotid intervention
to different involved specialties)

Neurology

N 10

SUBARACHNOID HAEMORRHAGE
Investigations
1. CT brain as soon as possible
2. Lumbar puncture if CT is negative, to look for bloody CSF and send
CSF for xanthochromia. Xanthochromia is expected if LP is
performed > 12 hr after presumed SAH onset. If LP is performed
within 6 hr from headache onset, absence of xanthochromia is not
reliable to rule out SAH.
3. In patient with high clinical suspicion of CT negative SAH, if LP
result is inconclusive, it is reasonable to proceed to urgent CT
angiogram of brain.
4. Urgent cerebral angiogram if early surgery is considered. If DSA
cannot be arranged urgently, CT angiogram of brain should be
arranged. Most of the aneurysm with size > 5mm can be detected by
CTA.
Management
1. Correct any compromised airway, breathing and circulation
2. Confirm diagnosis (CT + LP) and consult neurosurgeons
3. Assess severity (Hunt and Hess1) and neurological status
4. Early surgery/endovascular coiling should be considered in patients
with grade 1, 2 and 3 SAH after aneurysm demonstrated by
DSA/CTA.
5. Begin nimodipine 60 mg po q4h, or 1 mg/hr iv infusion in grade 1,
2 and 3 patients (use of nimodipine should be individualized in
grade 4 and 5 patients) with BP check
6. Monitor BP closely and control high BP very carefully (exact level of
target BP is controversial, but avoid treating reactive HT due to raised ICP).

BP should be monitored and controlled to balance the risk of

hypertension-related rebleeding, and maintenance of cerebral
perfusion pressure.
7. Antifibrinolytic agent (Transamine): recent evidence suggests that
early treatment with a short course of antifibrinolytic agents (to
reduce rebleeding) combined with early aneurysm treatment
followed by discontinuation of the antifibrinolytic agent (to reduce
its side effect of aggravating ischaemic complication) may be

N 11

1
Hunt & Hess Grading:
Grade 1 Asymptomatic/slight headache
2 Mod/severe headache and nuchal rigidity but no focal or lateralizing neurologic
signs except cranial nerve palsies
3 Drowsiness, confusion and mild focal deficit
4 Stupor, hemiparesis, early decerebrate rigidity and vegetative disturbances
5 Deep coma and decerebrate rigidity

Neurology

reasonable.
8. Monitor GCS, brainstem reflexes, neurological deficits
9. Correct for any abnormalities in To, fluid balance, electrolytes,
osmolality, blood glucose, SaO2 and cardiac rhythm. Dehydration
should be avoided, which might aggravate the severity of
vasospasm if developed subsequently
10. Anticonvulsant if seizures occur
11. Analgesics, sedatives, acid suppressants and stool softener prn
12. Prophylactic anti-convulsant may be considered (benefit
controversial)

Neurology

N 12

TONIC-CLONIC STATUS EPILEPTICUS

Operational definition:
1. Two or more epileptic seizures without full recovery of
consciousness between attacks
2. Continuous seizure lasting more than 5 minutes.
High index of suspicious is needed for diagnosis of non-convulsive
status epilepticus. Consider EEG when patient has impaired
consciousness with no accountable cause.
General Management
1. Establish ABC, administer oxygen
2. Ensure good oxygenation and IV access
3. Check glucose and hstix, electrolytes , NH3, ABG, anticonvulsant
level
4. Give D50 50 ml iv and/or 200 mg thiamine iv if chronic alcoholism
is suspected
5. Resume usual AED for known history of epileptic disorder
6. Suppress clinical seizures, identify complications and etiology
search
7. Consider special test like autoimmune NMDA antibodies when
indicated (like de novo SE)
(1) Stage 1: stage of early status (010 mins )
Treat with short acting anticonvulsants (benzodiazepine)

Lorazepam IV: 4mg over 2 minute, repeat once in 5-10 min, if still
seizure, up to 8mg

Diazepam IV: 5 10 mg over 1-2 minutes, up to 20 mg (if

lorazepam not available)

Midazolam 0.2 mg/ kg imi, max. 10 mg if no iv access, repeat

once 5-10 mins if still seizure (if no iv access)
Note: total dose of benzodiazepine included those given pre-hospital.

N 13

Treat with IV long acting antiepileptic drugs (usually give long

acting AED simultaneously when seizure develops)

Phenytoin iv loading dose 15mg/kg at a max. rate of 50mg per

minute. Undiluted (phenytoin precipitates with dextrose). To
consider giving 50% loading dose if patient is taking it before.
Monitor ECG and BP for cardiorespiratory depression,
hypotension and arrhythmias. Beware of purple glove syndrome.
Maintenance dose 5mg/kg/day (usually 100mg Q8H iv).

Valproate: i.v. bolus 15-30 mg/ kg. Monitor LFT and NH3 level.
Maintenance dose: 30-60mg/kg /day in three to four divided
doses(usual dose : 4-8 mg /kg q8h)

Levetiracetam: 30-70 mg /kg i.v.bolus over 15 mins,(usual dose :

1.5 -3 gm) then 2-12 gm/d iv divided to Q12H to Q6H (usual
dose:<1500 mg Q12H )

Phenobarbital: i.v. infusion 10-20 mg/kg at a maximum rate of

100 mg/min. Give IV only when airway is protected due to risk of
respiratory suppression. Maintenance dose 2-3mg/ kg/ day in 2-3
divided doses
(3) Stage 3: stage of refractory status (Seizure despite
benzodiazepine and one anti-epileptic drug treatment)
Treat with general anesthesia, maintain for 12-24 hour before
gradual withdrawal. Use EEG as guideline for treatment response
If seizure recurs, escalate to higher dose and use for longer duration

Midazolam Bolus 0.1-0.2 mg/kg maintenance infusion 0.05- 3

mg/kg/hour

Propofol Bolus 3-5 mg/kg maintenance infusion 2 -15

mg/kg/hr.

Thiopental Bolus 2-3 mg/kg maintenance infusion 3-5

mg/kg/hr.

Neurology

(2) Stage 2: stage of established status (10-60 mins)

Neurology

N 14
(4) Stage 4: stage of super-refractory status epilepticus
SE which has been continued or recurred despite therapy with
general anesthesia for 24 hours or more

Consider use of ketamine, magnesium, immunotherapy, ketogenic

diet etc.

N 15

Clinical Presentation
1.
2.
3.
4.
5.
6.

Subacute progressive polyneuropathy

Bilateral symmetric weakness of the limbs
Generalized areflexia or hyporeflexia
Monophasic illness pattern; clinical plateau by about 4 weeks
Miller Fisher syndrome: bilateral ophthalmoparesis, ataxia,
areflexia
Look for preceding infection e.g. Campylobactor jejuni,
Mycoplasma pneumonia, CMV/ EBV/ VZV; recent vaccination

Diagnosis
1. Should NOT have new-onset upper motor neuron signs or
sensory level.
2. Consider paralysis due to other acute neuropathies e.g. toxic
neuropathy (alcohol, heavy metals, insecticides, solvents, drugs
like cytotoxic agents), vasculitis, lymphomatous infiltration,
porphyria, critical illness polyneuropathy; or neuromuscular
junction disorders (e.g. myasthenic crisis, botulism)
3. Arrange nerve conduction study (may be normal in 1st week)
4. Perform lumbar puncture: look for cytoalbuminologic
dissociation [Raised CSF protein (may be normal in 1st week,
~80% abnormal in 2nd week, peak in 3rd to 4th week) and CSF
total white cell count < 50 cells/uL]
5. Anti-ganglioside antibodies:
GQ1b is closely associated with Miller-Fisher Syndrome
GM1 and GD1a are associated with acute motor or
motor-sensory axonal neuropathy.
.

Neurology

GUILLAIN-BARR SYNDROME

Neurology

N 16
Management
1.

2.
3.

4.

6.

Monitor pulmonary dysfunction; consider mechanical ventilation

if:
- hypercarbia and/or hypoxaemia
- FVC < 15 ml per kg of BW
- inefficient cough, impaired swallowing, atelectasis
Watch for autonomic dysfunction (potentially fatal):
- cardiac monitoring (for arrhythmia and severe bradycardia)
- close BP monitoring (for extreme hypertension or hypotension)
Other supportive measures:
- monitor swallowing +/- temporary non-oral feeding
- DVT prevention
- urinary retention, constipation
- clear secretion
- early mobilization
- medical treatment for pain and paraesthesia
Immonotherapy (in severe cases):
- give intravenous immunoglobulin (IVIg) 0.4g/kg/day for 5 days
- alternatively start plasma exchange 50ml/kg/session of plasma for
5 exchanges over 2 weeks
Combination of IVIg and PE is not better than PE or IVIg alone.
Steroid treatment has no benefit.

N 17

Crisis: severe generalized weakness and need for respiratory support.

*Tensilon test - diagnostic test in untreated disease; not reliable in
differentiating myasthenic and cholinergic crisis and not without risk,
hence not recommended.
Management
1.
Watch out for respiratory failure in any patient with progressive
weakness and bulbar symptoms
2.
Closely monitor FVC, SaO2 and ABG. Consider mechanical
ventilation if:
hypercarbia and/or hypoxaemia
FVC < 15 ml per kg of BW
inefficient cough, impaired swallowing, atelectasis
3.
Stop anticholinesterase if patient is intubated
4.
Give intravenous immunoglobulin (IVIg) 0.4g/kg/day for 5 days.
An alternative is plasma exchange 50ml/kg/session of plasma on
alternate days until adequate response achieved (usually after 5 - 6
exchanges)
5.
Resume anticholinesterase at a smaller dose 48-72 hours after
stabilization and titrate accordingly
6.
Start prednisolone 1 mg/kg/day; beware that early steroid-induced
deterioration may occur
7.
Identify and treat any precipitating conditions (e.g. underlying
infection)
8.
General supportive measures:
monitor swallowing +/- temporary non-oral feeding
DVT prevention
urinary retention, constipation
clear secretion
early mobilization
9.
Beware with the use of any drug that might worsen MG. e.g.
aminoglycosides, quinolones, quinine, quinidine, procainamide,

Neurology

MYASTHENIC CRISIS

Neurology

N 18
-blockers, muscle relaxants, phenytoin, penicillamine,
magnesium.

N 19
(Also refer to page PM15 and GM26)

It is of paramount importance to make an early diagnosis of acute

spinal cord compression, to provide the patient with the best chance for
neurological recovery. Sensory level can be falsely localizing and
imaging of spinal cord rostral to clinical sensory level is advisable.
Investigations to delineate level and nature of spinal cord lesion
1. XR spine
2. MRI spine of relevant level if immediately available; otherwise
myelogram and CT myelogram
3. Lumbar puncture if transverse myelitis is suspected; send CSF for
microscopy and cell counts, culture, AFB culture, biochemistry,
viral study and cytology; VDRL and oligoclonal band in selected
cases
Management
1. Correct any compromised airway, breathing and circulation
2. Immobilize relevant level of spine in case of traumatic spinal cord
injury or spine instability.
3. Initiate appropriate treatment for specific spinal cord lesions:

4.

neurosurgical / orthopaedic consultation for structural lesions

antimicrobial therapy for abscess or other infections
consider methylprednisolone (1 gram iv over one hour daily for 3 days,
with cardiac monitoring) in non-infectious transverse myelitis

Institute general supportive care:

5.

proper positioning & splinting

adequate hydration and nutrition
bladder catheterization
prevent DVT

Close monitoring of respiratory function (FVC, respiratory rate)

and cardiac monitoring in case of high cord lesions

Neurology

ACUTE SPINAL CORD SYNDROME

Neurology

N 20

DELIRIUM TREMENS

Characterized
by
hallucinations,
agitation,
confusion,
disorientation and autonomic overactivity including fever,
tachycardia and profuse perspiration in the setting of acute
reduction or abstinence from alcohol.
Typically occurs 24-48 hours after the last drink and lasts one to
five days.
Associated with a mortality of up to 5 %
Diagnosis based on clinical features and exclusion of other causes
of delirium

Management
1. General supportive care
2. Monitor BP/P, I/O, To, cardiac rhythm
3. Correct fluid and electrolyte disturbance. Watch out especially for
hypomagnesaemia, hypokalaemia , hypoglycaemia and
rhabdomyolysis
4. Start benzodiazepine to treat psychomotor agitation
chlordiazepoxide 10 mg 20 mg TDS oral ( avoid in patients with
severe liver disease because of the risk of oversedation )
lorazepam 2 mg TDS oral
diazepam 5 mg TDS oral
adjust dose according to severity. Reduce dose in elderly. Taper
dosage gradually over 5-7 days.
5. Concurrent use with IV thiamine. Give high dose thiamine in IV
form, e.g.100 mg IV Q8H
6. Ensure adequate nutrition and vitamins
7. Search out for and treat any concurrent illnesses
8. Reassuring nursing care in well-illuminated, quiet place.

N 21

An acute or subacute neuropsychiatric disorder due to thiamine

deficiency which is underdiagnosed. Delayed diagnosis and treatment
can lead to irreversible brain damage (Korsakoffs syndrome) and fatal
outcome.
The classical triad ophthalmoplegia, ataxia and confusion occurs only in
10% of patients. Difficult to differentiate from acute alcohol
intoxication.
Caines Criteria in Alcoholics
2 of the following 4 signs
Dietary deficiency
Oculomotor abnormalities
Cerebellar dysfunction
Either an altered conscious state or mild memory impairment
Predisposing Factors
Alcoholics plus malnutrition
GI surgery including bariatric surgery
Repeated vomiting including hyperemesis gravidarum
Chronic diarrhea
Cancer
Systemic illnesses (renal failure on CAPD or HD, AIDS, prolonged
infectious diseases, thyrotoxicosis)
Dietary restriction e.g. anorexia nervosa, hunger strike, elder neglect
Investigations
WE is a clinical diagnosis which requires high index of suspicion
EEG and CSF are normal or non-specific.
MRI brain may show atypical features especially in non-alcoholics
Pretreatment RBC transketolase is available locally but of limited
value in emergency diagnosis and treatment
Serum magnesium (a co-factor for normal functioning of
thiamine-dependent enzymes)

Neurology

WERNICKES ENCEPHALOPATHY

Neurology

N 22
Management
Thiamine must be given immediately and in adequate amounts
Oral thiamine is poorly absorbed and ineffective
Intravenous 200-500mg thiamine in 100ml normal saline or 5%
dextrose over 30 minutes thrice daily for 2-3 days
If improved, followed by 250mg thiamine IV/IM daily for 3-5 days,
or until improvement ceased
Thiamine must be given before or concomitantly with any
carbohydrate
Resuscitation facilities and adrenaline for rare occurrence of
anaphylaxis
Monitor BP/P and temperature (hypo-/hyperthermia, hypotension
and tachycardia can occur)
Monitor neurological signs (ophthalmoplegia can resolve within
hours)
Correct any hypomagnesaemia
Balanced diet
Treat any concurrent illnesses (e.g. delirium tremens, hepatic
encephalopathy, traumatic subdural hematoma, sepsis)

N 23

High risk of peri-operative pulmonary complications:

Parkinsonism, myasthenia gravis, other neuro-muscular disorders
affecting respiratory muscles and any neurological deficits
compromising respiratory effort.
Peri-operative management:
1. Comprehensive pulmonary assessment before operation
2. Optimal control of neurological conditions
3. Vigorous peri-operative chest physiotherapy
4. Regular monitoring of FVC, respiratory rate, SaO2, ABG
5. Continue anti-epileptic, anti-cholinesterase and anti-parkinsonism
drugs as close to normal schedule as possible.
Resume as soon as possible after operation.
Alternative preparation or drugs:
Anti-cholinesterase: Neostigmine 0.5 mg im/iv q4-6h
Anti-epileptic: phenytoin / sodium valproate/ levetiracetam /
lacosamide available in iv form
Transdermal patch of Rotigotine and parenteral apomorphine is
available if anti-parkinsonism drugs cannot be resumed quickly.
6a. Bridging therapy is recommended for patient with high risk of
thromboembolic event after anti-coagulant is stopped
6b. Discontinue anti-platelet agents 1 week before elective surgery, but
aspirin may be continued in the following procedures: (i) dental
procedure (ii) endoscopies with biopsies and polypectomies, (iii)
ophthalmologic procedures, (iv) peripheral vascular procedure, (v)
neuraxial anesthesia. Warfarin can be continued for most dental
procedures if INR is kept at a lower range before the procedure and
close monitoring in the day ward after the procedure is available.
7. Avoid aminoglycosides, quinolones, morphine, quinidine,
-blockers, procainamide, penicillamine for myasthenia gravis

Neurology

PERI-OPERATIVE MANAGEMENT IN
PATIENTS WITH NEUROLOGICAL DISEASES

Neurology

N 24
Risk of Peri-operative stroke
1. Increase in hypertension
2. Asymptomatic carotid bruit is not an independent risk factor.
Intervention to asymptomatic carotid stenosis before general surgery
(open heart surgery is excluded) might not be justified since the risk
of intervention would outweight its potential benefit.
3 Symptomatic severe carotid stenosis (> 70%) should be repaired
before non-emergency operation. Symptomatic large vessel stenosis
in the posterior circulation need to have aggressive intraoperative
maintenance of blood pressure to avoid prolonged hypotenion
4. Decreased by avoiding hypotension, hypovolaemia, polycythaemia
and anaemia.
5. Postpone elective procedures for at least 6 weeks after an ischaemic
stroke to allow healing at the infarct site; minor or lacunar stroke
may require shorter waiting period.

Respiratory
Medicine

Respiratory
Medicine

P1

MASSIVE HAEMOPTYSIS

Management objectives

Prevent asphyxia, localize bleeding site, stop bleeding, determine cause

of bleeding and treat underlying cause.

Management
1.

Close monitoring of vital sign, i.e. BP/P, RR, SaO2

O2 supplement
Establish IV access
Take blood for CBP, clotting, ABG and X-match
Sputum for C/ST, AFB & cytology
Avoid sedation and cough suppressant
Antibiotic if infection is suspected, e.g. bronchiectasis, TB
Lie lateral on side of bleeding if lateralized
If depressed conscious state with risk of asphyxia, intubate for
suction and ventilation (single lumen ET if urgent airway access is
required; double lumen ET placement by anaesthetist is better for
isolation of bleeding side)
10. Early bronchoscopy to localize bleeding, diagnose endobronchial
lesion and for therapy
2.
3.
4.
5.
6.
7.
8.
9.

Persistent life-threatening haemoptysis

Consult radiologist for bronchial arteriogram bronchial artery

embolization if expertise available

Respiratory
Medicine

Definition: Arbituary, expectorated blood ranging from

>100-200ml/day. Important management considerations include rate of
bleeding and underlying lung function. Increased volume of bleeding
confers a much higher risk of death due to asphyxia than to
haemodynamic derangement. Airway protection is most important in
massive haemoptysis, close observation and treatment in ICU/HDU is
desirable.

P2

Respiratory
Medicine

Consult surgeon for emergency lung resection if bleeding is

localized and adequate pulmonary reserve.

P3

SPONTANEOUS PNEUMOTHORAX
(Ref. BTS pleural disease guideline 2010)

Definition

Size: visible rim between lung margin and chest wall at level of hilum.
Small < 2cm & large 2cm
Primary spontaneous pneumothorax (PSP): no underlying lung
disease
Secondary spontaneous pneumothorax (SSP): underlying lung
disease

Management

O2 and analgesic prn

Patients with PSP or SSP and significant breathlessness associated with
any size of pneumothorax should undergo active intervention.

PSP
1.

Minimal symptoms
Observation is treatment of choice for small PSP without
significant breathlessness

2.

Symptomatic
Needle aspiration (NA) or small-bore (< 14 F) chest drain

SSP

Small bore chest drain

Respiratory
Medicine

Suspect tension pneumothorax if associated with cyanosis, sweating,

severe tachypnea, tachycardia and hypotension.
Proceed to chest drain if bilateral pneumothorax / haemodynamically
unstable.

Respiratory
Medicine

P4
Referral to thoracic surgeons for persistent air leak at day 2 for SSP
and day 3 to 5 for PSP
Chemical pleurodesis may be considered for patients with SSP but unfit
for surgery

Indication for surgical advice

Second ipsilateral pneumothorax, first contralateral pneumothorax,

synchronous bilateral spontaneous pneumothorax, spontaneous
haemothorax, professions at risks (eg. pilots, divers), pregnancy.

P5

PLEURAL EFFUSION
Diagnosis

2.
3.
4.
5.

Pleural tapping should not be done for bilateral pleural effusions in

clinical setting strongly suggestive of a transudate unless presence
of atypical features or fail to respond to therapy
Diagnostic tapping with bedside USG guidance improves success
and reduces complications
Percutaneous pleural biopsy only diagnostically useful in areas
with high incidence of TB
Thoracoscopy is next investigation of choice in exudative pleural
effusions with inconclusive diagnostic pleural tap
Bronchoscopy can be considered if presence of haemoptysis or
clinical or radiologic features suggestive of endobronchial
obstruction

Indications for pleural fluid drainage in pleural infection

1.
2.
3.
4.
5.

Frank pus or turbid/cloudy pleural fluid on diagnostic tapping

Loculation on CXR or pleural thickening with contrast
enhancement on CT thorax
Positive gram-stain +/- positive culture of pleural fluid
Pleural fluid biochemistry: pH <7.2, LDH >1000 IU/L or glucose
<2.2mmol/L
Large non-purulent effusions (> 40% of hemithorax)

Respiratory
Medicine

1.

P6

Respiratory
Medicine

Consider intrapleural fibrinolytic to decompress

multiloculated pleural collections in patients not fit for
surgery
Indication for chest drain insertion
1.
2.
3.

Empyema or complicated parapneumonic effusion

Symptomatic malignant pleural effusion (see below)
Haemothorax (surgical consultation is usually indicated)

Management of persistent/ recurrent malignant pleural effusion

1.
2.
3.

4.
5.

Supportive care
Consult respiratory physician for difficult cases
Tube drainage and chemical pleurodesis
Agent: Talc up to 5g in 100ml NS
Must be performed under adequate analgesia +/- sedation
Clamp drain for 1 to 2 hours post-sclerosant application, then
release clamp
Chest tube kept unclamped thereafter for drainage until daily
output <150ml /day and CXR shows the lung to be re-expanded
with most of the effusion drained
Surgical pleurodesis (can be considered in patients with good
performance status)
Long term ambulatory indwelling pleural catheter drainage
(including patients with trapped lung)

P7

OXYGEN THERAPY

Common oxygen delivery methods

Variable performance devices
Actual FiO2 delivered not fixed, depends on multiple factors including
O2 flow, oropharyngeal geometry, tidal volume, respiratory rate &
pattern
1. Standard dual-prong nasal cannula
o FiO2 0.23 to 0.40 if O2 flow rate set at 1 to 6 L/min
o FiO2 non-specific roughly 20% + (4 oxygen litre flow per
minute)
o Most comfortable and cost-effective
o Higher flow (i.e. >6L/min), leading to wastage of O2 and dryness
of nasal mucosa
2. Simple face mask with no reservoir bag
o FiO2 up to 0.50 if O2 flow rate set at 6 to 10 L/min
o Actual FiO2 non-specific, depends on patients condition
o O2 flow rate set below <5L/min may cause CO2 rebreathing
3. Rebreathing mask with reservoir bag
o FiO2 0.70 if O2 flow rate set at 6 to 10L/min
o O2 flow must be 6 L/min to keep reservoir bag inflated
throughout inspiration & expiration
o No one way valve between reservoir bag and mask

Respiratory
Medicine

The goal of O2 therapy: to deliver the minimum concentration

required for adequate tissue oxygenation with the least risk of toxicity.
Prescriptions should be precise and adequately monitored (e.g. by SpO2
or ABG).
Device used should be safe, effective and with the greatest patient
comfort and acceptance at the least cost.

Respiratory
Medicine

P8
4. Non-rebreathing mask with reservoir bag
o FiO2 0.60 1.00 if O2 flow rate set at 10 15 L/min
o Equipped with one-way valves to prevent exhalation into
reservoir bag and inhalation through mask exhalation ports (but
usually only one of the two valves on the mask exhalation ports
is installed for safety reason)
Fixed performance devices
Delivery of oxygen at a fixed and pre-set concentration regardless of
patients clinical status (e.g. respiratory rate, tidal volume.)
1. Venturi mask
o Accurate FiO2 adjustable from 0.24 to 0.50 if O2 flow rate set at
3 15 L/min (O2 required to drive can be read off from the
Venturi device)
2. Humidified high flow nasal cannula, e.g. Optiflow, Airvo systems.
o Delivers humidified O2 at fixed FiO2 at high flow (up to
60L/min)
o Better patients tolerance to high flow O2 and the O2 is
humidified
o Actual FiO2 delivered can be set (by internal oxygen blender) or
determined (by sensor) depending on the device used
Other common oxygen delivery methods
1. T-piece to endotracheal or tracheostomy tube: O2 delivered through
the shorter end, open window by one-third if PCO2 is high
2. Thermovent to endotracheal or tracheostomy tube: watch out for
sputum blockage
3. Tracheostomy mask: consider to use humidification in
non-infectious situation (e.g. heated humidifier)

P9
Indications for long-term O2 therapy in COPD
Start only when clinically stable for 3-4 weeks and after optimization of
other therapy

Noncontinuous oxygen:
Oxygen flow rate and number of hours per day must be specified
1. During exercise: PaO2 7.3 kPa (55 mmHg) or oxygen saturation
88% with a low level of exertion
2. During sleep: PaO2 7.3 kPa (55 mmHg) or oxygen saturation
88% with associated complications, such as pulmonary
hypertension, daytime somnolence, and cardiac arrhythmias.

Respiratory
Medicine

Continuous oxygen:
1. Resting PaO2 7.3 kPa (55 mm Hg) or SaO2 88%: to maintain
PaO2 8 kPa (60 mm Hg or SaO2 90%)
2. Resting PaO2 7.4 to 7.9 kPa (56 to 59 mm Hg) or SaO2 89% in the
presence of any of the following:
Dependent oedema suggestive of cor pulmonale.
P pulmonale on ECG (P wave >3mm in standard leads II, III, or
aVF)
Erythrocythaemia (haematocrit >56%)

P 10

Respiratory
Medicine

ADULT ACUTE ASTHMA

(Ref: GINA Guidelines 2014)
Definition of asthma exacerbations
Episodes characterized by a progressive increase in symtoms of
shortness of breath, cough, wheezing or chest tightness AND
progressive decrease in lung function.
The decrease in expiratory airflow by PEF or FEV1 is more reliable
indicators of severity of the exacerbation than symptoms
Assessment
Initial assessment:
- Airway, Breathing, Circulation
- Life-threatening features
o
Drowsiness, Confusion, Silent chest
- Consult ICU if any +ve
- Prepare for intubation
Further assessment
- According to worst feature identified Moderate vs Severe
Exacerbation

Mild/Moderate

Severe

Talks in phrases
Prefers sitting to lying
Calm
Increased respiratory rate
No use of Accessory muscles
Pulse rate 100-120/min
SpO2 (RA) 90-95%
PEF >50% predicted/best

Talks in words
Sits hunched forwards
Agitated
RR >30/min
Use of Accessory muscles
Pulse rate >120/min
SpO2 (RA) <90%
PEF 50% predicted/best

P 11
Monitoring
- Vital signs, pulse oximetry, PFR/FEV1, ABG, electrolytes, CXR

Severe exacerbation
Same as treatment for moderate episode plus
Ipratropium bromide 3-4puffs with spacer
Oral/IV corticosteroids
Consider magnesium sulphate 1.2-2g iv over 20 minutes
Reassessment
- Clinical status and response to treatment
- Preferably with lung function measurement (PEF/FEV1)
- In ALL patients 1 hr after initial treatment
-

If satisfactory response

Controlled O2 aiming 93-95%, gradual weaning

Prednisolone up to 50mg/d (or Hydrocortisone 200mg/d in

divided doses) for 5-7 day, adequate for most patients

Continue inhaled 2 agonist q4h

If unsatisfactory response

Inhaled 2 agonist 6-10 puffs up to q15min

Inhaled ipratropium bromide 3-4puffs then q6-8h

Respiratory
Medicine

Management
Moderate exacerbation
Controlled O2 aiming SpO2 93-95% by nasal cannulae or mask
Short-acting 2-agonists
o Salbutamol 4 puff q4h with spacer + prn use
o Higher dose/more frequent dosing may be considered in
very symptomatic patients or those with severe exacerbation
Oral corticosteroids
Ipratropium bromide

Respiratory
Medicine

P 12
Consider ICU admission if
- Life threatening features present
- Deterioration in PEF/FEV1
- Worsening or persistent hypoxia or hypercapnia
- Respiratory failure requiring IPPV
- Respiratory or cardiorespiratory arrest
After improvement
- Stabilize in ward
- Discharge may be considered when symptoms have cleared, lung
function PEF/FEV1>60% predicted/best
- Actions recommended on discharge include

Identifying & avoiding trigger factor(s) that precipitated

attack

Prednisolone tablets (up to 50mg daily for 5-7 days)

EARLY outpatient follow-up and review of long term

treatment plan especially inhalational steroids, AND
reviewing technique on use of inhaler and peak flow meter
Therapies NOT recommended during acute attacks:
- Sedatives (avoid strictly)
- Cough suppressant (avoid as far as possible)
- Mucolytic drug (may worsen cough)
- Chest physiotherapy (may increase patient discomfort)
- Antibiotics (unless strong evidence of lung infection)
- Hydration with large volumes of fluid

P 13

LONG TERM MANAGEMENT OF ASTHMA

(Ref: GINA Guidelines 2014)

GINA assessment of Asthma control (2014)

1. Symptom control over past 4 weeks
- Daytime asthma symptoms > 2/week
- Nocturnal symptoms/awakening
- Reliever needed for symptoms > 2/week
- Activity limitation due to asthma
Well controlled: None
Partly controlled: 1-2 features
Uncontrolled: >3-4 features
2. Assessment on risk factors for poor asthma outcomes/ risk of
exacerbations

Respiratory
Medicine

NOTE
a. The goal of asthma care is to achieve and maintain symptoms
control; and to minimize future risks, such as exacerbations, fixed
airflow limitation and side effects of treatment.
b. Partnership between the patient and the health care providers is
needed for effective asthma management.
c. A continuous cycle of assessment/treatment/review of response
formed the basis of asthma management
d. Each patient is assigned to one of five treatment steps. Depending
on their current level of asthma control, treatment should be
adjusted (e.g. stepping up/down), taking into account of the
patients characteristics and preference
e. In treatment-nave patients with persistent asthma, treatment should
be started at Step 2, or Step 3 if very symptomatic.
f. Reliever medication (rapid-onset bronchodilator) should be
provided for quick relief of symptoms at each treatment step.
g. Patients should avoid or control triggers at all times.
h. Patient education and treatment of modifiable risk
factors/comorbidities (e.g. smoking, obesity, anxiety) should be
included in every treatment step.

P 14

Respiratory
Medicine

Uncontrolled symptoms
Excessive SABA use
Inadequate ICS: not prescribed, poor compliance, poor inhaler
technique
Low FEV1, esp if <60% predicted/best
Major psychological/socioeconomic problems
Exposures: e.g. smoking, allergen
Comorbidities
Sputum or blood eosinophilia
Pregnancy
History of intubation/ICU admission for asthma
1 severe exacerbation in last 12 months

TREATMENT
STEP 1: As-needed reliever medication
a. For untreated patients with occasional daytime symptoms
b. Short-acting bronchodilator as reliever: Inhaled 2-agonist prn
(but 2times/week).
c. Inhaled anticholinergic, short-acting oral 2-agonist or
therophylline NOT recommended for slower onset of action and
higher risk of side-effects.
d. Inhaled 2-agonist, leukotriene modifier may be considered
before exercise or allergen exposure.
STEP 2: Reliever medication plus a single controller
a. Reliever: Inhaled 2-agonist prn (but 2times/week).
b. Preferred daily controller medication: Low dose Inhaled
corticosteroids (ICS)
c. Alternatives: Leukotriene receptor antagonists (LTRA)
d. Not-recommended for routine use:
Cromoglycate or
Nedocromil or Theophylline SR.
STEP 3: Reliever medication plus one or two controllers
a. Reliever: Inhaled 2-agonist prn (but 2 times/week).
b. Preferred daily controller medication:

P 15
Low dose ICS + long-acting inhaled 2-agonist (LABA),
OR
(ii)
Combination of low dose ICS/Formoterol as both
maintenance and reliever treatment
Alternatives:
(i)
Medium dose ICS
(ii)
Low dose ICS + LTRA
(iii) Low dose ICS + Theophylline SR
LTRA for aspirin sensitivity or exercise-induced asthma
(i)

d.

STEP 4: Reliever medication plus two or more controllers

a. Reliever: Inhaled 2-agonist prn.
b. Preferred daily controller medications:
(i)
Medium/high dose ICS + LABA
(ii)
Combination of low dose ICS/Formoterol as both
maintenance and reliever treatment
c. Alternatives
(i)
High dose ICS + LABA
(ii)
Medium/high dose ICS + Theophylline SR/LTRA
STEP 5: Reliever medication plus additional controller options
a. As in Step 4 plus Specialist referral for investigation and
consideration of add-on treatment
(i)
Options
a. Anti-IgE treatment
b. Sputum-guided treatment (sputum eosinophilia)
c. Bronchial thermoplasty
d. Low dose oral corticosteroid
Step-down
Review treatment every 36 months. If control has been sustained for >3
months, consider a gradual stepwise reduction.
Aim at finding the patients lowest treatment that controls both
symptoms and exacerbations.

Respiratory
Medicine

c.

Respiratory
Medicine

P 16
Step-up
If control is not achieved, consider stepping up AFTER reviewing
patients inhaler technique, compliance, environmental control
(avoidance of allergens/trigger factors), comorbidities and alternative
diagnoses.
ICS dose

Drug

Daily dose (mcg)

Low

Medium

High

Beclometasone
dipropionate (CFC)

200-500

>500-1000

>1000

Beclometasone
dipropionate (HFA)

100-200

>200-400

>400

Budesonide (DPI)

200-400

>400-800

>800

Ciclesonide (HFA)

80-160

>160-320

>320

Fluticasone
propionate (DPI)

100-250

>250-500

>500

Fluticasone
propionate (HFA)

100-250

>250-500

>500

Mometasone furoate

110-220

>220-440

>440

Triamcinolone
acetonide

400-1000

>1000-2000

>2000

P 17

CHRONIC OBSTRUCTIVE
PULMONARY DISEASE (COPD)

Treatment of acute exacerbation

1. Supplemental oxygen (start with 24% Venturi mask or 1-2L/min by
nasal prongs) to maintain SpO2 88-92%.
Check ABGs 30-60 mins later and modify flow rate according to
PaO2 and pH.
2. Short acting inhaled (with spacer) 2 agonist (Ventolin) +/ipratropium bromide (Atrovent)
3. If no response, consider iv aminophylline (second line therapy)
4. Corticosteroids (Hydrocortisone 100 mg iv Q6-8 hours or oral
Prednisolone 30-40 mg daily). Steroid should be discontinued after
the acute episode (e.g. 5-10 days)
5. Antibiotic in patients required invasive or non-invasive ventilation
(NIV), and/or at least two cardinal symptoms (one being sputum
purulence):
dyspnoea;
sputum volume;
purulent sputum
6. NIV to relief dyspnoea by work of breathing (WOB), improve
respiratory acidosis, avoid complications
Indications (NB also read contraindications in NIV chapter):
Respiratory acidosis (pH 7.35 and/or PaCO2 >6.0kPa)
Moderate to severe dyspnoea with signs of respiratory muscles
fatigue and WOB, e.g. use of accessory muscles, paradoxical
abdominal motion, intercostal space retraction, RR > 25/min.
Check ABG 30-60mins after initiation of NIV. Do not delay
intubation and mechanical ventilation if no improvement.

Respiratory
Medicine

Based on Global Initiative for Chronic Obstructive Lung Disease

(GOLD) guidelines 2014

Respiratory
Medicine

P 18
7. Invasive mechanical ventilation (IMV)
For patients who are / have:
Unable to tolerate or failed NIV
Severe haemodynamic instability without response to fluid and
vasopressor.
Severe ventricular arrhythmia, respiratory or cardiac arrest.
Impaired consciousness, massive aspiration, or unable to clear
secretions.
** These patients should be managed in intensive care unit (ICU); if
not available, then preferably in intermediate or special respiratory
care units with expertise in this area **

P 19
Treatment of stable COPD

Respiratory
Medicine

All patients should have smoking cessation, encouraged physical

activity and vaccination +/- rehabilitation.
Pharmacological treatment according to patient groups (A, B, C, D)
based on symptom level and risks (airflow limitation and
exacerbation history)
A: Less symptom, low risk
B: More symptom, low risk
C: Less symptom, high risk
D: More symptom, high risk

(SABA, short acting beta-agonist; SAMA, short acting

anti-muscarinic agents; LABA, long acting beta-agonist; LAMA,
long acting anti-muscarinic agents; ICS, inhaled corticosteroid; CAT,
COPD Assessment Test; mMRC, modified Medical Research
Council breathless scale)

Respiratory
Medicine

P 20
Other points to note:
1. Steroid trial not predictive of response to inhaled steroid
2. Long-term oxygen therapy for chronic respiratory failure with
severe resting hypoxaemia
Start only when clinically stable for 3-4 weeks after optimization
of other therapy, in COPD patients who have:
A. Continuous oxygen therapy ( 15hours/day):
Resting PaO2 7.3 kPa (55 mm Hg) or SaO2 88%: to maintain
PaO2 8 kPa (60 mm Hg or SaO2 90%); or
Resting PaO2 7.3 to 8.0 kPa (55-60 mm Hg) or SaO2 >88% with
evidence of peripheral oedema suggestive of CCF, pulmonary
HT( p pulmonale on ECG (P wave >3mm in standard leads II,
III, or aVF), or polycythaemia (haematocrit > 55%)
B. Non-continuous oxygen: Oxygen flow rate and number of hours per
day must be specified.
During exercise: PaO2 7.3 kPa (55 mmHg) or oxygen saturation
88% with a low level of exertion
During sleep: PaO2 7.3 kPa (55 mmHg) or oxygen saturation
88% with associated complications, such as pulmonary HT,
daytime somnolence, and cardiac arrhythmias

P 21

OBSTRUCTIVE SLEEP APNOEA

Indications for diagnostic sleep study

1. Suspect OSA
2. Unexplained pulmonary hypertension
3. Recurrent cardiovascular events e.g. CVA, angina, CHF; or poorly
controlled hypertension despite adequate medical therapy and
optimization of risk factors
Severity of OSA based on apnoea-hypopnoea index (AHI)
Mild: 5-15/hr

Moderate: 15-30/hr

Severe: > 30/hr

Indications for urgent arrangement of nasal CPAP

1. Pickwickian syndrome with daytime alveolar hypoventilation,
pulmonary hypertension or cor pulmonale.
2. Nocturnal malignant arrhythmia related to the OSA.
3. Nocturnal angina related to the OSA.
4. Severe EDS that may impose risk to the patient and/ or others e.g.
professional driver especially with history of road traffic accident.

Respiratory
Medicine

Suspect OSA if
(1) Snoring at night, PLUS
(2) Excessive daytime sleepiness (EDS)
Mild: activity with little attention needed e.g. public transport
Moderate: activity with some attention e.g. conference
Severe: activity with much concentration e.g. phone call,
conversation; OR
(3) Any two out of the followings:
(i) Intermittent nocturnal arousal, (ii) Nocturnal choking, (iii)
Unrefreshed sleep at wakening, (iv) Daytime fatigue,
(v) Impaired daytime concentration

P 22

Respiratory
Medicine

PREOPERATIVE EVALUATION OF PULMONARY

FUNCTION

P 23

Respiratory
Medicine

High postoperative risk if :

1. Thoracic surgery: pre-op FEV1<1L or epo FEV1 < 40% predicted
2. ABG Elevated PaCO2 >6kPa (45mmHg)
3. FEV1, FVC or MVV < 50% predicted
4. Evidence of pulmonary hypertension
5. Preoperative cardiopulmonary exercise testing (CPET): VO2max <
15ml/kg/min.
Consult respiratory physician in high risk cases.

P 24

MECHANICAL VENTILATION
Indications

Respiratory failure not adequately corrected by other means

Failure to protect the airway - (e.g. GCS<8)

Cardiac and/or respiratory arrest

Clinical instability e.g. severe hypotension

2.

Criteria suggesting the need of Mechanical ventilation

Laboratory Criteria:
Blood gas
PaO2 < 7.3 kPa despite O2 supplement
PaCO2 > 6.7 kPa with pH < 7.32
Pulmonary funtion tests
Vital Capacity < 10 ml/kg
FEV1 < 10ml/kg

Respiratory
Medicine

1.

Clinical Criteria:
Apnoea / hyponoea
Stridor
Depressed menal status
Remarks: Clinical assessment is more impotant than these criteria

3.

Suggested initial ventilator settings

Disease
condition
Tidal volume
(ml/kg
predicted BW)

Acute Resp distress Acute pulmonary *Obstructive

Restrictive
syndrome (ARDS) oedema
lung disease
lung
(COPD/Asthma) disease
6

8 10

Frequency or
10 12
RR(breath/min) Permissive
hypercapnia (keep
pH just > 7.25 as
lung protective
strategy)

10 12
Pressure control
(PC) +/- pressure
support (PS)
mode to achieve
comfort

PEEP (cmH2O) 8 15
May need > 10
(open lung
approach)

High (8 15)
initially, can be
rapidly tailed
down

*Peak pressure usually targeted at <35 cmH2O

68

8 10

8 10
Ensure long
enough
expiratory time
to avoid
air-trapping

10 12
To achieve
desired pH
and ABG

05

P 25

Respiratory
Medicine

3 Monitoring during mechanical ventilation

a. General: vital signs, bowel motion, conscious level,
psychological status
b. P/E: Signs of upper airway obstruction (excessive inspiratory
efforts, inspiratory in-sucking of lower rib cage), ETT (patency,
positioning), chest wall movement (especially asymmetry),
pressure sores, signs of DVT, hydration & nutritional status
c. Important parameters:
i. Cuff pressure: 20 30 cm H2O
ii. Ventilatory status:

Volume-controlled mode or SIMV (VC + PS): avoid

excessive airway pressure

Pressure-controlled mode or SIMV (PC + PS): monitor

tidal volume which varies with airflow obstruction or
lung compliance

Pressure support mode: avoid excessive/inadequate tidal

volume and long/short inspiratory time

Pause or plateau pressure (PP): Barotrauma risk if PP

35 cm H2O

Auto-PEEP
4 Patient-ventilator asynchrony
Do not simply sedate a patient who is asynchronous with the
ventilator, look for possible underlying cause(s).
Checklist for trouble-shooting:
Problems

Examples

a. Airway-related

Inappropriate size/position (Normal 4-6 cm

above carina) of ET tube, leaky cuff/excessive
cuff pressure, blocked /kinked tube,
dislodgement

b. Ventilator-related

Inadequate humidification, obstruction/ leak in

circuit, ventilator malfunction

Respiratory
Medicine

P 26
c. Inappropriate
ventilator settings

Inappropriate TV/ RR (or I:E) /sensitivity

settings, inadequate FiO2 and/or ventilation
with persistent hypoxaemia or hypercapnia

d. Underlying disease

Stiff lungs, low cardiac output, poor cerebral

perfusion, septic state

e. Complications of
mechanical
ventilation

Atelectasis, ventilator-associated pneumonia,

pneumothorax, endobronchial intubation

f. Others

Fear, anxiety, pain, secretions in airway,

hunger, inability to open bowels/to move,
pressure sore

P 27

NON-INVASIVE VENTILATION (NIV)

Less efficacious or even harmful in:

1. Acute severe asthma
2. Acute lung injury (ALI) or Acute respiratory distress syndrome
(ARDS)
3. Pneumonia, esp if copious secretions
4. Treatment of established post-extubation respiratory failure
Contraindications: respiratory arrest, medical instability, inability to
protect airway, excessive secretions, uncooperative or agitated status,
unfitting mask, and recent upper airway or gastrointestinal surgery
Practical aspects
1. Machine: sophisticated ICU ventilator (independent insp/exp limbs,
higher max flow); or smaller-sized ventilator dedicated for NIV
delivery (single limb only, with expiratory port which can be just a
hole or a dedicated device, e.g. Whisper-Swivel II valve); or a
hybrid type ventilator with function in between the above two types
2. Interface: nasal mask, oronasal mask, total full face mask, helmet,
nasal pillows (In acute respiratory failure, start with oronasal mask.)
3. Mode of deliverySingel level (CPAP) or Bi-level (IPAP + EPAP)

Respiratory
Medicine

More evidence of efficacy in:

1. COPD with respiratory acidosis pH 7.25-7.35
2. Hypercapnic respiratory failure secondary to chest wall deformity
or neuromuscular disease
3. Cardiogenic pulmonary edema
4. Weaning from tracheal intubation (esp COPD)
5. Acute respiratory failure in immunosuppressed states
6. Post-operative hypoxaemia (except in upper GI surgery)
7. Patients decided not for intubation

P 28

Respiratory
Medicine

Factors associated with success: less sick (lower APACHE II score),

higher pH, lower respiratory rate (RR), lower PaCO2, subjective
improvement within one hour of start
Factors associated with failure: edentulous, pneumonia, excess
secretions, mouth leaks, poor coordination, ARDS, PaO2/FiO2 146,
sicker patient (Simplified Acute Physiology Score (SAPS II)35).
Common setting
1. Spontaneous/ timed (ST) mode or Spontaneous (S) mode
2. CPAP/EPAP: Pulmonary oedema: 8 to 12 cmH2O; COPD: 4-5
cmH2O. Normal lung: 5 cmH2O
3. IPAP: For COPD, start at 8-15 cmH2O, titrate up to 20 cmH2O.
Aim at tidal volume (Vt) around 7ml/kg BW and RR 25/min;
4. Backup RR: 6 to 12; with I:E ratio: 1:2 to 1:4 or Ti 0-8-1s
Points to note
1. Watch out for gastric distension
2. Monitor ABG: Within 1st 1-2 hours after start to determine success,
3. Consider invasive mechanical ventilation if there is no objective
signs of improvement after 1 hour of use
4. Consider repeat ABG at 4-6 hours if first set ABG show little
improvement. If still no response, consider intubation
5. Apply NIV for 4-6 hours, then remove mask for short periods every
few hours for meals, sputum clearance or bronchodilator inhalation
6. Stringent infection control measures should be taken during NIV
for patients with suspected respiratory infections (Single room with
airborne isolation might be needed, please refer to your hospital
guidelines).

Rheumatology &
Immunology

Rheumatology
&
Immunology

R1

APPROACH TO INFLAMMATORY ARTHRITIS

Rheumatology &
Immunology

Assessment

Arthralgia pain in a joint without demonstrable synovitis

Inflammatory Arthritis (Synovitis) joint swelling, warmth, pain

and tenderness

Polyarthralgia/polyarthritis 5 or more joints

Chronic polyarthralgia/polyarthritis more than 6 weeks

Polyarthralgia/polyarthritis common causes

Bacterial arthritis (staphylococcal, streptococcal, gonococcal,

meningococcal)

Bacterial endocarditis

Viral arthritis

Reactive arthritis

Crystalinduced arthritis: gout, pseudogout

Rheumatoid arthritis

Seronegative spondyloarthropathies: ankylosing spondylitis,

psoriatic arthritis, inflammatory bowel disease

Connective tissue diseases: SLE, systemic vasculitis, scleroderma,

Stills disease

Others: sarcoidosis, palindromic rheumatism, malignancy,

hyperlipoproteinemias, Lyme disease, rheumatic fever
Monoarthritis common causes

Septic arthritis

Crystal-induced arthritis: gout, pseudogout

Haemarthrosis / trauma / overuse

Tuberculous arthritis

Osteoarthritis

Spondyloarthropathies: ankylosing spondylitis, psoriatic arthritis

Monoarthritic onset rheumatoid arthritis

Reactive arthritis

Other uncommon causes: avascular necrosis, synovial metastasis

Rheumatology &
Immunology

R2
Relevant investigations

CBP, ESR, CRP

Renal / liver function, calcium, phosphate, urate

Urinalysis

ANA, RF (if SLE or RA is suspected)

X-ray of the affected joints, USG & MRI if indicated

Joint aspiration

Synovial biopsy (in undetermined cases)

Joint fluid analysis
Send fluid for:

Gram stain (urgent if septic arthritis suspected)

Bacterial culture

AFB smear and culture (if indicated)

White cell count

Crystal microscopy
Joint fluid white cell count:
Classification

Clarity

Normal
Non-inflammatory
Inflammatory
Septic

Transparent
Transparent
Translucent
Opaque

WBC/ml
< 200
< 2000
2,000-100,000
50,000-300,000

% of
Neutrophils
< 25
< 25
25 75
> 90

Crystal microscopy:

Urate crystals slender and needle-shaped; strong negative

birefringence under polarized light

Calcium pyrophosphate crystals pleomorphic or

rhomboid-shaped; weakly positive birefringence under polarized
light

R3

GOUTY ARTHRITIS
Clinical features

Acute gout (monoarticular, polyarticular)

Chronic tophaceous gout

Uric acid calculi

Gouty nephropathy

Management
Acute Gouty arthritis
1. NSAID/COX2 inhibitors (Note! Check patients drug allergy)
High dose, tapering over 5 days, reduce dose in renal impairment:
a) indomethacin 50mg tds 25mg tds 25mg bd
b) naprosyn 500mg stat 250mg tid 250mg bd
c) ibuprofen 800mg stat 400mg qid 200mg tid
2. Colchicine
0.5 mg tds for 1-2 days (stop if nausea/diarrhoea)
Renal impairment caution and reduce frequency
Not recommend Q1H Q2H for 10 doses regime
3. Corticosteroid
a) Intra-articular steroid injection after septic arthritis ruled out
b) Prednisolone 20 to 40 mg daily within 1 week, rapid tapering
(consider for patients with NSAID or colchicine
contraindications, or renal failure)
Urate lowering therapy
Low purine diet advisable but only attain small changes in serum uric
acid

Rheumatology &
Immunology

Diagnosis
Definite gout
Intracellular negative birefringent urate crystal on joint fluid microscopy
Presumed gout
Classical history of episodic acute arthritis rapidly resolved with NSAID
(or colchicine) + history of hyperuricaemia

R4

Rheumatology &
Immunology

Urate lowering therapy is indicated in patients with hyperuricaemia and

>2 acute gouty attacks of in 1 year (in terms of cost-effectiveness),
tophaceous gout or urate renal calculi.
1. Xanthine oxidase inhibitors
(Do NOT use with azathioprine!)
a. Allopurinol (usual dose 300 mg daily)
Start with low dose 100 mg daily; inform patients to stop if skin
reaction (~ 5%) and seek medical attention early
Further reduce dose in renal impairment
Start allopurinol only when acute gout has subsided
Prophylaxis: add regular colchicine 0.5 mg daily or bd, or NSAID,
for 3 to 6 months, to prevent acute gout attacks
Titrate dose to target serum uric acid < 0.36 mmol/L
FDA approved maximal dose is 800 mg daily
Severe cutaneous adverse reations are associated with HLA B*5801
in Han Chinese (allele frequency ~7.3% locally). HA Expert Panel
(2012) opined that checking this gene before starting allopurinol is
not necessary
b. Febuxostat a new non-purine selective xanthine oxidase inhibitor
Alternative for patients with allopurinol cutaneous adverse reaction
Usual dose 40 mg to 80 mg daily
Caution in patients with high cardiovascular thromboembolic risks
2. Uricosuric drugs
Probenecid 250 mg bd to 1000 mg tds
(Contraindications: moderate renal impairment, urate renal stone,
tophaceous gout, and high 24-hour urine uric acid excretion)
Benzbromarone licensed in HK but not under HA formulary
Sulfinpyrazone not licensed in HK
3. Uricase
Rasburicase, a recombinant urate-oxidase enzyme, is for
pre-chemotherapy prevention of acute tumour lysis syndrome

R5

SEPTIC ARTHRITIS

Rheumatology &
Immunology

1. A hot, swollen and tender joint should be regarded as septic arthritis

until proven otherwise, even in the absence of fever, leucocytosis,
elevated ESR or CRP. Septic arthritis can present as monoarthritis
(80-90%), oligoarthritis or polyarthritis. Delay in diagnosis and
treatment can result in irreversible joint destruction or septicaemia.
2. Prompt aspiration of the joint is warranted. Synovial fluid should be
sent for:
Differential cell counts: Usually >50,000 WBC/ml and often
>100,000/ml, predominantly neutrophils.
Gram stain
Culture and sensitivity
Polarising microscopy for crystals (septic arthritis may co-exist
with crystal arthropathies)
3. Other investigations: CBC with differentials, RFT, LFT, blood
culture, X-ray of the joint. Swabs of pharynx, urethra, cervix and
anorectum if gonococcal infection suspected.
4. Start empirical IV antibiotics immediately according to suspected
organisms and gram stain. Modify according to culture and
sensitivity results. Opinion from microbiologists is helpful. Refer to
IMPACT guideline (available as apps for mobile phone), or
(http://www.chp.gov.hk/files/pdf/reducing_bacterial_resistance_with
_impact.pdf)
5. Repeat aspiration of the joint to dryness.
6. Consult orthopaedic surgeon for drainage especially for infected
prosthetic joint. Open drainage is usually necessary for hip infection.
7. Start physiotherapy early.
8. NSAIDs for pain relief.
9. IV antibiotics for at least 2 weeks or until signs improved for
non-gonococcal arthritis, then orally for an additional 2-4 weeks.

Rheumatology &
Immunology

R6
Suggested choice of antibiotics:
(Note! Check patients drug allergy)
Synovial fluid Organism
IV Antibiotics
gram stain
Gram +ve
Staph aureus
Cloxacillin 1-2 g Q6H or
cocci (clusters) MSSA
Cefazolin 1-2 g Q8H
Gram +ve
Streptococcus
Penicillin 2 megaunits Q4H
cocci (chains)
or Cefazolin 1-2g Q8H
Gram ve
Enterobacteriaceae
Ceftriaxone 2 g Q24H or
Bacilli
Cefotaxime 1g 8H
Pseudomonas
Cefepime 2g Q12H or
Piperacillin 3g Q6H or
Imipenem 500 mg Q6H
+ gentamicin
Gram ve
Neisseria
Ceftriaxone 2g Q24H or
diplococci
gonorrhoeae**
Cefotaxime 1g Q8H or
Ciprofloxacin 400mg Q12H
Empirical
initial therapy

1. No risk factors for

atypical organisms
2. High risk for
Gram-ve sepsis
(elderly, frail, recurrent
UTI, recent abdominal
surgery,
immunocompromised)
3. Gonorrhoea
suspected
4.MRSA suspected:

Cloxacillin or
Cefazolin or Ceftriazone
Cloxacillin +
Ceftriaxone or Cefotaxime

Ceftriazone or cefotaxime or
ciprofloxacin
Vancomycin 1g Q12H +
Ceftriaxone or Cefotaxime

** Treat possible concurrent Chlamydia trachomatis infection with doxycycline (100 mg

BD for 7 days) in patients with gonococcal infection.

R7

RHEUMATOID ARTHRITIS

2010 ACR/EULAR classification criteria for RA

6/10 points classified as having definite RA
Joint involvement
1 large joint
2-10 large joints
1-3 small joints (with or without large joints)
4-10 small joints (with and without large joints)
>10 joints (at least 1 small joint)
Serology
Negative RF and negative anti-CCP
Low positive RF or low positive anti-CCP
High positive RF or high positive anti-CCP
Acute phase reactants
Normal CRP and normal ESR
Abnormal CRP or ESR
Duration of symptoms
< 6 weeks
6 weeks

(0)
(1)
(2)
(3)
(5)
(0)
(2)
(3)
(0)
(1)
(0)
(1)

Rheumatology &
Immunology

1. Diagnosis:
1987 ACR criteria for the classification of established RA
At least 4 of the following features
Morning stiffness >1 hour
Arthritis and soft tissue swelling of 3 joint areas
Arthritis of hand joints
Symmetric arthritis
Subcutaneous nodules in specific places
Rheumatoid factor at a level above 95th percentile
Radiographic changes suggestive of joint erosion
Clinical symptoms must be present for at least 6 weeks.

R8

Rheumatology &
Immunology

2. Investigations
ESR and C-reactive protein (CRP)
RF (sensitivity ~70%)
Anti-cyclic citrullinated peptide antibody (anti-CCP) highly
specific for RA, helpful in undetermined situations
Plain X-ray of the hands and feet for erosion
MRI or USG may be useful for detecting early bony erosion
3. Clinical assessment
Includes: subjective & objective evidence of active synovitis;
efficacy, tolerability & need for adjustment of present Rx;
associated comorbidities (cardiovascular / osteoporosis) &
extra-articular problems
Useful parameters:
degree of joint pain
duration of morning stiffness
number of tender and swollen joints
functional status (Health Assessment Questionnaire)
patients and physicians global assessment
ESR or CRP (if persistently raised without obvious synovitis
beware of infection)
radiographic progression
4. Management overview:
Goals:
Treat-to-target: aim at low disease activity or remission
Treat RA early: best outcome in first 2 years from onset
Prevent joint damage and preserve daily function
Patient education / counseling; rheumatology nursing
Medications (plain analgesic / NSAID / DMARDs / biologics /
judicious use of steroid)
Non-pharmacological: physiotherapy, occupational therapy,
podiatrist, dietitian (multi-disciplinary team care)
Orthopaedic operations
Management of associated comorbidities & their risk factors

R9
5.

Conventional DMARDs
Start DMARDs early! All take time to act.
Usually start with monotherapy, but step-up combination may be
considered early in patient with severe disease
Titrate up to optimal doses according to RA disease activity
Switch or add-on another DMARD promptly if target not met
Counsel patients on DMARD effects and side effects and their
slow action
Anchor drug is methotrexate
Other examples: sulphasalazine, hydroxychloroquine,
leflunomide, low dose prednisolone (less than 10mg/day),
cyclosporin A, azathioprine, intramuscular gold

7. Biologics
Should be prescribed by rheumatologist with reference to local &
international guidelines
E.g. anti-TNF (Etanercept, Adalimumab, Infliximab,
Golimumab, Certolizumab), IL-6 receptor blocker
(Tocilizumab), co-stimulation molecule blocker (Abatacept),
anti-CD 20 (Rituximab)
Safety Net available for many of them. Check HAHO intranet
site for updated details under Samaritan fund: ha.home >
Guidelines > Non-clinical Manual / Guidelines > Samaritan Fund
Need to screen for hepatitis carrier and latent TB before use

Rheumatology &
Immunology

6.

EARLY aggressive use of DMARDs is especially indicated for

patients with poor prognostic factors
High disease activity at onset ( 18 joints)
High baseline joint damage (erosive disease)
Persistently high CRP level
Positive IgM rheumatoid factor or anti-CCP (esp. high titer)
Positive family history of RA
Nodular disease
Extra-articular manifestations

R 10
Response criteria

Rheumatology &
Immunology

1.

ACR response criteria

ACR20/50/70 responses
20%/50%/70% improvement in
(a) Swollen joint count
(b) Tender joint count
(c) Improvement in at least 3 of the following 5 measures:
Patients global assessment of disease activity
Physicians global assessment of disease activity
Patients assessment of pain
Acute-phase reactant (ESR, CRP)
Functional scores (HAQ)

2. EULAR response criteria

Disease activity score (DAS)
DAS44 and DAS28 (more convenient in daily clinical practice)
DAS28 = 0.56 (t28) + 0.28 (sw28) + 0.70Ln(ESR) +0.014GH
Number of tender joints among 28 joints (t28)
Number of swollen joints among 28 joints (sw28)
Erythrocyte sedimentation rate (ESR, mm/hour)
General health status (GH) using a 100-mm visual analog scale
Disease status:

High disease activity

Low disease activity
Remission

> 5.1
3.2
< 2.6

Response criteria (Good / Moderate / No):

Final score
Decrease in DAS28
< 3.2
3.2 5.1
> 5.1

> 1.2
Good
Moderate
Moderate

0.6 to 1.2
Moderate
Moderate
No

< 0.6
No
No
No

R 11

ANKYLOSING SPONDYLITIS

2. ASAS criteria for axial spondyloarthritis (SpA) (2009):

a. Imaging evidence of sacroiliitis (XR, MRI or CT) plus one SpA
features*
b. HLA-B27 positivity plus 2 other SpA features*
SpA features:
Inflammatory back pain age of onset < 40
Arthritis
Enthesitis
Psoriasis
Uveitis
Dactylitis
Crohns/colitis
Good response to NSAIDs
Family history for SpA
Elevated C-reactive protein (CRP)
HLA-B27
3. Other extra-skeletal features apical fibrosis, aortic insufficiency
4. Measurements
a. Modified Schober test spinal forward bending (excursion of
two points: PSIS level and 10 cm above; normal > 10 cm). Note:
finger floor distance may be apparently normal when good hips
flexion compensates limited spinal flexion

Rheumatology &
Immunology

1. Modified New York criteria for definite AS (1984)

a. Radiological criterion
Sacroiliitis: grade II bilateral or grade III to IV unilaterally
b. Clinical criteria (at least 1 out of 3)
Low back pain & stiffness for > 3 months that improve with
exercise but not relieved by rest
Limitation of motion of lumbar spine in both sagittal &
frontal planes
Limitation of chest expansion relative to normal correlated for
age & sex

R 12

Rheumatology &
Immunology

5.

6.

7.

8.

b. Occiput to wall distance, tragus to wall distance

c. Chest expansion
d. Lumbar lateral flexion
e. Cervical spine rotation
f. Intermalleolar distance
Investigations
a. XR sacroiliac joints and spine
b. MRI / CT SI joints in doubtful cases
c. HLA-B27 (role refers to ASAS criteria)
Disease assessment
a. BASDAI (Bath Ankylosing Spondylitis Disease Activity Index),
active disease defined as 4 (out of 10)
b. BASFI (Bath Ankylosing Spondylitis Functional Index)
c. BAS-G (Patients / Physicians Global score)
d. BASMI (Bath Ankylosing Spondylitis Metrology Index)
e. Acute phase reactants (ESR/CRP) can be normal in patients with
predominant axial involvement
Treatment
a. Education, stretching exercise & physiotherapy
b. NSAIDs for pain and stiffness at optimal tolerated dose
c. Addition of gastroprotective agents or use selective COX-2
inhibitor in patients with high GI risks (elderly, history of peptic
ulcer, comorbidity)
d. Analgesics such as paracetamol and tramadol for patients in
whom conventional NSAIDs or COX-2 inhibitor are insufficient,
contraindicated or intolerated
e. Sulphasalazine for patients with peripheral arthritis
f. Anti-TNF therapy for patients with persistent high disease
activity despite adequate trial of the above treatment including
2-3 NSAIDs (at least 2 months for each unless contraindicated).
Refer rheumatologist for assessment of disease activity and
indications for anti-TNF therapy
ASAS 50 Response criteria: BASDAI by 50%

R 13

PSORIATIC ARTHRITIS

2.

The Classification of Psoriatic Arthritis criteria (CASPAR):

Mandatory: Inflammatory articular disease (joint, spine or
entheseal)
With 3 or more points from the following:
1. Current psoriasis (scores 2 points)
2. Personal history of psoriasis (if current psoriasis absent)
3. Family history of psoriasis (if personal history of psoriasis
or current psoriasis absent)
4. Psoriatic nail dystrophy
5. A negative test for rheumatoid factor
6. Current dactylitis
7. History of dactylitis (if current dactylitis absent)
8. Radiological evidence of juxta-articular new bone formation
Clinical features
30% psoriasis population has arthritis
60% psoriasis preceeds arthritis, 20% arthritis preceeds
psoriasis, 20% concurrent
Also watch out for associated metabolic syndrome e.g.
overweight, diabetes mellitus, hypertension, hyperlipidaemia,
hyperuricaemia etc

Rheumatology &
Immunology

Diagnostic criteria
1. Moll & Wright criteria 1973:
Inflammatory arthritis (peripheral arthritis and/or sacroiliitis or
spondylitis)
The presence of psoriasis
The absence of rheumatoid factor
Five types: asymmetrical oligoarthritis, predominant DIP,
symmetrical polyarthritis, axial AS like, arthritis mutilans

Rheumatology &
Immunology

R 14
Features distinguishing PsA from RA

Presence of psoriasis
- Hidden lesions common, e.g. scalp, hairline, behind the ear and
inside ear cannel, guttate lesions on back, under the breasts,
around umbilicus, around the perineum or even natal cleft

Nail dystrophy
- Onycholysis, pitting, ridging, etc

Distal phalangeal joint involvement

Spondylitis or sacroiliitis

Enthesitis (inflammation of junction of tendon and bone)

Dactylitis
Treatment
Oral steroid risk of psoriasis flare up upon tapering, and hence steroid
dependency. So be cautious with starting oral steroid.
Early DMARD treatment for psoriatic arthritis

Active arthritis (> 3 tender/ swollen joints, dactylitis counted as one

active joint)
DMARD. Methotrexate, sulphasalazine, leflumomide, cyclosporin
Anti-TNF therapy (refer to rheumatologist)

For skin psoriasis

(a) Topical steroid (potency)
- Fluocinolone < betamethasone < clobetasol (to be used by
specialist)
- Lotion < cream < ointment < occlusive dressing
- Common e.g.: 0.1% betamethasone cream, Diprosalic
(betamethasone + salicylate)
(b) Topical Tar products, e.g. shampoo, bathing soap
(c) Vit D analogues: e.g. Dovonex (calcipotriol) (to be used by
dermatologist)
(d) UVA or UVB (to be used by dermatologist)
(e) Anti-TNF therapy, anti-IL 12/23, anti-IL 17 and other
biologics (to be used by specialist)

R 15

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

SLICC (Systemic Lupus International Collaborating Clinics)

Classification criteria for SLE (Petri et al. 2012)
4 criteria (at least 1 clinical + 1 immunologic criteria) OR
biopsy-proven lupus nephritis with positive ANA or anti-DNA
Clinical Criteria
1. Acute or subacute cutaneous lupus
2. Chronic cutaneous lupus
3. Oral/Nasal ulcers
4. Non-scarring alopecia
5. Inflammatory synovitis with physician-observed swelling of two or
more joints OR tender joints with morning stiffness
6. Serositis

Rheumatology &
Immunology

American College of Rheumatology (ACR) criteria for the

classification of SLE (Tan et al. 1982, revised 1997, Hochberg et al.)
4 criteria, serially or simultaneously = classified as SLE (specificity = 96%)
1. Malar rash
2. Discoid rash
3. Photosensitivity
4. Oral ulcers
5. Arthritis
6. Serositis (pericarditis, peritonitis, pleuritis)
7. Renal disease (proteinuria > 0.5 g/day, or +++ by dipstick, or
cellular casts)
8. Neurological (seizure, or psychosis)
9. Haematological (haemolytic anaemia, or leucopenia < 4109/L,
lymphopenia < 1.5109/L, on two or more occasions, or
thrombocytopenia < 100109/L)
10. Immunological (anti-dsDNA, or anti-Sm, or false +ve VDRL for
more than 6 months, or the presence of the antiphospholipid
antibodies)
11. Positive anti-nuclear antibody (ANA)

Rheumatology &
Immunology

R 16
7. Renal: Urine protein/creatinine (or 24 hr urine protein) representing
at least 500 mg of protein/24 hr or red blood cell casts
8. Neurologic: seizures, psychosis, mononeuritis multiplex, myelitis,
peripheral or cranial neuropathy, cerebritis (acute confusional state)
9. Haemolytic anaemia
10. Leukopenia (<4109/L at least once) OR Lymphopenia (<1109/L
at least once)
11. Thrombocytopenia (<100109/L) at least once
Immunologic Criteria
1. ANA above laboratory reference range
2. Anti-dsDNA above laboratory reference range (except ELISA:
twice above laboratory reference range)
3. Anti-Sm
4. Antiphospholipid antibody: e.g. lupus anticoagulant, false-positive
test for syphilis, anticardiolipin antibody (at least twice normal or
medium-high titre), anti-2 glycoprotein 1 antibody
5. Low complement: e.g. low C3, low C4, low CH50
6. Direct Coombs test in absence of haemolytic anemia
Anti-ENA antibodies
Anti-Ro: associated with photosensitivity and an increased risk of
congenital heart block (~2% incidence). Pre-pregnancy counseling
and ultraviolet light protection should be advised.
Anti-ENA antibodies seldom sero-convert and repeating tests is not
necessary.
Anti-phospholipid antibodies
Lupus anticoagulant (LAC) and anti-cardiolipin (aCL) antibody
(IgG) are available in most HA hospitals.
They are strongly associated with cerebro-vascular accidents in
Chinese SLE patients. Other associations: thrombocytopenia,
livedo reticularis, valvular heart lesions, recurrent miscarriages and
venous thrombosis.

R 17

Monitoring of disease activity

Clinical assessment (signs and symptoms of disease flares)
Serology: C3 and C4 level, anti-dsDNA titer
Points to note
The ANA titer only correlates with disease activity very roughly
and is not reliable for disease monitoring. Thus, there is no need
to repeat ANA every visit.

C-reactive protein (CRP) is usually not elevated in patients with

active SLE. An elevated CRP in SLE may indicate persistent
synovitis / arthritis, serositis or infection. Infection has always to
be considered before augmentation of immunosuppressive therapy.
Disease activity scoring system
The ACR SELENA-SLEDAI is most widely used disease activity index.
Items can be used as a checklist for disease flares:
Seizure
(8)
Psychosis
(8)
Organic brain syndrome (8)
Lupus headache
(8)
Cranial nerve disorder (8)
Arthritis (> 2 joints)
(4)
Myositis
(4)

Cerebrovascular accident (8)

Retinal hemorrhage / infarct /
optic neuritis
(8)
Vasculitis
(8)
Oral ulcer
Pleuritis

(2)
(2)

Rheumatology &
Immunology

Twice positive tests 12 week apart are necessary for the diagnosis of
antiphospholipid syndrome.
Only strongly positive aCL is
clinically relevant.
Because of the association with recurrent abortions and miscarriages,
these antibodies have to be checked before pregnancy.
Anti-2-GPI antibody is more specific than aCL for thrombosis.
Because of its limited sensitivity, anti-2-GPI should only be
considered in patients in whom antiphospholipid syndrome is
suspected but yet aCL and LAC is negative.

R 18
Pericarditis
(2)
New skin rash
(2)
Alopecia
(2)
anti-dsDNA titre
(2)
C3
(2)
Leukopenia (< 3109/L) (1)
Fever
(1)
Thrombocytopenia
(1)
* Only new features or manifestations are scored

Rheumatology &
Immunology

Proteinuria
Urine cast
RBC cast in urine
Sterile pyuria

(4)
(4)
(4)
(4)

Treatment of SLE
General: Patient education and counseling, sun-screening (avoid strong
sunlight, frequent application of SPF 15+ sun lotion), screening and
treatment of cardiovascular risk factors and osteoporosis, vaccination
and infection prevention, early recognition and prompt treatment
Hydroxychloroquine should be considered for every lupus patient:

Overall stabilizing SLE

Decreases infection, some anti-thrombotic and lipid lowering
effect
Stabilises pregnant SLE patients and improves foetal outcome
Recommend < 6.5 mg/kg/day

Mild SLE manifestations

NSAIDs arthritis, serositis, fever
Hydroxychloroquine arthritis, skin lupus
Methotrexate persistent and refractory arthritis and skin
Topical steroid skin lupus
Small to moderate doses of prednisolone fever, systemic upset,
mild cytopenias, more severe serositis and skin lupus

Azathioprine haematological, mild renal disease, steroid sparing

R 19

Lupus nephritis (ISN/RPS Classification 2003)

Class I:
Minimal mesangial lupus nephritis
Class II:
Mesangial proliferative lupus nephritis
Class III:
Focal proliferative lupus nephritis
Class IV-G: Diffuse global proliferative lupus nephritis
Class IV-S: Diffuse segmental proliferative lupus nephritis
Class V:
Membranous lupus nephritis
Class VI:
Advanced sclerotic lupus nephritis
MMF is increasingly used as first line treatment for proliferative lupus
nephritis because of lower frequency of adverse effects compared to
cyclophosphamide e.g. premature ovarian failure and haemorrhagic
cystitis.
However, cyclophosphamide remains the conventional
treatment for those with rapidly progressive crescentic GN and those
with impaired renal function.

Rheumatology &
Immunology

Severe SLE manifestations

Glomerulonephritis, neuropsychiatric lupus, severe cytopenias,
thrombotic thrombocytopenic purpura, pulmonary haemorrhage,
myocarditis, pneumonitis, pulmonary hypertension

Moderate to high doses of prednisolone

Intravenous pulse methylprednisolone

Azathioprine

Cyclophosphamide (intravenous pulse or oral)

Mycophenolate mofetil (MMF)

Cyclosporin A and Tacrolimus

Plasma exchange

Intravenous immunoglobulin

Rituximab

Vasodilatation (bosentan, inhaled iloprost, sildenafil)

Anticoagulation

Rheumatology &
Immunology

R 20
Neuropsychiatric lupus
19 Neuropsychiatric syndromes according to the 1999 ACR
classification
Central nervous system
Peripheral nervous system
Aseptic meningitis
Guillain-Barre syndrome
Cerebrovascular disease
Autonomic neuropathy
Demyelinating syndrome
Mononeuropathy
Headache
(single/multiplex)
Movement disorder
Myasthenia gravis
Myelopathy
Cranial neuropathy
Seizure disorder
Plexopathy
Acute confusional state
Polyneuropathy
Anxiety disorder
Cognitive dysfunction
Mood disorders
Psychosis
Diagnosis
Till now, no specific confirmatory serological & imaging tests
A diagnosis by exclusion (to rule out CNS infections, metabolic
encephalopathy, effects of drugs / toxins including corticosteroids,
electrolyte disturbances, rarely brain tumour)
Lupus activity in other systems increases likelihood of active
neuropsychiatric lupus but CNS infection may coexist with active
neuropsychiatric lupus
CT brain, MRI brain / spinal cord for anatomical diagnosis
Lumbar puncture to rule out CNS infection
EEG
Antiphospholipid antibodies
Anti-ribosomal P antibody (private laboratory) is associated with
lupus psychosis but its usefulness is limited by the low sensitivity

R 21
Treatment

Novel / investigational therapies for SLE

Belimumab for sero-positive SLE, steroid sparing effect

Rituximab efficacy shown in cohort series
Other novel agents: Sirolimus, Ocrelizumab, Epratuzumab,
Abatacept, anti-type I interferons
Immunoablative cyclophosphamide stem cell rescue
Mesenchymal stem cell therapy

Useful apps: RheumaHelper for Classification criteria and Disease

Activity scoring of many rheumatic diseases. Available free from iTune
App Store and Google Play Store.

Rheumatology &
Immunology

Symptomatic: anti-convulsants, anti-psychotics, anti-depressants,

sedatives
Secondary prophylaxis for atherosclerotic vascular disorders:
aspirin / warfarin
Immunosuppressive or immunomodulating treatment (eg. high dose
corticosteroids, pulse methylprednisolone, cyclophosphamide, IVIG,
rituximab): severe psychosis, acute confusional state, myelopathy,
myasthenia gravis, neuropathies, demyelinating syndrome.

R 22

Rheumatology &
Immunology

RHEUMATOLOGICAL EMERGENCIES
CERVICAL SUBLUXATION
Suspect in RA patients with long standing and severe disease
Commonly presents with neck pain radiating towards the occiput,
clumsiness, abnormal gait, spastic quadriparesis, sensory and sphincter
disturbances. May cause cord compression and death.
4 forms in descending order of frequency: anterior, posterior, lateral,
vertical
Investigations:
Plain AP and lateral XR of cervical spine with flexion and extension
views
Anterior subluxation: distance between the posterior aspect of the
anterior arch of the atlas and the anterior aspect of the odontoid process
(Atlanto-dens interval, ADI) 4mm
Dynamic (flexion-extension) MRI (if surgery indicated)
Management:
Medical
High-impact exercises and spinal manipulation are contraindicated
Soft collars may serve as reminder for patients and physicians but
provide little structural support
Stiff cervical collars may provide marginal benefit but compliance is a
problem
Neuropathic pain relief
Surgical
Urgent referral to orthopaedic surgeons or neurosurgeons if signs of cord
compression
Patients with severe subluxation but without signs of cord compression
are at risk for severe injury and perhaps death due to a variety of insults
including falls, whiplash injuries, and intubation. Surgical decision
should be individualized.
Surgical
options: craniocervical decompression, cervical or
occipito-cervical fusion (alone or in combination)

R 23
GIANT CELL ARTERITIS (GCA)

SEPTIC ARTHRITIS (see page R5-6)

Rheumatology &
Immunology

Presentation: At least 3 of the following 5 criteria

1. Age 50 years
2. Localized headache of new onset
3. Tenderness or decreased pulse of the temporal artery
4. ESR > 50 mm/hr
5. Biopsy revealing a necrotizing arteritis with a predominance of
mononuclear cells or a granulomatous process with
multinucleated giant cells.

Polymyalgia Rheumatica (PMR) is characterized by aching and

morning stiffness in the shoulder and hip girdles, occurring in
40-50% of GCA patients.

Other presentations: jaw or arm claudication, weight loss, PUO

Complications: Ischaemic optic retinopathy (visual loss 15-20%).

Blindness is abrupt and painless, may be preceded by amaurosis
fugax.

Aneurysms, dissections, stenotic lesions of the aorta and its major

branches
Investigations

Elevated ESR, often >100mm/hr (5% of GCA has ESR<

40mm/hr)

Temporal artery biopsy of the affected side

Treatment

High dose prednisolone (1mg/kg/day)

For visual symptoms or signs (eg, amaurosis fugax, partial or

complete visual loss), start empirical steroid before temporal
artery biopsy result

Acute visual changes - consider IV pulse methylprednisolone

(250-1000mg) daily for 3 days

R 24
ANCA VASCULITIS Pulmonary Renal syndrome

Rheumatology &
Immunology

Presentation:

Acute renal failure, signs of acute glomerulonephritis, or

Acute pulmonary haemorrhage

Investigations
ANCA (anti-neutrophil cytoplasmic antibody) +ve
Cytoplasmic (c-ANCA) or Perinuclear (p-ANCA) pattern

Anti-PR3 (proteinase 3) +ve or anti-MPO (myeloperoxidase) +ve

respectively

Raised ESR/CRP

Renal biopsy to show pauci-immune glomerulonephritis

CXR, HRCT, bronchoscopy etc for pulmonary haemorrhage

Treatment
Organ support: dialysis and ventilator care (consult ICU if needed)
Intravenous pulse steroid or high dose steroid
Cyclophosphamide or rituximab in refractory patients
Plasma exchange possibly useful in:
Patients with acute renal failure requiring dialysis support
Pulmonary haemorrhage
Concomitant anti-GBM +ve patients

R 25

NON-STEROIDAL ANTI-INFLAMMATORY DRUGS

(NSAIDS)
o
o
o

Adverse Effects
Beware of cross allergy between NSAIDs and COX-2 inhibitors
o GI: dyspepsia, peptic ulcer, GI bleeding and perforation
o Renal: renal impairment
o CVS: fluid retention, worsening of hypertension, increased
cardiovascular events
o Liver: raised transaminases
o CNS: headache, dizziness and cognitive impairment, especially use
of indomethacin in elderly
o Skin: may range from mild rash to Steven Johnsons Syndrome
o Resp: may precipitate or exacerbate bronchospasm in aspirin
sensitive individuals
Risk factors for gastrointestinal toxicity:
a. Chronically disabled
b. Age > 60 years
c. Previous history of proven peptic disease
d. Co-administration of high dose prednisolone or anticoagulation
e. Higher dosage of NSAIDs
f. Extent of inflammatory disease for which NSAIDs is prescribed

Rheumatology &
Immunology

Do not use > 1 NSAID at a time

Use the lowest possible dosage and frequency sufficient for pain
relief
Efficacy is similar among various NSAIDs. Conventional ones
such as naproxen, ibuprofen and indomethacin are equally
effective.
If one NSAID is not working despite 2-3 week of treatment at full
dosage, shifting to another NSAID may be considered.
Coexisting hypertension, fluid retention and/or renal impairment
consider sulindac

Rheumatology &
Immunology

R 26
COX-2 inhibitors
Efficacy: similar to non-selective conventional NSAIDs
Advantages:
o Reduce gastrointestinal toxicity.
o Less effect on platelet function, hence less bleeding risk.
o Less risk of precipitating bronchospasm
Adverse effects:
o Increase risk of cardiovascular events (MI, stroke). Risk proportional
to dosage. May worsen BP control and heart failure
o Nephrotoxicity, hepatotoxicity, cardiotoxicity similar to conventional
NSAIDs
o Celecoxib should be avoided in patients with sulphonamide allergy
Current recommendations for patients receiving NSAIDs
1. Prescribe lower-risk agents. Weigh GI against CV risk in individual
patient:
o If estimated risk of life-threatening GI bleeding > risk of CV events,
consider use of NSAIDs with gastroproection or the COX-2
inhibitors.
o If risk of CV events > the risk of GI bleeding, COX-2 inhibitors
should be avoided.
2. Limit duration, frequency and dosage.
3. Patients with known H pylori infection should undergo eradication
before NSAID therapy.
4. For patients at higher risk for GI complications, consider assessing
for and treating H pylori if present and co-therapy with
gastroprotective agents.
5. Gastroprotection:
o Proton pump inhibitors (PPIs)
o Misoprostol
o COX-2 inhibitor alone is beneficial in reducing GI risks, but with
the possible trade-off of increasing CV risk.
o COX-2 inhibitor with concurrent PPI therapy may be considered
in ultra-high risk patients eg. recurrent ulcer bleeding.

Infections
Infections

In 1

COMMUNITY-ACQUIRED PNEUMONIA
Definition of pneumonia
Clinical: syndrome of fever, chills, dyspnoea, cough with sputum and
pleurisy etc.
Radiological: consolidation on X-ray imaging Causative agents
Pathological: a form of acute respiratory infection that alveoli are
filled with pus and fluid, which makes breathing painful and limits
oxygen intake
Others

Bacteria

Mycobacterium tuberculosis
Viruses (Influenza, RSV, VZV,
Measles)

Emerging agents (MERS, Avian

influenza)

Pneumocystis jirovecii

Atypical
Legionella pneumophila
Mycoplasma pneumoniae
Chlamydophila pneumoniae

General principles
Tuberculosis is endemic in Hong Kong
Aware host factors like immunocompromised status
Aware risk factors and exposure history for atypical pathogen
infection
Early isolation of patients with suspected or confirmed air-borne
pathogens (tuberculosis, measles), or infectious diseases with special
significance (MERS, avian influenza)

Infections

Typical
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Klebsiella pneumoniae & other
gram -ve organisms (DM,
Alcoholic, those with risk of
aspiration)

In 2

Due to high prevalence of macrolide resistance in Mycoplasma

pneumoniae in Asia, early substitution of macrolide to doxycycline is
recommended when clinical suspicion arises

Infections

Empirical treatment
1. Patients who are stable for management in outpatient setting
PO Amoxicillin-clavulanate (beta-lactam with beta-lactamase
inhibitor) +/- macrolide or doxycycline
2. Hospitalized patients with mild to moderate pneumonia
PO/IV Amoxicillin-clavulanate +/- macrolide or doxycycline
Alternatives: IV ceftriaxone, cefotaxime +/- macrolide or
doxycycline
With chronic lung condition like bronchiectasis
Anti-pseudomonal antibiotics (e.g. IV piperacillin-tazobactam,
cefepime) +/- macrolide or doxycycline
3. Hospitalized patients with severe pneumonia, defined as having any 1
in 3 major criteria OR 2 in 6 minor criteria:
Major criteria: need of mechanical ventilation, septic shock, acute
renal failure;
Minor criteria: multilobar involvement, mental confusion,
respiratory rate >30 bpm, PaO2/FiO2 <250, SBP < 90mmHg/ DBP
< 60mmHg, serum urea level > 7 mmol/L)
IV piperacillin-tazobactam or ceftriaxone or cefepime +/macrolide or doxycycline +/- oseltamivir
Remarks:
1. In Hong Kong, macrolide/azalide, tetracycline or cotrimoxazole should not be
used alone for empiric treatment of CAP. Locally, 5070% pen-sensitive and
pen-resistant Streptococcus pneumoniae isolates are multi-resistant to these
agents (Interhospital Multi-disciplinary Programme on Antimicrobial
Chemotherapy (IMPACT), Fourth Edition (2012, version 4.0))
2. Caution required as unique groups of COPD patients appears to be the main
reservoir of levofloxacin-resistant Streptococcus pneumoniae (IMPACT,
Fourth Edition (2012, version 4.0))

In 3

HOSPITAL ACQUIRED PNEUMONIA (HAP)

Risk factors for MDR pathogens (Pseudomonas aeruginosa,

ESBL-producing Enterobacteriaceae, Acinetobacter species and
MRSA)
Antimicrobial therapy in preceding 90 days
High frequency of antibiotic resistance in the community or in the
hospital
Hospitalization for 2 days in the preceding 90 days
Residence in a nursing home or extended care facility
Chronic dialysis within 30 days
Home wound care
Family member with multi-resistant pathogen
Immunosuppressive disease and/or therapy

Infections

Pneumonia occurring 48 hr after admission and excluding any infection

that is incubating at the time of admission
There are two principles guiding the strategy of antibacterial therapy for
HAP:
Initial administration of adequate treatment with an antibacterial
agent(s) active against the causative pathogen(s).
De-escalation once the causative pathogen is known.
2 empiric Rx categories :
1. Early-onset pneumonia ( 4 days admission) with no risk factors
for multidrug-resistant (MDR) pathogens & any disease severity
3rd generation cephalosporin OR
-lactam/-lactamase inhibitor
(Amoxycillin-clavulanate/ Ampicillin-sulbactam)
2. Late-onset pneumonia (> 4 days admission) OR risk factors for
MDR pathogens and all disease severity
Antipseudomonal -lactam/-lactam inhibitor OR
Antipseudomonal cephalosporin OR
Antipseudomonal carbepenem
aminoglycoside OR fluoroquinolone
Vancomycin after careful assessment of indication

In 4
Empiric antibiotic may need modification/de-escalation once the results of
blood or respiratory tract cultures become available

Infections

Organisms

Antibiotics

Onset <4 days after

admission with no
previous antibiotics

S. pneumoniae,
H influenzae
M. Catarrhalis
S. aureus

IV/PO

Onset 4 days after

admission + had
received antibiotic
recently, OR
onset 5 days after
admission OR
mechanical
ventilation

MRSA;
P aeruginosa,
Acinetobacter,
Klebsiella spp.,
Enterobacter spp.

IV

Amoxicillin-clavulanate
or
Cefuroxime if penicillin
allergy (non-type I
hypersensitivity)
cefoperazone-sulbactam,

Cefepime or
piperacillin-tazobactam

an aminoglycoside
Vancomycin after careful
assessment of indications

In 5

PULMONARY TUBERCULOSIS
Recommendations
* Directly observed treatment (DOT) should be given as far as possible.
1. Uncomplicated new cases 6 months in total
2 HRZ + (E or S)/ 4 HR (When Rx started in hospital or when
3x/week regimen not tolerated)
2 HRZ + (E or S)/ 4 HR3
2 HRZ + (E or S)3/ 4HR3 (Government Chest Clinic regimen)
2. Retreatment cases 9 months in total.
3 (or 4) HRZES/ 6 (or 5) HR E

Drugs and dosages

Daily
BW

3x/week

Dose
mga

BW

Dose

H = Isoniazid

--

300

--

10-15 mg/kg

R = Rifampicin

<50 kg
>50 kg

450 mg
600 mg

--

600 mg

Z = Pyrazinamide

<50 kg
50 kg

1-1.5 g
1.5-2 g

<50 kg
50 kg

2g
2.5 g

E = Ethambutolb

--

15 mg/kg

--

30 mg/kg

<50 kg 500-750
<50 kg 500-750 mg
50 kg 750 mg
50 kg 750-1000 mg
a) i) Some elderly and/or malnourished can only tolerate 200 mg.
ii) Vitamin B6 10 mg/d for malnutrition, alcoholism, pregnancy.
S = Streptomycin

mgc

Infections

Notations:
Figures in front of drug combinations = duration in months.
Subscript 3 = thrice weekly & absence of subscript indicates
daily.
The slash / is used to separate different phases of Rx.

In 6
iii) May cause peripheral neuropathy, encephalopathy and convulsions
especially in renal impairment.
iv) Drug interaction with phenytoin & carbamazepine.
b) Assess baseline visual symptoms & acuity before starting Rx with close
monitoring during therapy & consult ophthalmologist prn
c) Lower dose for > 60 years old.

Infections

Reference: Chemotherapy of TB in HK updated in 2006.

www.info.gov.hk/tb_chest

In 7

CNS INFECTIONS
Consider CNS infections in the presence of sepsis and one or more of the
followings: meningism, seizures, headache, impaired consciousness,
photophobia, confusion, signs of increased intracranial pressure ( ICP),
focal neurological deficits, presence of parameningeal focus of sepsis.
Signs and symptoms may be subtle or absent in elderly or
immunocompromised host.

Typical CSF findings in meningitis

Normal

Viral

Bacterial

TB / Cryptococcal

Appearance

clear

clear

turbid

turbid/viscous

Mononuclear
cells (/mm3)

<5

10-100

<50

100-300

PMN (/mm3)

nil

nil

200-3000

0-200

Protein (g/l)

0.2-0.4

0.4-0.8

0.5-2.0

0.5-3.0

>1/2

>1/2

<1/2

<1/2

CSF/blood
glucose

Infections

1. CSF examination is crucial in the diagnosis of meningitis

2. Watch out for signs of ICP and do urgent CT brain before LP. If LP
is contraindicated, likely to be delayed or fails, empirical antibiotics
can be started after taking blood cultures
3. CSF analysis: cell count, protein, glucose (simultaneous blood
sugar), gram stain, culture, AFB (smear and C/ST), Cryptococcus
(India ink smear, Ag and culture), viral studies. Do not wait for C/ST
results before starting Rx
4. Other Ix: CBP, RFT, LFT, CXR, EEG, XR skull, sinuses and
mastoid
5. Look for any predisposing factors: sinusitis, endocarditis, otitis
media, skull fracture, immunocompromised state, etc

In 8
Initial empirical anti-microbial regimes
Bacterial
meningitis

Ceftriaxone 2 g q12h OR Cefotaxime 1.5-2 g iv q4h iv +

Vancomycin$ 500 -1000 mg q6-12h +
Ampicillin 2g iv q4h (if risk of listeriosis anticipated@)

Brain abscess

Ceftriaxone 2 g q12h OR Cefotaxime 1.5-2 g iv q4h iv +

Metronidazole 500 mg iv q8h

Infections

TB meningitis INAH 300-600 mg daily

Rifampicin 450-600 mg daily
Pyrazinamide 1.5-2 g daily
Ethambutol 15 mg/kg/d daily (25 mg/kg/d for first 2/12)
Pyridoxine 100 mg daily
Streptomycin 0.75 g im daily
Cryptococcal
meningitis

Amphotericin B 0.7 1 mg/kg iv infusion over 4-6 hrs +

5-Flucytosine 25 mg/kg q6h po for 2 weeks, then
fluconazole at least 400mg/d for a minimum of 8 weeks
(immunocompetent patients)

Viral
encephalitis

Acyclovir 10 mg/kg iv q8h (or 500mg iv q8h)

$ Aim at trough concentration 15-20 micrograms/ml

@ Immunocompromized, pregnancy and elderly

Dexamethasone 4 mg q6h in complicated TB meningitis or brain abscess with

significant cerebral oedema.
Dexamethasone (0.15 mg/kg q6h for 2-4 days with the first dose administered
10-20 min before, or at least concomitant with, the first dose of antimicrobial
therapy) in adults with suspected or proven pneumococcal meningitis
Prophylactic anti-convulsant may be considered in cerebral abscess and subdural
empyema
Duration of Rx for brain abscess 6-8 weeks
Duration of Rx for meningitis: 7days for H. influenzae, 10-14 days for S.
pneumoniae, 14-21 days for L. monocytogenes and S. agalactiae, and 21 days for
Gram negative bacilli. DO NOT change to oral therapy.
Consider prophylaxis for contacts in cases of meningococcal meningitis:
ciprofloxacin 500mg stat, ceftriaxone 250mg IM stat

In 9

URINARY TRACT INFECTION

Diagnosis

Organisms (a)

Antibiotics

Cystitis

E. coli;
S. saprophyticus;
Gp B streptococcus;
Proteus spp;
klebsiella spp.

Acute
pyelonephritis

E. coli;
other
enterobacteriacea;
enterococcus
(Pseudomonas in
Catheter related,
obstruction or
transplant related
infection)

IV Amoxicillin-clavulanate
3rd cephalosporins (e)
Aminoglycoside (f)
Piperacillin-tazobactam or
carbapenem if suspect
Pseudomonas infection

PO Nitrofurantoin(b, c)
Amoxicillin-clavulanate(c)
TMP-SMX(d)
Fluoroquinolone (d)

Infections

Remarks
a. Escherichia coli is the most common causative pathogen. ESBL
strain is not uncommonly seen in Enterobacteriaceae. Empiric
Carbapenem may be considered for severe clinical cases.
b. Nitrofurantoin is well tolerated, and demonstrates a consistently low
level of resistance among E. coli, gram-positive cocci (including
Enterococcus and S. saprophyticus), but inactive against most
Proteus, and Klebsiella strains. Nitrofurantoin should not be used to
treat pyelonephritis since it does not achieve reliable tissue levels.
c. Give 5-7 day of amoxicillin-clavulanate or Nitrofurantoin as 3-day
course may not be as effective as ciprofloxacin and TMP-SMX.
d. There is the increasing problem of resistance to TMP-SMX and
fluoroquinolone.
e. For example ceftriaxone and cefotaxime. A 14-day regimen is
generally recommended for upper UTI.
f. Aminoglycosides achieve higher tissue levels, relative to serum
levels, than do beta-lactams.

In 10

ENTERIC INFECTIONS
Acute infective diarrhoea may be due to viruses e.g. Norovirus, bacteria
and their toxin, and sometimes protozoa. Most are self-limiting.
Clinical presentation

Infections

1. Secretory diarrhoea (Non-inflammatory enteritis)

Commonly caused by salmonellosis
Norovirus: pronounced vomiting
Cholera classically presents as acute painless profuse rice water
diarrhoea without blood or mucus
2. Invasive diarrhoea (Inflammatory enteritis)
Presents as dysenteric syndrome i.e. transient diarrhoea followed by
abdominal colic, tenesmus, fever, blood and mucus in stool
Commonly caused by shigellosis (bacillary dysentery), non-cholera
vibrios (Vibrio parahaemolyticus and Plesiomonas shigelloides)
and occasionally Entamoeba histolytica (amoebic dysentery).
3. Typhoid and paratyphoid fever (enteric fever)
Caused by Salmonella typhi (typhoid fever) and Salmonella
paratyphi (paratyphoid fever)
Suspect in patient of high fever with relative bradycardia, platelet,
N to WCC, no localized focus of infection.
4. Clostridium difficile infection (CDI)
Common cause of hospital acquired diarrhoea.
Clinical presentation can range from mild diarrhoea to
pseudomembranous colitis (PMC). Fulminant colitis can result in
toxic megacolon and death
Common risk factors: use of broad spectrum antibiotics, e.g.
cephalosporins, fluoroquinolones and clindamycin, use of
immunosuppressants and prolonged hospitalisation

In 11
5. Enteric infections associated with systemic complications
E coli O157:H7 haemolytic-uraemic syndrome
Campylobacter enteritis Guillain-Barr syndrome
Non-polio enteroviruses Hand-foot-mouth disease, myocarditis,
encephalitis, etc.
6. Enteric infections are often more severe in immuno-compromised
patients, e.g. elderly, diabetes mellitus, cirrhosis, anatomical or
functional hyposplenism, concurrent immunosuppressant therapy
Management for enteric fever

Management for other bacterial enteric infections

1. Adequate fluid and electrolyte supplement
2. Routine antibiotic not recommended for

mild to moderate
gastroenteritis
3. Consider fluoroquinolone e.g. ciprofloxacin 500mg bd for 3 days or
azithromycin 500mg daily for 3 days, for cases of febrile
dysentery, especially for toxic patients.
4. Use of antibiotics as adjuvant therapy, e.g. doxycycline 300mg for
single dose, tetracycline 500mg qid for 3 days, or ciprofloxacin
500mg bd for 3 days, can reduce duration and severity of diarrhoea in
cases of cholera

Infections

1. Enteric fever is diagnosed by compatible clinical features and positive

culture from bone marrow aspirate, blood or stool. Widal serology is
neither sensitive nor specific.
2. Antibiotics treatment:
Levofloxacin 750mg daily iv/po OR ciprofloxacin 500mg bd po x
7d (10-14d for severe disease).
Alternative: Ceftriaxone 2g iv q24h x 10 14 days
Strains with nalidixic acid resistance (a surrogate marker
predicting clinical failure with fluoroquinolone therapy):
Azithromycin 500mg daily x 7 days or Ceftriaxone 2g iv q24h x
10 14 days

In 12
NOTE: If Campylobacter enteritis is suspected and antimicrobial is
indicated on clinical grounds, a macrolide (e.g. clarithromycin
or azithromycin) is preferred because of increasing report of
fluoroquinolone resistance.

Infections

Management of Clostridium difficile infection

1. Diagnosed by detection of C. difficile toxin or PCR in stool
2. Discontinuation of inciting and unnecessary antimicrobial therapy
3. Specific antimicrobial therapy
For mild case: oral metronidazole 400mg tds for 10-14 days
For severe case: oral vancomycin 125mg qid for 10-14 days
- add IV metronidazole 500mg q8h for cases complicated with
ileus or megacolon, surgery may be necessary
- consider rectal instillation of vancomycin for case of complete
ileus
For relapsed case: can repeat course of oral vancomycin; can
consider oral vancomycin with gradual tapering regimen for case
of repeated relapse or fecal transplant for refractory case
Reference
1. HA fact sheet on typhoid and paratyphoid fever (Jul 2011)
2. HA factsheet on cholera (Jul 2011)
3. HA fact sheet on Management of E coli O157: H7 (Jun 2011)
4. HA infection control guideline on Clostridium difficile infection
(Oct 2012)

In 13

ACUTE CHOLANGITIS
Investigations
a) CBP, LFT, RFT
b) PT, APTT, Glucose
c) Blood culture
d) Abdominal USG

2.

Management
a) Active resuscitation and monitor vital signs
b) IV antibiotics for mild to moderate cases:
- Amoxicillin-clavulanate (Augmentin) ( Aminoglycoside)
- Cefuroxime + metronidazole ( Aminoglycoside)
- If penicillin allergy, Levofloxacin + metronidazole
- IV antibiotic can be switched to oral formulary for completion
of therapy if clinically stable.
c) IV antibiotics for severe cases: Consider Tazocin, carbapenems,
3rd generation cephalosporin or levofloxacin + metronidazole.
d) Duration of Rx: 4-7d unless difficult to achieve biliary
decompression.
e) Early decompression of biliary obstruction by ERCP or PTBD.

3.

Preparation for ERCP

a) Indications for emergency ERCP
- Increasing pain and guarding in epigastrium or RUQ
- Hypotension despite resuscitation
- High fever (> 39oC)
- Mental confusion, which is a predictor of poor outcome
b) Correct coagulopathy
c) Fast patient

4.

Care for patients who have nasobiliary or percutaneous (PTBD)

drainage of obstructed biliary tract
a) Check input/output chart (including NB drain) daily
b) Check hydration status, RFT, HCO3 and correct fluid and
electrolyte derangement as necessary

Infections

1.

In 14

SPONTANEOUS BACTERIAL PERITONITIS

Infections

High index of suspicion is necessary

1. Cirrhotic patients may have an insidious onset of fever and lack of
peritoneal signs, perform diagnostic paracentesis, send ascitic fluid
for:
Cell count (EDTA bottle to haematology laboratory, request
differential WBC)
Low protein level is consistent with spontaneous bacterial
peritonitis
Fluid for bacterial culture in blood culture broth
Cytology
2. Diagnostic criteria:
ascitic fluid WCC > 500/mm3 or neutrophil > 250/mm3
(In traumatic tap, subtract 1 PMN for every 250 RBCs)

3. Perform blood culture

4. Common organisms:
Enterococci.

E.coli,

Klebsiella

sp,

Pneumococcus,

5. Empirical treatment:
IVI Ceftriaxone 2gm q24h OR IVI Cefotaxime 2 gm q8h (q4h if
life-threatening)
May consider reassessment by repeating paracentesis 48 hours
later.
Usual duration of treatment : 5-10 days
Consider IV albumin 1.5gm/kg at diagnosis and 1gm/kg on day 3,
especially in patients with renal impairment
Watch out for hepatic encephalopathy.

In 15

NECROTIZING FASCIITIS
Necrotizing Fasciitis is a deep seated infection of the subcutaneous tissue
that results in progressive destruction of fascia and fat, but may spare the
skin. Early Recognition is important because there may be a remarkably
rapid progression from an inapparent process to one associated with
extensive destruction of tissue, systemic toxicity, loss of limb or death.

Risk Factors

Organisms

Following exposure
to freshwater,
seawater or seafood

Aeromonas spp.
Vibrio vulnificus

Following
intraabdominal,
gynecological or
perineal surgery

Following cuts,
abrasion, recent
chickenpox, IVDU,
healthy adults

Antibiotics
IV Levofloxacin
Plus
IV Amoxicillin-clavulanate

Polymicrobial
Enterobacteriacea
Imipenem or Meropenem
Streptococci
Anaerobes

IV penicillin G 4 megaunits
Group A

Streptococcus

Q4H Plus

IV Linezolid 600mg Q12H

IVIG (1-2g/kg for 1 dose)

for streptococcal toxic shock

syndrome

Infections

Diagnosis and Management:

1. Difficult to distinguish from cellulitis in early stages.
2. Excruciating pain and presence of systemic toxicity out of proportion
to the local findings.
3. Skin breakdown with bullae and frank cutaneous gangrene can be
seen.
4. Risk factors assessment and urgent Gram stain may guide choice of
antibiotics.
5. Immediate surgical intervention and antibiotic therapy are the
mainstay of treatment.

Infections

In 16

If culture showed
MRSA, please notify
Department of
Health.

In 17

SEPTIC SHOCK
Terminology:
Systemic inflammatory response syndrome (SIRS): manifests by 2 or
more of the following conditions:
Temperature > 38C or < 36C
Heart rate > 90 bpm
Respiratory rate > 20 bpm or PaCO2 < 4.3kPa
WBC > 12,000/L, < 4000/L, or 10% immature (band) forms

Septic shock: A subset of severe sepsis with hypotension despite

adequate fluid resuscitation, along with the presence of perfusion
abnormalities.
Principles of management
Early recognition: high index of suspicion and perform sepsis
work-up whenever appropriate
Early and adequate antibiotic therapy: choice based on the suspected
primary site of infection and risk factor(s) for drug resistant pathogens
Source control: e.g. removal of indwelling devices, drainage of
abscess
Early haemodynamic resuscitation and continued support: targeted
MAP 60 mmHg. Fluid resuscitation initially. Start vasopressor (e.g.
dopamine, noradrenaline) if patient does not respond to fluid
resuscitation (e.g. 4L of crystalloid) or evidence of fluid overload is
present
Proper ventilator management with low tidal volume in patients with
ARDS
Target blood glucose level 10mmol/L
Strategies with less clear value:
- Corticosteroids (refractory vasopressor-dependent shock)

Infections

Sepsis: SIRS due to a documented infection. With sepsis, at least 1 of

the following manifestations of inadequate organ function/perfusion
also must be included:
Alteration in mental state
Hypoxaemia
Elevated plasma lactate level
Oliguria (urine output <30 mL or 0.5 mL/kg for at least 1 h)

In 18

Infections

ANTIBIOTICS FOR FEBRILE NEUTROPENIC

PATIENTS

1. Definition:
Neutropenia: Neutrophil (ANC) 0.5 x 109/L or 1 x 109/L
with a predictable decline to 0.5 x 109/L in 24 - 48h
Note: Neutropenia can occur either from disease or treatment.
Fever: Pyrexia > 38.3oC or > 38oC for > 1 hour
2. Work up:
Assess localizing signs & symptoms for infection, sepsis &
shock
Initially blood, sputum & urine cultures, CXR; other
specimens if clinically indicated
3. Risk assessment:
Low risk: Neutropenic period 7 days, no or few co-morbidities
High risk: ANC 0.1 x 109/L for > 7 days, shock, pneumonia,
newly onset abdominal pain or CNS signs
4. Empirical antibiotic therapy for neutropenic fever:
Give antibiotics as soon as possible (after immediate
sepsis workup)!
Low risk:
Ciprofloxacin 750mg BD PO + Augmentin 1g BD PO
Levofloxacin 750mg daily PO if penicillin allergy
If Fluoroquinolone has been used for prophylaxis, use regime as
for high risk
High risk:
Possible IV regimes for high risk cases
Ceftazidime 1-2 g q8h IV

Cefepime 2 g q12h or 1g q8h IVI

Imipenem 500 mg q6h IVI

Meropenem 500mg q6-8h to 1 g q8h

IVI

Tazocin 4.5 g q6-8h IVI

Sulperazon 1-2g q8-12h IV

+ Aminoglycoside for ill cases (e.g. IVI Amikacin 15mg/kg over 1h q24h,
750mg q24h or 375mg q12h)

In 19
+ Vancomycin 500 mg q6h or 1gm Q12H if culture +ve or highly suggestive of
MRSA/skin/catheter infection
+ Amphotericin B 0.5 1.0 mg/kg/day if no response after 5d & culture ve
Reference: Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical Practice Guideline for the
Use of Antimicrobial Agents in Neutropenic Patients with Cancer: 2010 Update by the
Infectious Diseases Society of America. Clinical Infectious Diseases 2011:52(4);427-31.

Additional notes by Medical Oncology:

Neutropenia can be resulted from either the disease or treatment e.g.
chemotherapy
Infections

Prompt initiation of broad-spectrum antibiotics after immediate sepsis

workup is important as patients with febrile neutropenia can rapidly
deteriorate

In 20

MALARIA
Management of Acute Attack
1.
2.
3.
4.

Infections

5.
6.
7.

Anti-malarial chemotherapy should be administered as soon as the

diagnosis is made
Monitor blood for parasites and repeat testing is needed if the
diagnosis is strongly suspected
Maintain fluid and electrolytes balance; avoid over-hydration
Renal failure regime for blackwater fever; treat hypoglycaemia
and/or shock if present
Pulmonary oedema may develop, treated by prop up, oxygen, loop
diuretic, veno-dilator; if hypoxic may need positive pressure
ventilation
Avoid sedatives and corticosteroids
Watch for relapse (usually within 2 months) and signs of peritoneal
irritation (splenic rupture).

Anti-malarial Chemotherapy
A.

Uncomplicated P. vivax, P. malariae and P. ovale

Chloroquine 600 mg base po stat
and
300 mg base 6 hours later
then
300 mg base daily for 2 more days
plus Primaquine 15 mg base (0.25 mg/kg) po daily taken with food
for 14 days in P. vivax and P. ovale infection to eradicate hypnozoites
in the liver.
NOTE 1 Chloroquine-resistant P. vivax reported from Oceania, Indonesia
and South America, treatment similar to that of P. falciparum
malaria is required.
NOTE 2 Primaquine-resistant P. vivax reported in South-east Asia and
Western Pacific. An increased of the dose to 22.5 30 mg daily
(or 0.5 mg/kg) is effective
NOTE 3 Primaquine is contraindicated in pregnancy. In G6PD deficiency,
primaquine is safe in dosage of 0.75mg/kg once a week for 8
weeks. Monitor Hb level.

In 21
B. Uncomplicated P. falciparum malaria
1. Definition: symptomatic malaria without signs of severity or evidence
of vital organ dysfunction
2. Treatment:
a. Artesunate 200 mg (4 mg/kg) po daily for 3 days
plus Mefloquine 1000 mg base po on day 2, then 500 mg po on day
3
b. Quinine 600 mg salt (10 mg/kg) po 8 hourly for 7 days
plus Doxycycline 100 mg po BD for 7 days
C. Severe P. falciparum malaria

2. Treatment:
a. Artesunate 2.4 mg/kg i.v. or i.m. given on admission (time = 0), then
at 12 h and 24 h, then once a day until oral medication could
be taken, treat for a total of 7 days
plus Doxycycline 100 mg po bid for 7 days once oral medication
could be taken or Mefloquine as in above section B2a
b. Quinine dihydrochloride 20 mg/kg loading dose in 5% dextrose
infused over 4 hours, maintenance dose 10 mg/kg infused over 2 4
hours every 8 hours. Change to oral dose when feasible to
complete a 7-day course
plus Doxycycline as in above section C2a
Note 1 Consider Primaquine 45 mg single dose to eradicate gametocytes in
blood at the end of treatment of falciparum malaria
Note 2 Do not use loading dose if patient has received quinine, quinidine, or
mefloquine in preceding 24 hours.

Infections

1. Definition: presence of one or more of the following clinical or

laboratory features, after excluding other obvious cause of their
symptoms:
a. Clinical: Prostration, Impaired consciousness, Respiratory distress
(acidotic breathing), Multiple convulsions, Circulatory collapse,
Pulmonary oedema (radiological), Abnormal bleeding, Jaundice,
Haemoglobinuria
b. Laboratory: Severe anaemia, Hypoglycaemia, Acidosis, Renal
impairment, Hyperlactataemia, Hyperparasitaemia (>5%)

In 22

CHICKENPOX / HERPES ZOSTER

Diagnosis
1. Acute illness of typical generalised papulovesicular rash without
other apparent cause (the rash may be atypical with few or no
vesicle in vaccinated persons)
2. Confirmed by laboratory test
Virus detected by DIF, PCR or culture from clinical
specimens
Paired serology in acute and convalescent phases

Infections

Management

1. Keep patients from school / work for at least 5 days after onset of

eruption or until vesicles become dry

2. Airborne and contact precautions for chickenpox/ disseminated zoster

when in hospital

3. Give acyclovir 10 12 mg/kg q8h IV infusion for 7 days for severe

zoster or chickenpox in elderly or immuno-compromised patients

4. Therapy for neuralgia usually required for zoster

5. Watch for development of severe secondary skin infection

(Staphylococcus/Streptococcus) and consider antibiotics (e.g. oral

cloxacillin) if necessary.
6. For herpes zoster with ophthalmic involvement, urgent eye
consultation is recommended.
7. Varicella-zoster immunoglobulin (VZIG) should be administrated as
soon as possible after exposure and within 10 days for high risk
patients, e.g. immunocompromised persons and pregnant women.
8. VZV vaccination should be given within 3 to 5 days after exposure as
PEP in persons who i) do not have evidence of immunity, ii) eligible
for vaccination, e.g. immunocompetent, non-pregnant and >12
months of age, and iii) are not indicated for VZIG
Reference:
HA Guideline on varicella zoster virus infections. CCIDER. 8 Nov 2013.
Prevention of Varicella. Centres of Disease Control and Prevention. 22
Jun 2007.

In 23

HIV / AIDS

Infections

Diagnosis of HIV infection and AIDS:

1. HIV infection: Screening test (ELISA) followed by confirmatory test
(Western Blot or Line Immunoassay)
2. AIDS: Laboratory evidence of HIV infection plus indicator diseases
for AIDS
3. Obtain informed consent before performing HIV test
4. Counselling is crucial because of major psychological and social
implications of a positive result. Patient confidentiality should be
respected and protected.
5. Referral for counselling and medical consultation available from
a. PMH Infectious Diseases Special Medical Clinic (IDSM)
(Tel: 6461 0613)
b. QEH Special Medical Service (Tel: 3506 5855)
c. CHP Kowloon Bay Integrated Treatment Centre (ITC)
(Tel : 2116 2888)
6. Voluntary reporting of HIV infection and AIDS to Department of
Health (DH 2293 form) is encouraged for epidemiological purpose.
Clinical management of HIV/AIDS
1. Baseline assessment:
CD4/CD8 count
HIV RNA level
Consider baseline genetic resistance testing (GRT)
Serological evidence of HBV and HCV coinfection
Syphilis serology and screen for other STIs
Toxoplasma and CMV serology
CXR for evidence of tuberculosis and tuberculin skin test
G6PD status
Baseline CBP, RFT with eGFR, LFT, CaPO4, fasting lipid and
glucose, ECG
Urine dipstick analysis
2. For patients with respiratory symptoms:
CXR, ABG, LDH +/-1,3 glucan

In 24

Infections

3.

4.

5.
6.

Sputum for C/ST, AFB smear and C/ST +/- TB PCR, staining for
Pneumocystis jirovecii +/- PCP PCR (if available)
Consider empirical Rx for PCP if hypoxaemia present
Bronchoscopy for non-responsive cases
For patients with GI symptoms:
Stool for microscopy and C/ST
Stool for Cryptosporidia /Cyclospora/Isospora / Microsporidia
Stool for AFB smear and culture
Workup for the GI pathogens (e.g. Norovirus infection, and
Clostridium difficile infection etc.)
OGD for dysphagia, colonoscopy for chronic diarrhoea,
USG abdomen & check viral hepatitis serology for deranged LFT
For patients with neurological symptoms:
CT / MRI brain, CSF examination
Toxoplasma serology, cryptococcal Ag
Consider PML or HIV Associated Neurocognitive Disorders
(HAND) as DDx
Nerve conduction studies for neuropathy
For patients with haematological problems:
Marrow biopsy for histology, AFB smear and culture, Parvovirus
B19 antibody and consider marrow for Parvovirus B19 DNA
For patients with PUO:
Blood +/- marrow for bacterial, fungus and mycobacteria culture
Blood for CMV pp 65 antigen, cryptococcal Ag and penicillium
serology/ galactomannan
CXR, CT thorax and abdomen/pelvis +/- PET scan

Antiretroviral therapy
Nucleoside/Nucleotide reverse transcriptase inhibitors (NRTIs):
Zidovudine (Retrovir, AZT, ZDV)

250 300 mg bd

Didanosine (Videx, ddI)

250 400 mg daily

Lamivudine (Epivir, 3TC)

150 mg bd

In 25
Stavudine (Zerit, d4T)

30 40 mg bd

Abacavir (Ziagen, ABC)

300 mg bd (check HLA B*5701

before initiation)

Tenofovir (Viread, TDF)

300 mg daily

Non-nucleoside reverse transcriptase inhibitors (NNRTIs)

200 mg daily for 2 weeks, then
200 mg bd (*avoid in female with
CD4 > 250 and male with CD4 >
400)

Nevirapine XR (Viramune XR)

Can replace NVP 200 mg bd

Efavirenz (Stocrin, EFV)

600 mg nocte (*avoid in women

of child-bearing age)

Rilpivirine (Edurant, RPV)

25 mg daily

Etravirine (Intelence, ETR)

200 mg bd

Protease inhibitors (PIs)

Indinavir (Crixivan, IDV)

800 mg (with RTV 100 mg) bd

Saquinavir (Invirase, SQV)

1000 mg (with RTV 100 mg) bd

Lopinavir /Ritonavir
(Kaletra, LPV/RTV)

2 tab bd or 4 tab daily (nave pt)

(400/100 mg)

Atazanavir (Reyataz, ATV)

300 mg (with RTV 100 mg) daily

or 400 mg daily

Darunavir (Prezista, DRV)

600 mg (with RTV 100 mg) bd

800 mg (with RTV 100 mg) daily
(for treatment nave patients)

Tipranavir (Aptivus, TPV)

500 mg (with RTV 200 mg) bd

Infections

Nevirapine (Viramune, NVP)

In 26
Ritonavir (Norvir, RTV)

Used in low-dose (100 mg) for

boosting level of other PIs

Integrase inhibitor (II)

Raltegravir (Isentress, RAL)

400 mg bd

Entry inhibitor (CCR5 antagonist)

Maravoric (Celsentri, MVC)

300 mg bd (dose adjustment

needed for drug interaction)

Infections

Fusion inhibitor
Enfuvirtide (Fuzeon, ENF, T20)

90 mg SC q12h

Combination formulations
Combivir

AZT + 3TC

Kivexa

ABC + 3TC

Truvada

TDF + emtricitabine (FTC)

Atripla

TDF + FTC + EFV

Stribild

Elvitegravir (EVG) + cobicistat

(COBI) + TDF + FTC

1. Patients should be prescribed combination anti-retroviral therapy

(cART) consisting of three active drugs.
The first-line regimen usually consists of
- 2 NRTIs + 1 PI (usually boosted with RTV),
- 2 NRTIs + 1 NNRTI or
- 2 NRTIs + 1 II.
The other classes of drugs are generally reserved for patients with
HIV drug resistance.

In 27
2. cART is recommended for all HIV-infected individuals to reduce the
risk of disease progression unless contraindicated. The strength and
evidence for this recommendation vary by pretreatment CD4 count
3. cART is also recommended for HIV-infected individuals for the
prevention of transmission of HIV
4. Drug adherence should be regularly assessed and reinforced to
prevent emergence of viral resistance
5. CD4 count and HIV RNA level should be monitored regularly and
therapeutic drug level monitoring and genotypic resistance assay
should be arranged for patients with non-suppressed viral load
6. Cautious about drug interactions especially when patient is receiving
PI or NNRTI

First line:

Septrin 480 mg to 960 mg daily

Second line:

Aerosolised pentamidine 300 mg every 4 weeks

(*should be conducted in facilities with adequate
ventilation to prevent transmission of TB)
Dapsone 100 mg daily

2. Mycobacterium avium complex (MAC)

Indication: CD4 <50/ul
Azithromycin 1000 mg once weekly OR clarithromycin 500 mg BD
Treatment of Opportunistic Infections
1. Pneumocystis jiroveci pneumonia
a) Consider in patients with fever, dry cough and dyspnoea
b) May have normal CXR during early stage
c) Diagnosis by sputum induction with hypertonic saline/ BAL/
transbronchial lung biopsy for staining for Pneumocystis jirovecii
+/- PCP PCR, hypoxaemia on ABG

Infections

Opportunistic Infection Prophylaxis

1. Pneumocystis jiroveci pneumonia (PCP)
Indications: a. after an episode of PCP
b. when CD4 count falls below 200/ul

In 28

Infections

d) Oxygen supplement
e) Drugs:

Septrin at TMP 15 mg/kg/d po/IV (3-4 tab qid) for 3 Wks

If acutely ill or PaO2 <8: add Prednisolone 40 mg bd for 5 days,
then 40 mg daily for 5days, then 20 mg daily for 11 days
Alternative regimen:
i. Clindamycin 600 mg IV q8h + Primaquine 30 mg daily po for
3 Wks
ii. Pentamidine isethionate 4 mg/kg/d IV for 3 weeks
2. Tuberculosis
Combination therapy (DOTS): isoniazid,
rifampicin, pyrazinamide and ethambutol;
levofloxacin and streptomycin for patients with
adverse reaction or intolerable to first-line drugs
3. MAC

Combination therapy with 3 - 4 drugs:

Ciprofloxacin 750mg bd/ levofloxacin 500mg/d
Clarithromycin 500mg bd/azithromycin
500mg/d
Ethambutol 15 mg/kg/d
Rifabutin 300 mg daily
Amikacin 10 - 15 mg/kg/d IV

4. Candida

Fluconazole 100 mg/d (higher dose up to 400

mg/d for refractory cases) or
Itraconazole solution 200 mg daily for 2 3
weeks Can consider echinocandin

5. Cryptococcosis

Amphotericin B 0.7 mg/kg/d IV (Max 1.5

mg/kg/d) or liposomal amphotericin B 3-4
mg/kg/d IV for 2 weeks + flucytosine 25 mg/kg
q6h for 2 weeks, then fluconazole 400 mg/d po
for total of at least 10 weeks

oesophagitis

In 29
6.

Penicilliosis

Induction: amphotericin B 0.5-1 mg/kg/d IV or

liposomal amphotericin B 3-5 mg/kg/d IV for 2
wks
Maintenance: itraconazole 200 mg bd
Pyrimethamine 200 mg po x 1 then 50-75 mg/d +
clindamycin 600 mg qid + folinic acid 10-20 mg
daily for 6 wks
Maintenance: Pyrimethamine 25-50 mg/d +
clindamycin 300-450 mg qid + folinic acid 10-20
mg daily

8. CMV retinitis

Ganciclovir 5 mg/kg IV q12h, foscarnet 60

mg/kg IV q8h or valganciclovir 900 mg po bd for
3 wks
Maintenance: Valganciclovir 900 mg daily po

9. Cryptosporidiosis Nitazoxanide 500 mg bd po for 2 wks

10. Cyclosporiasis

Septrin 960 mg bd for 3-4 wks

11. Isosoporiasis

Septrin 960 mg qid for 10 days

12. Microsporidiosis Albendazole 400 mg bd for 3 wks

Reference:
1)

EACS guideline 2013

2)

Panel on Antiretroviral Guidelines for Adults and Adolescents.

Guidelines for the use of antiretroviral agents in HIV-1-infected
adults and adolescents. Department of Health and Human Services.
Available at
http://aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf
Accessed in June 2014

Infections

7. Toxoplasmosis

In 30

Infections

3)

Panel on Opportunistic Infections in HIV-Infected Adults and

Adolescents. Guidelines for the prevention and treatment of
opportunistic infections in HIV-infected adults and
adolescents:recommendations from the Centers for Disease Control
and Prevention, the National Institutes of Health, and the HIV
Medicine Association of the Infectious Diseases Society of America.
Available at
http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf
Accessed in June 2014

In 31

RICKETTSIAL INFECTION
Rickettsiae are obligate intracellular bacteria. They are maintained in
nature through cycle involving reservoir mammals and arthropod vectors
except louse borne typhus. Humans are incidental hosts via arthropod
vector. In Hong Kong, majority of the reported cases contracted the
diseases locally and mostly related to outdoor activities. Vasculitis of
small vessels is basic underlying pathology. The severity of disease can
range from mild to multi-organ failure and even fatal outcome. Patients
usually present with triad (i.e. fever, skin rash/eschar and headache).

1.

Weil-Felix test: non-sensitive and non-specific

2.

Indirect immunofluorescence assay (sent to PHLC):

Spotted fever group

Typhus group
Scrub typhus

Management
1.

All beta-lactams and aminoglycosides are not effective.

2.

Doxycycline is the most effective drug

3.

The usual adult oral dose of doxycycline is 100mg twice daily for
7-14 days.

4.

Azithromycin is an option for those who are contraindicated for

tetracycline such as pregnant women and children.

5.

Notify to CHP

Infections

Diagnosis

In 32

INFLUENZA
An acute viral disease of the respiratory tract caused by the influenza A
(H3N2, H1N1, H5N1, H7N9 etc.), B and C viruses, with fever, headache,
myalgia, prostration, coryza, sore throat and cough.
Diagnosis
1.

Nasopharyngeal aspirates/ tracheal aspirates/ broncho-alveolar

lavage specimens for direct antigen detection (immunofluorescence
or EIA), AND viral culture; PCR in selected cases (consult clinical
microbiologist).
Acute and convalescent sera for specific Ab rise

Infections

2.

Complications
Primary viral pneumonia, secondary bacterial pneumonia, myocarditis,
myositis, rhabdomyolysis, Guillain-Barr syndrome, transverse myelitis,
Reyes syndrome (associated with use of aspirin in children)
Management
1. Droplet precautions
2. Treatment
Effective against influenza A and B
- Oseltamivir 75 mg bd po x 5 d
- Zanamivir 10 mg bd inhaler puff x 5 d
N.B.

Beneficial effects of treatment are most apparent if started early (i.e. within 48

hrs of symptom onset). However, in severe, hospitalized cases, therapy should

still be considered beyond the 48-hr window period.
In complicated cases (e.g. viral pneumonia), increased dose of oseltamivir
(150 300mg bd for 5 days) may be considered.
Seasonal influenza A/H1N1 virus exhibits a high level of oseltamivir
resistance (except for the influenza A/ H1N1 (2009) virus, which caused
pandemic in 2009 2010.)
Intravenous preparations of zanamivir and peramivir may be considered as
salvage therapy for critical cases.

In 33

Reference
1. HA fact sheet on antiviral therapy against influenza (Jan
2009)
2. HA fact Sheet on H5N1 Avian Influenza (Jan 2009)
3. HA Interim Guidance on Clinical Management of Human
Infection due to Avian Influenza A (H7N9) (May 2013)
4. HA Interim Recommendation on Antiviral Therapy for
Human Infection due to Avian Influenza A (H7N9) (May
2013)

Infections

Special points on Novel Influenza A

1. A statutory notifiable disease
2. Influenza A/H5N1 virus is a highly pathogenic form of
avian influenza that caused outbreak in various countries.
3. Since 2013, outbreaks of infection due to influenza
A/H7N9 have occurred in Mainland China
4. Pay attention to epidemiological link (Travel/ Occupation/
Contact/ Clustering) in evaluation of patients with fever
+/- URTI.
5. In general, neuraminidase inhibitors remain effective as a
treatment for novel influenza A/H5N1 and A/H7N9.
Prolonged duration and/ or increased dose of of therapy
may be necessary.
6. Intravenous preparation of zanamivir and peramivir may
be considered for critical cases.

In 34

INFECTION CONTROL

Infections

Hand Hygiene (HH)

Good hand hygiene practices is utmost important to prevent healthcare
associated infections.
Five moments for HH (WHO recommendations):
1. Before patient contact
2. Before aseptic task
3. After body fluid exposure risk
4. After patient contact
5. After contact with patient surroundings
Precautions to prevent transmission of infectious agents
2 tiers of precautions:
1.

Standard precautions (SP)

Applied to all patients in all healthcare setting, regardless of suspected
or confirmed presence of an infectious status. HCWs should apply SP
when contact with
blood;
all body fluids, secretions, and excretions except sweat, regardless of
whether or not they contain visible blood;
non-intact skin; and
mucous membranes.

2.

Transmission-based precautions
Applied to patients who are known or suspected to be infected or
colonized with infectious agents, including epidemiologically important
pathogens which require additional control measures to effectively
prevent transmission. These composed of droplet, contact and airborne
precautions.

In 35
Precautions Prevent transmission of infectious agents
spread by direct/ indirect contact with patients or
patients environment
e.g. Norovirus, RSV, C. difficile, MRSA

Droplet

spread through close respiratory or mucous

membrane contact with respiratory secretions
e.g. Influenza, N. meningitides, B. pertussis

Airborne

that remain infectious over long distance when

suspended in air
e.g. Measles, Chickenpox, M. tuberculosis

Syndromic and empiric applications of transmission-base

precautions
Clinical syndrome
Potential
Empiric
pathogens
precautions
Acute diarrhoea with likely Enteric
pathogens
infectious cause in an
incontinent/diapered patient

Contact

Abscess/draining wound
that cannot be covered

MSSA, MRSA,

Contact

Vesicular rash

Varicellar-zoster, Airborne + Contact

variola

Petechial/ecchymotic with
fever; meningitis

N.meningitides

Droplet (for 24
hrs.of antimicrobial
therapy); mask and
face protection for
intubation

Maculopapular rash with

cough, coryza and fever

Measles

airborne

Group A
Streptococcus

Infections

3.

Contact

In 36
Cough/ fever/ pulmonary
infiltrate and other clinical
features suggestive of TB

M. tuberculosis

airborne

Infections

Diagnosis of many infections require laboratory confirmation.

Appropriate Transmission-based precautions should be implemented
when test results are pending based on the clinical presentation and
likely pathogens. Examples:

In 37

NEEDLESTICK INJURY OR MUCOSAL CONTACT

TO HIV, HBV AND HCV
Prevention of transmission of HIV, HBV and HCV in healthcare setting is
based on the principle of Standard Precautions.
1. Avoid recapping needles
2. Dispose of sharps immediately after use
3. Plan for safe handling and disposal before beginning any procedures
using sharps
4. Use safety devices, if available
Measures that involve exposure to blood, body fluids, and tissues:
Handhygiene Gloves

Gown / plastic
apron

Mask

Eye
Protection

1. Suctioning

2. Inserion of
airways

3. Artificial
Airway care

4. CPR

- intubation

- bronchoscopy

- tracheotomy

6. ABG punctures

7. Cleansing
surfaces or
equipment

8. Blood taking

5. Assisting with

+ Routinely

*if soiling or spluttering likely

Infections

Procedures

In 38

Infections

Management of needle-stick injuries or mucosal contact with

blood and body fluids
1. First Aid (of utmost importance for lowering the risk of
infection)
Express blood gently and wash immediately and thoroughly with soap
and water.
In case of mucosal contact such as spillage into the eyes, wash
immediately and liberally with running water
wound should be disinfected and dressed
Attend A & E
2. Reporting: Injured staff should report to his unit head or physician i/c
and Infection Control Team.
3. Counselling
4. Management of occupational exposure to HIV:
Risk of HIV transmission is about 0.3% after needlestick injury and
0.1% after mucosal exposure.
Source patient should be assessed for risk of HIV infection. Counselling
and HIV testing with consent should be offered where appropriate.
The injured staff should be encouraged to undergo HIV testing at 0, 3
and 6 months; additional test at 12 months for those who have taken
PEP; or have become infected with HCV after exposure to source
co-infected with HIV and HCV to detect delayed HIV conversion.
Post-exposure prophylaxis with a 4-week course regimen containing 3
antiretroviral drugs should be initiated as soon as possible, preferably
within 2 hours after the exposure.
PEP can be initiated at any A&E department followed by referral to the
Therapeutic Prevention Clinic, at
.1. IDSM, PMH (Tel:6461 0613),
.2. Special Medical Service, QEH (Tel:2958 5855), or
.3. ITC, CHP (Tel:2116 2929), for counselling, follow up and HIV
testing.
Reference :
1) Updated US Public Health Service guidelines for the management of occupational exposures
to human immunodeficiency virus and recommendations for postexposure prophylaxis.
2) EACS guideline 2013

In 39
5. Post-exposure prophylaxis against hepatitis B infection
Save blood for HBV status of source and injured staff, if status
unknown.
If source person cant be traced, may treat as if he is HBsAg +ve
No treatment is required if injured staff is anti-HBs is +ve
HBIG and HB Vaccine can be offered to injured staff if anti-HBs is
negative (depends on HBsAg status of source and vaccination
history of injured staff)
POST-EXPOSURE PROPHYLAXIS
Previously Vaccinated

Unvaccinated

Known
Responders

Known
Non-respo
nders

Unknown
Response

HBV
markers
-ve

HBV
markers
+ve

HBsAg
+ve

Nil

HBIG
within 24
hrs,rept
after 1/12

Depends
on antiHBs status
of exposed

HBIG +
HB Vac

Nil

HBsAg
-ve

Nil

Nil

Nil

HB Vac

Nil

HBsAg
unknown

Nil

Depends
on source
HBsAg
status

Depends
on antiHBs status
of exposed
person

HBIG +
HB Vac
or
HBVac,
depending
on source
HBsAg
status

Nil

Infections

Source
HBsAg
status

In 40

Infections

means HBsAg -ve AND anti-HBs -ve

means HBsAg +ve OR anti-HBs +ve
Where indicated, one dose of HBIG (0.06 ml/kg) should be
given within 24 h of exposure, and preferably within 7 days
If HBIG has been given, the first dose of vaccine can be delayed for
up to 1 week after exposure.
HBIG and HB vac can be given together but at a different sites
Injured staff can be referred to the Viral Hepatitis Preventive Service
of DH (Tel: 21129911) for vaccination.
6. Post-exposure management against Hepatitis C infection
There is no universally accepted effective therapy for preventing
HCV infection after accidental occupational exposure. Early
identification of acute HCV infection and treatment with Interferon
plus ribavirin may prevent chronic HCV.
Check anti-HCV of source patient after informed consent.
Check anti-HCV and aminotransferase (ALT) of exposed person
soon after exposure and again at 6 months. Repeat at 12 month if
source is HIV-HCV co-infected.
If source is HCV infected /IV drug addict /unknown HCV status,
arrange follow-up in 6-8 weeks to test for anti-HCV, ALT and
HCV RNA. Refer the injured to specialist if HCV-RNA positive.

In 41

Middle East Respiratory Syndrome (MERS)

Background
Caused by MERS-coronavirus (MERS-CoV), first reported in
Middle East in 2012.
Most cases occur in Arabian Peninsula
Suspected source for human infection : Dromedary camels and bats
Incubation period : 2 to 14 days
Case fatality rate : around 30%

Investigations
Upper respiratory tract specimens (NPA, NPS), or lower respiratory
tract specimens (sputum, tracheal aspirate, BAL) in patients with
pneumonia, for MERS-CoV PCR (lower respiratory tract specimens
may have a better diagnostic yield)
Repeated testing may be necessary to exclude the diagnosis.
Stool for MERS-CoV PCR in patients with epidemiological link
presenting with diarrhoea.
Microbiological workup to exclude other infections
Clinical management
Isolate the patient(s) in airborne infection isolation room (AIIR) with
standard, contact, droplet and airborne precautions
Start empirical antimicrobial agents
-lactam/-lactamase inhibitor combination OR 3rd generation
cephalosporin + macrolide
Respiratory fluoroquinolones for patient with -lactam allergy
Liaise with lCU early for intensive care if anticipate clinical
deterioration

Infections

Clinical manifestation
Can be asymptomatic
Common presentation : pneumonia presenting with fever, cough, and
shortness of breath
Other symptoms : gastrointestinal symptoms, including diarrhoea
Severe illness : Organ failure e.g. respiratory failure, renal failure, or
septic shock

In 42

Infections

Provide supportive treatments : Oxygen, IV fluid, Inotropic support

+/- steroid* (septic shock), Mechanical ventilation +/- ECMO
(respiratory failure), Renal dialysis (renal failure)
* Avoid high-dose systemic corticosteroids for viral pneumonitis;
consider administration of intravenous hydrocortisone (up to 200
mg/day) or prednisolone (up to 75 mg/day) to patients with
persistent shock who require escalating doses of vasopressors
Based on the current scientific evidence, no specific anti-viral
treatment can be recommended at the moment
Continue isolation and infection control measures till asymptomatic
and specimens negative for novel coronavirus.

Reference:
Interim Recommendation on Clinical Management of cases of Middle
East Respiratory Syndrome. HA CCIDER.

In 43

Viral haemorrhagic fever (VHF)

Summary of common VHF agents are listed below

Disease (Virus)

Family

Natural
Distribution

Source of
Human
Infection

Incubation
(Days)

Lassa fever

Arenaviridae

W. Africa

Rodent

5-16

Argentine HF

Arenaviridae

S. America

Rodent

7-14

Rift Valley
fever

Bunyaviridae

Africa, Middle
East

Mosquito

2-5

CrimeanCongo HF

Bunyaviridae

Europe, Asia,
Africa

Tick

3-12

Hantavirus

Bunyaviridae

worldwide

Rodent

9-35

Marburg virus

Filoviridae

Africa

Fruit Bats

2-21

Ebola virus

Filoviridae

Africa

Fruit Bats

2-21

Yellow fever

Flaviviridae

Africa, South &

Central America

Mosquito

3-6

Dengue HF

Flaviviridae

Asia, Africa,
American

Mosquito

3-15

Infections

Background
VHF can be caused by four families of enveloped RNA viruses Arenaviruses, Bunyaviruses, Filoviruses and Flaviviruses
VHF in general refers to severe febrile illnesses with abnormal
vascular regulation and vascular damage but not all patients infected
with a VHF agent develop this syndrome
The routes of transmission are variable :
Most are zoonotic with spread via arthropod bites or contact with
infected animals
Human to human transmission possible e.g. in Ebola virus,
Marburg virus, Lassa virus and CCHF virus infection - usually
occur through direct contact with contaminated blood or body
fluids via mucous membrane during care of sick patients or
handling of dead bodies in burial ritual

In 44
Clinical features
Vary according to specific viral infection, range from minimally symptomatic
to fulminant presentations
Common presenting features : fever, myalgia, headache and prostration,
conjunctival injection, mild hypotension, flushing and petechial haemorrhages

Infections

GI symptoms e.g. nausea, vomiting, diarrhoea and abdominal pain are often
present in the pre-haemorrhage stage
Severe haemorrhagic manifestations in later stage: bruising, ecchymoses,
bleeding at injection sites, gingival haemorrhage and GI bleeding. It is often
accompanied by renal failure, hepatic damage, multi-organ failure and shock.
Diagnosis
Suspect VHF based on clinical assessment and travel history
Need to exclude other differential diagnosis e.g. malaria, meningococcemia
Diagnosis of VHF can be confirmed by blood test using PCR method to detect
specific virus
Management
Infection control (those with possible human to human transmission) : i) Single
room (in practice, use an Airborne Infection Isolation Room (AIIR) with toilet
facility); ii) Standard, Contact and Droplet precautions; iii) Prevention of
sharps injury and mucocutaneous exposure to blood, body fluids, secretion and
excretions; and iv) Meticulous Hand Hygiene
Mainly supportive care: i) Fluid and electrolyte management; ii)
Hemodynamic monitoring; iii) Ventilation and/or dialysis support; iv) Treat
secondary bacterial infections; v) Manage severe bleeding complications
Anticoagulants, aspirin, NSAIDS and intramuscular injections are
contraindicated
Ribavirin can be considered in VHF caused by Arenavirus or Bunyavirus
ZMapp and Favipiravir have been investigated in the management of Ebola
virus disease (EVD).
Vaccination
Yellow fever vaccine is recommended and required for travelers to some
countries in Africa and South America (refer to CDC/WHO website for
details)
Vaccines for other VHF agents e.g. Ebola virus are under investigation.
Reference:
Guidelines on Management of Patients with Suspect Viral Haemorrhagic Fever. HA CCIDER

Palliative
Medicine
Palliative
Medicine

PM 1

ANOREXIA
Anorexia can be due to multiple causes, leading to early satiety or loss
of desire to eat; may or may not be associated with cachexia.
Causes:
1. Concomitant symptoms: pain, depression, constipation, dyspnoea,
dysphagia, nausea, vomiting, anxiety
2. Oral problems: dry mouth, candidiasis, ulcers, ill fitting denture,
change in taste
3. Delayed gastric emptying: hepatomegaly, autonomic neuropathy
4. Medications: opioids, antibiotics
5. Odour: foul smelling discharge, fungating mass, incontinence

Appetite stimulating agents:

1. Corticosteroids: e.g. dexamethasone 2-4 mg daily
Rapid onset, but effect tails off after 4 weeks
Increase food intake, but no weight gain
May reduce nausea and improve sense of well being
Discontinue after 1 week if no benefit; if effective, keep minimum
effective dose; tail off if effect wears off
Look out for DM, TB before starting; give OM or before noon to
avoid disrupting diurnal rhythm; monitor mouth condition for oral
candidiasis.

Palliative
Medicine

Management:
1. Treat reversible causes and optimize symptom palliation
2. Maintain good oral hygiene
3. Provide frequent small meals or food on demand, allow patient to eat
what they wish, keep company during eating
4. Acknowledge concerns on prognosis, body image, social impact
5. Proper mood assessment and psychological support

PM 2
2. Progestogen: e.g. megestrol acetate 160 mg daily to Qid
Improve appetite and has a small effect on weight gain
Less rapid onset but action lasts longer than corticosteroid
S/E:
Oedema, thromboembolism and deaths are more frequent
Potential application in anorexia-cachexia syndrome related to
cancer, AIDS, advanced COPD.
3. Prokinetics e.g. metoclopramide 5-10mg tid
For early satiety, delayed gastric emptying, gastroparesis

Palliative
Medicine

PRACTICAL POINT:
Appetite stimulating agents does not reverse cachexia.

PM 3

NAUSEA & VOMITING

Causes:
1. GI related: GI obstruction, constipation, gastroenteritis, gastric
irritation, GERD, autonomic neuropathy
2. Metabolic: hypercalcaemia, uraemia, liver failure
3. Drugs: opioids, antibiotics
4. Cancer treatment: chemotherapy, radiotherapy
5. CNS: increased ICP, brain stem disease, vestibular dysfunction

PRACTICAL POINTS:
1. Do NOT use metoclopramide in complete GI obstruction.
2. Dosage adjustment of metoclopramide is required in renal failure.

Palliative
Medicine

Management:
1. Elucidate and remove cause of nausea and vomiting if possible (e.g.
constipation, hypercalcaemia).
2. Pay attention to environment, odour, food presentation.
3. Antiemetics (If oral absorption is in doubt, use other routes)
Prokinetic: e.g. metoclopramide 5-10mg tid, domperidone 10mg
tid.
Central anti-dopaminergic drugs e.g. haloperidol 0.5-5 mg bid (e.g.
uraemia, opioid-induced).
Dexamethasone 16 mg OM initially for brain tumour while
pending tumour targeted treatment; 8 mg OM initially for reducing
compression on gut by tumour masses.
For emetogenic chemotherapy related nausea and vomiting,
consider 5HT3 antagonists e.g. granisetron, ondansetron,
tropisetron, and neurokinin-1 (NK-1) antagonist e.g. aprepitant

PM 4

Palliative
Medicine

CANCER PAIN MANAGEMENT

Optimum management of cancer pain requires a multidisciplinary
approach. The Basic General Principles are:
1. By the Mouth: oral route the preferred route.
2. By the Clock: regular analgesics.
3. By the Ladder (WHO Analgesic Ladder) adjuvants.
Start appropriate analgesic according to the intensity of pain
WHO analgesic ladder step
Analgesics of choice
1 ( mild pain)
Paracetamol and/or NSAIDs
2 (mild to moderate pain)
Weak opioids (e.g codeine,
dihydrocodeine, tramadol)
paracetamol and/or NSAIDs
3 ( moderate to severe pain)
Strong opioids (e.g morphine,
methadone, fentanyl)
paracetamol and/or NSAIDs
Adjuvants: antidepressants (e.g amitriptyline and imipramine) and
anticonvulsants (e.g gabapentin and pregabalin)
PRACTICAL POINTS:
1.
2.
3.
4.
5.
6.
7.
8.

Consult palliative care or cancer pain specialist when patient in severe pain
crisis.
Pethidine NOT recommended because of adverse S/E profile.
FDA recommended withdrawal of propoxyphene in 2010.
Potency of Tramadol is between weak and strong opioids; similar S/E
profile; watch out for drug-drug interaction e.g. SSRI, TCA, warfarin.
Fentanyl patch is NOT for opioid nave patients, acute pain or initial
titration. Consult specialists.
Caution was recommended on chronic use of NSAIDs, as many cancer
patients are at high risk of GI, renal, cardiac toxicities or bleeding
disorders.
In ESRD, paracetamol is the first line drug. Weak opioids, morphine,
NSAID, COX-2 inhibitor should be AVOIDED. Methadone and fentanyl as
suitable strong opioids, consult specialist.
COX-2 inhibitor is no different from NSAID in renal toxicity.

PM 5

GUIDELINES ON USE OF MORPHINE FOR CHRONIC

CANCER PAIN CONTROL

Palliative
Medicine

1. Morphine is the strong opioid of choice for moderate to severe

cancer pain.
2. Morphine has no standard upper dose range. The optimal dose is the
dose providing adequate pain relief with minimal or tolerable S/E.
3. Oral route is preferred unless not feasible e.g. GIO, dysphagia
4. Use immediate release morphine i.e. syrup morphine for titration.
5. Start with syrup morphine 5mg Q4H regularly, not PRN. Some
prefer to double the dose at bedtime to avoid waking the patient up at
4 am.
6. Consider a lower starting dose of 2.5mg for patients susceptible to
S/E e.g. old age, COPD, frailty, sleep apnoea.
7. Dose increment: e.g. 5mg7.5mg10mg15mg20mg30mg
etc.
8. For breakthrough pain, prescribe the SAME dose as the one for
regular use in between the regular intervals, given up to hourly.
Review within 24 hours and adjust the regime according to
breakthrough requirement.
9. AVOID morphine in renal failure as active metabolites are excreted
by renal route.
10. Side effect of opioids and their management:
GI
Nausea, vomiting, constipation
ANS Dry mouth, urinary retention, postural hypotension
cognitive impairment, delirium, hallucination,
CNS Sleepiness,
respiratory depression, myoclonus, seizure, hyperalgesia
Skin Itchiness, sweating
a. Good explanation is important.
b. Ensure adequate hydration of patient.
c. Give laxatives CONCURRENTLY if not contraindicated,
preferably a combination of stimulant and stool softener e.g.
Senna 15mg Nocte and lactulose 10ml tid.
d. Nausea may occur initially. May prescribe antiemetic PRN
e.g.metoclopramide 5-10mg tid, haloperidol 0.5-5mg daily.
e. May consider methylphenidate 5 20mg daily for sleepiness

PM 6
f. Consider reduce dose of morphine if pain is well controlled;
abrupt discontinuation may precipitate withdrawal symptom.
g. Consider adjuvant analgesics.
h. Consult specialist to switch to another strong opioid.

Palliative
Medicine

Dose conversion of oral morphine to parenteral route

1. Parenteral route has NO special advantage over oral route.
2. SC route is the preferred alternate route, or IV if access available.
No indication for IMI generally.
3. Dose conversion
Oral daily dose of morphine2 = daily dose of morphine SC
Oral daily dose of morphine3 = daily dose of morphine IV
E.g. Morphine 60mg PO = 30mg SC = 20mg IV
PRACTICAL POINTS ON PARENTERAL DRUGS:
Generally, parenteral drugs for symptom control can be given by:
1. Syringe driver (10ml syringe or specified syringe) OR
2. Infusion pump by adding drugs to parenteral fluid to be given SC
(NS only for SC) or IV.
PRACTICAL POINTS ON LAXATIVES:
1. Metamucil requires good fluid intake and has high K content; NOT
for frail patients with reduced water intake.
2. Mg Trisilicate has high Mg content; NOT for ESRD.
3. Fleet enema contains high phosphorus content; NOT for ESRD.

PM 7

DYSPNOEA
Causes:
Dyspnoea is a subjective experience of the patient and is usually
multifactorial in advanced cancer.
Common Cardiorespiratory Causes
Malignancy
related

Non-mlignant

Lung masses, Pleural effusion, Chest

infection, Major airway obstruction,
SVCO, Lymphangitis carcinomatosis,
Pneumothorax, Pericardial effusion,
Pulmonary embolism,
Post-irradiation or
post-chemotherapy Pneumonitis.
Co-existing COPD, Asthma, Heart
failure

Common Systemic
Causes
Anaemia, Cachexia,
Muscle weakness, Gross
hepatomegaly or Tense
ascites, Metabolic
acidosis

Anxiety

Palliative
Medicine

Management:
1. Identify and treat as many reversible causes as possible e.g. pleural,
pericardial or abdominal tapping, chest drain insertion, antibiotics,
anticoagulation, blood transfusion, bronchodilators, diuretics.
2. Oxygen for hypoxic patients, nasal prong better tolerated than face
mask.
3. Dexamethasone 4-8 mg daily for lymphangitis carcinomatosis,
post-irradiation or post-chemotherapy pneumonitis; 16mg daily for
SVCO, major airway obstruction.
4. Opioid:
For opioid nave patients, start with morphine 1-2 mg Q4H PO or
SC. Increment of 25% of baseline dosage for patient on
morphine
Monitor mental state, RR, SaO2. Withhold opioids if there is
sign of respiratory depression.
Titrate up in steps according to effect: e.g. 1 mg 2 mg 3mg
5mg

PM 8
Dyspnoea in the terminal phase: In opioid nave patients, start
with morphine 5mg SC infused over 24 hours; for patients with
CRF, start with fentanyl 50-100 microgram SC infused over 24
hours. For intermittent/ breakthrough dyspnoea, add morphine
1-2mg SC q2h prn; or fentanyl 12.5microgram SC q2h prn for
CRF.
5. Anxiolytic: indicated for patient with strong anxiety or panic.
6. Non-drug measures: prop up, face fan / good air circulation.
7. For severe dyspnoea refractory to above treatment, consult PC
specialist. The use of palliative sedation should ONLY be
prescribed by PC specialist for refractory dyspnoea. Patient and
family should be informed about the purpose, possible impairment in
communication, and this is not euthanasia.

Palliative
Medicine

PRACTICAL POINTS:
1. CXR is useful in elucidating most underlying causes.
2. SaO2 / lung function parameters do NOT correlate with intensity of
dyspnoea.
3. Look out for trapped lung in chest tapping, stop if patient coughing
or develop chest pain; document in patients record to guide decision
on chest tapping in subsequent admission.
4. USG guidance is helpful in chest tapping especially in the presence
of loculations.
5. Before abdominal tapping, watch out for coagulopathy; for patients
with suspected haemoperitoneum, consider the risk of removing the
tamponade effect on a ruptured tumour with release of
intra-abdominal pressure upon tapping.

PM 9

DELIRIUM

Palliative
Medicine

Delirium is an acute confusional state with fluctuating course,

characterized by altered consciousness and cognitive deficits.
Manifestations can be hyperactive, hypoactive, or mixed.
Delirium is common at terminal stage, but can have easily remediable
causes.
Common causes:
1. Drugs : opioid, anticholinergic, steroid, antidepressant, sedatives
2. Uncontrolled symptoms: eg pain, faecal impaction, urine retention
3. Infections
4. Metabolic : hypercalcaemia, electrolytes disturbance,
hyper/hypoglycaemia, liver failure, uraemia, dehydration, hypoxia,
CO2 retention
5. Organic brain disorder : brain tumour or metastases, cerebrovascular
events
Exacerbating factors:
1. Change of environment or excessive stimuli temperature, noise,
lighting
2. Insomnia, anxiety, depression, fear
Management:
1. Calm reassurance and explanation to patient and family
2. Reduce environmental stimuli, avoid restraints and keep patient
accompanied.
3. Identify reversible causes and treat accordingly.
Bedside examination include assessing the hydration status,
neurological exam, PR exam, palpating for urinary bladder,
checking temperature, SaO2 and Hstix
Take blood for CBP with d/c, RLFT, Ca2+, cultures as
appropriate and treat accordingly
Review drug charts if drug-related delirium is suspected, stop
the drug if possible or switch to alternatives where available; if
opioid toxicity, reduce dose by one-third to half. Ensure adequate
hydration.
+/- CT brain if suspected remediable CNS causes

PM 10

Palliative
Medicine

4. Drug treatment for delirium is indicated if the symptoms are

distressing (lower doses for frail elderly with caution):
Haloperidol po/sc 1 3mg stat (start at 0.5 in elderly) THEN q4
6h; or sc infusion 5 20mg q24h via a syringe driver ; shown
to be effective in hyperactive, hypoactive and mixed types of
delirium
Chlorpromazine po 25 50 mg q8h is an alternative and has
similar efficacy to haloperidol.
Benzodiazepine may aggravate agitation; use judiciously in
combination with haloperidol for sedation in terminal delirium or
if symptoms remain refractory. Midazolam sc 2.5 5mg stat for
acute control then 5 30mg q24h via syringe driver.

PM 11

MALIGNANT BOWEL OBSTRUCTION (MBO)

PRACTICAL POINTS:
1. Surgery carries high mortality, complication rates and substantial
hospitalization relative to the patients remaining survival time.
Consider stenting in individual cases.

Palliative
Medicine

1. Assess if surgery is feasible, more likely for patient with single level
obstruction with good performance status. Surgical intervention also
depends on other prognostic criteria (age, comorbidities, nutritional
status and history of radiotherapy to abdomen)
2. For inoperable cases, symptomatic medical treatment (should be
individualized):
a. Fasting, IV/SC rehydration
b. Antiemetics:
- Haloperidol SC: 5-15 mg/24 h
- Metoclopramide SC 30-60 mg/24 h (contraindicated in
complete obstruction)
- Ondansetron IV: 4-8 mg/24h in refractory cases
c. Anticholinergic antisecretory:
- Hyoscine-N-butylbromide SC 40-120 mg/24 h
d. Antisecretory somatostatin analogue:
- In refractory MBO with high output, consider Octreotide
SC/IV 300 micrograms/24 h for 3 days, up to 600
micrograms/24h (total duration <7 days)
e. Gastric antisecretory:
- Pantoloc 40 mg IV over 24 h or single injection
f. Steroids:
- Dexamethasone IV/SC 0.25-1 mg/kg/24 h or in one single
injection, short course 5-10 days
g. Analgesics:
- IV/SC morphine or fentanyl (dose titration as in pain
management)
h. Nasogastric tube (NG tube)
- Necessary if abundant vomiting and/or significant gastric
distention (> 1 litre/day)

PM 12

Palliative
Medicine

2. Stop stimulant laxatives and prokinetic agents if complete MBO.

3. NG tube is no longer used routinely and should instead be decided
on a case-by-case basis. Aim to remove the NG tube as soon as
possible to minimize patient discomfort.
4. Consider venting gastrostomy in refractory high output MBO.
5. MBO may be reversible under symptomatic medical treatment.

PM 13

PALLIATIVE CARE EMERGENCIES:

MASSIVE HAEMORRHAGE

Palliative
Medicine

Anticipation:
Important for care planning or advance directives; identify any
underlying causes e.g. coagulopathy or thrombocytopenia and /or
potential lesions e.g. H&N tumour eroding carotid artery; repeated
episodes of haemoptysis; invasion into internal structures e.g. aorta;
tumour rupture e.g. HCC.
Management:
If indicated, haemodynamic stabilization with transfusions and volume
replacement should be given. Repeated transfusion is warranted only if
clear benefit was obtained following the last transfusion. In case of
massive haemorrhage that occurs at the end- of-life with a DNACPR
directive, comfort measures should be taken.
1. Apply direct pressure with adrenaline (1 in 1000) soaked dressing to
any external bleeding point.
2. Use green surgical towels to reduce the frightening visual impact of
the bright red blood.
3. Sedate with midazolam 5-10 mg SC or diazepam 5-10 mg per rectal
stat to relieve panic and fear.
4. Address emotional impact on family and staff.

PM 14

MALIGNANT HYPERCALCAEMIA

Palliative
Medicine

(Also see page K6 and GM27)

Presentation: delirium, malaise, thirst, nausea, constipation

Common primary: myeloma, breast, lung, head & neck, kidney
Management:
1. Monitor Ca, P, RFT, urine output.
2. Withdraw drugs that promote hypercalcaemia (thiazide diuretics,
lithium, ranitidine, vitamins D and preparations containing calcium)
3. Rehydration with NS 2-3 litres/day, to keep adequate urine output e.g. >
2 L/day.
4. Bisphosphonate infusion after correction of dehydration
Pamidronate infusion
3.0-3.25 mmol/L - 60mg in 500ml NS over 2-4hrs
>3.25 mmol/L
- 90mg in 500ml NS over 2-4hrs
Zoledronic acid 4mg iv infusion over 15 min
Adjust dose or infusion rate in renal impairment.
Longer infusion in pamidronate (i.e., >2 hrs and up to 24 hrs) may
reduce the risk for renal toxicity, particularly in patients with
preexisting renal insufficiency.
Dose reduction in zoledronic acid
CrCl ml/min

Dose

>60

4mg

50-60

3.5mg

40-49

3.3mg

30-39

3mg

Bisphosphonate is generally contraindicated if CrCl<30

5. Consider steroid e.g. Prednisolone 30mg or hydrocortione 100mg iv q6h
for hypercalcaemia in myeloma and lymphoma
6. Haloperidol 0.5-5mg daily for delirium.
7. Maintain IV hydration till patient can maintain oral hydration.
PRACTICAL POINTS:
1. Allow time to achieve full treatment effect: check calcium level at day 5
to assess effectiveness. Do NOT repeat bisphosphonate infusion until
day 7.
2. Patient may look exceptionally ill with hypercalcaemia, on the other
hand, bisphosphonate may not be appropriate at EOL, if in doubt,
consult.
3. Effect of bisphosphonate lasts for 2-4 weeks, plan accordingly.

PM 15

METASTATIC SPINAL CORD COMPRESSION

(Also see page N19 and GM26)

Common primary: breast, lung, prostate (15-25%); myeloma, kidney,

lymphoma (5-10%); GI, melanoma, sarcoma, unknown primary (<5%)
Site of Compression: thoracic (70%), lumbosacral (20%), cervical
(10%)

Investigation & management:

1. Plain X ray may not show bone lesion till bone loss is considerable.
2. Urgent MRI of the whole spine.
3. Start dexamethasone 16mg per day PO or IV
4. Urgent referral for RT; tail down steroid after RT
5. Consult O&T for surgical intervention which may be appropriate in
selected cases (uncertain cause, radioresistant tumour, failed
radiotherapy, unstable spine, major structural compression, cervical
cord lesion, solitary vertebral metastasis)
PRACTICAL POINTS:
1. Functional status at the time of treatment is the most important factor
in determining the prognosis and outcome; early diagnosis important
2. CNS examination can be normal to begin with; keep monitoring

Palliative
Medicine

Presentation:
1. Back pain aggravated by coughing or lying down; neuropathic pain
radiating from back to thigh or around the trunk; motor weakness or
impaired sensation; sphincter disturbance is a late sign with poor
prognosis in functional outcome
2. Perform a FULL neurological examination in ANY cancer patient
with the slightest suspicion
3. Can be the first presentation of cancer
4. Site of pain may not correlate with level of compression

PM 16

Palliative
Medicine

LAST DAYS OF LIFE

1. Recognizing a patient is approaching end-of-life is important in
triggering the care planning and communication with patient and
family.
2. Inappropriate interventions, investigations and medications should
be withheld to focus on comfort measures.
3. Anticipatory prescription facilitates timely symptom control e.g.
pain, delirium, dyspnoea, death rattle, myoclonus. Medications must
be regularly reviewed and adjusted. Dose reduction in elderly and
frail is needed.
Pain: Morphine 2.5-5mg SC prn hrly or fentanyl 12.5 microgram SC
prn hrly if not on regular opioid; step up the regular dose of opioid if
already on opioid and change to SC route.
Nausea / vomiting: Haloperidol 0.5-1 mg SC prn hourly.
Agitation / anxiety: Haloperidol 2.5mg sc prn hrly, or Midazolam
2.5mg SC prn hourly.
Myoclonus: Midazolam 2.5mg SC prn hourly.
DEATH RATTLE & TERMINAL DYSPNOEA
1. Due to excessive respiratory secretions, the noise of which can be
distressing for relatives; explain that patient is not choking.
2. Avoid excessive fluid.
3. Gentle suction.
4. Hyoscine butylbromide (Buscopan) 20-60 mg q24h SC.
5. For terminal dyspnoea, please refer to DYSPNOEA session
PRACTICAL POINTS:
1. Do NOT use morphine for sedation.
2. Poor circulation may not give accurate SaO2; upward titration of
oxygen with plateau of dyspnoea relief or oxygen saturation is not
indicated. High oxygen flow may cause more discomfort to patient.

General
Internal
Medicine

General Internal
Medicine

GM 1

ANAPHYLAXIS

General Internal
Medicine

GM 2

ACUTE POISONING
The guidelines below are very general and treatment options may not
apply to all patient. For specific poisoning patient management, please
call Hong Kong Poison Information Centre (HKPIC) 27722211 or
26351111. (Note: all dosages quoted are for adult.)

General Internal
Medicine

General management of acute poisoning

(1) General measures
- Maintain ABC with precaution of secondary contamination
- Close monitor vital signs + neurological status
- Watch out and treat concomitant injuries; eg. head injury
- Obtain history of offending poison, dose, timing of ingestion
- Ix: Blood gas, CBP, L/RFT, glucose, Hstix,
Urine, blood, +/-gastric contents for toxicology
Specific drug level: Panadol, ethanol, salicylate, as indicated
ECG (assess for HR, QRS, QTc, arrhythmia)
- Correct fluid, electrolyte disturbance and treat arrhythmia.
- Psychiatry consultation, suicidal precautions as appropriate.
(2) Consider GI decontamination
Activated Charcoal (AC)
- Within first 1-2 hr after a toxic ingestion, Dose: 1g / kg PO.
- Not for small molecules (Fe, Li, toxic alcohols), caustic, hydrocarbon.
Gastric Lavage (GL)
- For potentially life-threatening poisonous ingestion
- Preferably within first hour post ingestion
- Intubation needed for confused, comatose patient
- Conscious patient must be cooperative, consent signed, lying head
down left lateral position, with powerful suction standby
- 36-40 F oro-gastric tube, 200-250ml water each time for at least 4-6L
or until return fluid is clear

GM 3
Multiple dose activated charcoal (MDAC)
- 1g/kg PO, follow by 0.5g/kg q2-4hr for 1-2 days.
- Consider for Theophylline, Phenobarbital, Phenytoin, Digoxin,
Carbamazepine, Dapsone, GI concretion forming drug; aspirin and
sustained release (SR) preparation
Whole bowel irrigation (WBI)
- Toxic dose of SR preparation, body packers, and drugs not adsorbed
to AC
- PEG 1-2 L/hr till clear rectal effluent (orally or via a NG tube)
(3) Consider use of specific Antidotes
Level I, II, III antidotes kept at acute hospitals, cluster hospitals and
HKPIC respectively
(4) Enhanced Elimination as needed

Haemodialysis / Haemoperfusion
Haemodialysis

Hemoperfusion

Strong
Indication

Methanol / Ethylene Glycol

Lithium, Aspirin

Theophylline

Rarer
Indication

Ethanol / Isopropanol

Carbamazepine, Phenytoin
Phenobarbital

General Internal
Medicine

Urinary Alkalinization
- Useful in Aspirin, Phenobarbital, Chlorpropamide, Formate,
Methotrexate
- 1-2 mEq/kg NaHCO3 IV bolus, then 50mEq NaHCO3 (8.4%) in 500ml
D5 Q4-6hr IV infusion
- Works by ion trapping, must get urine pH>7.5 to be effective
- Monitoring serum pH, avoid >7.55, avoid hypokalaemia

GM 4
Treatment of specific drug poisoning
Benzodiazepine overdose
- Supportive measure is the mainstay of treatment
- Flumazenil is an effective antidote indicated in selected case
- Start with 0.2 mg IV over 30 sec and titrate up to 1-2 mg in total
C/I : patient with undifferentiated coma, epilepsy, benzodiazepine
dependence, co-ingestion of pro-convulsion poisons; eg.TCA.

General Internal
Medicine

Opioid overdose
- Supportive measure is the mainstay of treatment
- Naxolone: 0.4 mg 2 mg as an IV bolus & repeated as needed.
- For chronic user, start with low dose of 0.1 mg.
- Naxolone infusion if repeated dose of naxolone needed.
(2/3 of initial effective naloxone bolus on an hourly basis:
ie. 4X initial effective dose + 500ml NS, Q 6 hour).
Amphetamine / Cocaine overdose
- Agitation, Hyperthermia - Rapid cooling, IV benzodiazepine
- HT- Phentolamine 1-5mg IV & repeat every 10 minutes or
Nitroglycerin 0.25-0.5 microgram/kg/min
- Cocaine (Na channel blocking effect) NaHCO3 1-2mEq/kg IV bolus
till QRS <100ms or pH >7.55.
Paracetamol overdose
- Acute toxic dose: >150mg/kg.
- Check paracetamol level at 4 hour, LRFT.
- AC if within 1st hour, NAC if toxic level above Tx line.
- NAC has full protection if given within 8 hr post-ingestion, useful
even on late administration.
NAC dose
In D5
Rate
Loading
150mg/kg
200ml
in 1hr
then
50mg/kg
500ml D5
in 4 hr
then
100mg/kg
1000ml D5
in 16 hr
- With evidence of liver injury, check prognostic markers:
PT, APTT, L/RFT, blood gas, lactate, PO4, FP.

GM 5
Salicylate overdose
- >150mg/kg acetylsalicylate (aspirin) potentially toxic
- Pure methyl salicylate (oil of wintergreen): 10ml 14g salicylate
- Ix: R/LFT, blood gas, serial salicylate level, glucose, urine ketone
- Consider GL, AC, MDAC, WBI
(depend on amount / formulation)
- Hydration, urine alkalinization if ASA >40mg/dL (>2.9mmmol/L)
- HD if end organ failure or ASA >100mg/dL (>7.3mmol/L)
Anti-cholinergic poisoning
- Physostigmine in selected case 0.5-1mg slow IV, repeat up to 2 mg
C/I: TCA, widen QRS, CV disease, asthma, gangrene.
Beta-blocker overdose / Calcium channel blocker overdose
- GI decontamination, haemodynamic and cardiac monitoring
- Treatment options for hypotension and bradycardia:
Atropine: 0.6mg IVI (up to 3mg) and iv fluid.
Glucagon: 2-5mg IVI over 1 min (up to 10mg) follow by 2-5mg/hr
in D5 (for blocker poisoning)
CaCl2 1g or Ca gluconate 3g slow IV, repeat Q10min
(For CCB poisoning, 2-3 doses can be safely given without check Ca level)

(Co-administration of calcium and glucagon is useful in refractory or mixed cases)

General Internal
Medicine

High Dose Insulin / Dextrose Start with 0.5 - 2 units/kg/hr, titrate

up to 10 units/kg/hr (Start early for the treatment takes time to be effective)
Inotropes: Adrenaline - 0.02 microgram/kg/min and titrate up
Noradrenaline - 0.1microgram/kg/min and titrate up
Dobutamine - 2.5 microgram/kg/min and titrate up
Isoproterenol - 0.1 microgram/kg/min and titrate up
(Dopamine not suggested due to its indirect effect)
NaHCO3 1-2 mEq/ kg IV bolus for propanolol poisoing if QRS >
100ms, repeat as indicated.

GM 6

General Internal
Medicine

Digoxin overdose
- Ix : RFT, digoxin level, ECG
- GI decontamination : consider GL, AC, MDAC
- Bradydysrhythmias atropine
- Tachydysrhythmia Tx hypoK, hypoMg, lignocaine,amiodarone
- Cardioversion may precipitate refractory VT, VF, start with low
dose: 10-25J, pre-Tx with lignocaine or amiodarone
- Digoxin Immune Fab fragments (Digifab in HA) indications:
Brady or Vent arrhythmia not responsive to atropine
Serum K+ > 5mEq/dL in acute DO
Digoxin level: 10-15ng/mL (13-19.5nmol/L) in an acute DO
Digoxin ingestion of > 10 mg
- The recommended dosage of Digifab can be calculated by any one
of the below formulas:
Known ingestion amount

No. of vial = Amount ingested in mg x 1.6

Known digoxin level

No. of vial = (digoxin level (ng/mL)) x (wt in kg)

100

Empiric dosing

Acute overdose: 10 vials

Chronic overdose: 4 vials

GM 7
Warfarin or superwarfarin rodenticide overdose

Asymptomatic

Symptomatic, check INR stat

INR at ~ 48 hours
No severe bleeding
Normal

Severe/ life threatening

bleeding

Prolonged INR

Not poisoned
No Vit K1

Oral Vit K1
(5-10mg for warfarin,10-25mg for
superwarfarin)

FFP, Vit K1

(oral, sc, iv - 10mg)

(<1mg/min if IV)

Monitor INR until plateau

FU, may need months
for superwarfarins

Vit K1 has short duration of action

tds/QID dose needed

Mx guideline for warfarin patient with over anti-coagulation

Bleeding
No
No

>9
> 20
Any

No
Yes (serious)
Yes (life-threatening)

Recommendation/Action
Reduce dose or omit next few doses
If no risk factors for bleeding, omit next few doses; if risk
factors for bleeding, administer 1.0-2.5 mg oral vitamin K
3.0-5.0 mg oral vitamin K
10 mg IV vitamin K and FFP or PCC
10 mg IV vitamin K and PCC

1998 and 2001 ACCP Recommendations for Reversing Excessive Warfarin-Associated

anti-coagulation

Theophylline poisoning
- Ix : Theophylline level, electrolytes, ECG
- ABC monitoring and supportive measures.
- GI decontamination: GL / MDAC
- Patient died from tachyarrhythmia, hypotension and seizure
- Hypotension IV fluid, -agonist (Phenylephrine, Noradrenaline)

General Internal
Medicine

INR
<5
> 5 but < 9

GM 8
- Tachyarrhythmia diltiazem or -blockers (esmolol, propranolol)
- HP indication: Ileus / IO prevents use of MDAC
Theophylline level >80mg/L (acute) or 60mg/L
(chronic)
Elderly with level > 40mg/L with severe symptoms

General Internal
Medicine

Psychiatric Drugs
Antipsychotics poisoning
- Supportive care, ECG, GI decontamination as indicated
- Hypotension IV fluid, inotropes (-adrenergic agonists)
- Cardiotoxicity, widen QRS treat like TCAs
- Dystonia diphenhydramine or cogentin
- Look out for neuroleptic malignant syndrome
Tricyclic antidepressant overdose
- Ix : Blood gas, ECG[ sinus tachycardia, widen QRS; > 100msec,
terminal 40ms right axis deviation (R in aVr)]
- Ensure ABC with intensive monitoring
- Consider GL and AC 1g/kg if < 1-2 hr post ingestion, MDAC
- Aggressive supportive care & early serum alkalization
- Physostigmine & Flumazenil are contraindicated
- Serum alkalization by NaHCO3
Indications

QRS > 100ms

Dose

1-2 mEq per kg IV bolus

May need repeated bolus or infusion to meet endpoints

Vent arrhythmia

End points

QRS <100ms* or
pH 7.5-7.55

Contraindications

pH > 7.55 [Consider hypertonic saline]

Intolerable to Na/fluid load [Consider hyperventilation]

Reversal of
arrhythmia or pH
7.5-7.55

Hypotension

Correction of BP or
pH 7.5-7.55

*QRS endpoint with reference to patient baseline ECG

GM 9
SSRI (selective serotonin reuptake inhibitors) and others
- Supportive care, ECG, GI decontamination as indicated
- Treatment for serotonin syndrome (SS) if present
Remove offending drugs, benzodiazepine, hydration, cooling,
cyproheptadine (8-12mg, then 2mg Q2hr, up to 32mg in 1st 24 hr),
neuromuscular blockage.
- Citalopram observe for > 24 hr, cardiac monitoring for prolonged
QT, Tdp (especially with dose >400mg)
- Venlafaxine seizure; esp with dose >1.5g, prolonged QRS
Lithium poisoning
- Ix: RFT, serial Lithium level (Q4hr), AXR
- GI decontamination: GL, WBI
- Volume replacement and correction of hyponatraemia
- Haemodialysis iflevel esp. >4mEq/L, sig DO +/- neuro-toxicity

Carbamazepine poisoning
- Ix: Carbamazepine level, ECG (widen QRS)
- ABC monitoring and supportive measures.
- GI decontamination: AC / MDAC
- NaHCO3 for widen QRS>100ms (theoretically beneficial)
- Haemoperfusion

General Internal
Medicine

Valproic acid poisoning

- Ix: LFT, valproic acid level, ammonia
- ABC monitoring and supportive measures.
- GI decontamination: AC , GL / MDAC / WBI
- L-Carnitine for VPA inducedammonemia, encephalopathy ,hepatotoxicity.
- IV Naloxone (0.4mg-2mg) for CNS and respiratory depression
- Haemodialysis / Haemoperfusion: rarely considered

GM 10
Non-Pharmaceutical
Organophosphate poisoning
- Decontamination and staff protection, supportive care
- Ix: plasma cholinesterase, ABG
- Atropine - Initial dose of 0.6-1.2 mg IV, repeat and double the dose
every 5 min until lungs clear (huge dose may be used)
- Pralidoxime - 1-2 g to 100ml NS IV over 30 min, follow by infusion
at 8-10 mg/kg/hr, can be titrated up to 20 mg/kg/hr.

General Internal
Medicine

Carbamate poisoning
- Similar to organophosphate poisoning
- Atropine - 0.6-1.2 mg IV, repeat and double the dose Q5min until
lungs clear.
- Pralidoxime not usually recommended
Paraquat poisoning
- More than 10ml 20% paraquat ingestion is potentially fatal
- GI decontamination: GL in early presentation, AC
- Largely supportive treatment, use lowest FiO2 as possible
- Contact HKPIC for option of anti-inflammation therapy in severe
paraquat poisoning.
Household products
- Disinfectants and multi-purpose cleaners ( Dettol, Salvon,
Swipe , Green water, Household hypochlorite bleach, etc )
- No antidote, mainstay of treatment is supportive
- GI decontamination is potential harmful
- Mainly irritant effect, upper endoscopy is not routinely indicated
- Can be caustic if large quantity & high concentration are ingested
- Need OGD if caustic ingestion (drain opener)
Methanol / Ethylene glycol [EG] poisoning
Ix: Blood: CBP, LRFT, ethanol level, anion gap, osmolar gap,
methanol or ethylene glycol level
Urine for Ca oxalate and fluorescence [in EG poisoning]

GM 11
Management:
- Consider NG suction, IV NaHCO3 to correct acidosis
- IV ethanol (16g/20ml), diluted to 10% solution
Loading: 0.8g/kg in 30min
Maintenance: start at 0.1g/kg/hr, titrate upwards prn
- IV folinic acid 1mg/kg q4-6hr (for methanol poisoning)
- Thiamine 100mg and pyridoxine 50mg q4-6hr (for Ethylene glycol)
- Fomepizole is available as Level III antidote.
[Contact HKPIC for its indication and mobilization if needed]

- HD indication:
Methanol or ethylene glycol level >250mg/L
High osmolar gap without other cause
Acid/base abnormality, End-organ toxicity

General Internal
Medicine

GM 12
Cyanide poisoning
ABC monitoring and supportive measures.
Surface decontamination and staff protection
Treat seizure and correct metabolic acidosis
GI decontamination: consider AC +/- GL if within 1 hr
Ix : RFT, ABG, lactate, AV O2 gradient (PaO2 PvO2),
CO-Hb, met-Hb, Cyanide level
- Early use of antidotes

General Internal
Medicine

Urgent use of antidote:

- Hydroxocobalamin: 5g IV in 15-30 min (can be repeated at 2-4 hr)
- Sodium nitrite - 10ml of 3% (300mg) IV over 5 min
(Adverse effects: hypotension, methaemoglobinemia)

- Sodium thiosulphate- 50ml of 25% (12.5g) IV

(Thiosulphate can be repeated if there is no response in 30 min)

GM 13
Carbon monoxide poisoning
- Pulse oximeter cannot detect CO-Hb; can be misleading
- Hyperbaric oxygen treatment (HBO)

Usefulness remains controversial

Potential risk for patient and medical staffs (during transfer / in the chamber)
No definite evidence to support routine use
Referral is a case to case individual decision by the in-charge physician

Suggested guideline for CO poisoning

Acute CO exposure with symptoms
100% O2, CO-Hb level, ABG, ECG
Syncope, coma, seizure, cardiac ischaemia or vent. arrhythmias
No

CO-Hb > 25%

Pregnancy with CO-Hb > 15%

Yes
Yes

Consider ICU care

Monitor acidosis

No

Continue 100% O2 therapy

Consider HBO*

Symptomatic (headache,nausea), abnormal mental or neuropsychiatric status

No

Discharge when CO-Hb < 10%

General Internal
Medicine

Yes

GM 14
Pulmonary irritant inhalation
- Highly water solubility: SO2, Ammonia, HCl, and Chloramine
(Cause upper airway, eye and nose irritation, rapid onset)

- Intermediate water solubility: Chlorine

(Delayed irritation, potential prolonged exposure, acute lung injury)

- Low water solubility: Phosgene, Nitrogen dioxide

(Non-irritating, affect lower airway, lack of noticeable effects prolonged exposure

and acute lung injury)

Clinical effects ranging from:

Stridor, bronchospasm lung injury, bronchiolitis obliterans
High water solubility irritant Low water solubility irritant

General Internal
Medicine

Monitoring / Ix
- Vital sign / SaO2 / PFR / FEV1/ FVC / voice quality
- ABG, ECG, CXR, Lung function test, fibreoptic bronchoscopy
Treatment
- Remove from exposure, ABC monitoring, O2 and supportive care
- Nebulized -agonists for bronchospasm
- No role for steroids, other than for bronchospasm
- Nebulized bicarbonate for Cl2, HCl or other acidic gas
[2ml NaHCO3 8.4% + 2ml water/saline]
Observation
- SO2, NH3, NH2Cl, HCl exposure have no delayed toxicity.
(Improving patients will continue to do well; only need to be observed
for the duration of their symptoms)
- Cl2, COCl2, NO2; Low and intermediate water solubility agents
(Potential for acute lung injury with delayed onset of symptom.
Observe all patients with any symptoms for at least 24 hour
Aware of risk of bronchiolitis obliterans)

GM 15

Smoke inhalation management flow-chart

Unconsciousness, stridor, resp distress, PaO2<8kPa
No

Yes

History of unconsciousness
Close space exposure
Carbonaceous sputum
Facial burn or singed nasal hair
Hoarseness
Oropharyngeal burn, swelling

Intubation
Use adequate-sized ET tube
Humidified O2
Frequent suction

Upper airway edema

Yes
No

Nasopharynoscopy / Bronchoscopy

No clinically important edema

Close monitoring

Worsen airway / pulmonary status

General Internal
Medicine

GM 16
Snake Bite
Local venomous Snake
Viper
Bamboo Snake
Chinese Habu
Mountain Pit Viper
Elapidae
Banded Krait
Many Banded Krait

Toxicity
Local pain swelling +/- bruising,
Systemic coagulopathy, DIC
Hypotension

Paralysis, minimal local reaction

King Cobra

Early local necrosis

(severe pain and swelling)
Rhabdomyolysis, Paralysis

Coral snake

Neurotoxicity with paralysis

Chinese Cobra

Colubridae
Red-necked Keel Back snake
Hydrophiidae
Mangrove Water snake
General Internal
Medicine

Chinese Water snake

Plumbeous Water snake

Prolonged bite required for effective

envenomation to cause DIC

Neurotoxic, myotoxic with

rhabdomyolysis

Investigation
- CBP, APTT, PT (esp. whole blood clotting time), RFT, CPK
- Urine for myoglobin and haemoglobinuria
- ECG, Bed side spirometry for FVC if available, serial PFR, CXR
Investigations should be repeated in the following situations
- Progression of local or systemic symptoms.
- Abn result from initial test until normal or other cause identified
- After anti-venom administration
- Snake identification is useful (Photographing at safe distance)
[head, tail, dorsal, ventral feature important for identification]
(Consult HKPIC for urgent contact with biologist for snake
identification and advice on anti-venom use)

GM 17
Treatment
- Supportive care, analgesic, Tetanus prophylaxis
- Q1/2 hour assessment for local / systemic S/S for first few hours
- Antivenoms should be considered for
Local progression, necrosis, compartment syndrome.
Systemic toxicities, i.e. coagulopathies, weakness,
rhabdomyolysis, hypotension etc.
First S/S of neurotoxicity after krait bite
Antivenoms available in HA

Starting
Dose

Snake bite in HK

3 vials

Bamboo snake

Agkistrodon halys (China)

6000U/vial

1-2 vials

Bamboo snake
Chinese Habu
Mountain Pit Viper

Antivenin of B. multicinctus and N. atra

(Taiwan)
1000U/vial

1 vial

Chinese Cobra
Many Banded Krait

Naja Naja (China)

1000U/vial

2 vials

Chinese Cobra

Cobra (Thailand)

10 vials

Cobra

Bungarus multicinctus (China)

10000U/vial

1 vial

Many Banded Krait

King Cobra

Banded krait (Thailand)

5 vials

Banded Krait

King cobra (Thailand)

5 vials

King Cobra

Agkistrodon acutus (China)

2000U/vial

4 vials

Hundred Pacer

Russels Viper (Thailand)

3 vials

Russells viper

Australian Tiger Snake (Australia)

1 vial

Probably for sea snakes

Precautions and pre-treatment in anti-venom administration

- Resuscitation equipment stand-by
- Pre-treatment with anti-histamine and hydrocortisone is advised
- 1st dose to 500 ml NS, give at 100ml/hr.
- If no allergy after 5-10min., fasten rate, dose finish in 30 min.
- May need further doses if clinically indicated
- No evidence to support routine prophylactic antibiotic use
- Debridement and surgery for compartment syndrome as indicated

General Internal
Medicine

Green Pit Viper (Thailand)

GM 18

ACCIDENTAL HYPOTHERMIA
(Use low temp thermometer for core temp)

Avoid rough handling of geriatric hypothermia patient as this may provoke

cardiac arrhythmia.

General Internal
Medicine

Ix - CBP, RFT, blood glucose, hstix, ABG, amylase, cardiac enzymes,

coagulation profile, TSH, blood culture (esp in elderly), CXR, ECG,
toxicology screen and SXR in comatose patient

GM 19

HEAT STROKE / EXHAUSTION

HEAT STROKE is caused by over-heating of the body core when
sweating is limited.
HEAT EXHAUSTION is caused by sustained heat stress that causes
water and salt depletion (may be complicated by heat stroke in
advanced stage).
Heat Stroke
Heat Exhaustion
Drugs or diseases causing
limited sweating esp in
elderly, infants

Skin:

Hot and dry in

non-exertional heat stroke.
Sweating can occur in
exertional heat stroke.

Warm and wet.

Core body temp:

40 41 C

38 39 C

Central nervous
system features:

Significant

Insignificant

Acid-base disorder:

Respiratory alkalosis
Lactic acidosis

Acute renal injury

Common

Pre-renal failure

Management
1. Check CBP, RLFT, ABG, coagulation profile, CPK, urine
myoglobin
2. Monitor vital signs (esp urine output) and core temp
3. Cooling of body by removing all clothing, tepid water sponging,
fanning
4. Oral fluid and salt replacement in heat exhaustion (25 g NaCl in 5
litres of water)
5. Correction of electrolyte disturbances and hypovolaemia

General Internal
Medicine

Risk Factors:

GM 20
6.
7.
8.

Lactic acidosis not responding to volume expansion should be

treated with bicarbonate
Convulsion should be treated with anticonvulsive therapy
Look out and support multiorgan failure in heat stroke

General Internal
Medicine

Remark:
1. Avoid alpha-adrenergic agonist (as vasoconstriction will impair
cooling).
2. In Exertional Heat Stroke: paracetamol or NSAID can
exacerbate acute kidney injury or liver derangement.

GM 21

NEAR DROWNING
The most important consequence of near-drowning is asphyxia which
leads to hypoxaemia, hypercapnia and metabolic acidosis.
1. Monitor and maintain ABC. Clear airway and CPR if necessary.
Look for cardiac arrhythmia.
2. Ix: ABG, RFT, ECG, CXR, SXR and X ray cervical spine, cardiac
monitoring and body temperature monitoring. Maintain euglycaemia.
3. Beware of head and cervical spine injury and hypothermia.
4. Correct hypoxia and metabolic acidosis. Give O2 therapy (PEEP
may be necessary for severe hypoxia). Treat bronchospasm with
2-agonist. Bronchoscopy may be necessary if persistent atelectasis
or localized wheezing.
5. Treat seizure with anticonvulsant. Watch out for cerebral oedema.
6. Consider antibiotics for pneumonia.
7. Rule out drug effects e.g. alcohol, hypnotics, narcotics.

ELECTRICAL INJURY

- Ix : ECG, ABG, RFT, CPK, LDH, urine myoglobin

- Monitor: Vital signs, cardiac rhythm, neurological status, urine output
and colour
- Look for fracture, spinal injury and internal organs damage
- CPR if necessary
- Antiarrhythmic drugs depend on nature of arrhythmia
- IV fluid replacement
- Treat burn and compartment syndrome as appropriate

General Internal
Medicine

Electrical injuries cause cardiopulmonary arrest, burn, acute renal

failure due to hypovolaemia or myoglobinaemia, injuries to nervous
system, damages to vessels causing thrombosis or haemorrhage.
Extent of external injury may not correlate with severity of internal
injury. Alternate current (AC) is more dangerous than direct current
(DC). Current with frequency of 50-60 cycles/sec is more dangerous.

GM 22

RHABDOMYOLYSIS

General Internal
Medicine

Dx:
Red or brown urine +ve for blood but no RBC under microscopy
Urine +ve for myoglobin
Pigmented granular casts in the urine
CK level
Others: hyperkalaemia, hypocalcaemia, hyperphosphataemia,
hyperuricaemia, DIC, Acute Kidney Injury.
Mx:
Aim: correction of hypovolaemia, enhance clearance of heme proteins,
mitigate the adverse consequences of heme proteins on the
proximal tubular epithelium
NS infusion 1-1.5 L/hr
Monitor urine output & haemodynamic parameters
Continue IV infusion with 500ml NS alternating with D5 1 L/hr after
satisfactory BP and urine output achieved
Keep urine output at 300ml/hr until myoglobinuria ceased
Add NaHCO3 50meq/L to each 2nd or 3rd bottle of D5 to keep
urinary pH > 6.5. Monitor arterial pH and serum calcium every 2
hours. Stop NaHCO3 if arterial pH > 7.5, or serum HCO3 >
30meq/L, or symptomatic hypocalcaemia.
Add 20% mannitol at a rate of 1-2g/kg BW over 4 hr with plasma
osmolar gap kept below 55 mosm/kg
Withhold mannitol and HCO3 if marked diuresis not achieved.
May try furosemide & renal dose dopamine for anuric patients
Extracorporeal elimination of heme protein is controversial
Look out and treat significant compartment syndrome
NB:
Regimen is less effective if began after the first 6 hrs when renal
failure may have already established.
Elderly patient may require slower volume replacement.
Look out for hypercalcaemia in recovering phase of AKI.

GM 23

SUPERIOR VENA CAVA SYNDROME

Causes: 80% due to malignancy
*Non-malignancy aetiologies: e.g. central venous catheter;
pacemaker wire, indwelling cardiac device; infection (e.g. TB, fungal);
aortic aneurysm; post-irradiation.
P/E: Dilated superficial veins over anterior chest wall
Engorged jugular veins facial and arm veins
Oedema of face, neck, and upper extremities with cyanosis
DDx: Pericardial effusion with tamponade
Ix: CXR, Duplex ultrasonography, CT, digital subtraction venography,
bronchoscopy
Look for secondary pulmonary embolism.

General Internal
Medicine

Tx Look out for upper airway obstruction (stridor) - may be

life-threatening
Malignant SVC syndrome - see pages GM24-25
Central venous catheter - removal under anticoagulation
regional fibrinolytic therapy
SVC stenting consult interventional radiologist for feasibility

GM 24

Medical Oncology
MALIGNANCY-RELATED SUPERIOR VENA CAVA
SYNDROME
(cross-reference from SVC SYNDROME)
Malignancy accounts for 80% of SVC syndrome
Non-small cell lung carcinoma
(50%)
Small cell lung carcinoma
(25%)
Non-Hodgkin lymphoma
(10%)
Others e.g. germ cell neoplasms, breast carcinoma, thymoma etc

General Internal
Medicine

Treatment is tailored to the specific neoplasm, therefore tissue diagnosis

is essential prior to empirical treatment, which could jeopardize
histological evaluation, e.g. corticosteroid in lymphoma.
Ix
For immediately life-threatening situations e.g. upper airway
obstruction due to tumour compression or severe laryngeal edema,
impaired conscious state due to cerebral edema
Stabilize airway, breathing, circulation
Urgent Oncology consultation for immediate treatment
Urgent endovascular stenting can provide the most rapid relief
without affecting subsequent tissue diagnosis. Total SVC occlusion
and SVC thrombus are not absolute contraindications for stenting.
Post stenting short-term anti-thrombotic therapy recommended e.g.
dual antiplatelets for 3 months.
For stable /stabilized patients
Clinical examination and investigations targeted to establish tissue
diagnosis by minimally invasive methods.
Sputum cytology, serum AFP, HCG levels, LN biopsy, pleural fluid
cytology/pleural biopsy, bone marrow biopsy, endoscopic biopsy,
image-guided biopsy. For suspected lymphoma, excisional biopsy of
enlarged lymph node is essential.
Watch out for coexisting pericardial effusion/cardiac tamponade.

GM 25
Tx
Empirical
Prop up for head elevation
Oxygen supplement
Dexamethasone 4mg q6h iv
Disease-specific (Consult Oncology)
Chemotherapy
Radiotherapy.
Targeted therapy
Presence of SVC thrombus
Long term anticoagulation, if not contraindicated, for 6 months AND
preferably continued beyond 6 months in those with active cancer or
receiving chemotherapy (ASCO guideline 2013 update). LMWH is
preferred over warfarin in malignancy-related thrombosis (and CrCl >
30 ml/min) for its lower rate of recurrent thromboembolism and less
drug interaction with subsequent systemic cancer therapy. Both have
similar bleeding risks.

General Internal
Medicine

GM 26

NEOPLASTIC SPINAL CORD/CAUDA EQUINA

COMPRESSION
(Also see page N19 and PM15)

Etiologies
Prostate cancer (20%)
Breast cancer (20%)
Lung cancer (20%)
Others : non-Hodgkin lymphoma, multiple myeloma/plasmacytoma,
renal cell carcinoma etc
Prompt diagnosis and immediate treatment important in maximizing
neurological outcome

General Internal
Medicine

Ix
Diagnosis confirmed with MRI of entire thecal sac since multiple level
involvement present in 33% of patients (CT myelography if
contraindicated for MRI)
For patients without known malignancy, actively search for potential
primary. Tissue diagnosis is essential for subsequent management.
Tx
General
dexamethasone 4mg q6h iv
adequate pain control
bowel care
bladder catheterization for retention of urine
compression stockings
Specific (Consult Oncology)
RT for most metastatic cancers
Chemotherapy for chemosensitive tumours
Hormonal therapy for selected cases
Surgery for suspected malignancy without tissue diagnosis and no
alternative site for biopsy, presence of spinal instability or
radiotherapy/chemotherapy-resistant tumours.

GM 27

HYPERCALCAEMIA OF MALIGNANCY
Aetiologies (in decreasing order of frequency)
Humoral hypercalcaemia of malignancy (PTHrP) e.g. squamous
cell/renal cell/transitional cell carcinomas, breast/ovarian cancers etc
Osteolysis from bone metastases
Calcitriol-secreting lymphoma
Ectopic PTH secretion
**Initial approach to and control of hypercalcaemia covered in
Electrolye Disturbances section on page K6 and PM14)

General Internal
Medicine

Oncology specific aspects:

Ensure adequate pain control
Workup for the cause of hypercalcaemia e.g. previously undiagnosed
malignancy, new development of bone metastasis, recurrence of cancer
etc
Consult Oncology for disease control of the underlying cancer
Systemic corticosteroid can be helpful for calcitriol-secreting lymphoma
in some circumstances, but to be avoided if the specific tissue diagnosis
has not been made yet, please discuss with oncologist first.

GM 28

TUMOUR LYSIS SYNDROME

TLS can occur after cytotoxic therapy or spontaneously in high-grade
malignancy or high tumour burden, most commonly lymphoblastic
leukaemia/high-grade lymphomas especially Burkitts.

General Internal
Medicine

Ix/monitoring
Fluid input/output, ECG/cardiac monitoring, serum potassium, calcium,
phosphate, urate, creatinine, LDH, G6PD level
Diagnosis
Laboratory TLS At least 2 of the following abnormal serum
biochemistries occurring within 3 days before/7 days after beginning
chemotherapy despite adequate prophylaxis :
potassium 6mmol/L or 25% increase from baseline
urate 0.5mmol/L or 25% increase from baseline
phosphate 1.45mmol/L or 25% increase from baseline
calcium 1.75mmol/L or 25% decrease from baseline
Clinical TLS laboratory TLS AND any of the following :
increased serum creatinine to 1.5 times ULN
seizure
cardiac arrhythmia
sudden death
Prophylaxis
Adequate hydration 3-4L/day, aim for urine output ~150ml/hr, +/- diuretics
Hypouricaemic agents : allopurinol adjusted for renal function, (or
rasburicase if the patient is of high risk of TLS, please note rasburicase is
contraindicated in patients with G6PD deficiency)
Tx
Correct electrolytes disturbances (see Electrolyte Disturbances section)
Maintain I/O balance
Monitor and treat arrhythmias
For persistent hyperkalaemia, hyperphosphataemia, hyperuricaemia,
hypocalcaemia or oliguria, Nephrology consultation with a consideration of
dialysis support.

GM 29

EXTRAVASATION OF
CHEMOTHERAPEUTIC AGENTS
Definition: escape of an irritant (causing tissue inflammation) or vesicant
(causing tissue necrosis) drug into the extravascular space.
Commonly used vesicants :
Anthracyclines e.g. doxorubicin, epirubicin, daunorubicin, idarubicin
Vinca alkaloids e.g. vinblastine, vincristine, vinorelbine
Prevention of extravasation is the best strategy against extravasation injury
Proper infusion technique is of paramount importance
Consider the use of central venous catheter for vesicant infusion
For peripheral infusion of chemotherapy, use a newly set IV line in a large
peripheral vein with close monitoring of any evidence of extravasation.

Anthracyclines

topical DMSO, consider IV

dexrazoxane if available
topical DMSO
SC sodium thiosulphate

Mitomycin
Mechlorethamine, (bendamustine,
dacarbazine, cisplatin, carboplatin)*
Vinca alkaloids, (etoposide, taxane)*
SC hyaluronidase
*(specific antidote recommendation is less consistent for drugs in bracket)

Elevate the extremity with extravasation.

Apply heat locally for vinca alkaloids and epipodophyllotoxins (e.g.
etoposide); apply cold locally for other agents.
Take clinical photos of the extravasation injury.
Document the extravasation process and measures taken.
Monitor the healing process, full-thickness skin or surrounding tissue
necrosis may necessitate surgical intervention.

General Internal
Medicine

When extravasation is suspected

Stop the infusion immediately
Leave the catheter in place
Aspirate fluid from the extravasation area
DO NOT flush the line or apply local pressure.
Administer antidote if applicable before removal of catheter.
Access the extravasation kit for specific antidote

GM 30

BRAIN DEATH
(Based on HA Guidelines on Diagnosis of Brain Death, 4 October 2010,
ref: HA752/10/1/3)
Use updated Brain Death Certification Form HA0090/MR.
- For patients who are 5 yrs of age or older

General Internal
Medicine

Concept: Brain death equates with death both medically and legally.
1. Pre-conditions and exclusions for considering diagnosis of brain
death
* All the following should coexist
a) Diagnosis of severe irremediable brain injury which is consistent
with progression to brain death (the clinical diagnosis is usually
confirmed by neuro-imaging). The diagnosis of a disorder
which can lead to brainstem death should have been fully
established.
b) Apnoeic patient on a ventilator
- Muscle relaxants and other drugs should have been excluded
as a cause of such findings
c) Exclusion of potentially reversible causes of coma
- Depressant drugs or poisons; peripheral nerve stimulator to
confirm intact neuromuscular conduction.
- Primary hypothermia: core temp >35C before diagnostic
tests of brain stem death are carried out
- Metabolic and endocrine disturbances (e.g. severe electrolyte
or endocrine disturbances)
- Arterial hypotension as the cause for the coma should be
excluded.
2. Tests for confirming brain death
* All brainstem reflexes must be absent.
* The testing of all the following is considered sufficient
a) Both pupils - fixed in diameter and non-reactive to light
b) Absence of bilateral corneal reflexes

GM 31

General Internal
Medicine

c) Absence of vestibulo-ocular reflexes - no eye movement occurs

during or after the slow injection of at least 20 ml ice-cold water
into at least one external auditory meatus, or preferably into each
external auditory meatus in turn. Clear access to the tympanic
membrane should be established by direct inspection. This test
may be contraindicated on one or other side by local trauma
d) No motor responses within the trigeminal nerve distribution can
be elicited by adequate pain stimulation of any somatic area
e) Absence of gag reflex
f) Absence of cough reflex
g) Testing for apnoea: should be done last. No respiratory
movements occur when the patient is disconnected from the
mechanical ventilator for long enough to ensure that the PaCO2
rises above the threshold for stimulating respiration (ie PaCO2 >
8.0 kPa and arterial pH < 7.30). ABG must be available for this
test to be performed. The patient should be disconnected from
mechanical ventilator when PaCO2 is close to normal.
Hypoxaemia during disconnection should be prevented by
preoxygenation and administration of oxygen during the test, e.g.
by delivering O2 through a catheter into the trachea
* Period of observation and repetition of tests: 2 full separate
examinations should be performed. The first examination should be
performed after all pre-conditions met, and after at least 4 hrs of
observation of coma (Glasgow Coma Scale of 3) with absent
brain-stem function. The second examination can be performed any
time after the first examination, so that total period of observation is at
least 4 hours. The minimum period of observation need to be totally
24 hours after cardiorespiratory arrest.
* Medical practitioners:
- One of the doctors must be a specialist recognised by the appropriate
College as having demonstrated skill and knowledge in the

GM 32

General Internal
Medicine

certification of death following irreversible cessation of brainstem

function (usually an Intensivist, Critical Care Physician, Neurologist
or Neurosurgeon).
The other doctor should preferably be of the same qualification but
should be at least 6 years after registration and possess the skill and
knowledge in the certification of death following irreversible cessation
of brainstem function
The person authorizing removal of tissues and the person removing
tissues MUST NOT be responsible for determining brainstem death.
Confirmatory Ix
If the preconditions for clinical diagnosis and confirmation of
brainstem death cannot be satisfied, objective demonstration of
absence of intracranial blood flow is required (after the 4 hour period
of observation of coma and of absent brainstem responses, where
these can be tested).
Time of death - the time when certification of brain death has been
completed (ie following the second confirmatory examination) or if a
confirmatory investigation is used, then the time of death should be
after the confirmatory investigation.
Clinical observations compatible with diagnosis of brain death
- movements of limbs in response to a stimulus outside the
distribution of cranial nerves
- sweating, blushing, tachycardia
- normal BP without pharmacologic support
- absence of diabetes insipidus
- deep tendon reflexes
- extensor plantar reflex
Features NOT COMPATIBLE with brainstem death:
- decerebrate or decorticate posturing.
- seizure.

Procedures
For all procedures,

INFORMED CONSENT

Always mark the correct side

before procedure

Procedures

Must be obtained except

in an emergency life-saving
situation

Pr 1

ENDOTRACHEAL INTUBATION

Procedures

Indications
1. Respiratory / ventilation failure, including CPR
2. To protect airway against aspiration
3. To manage excessive airway secretions
Equipment
1. Bag-Mask-Valve device (BMV)
2. IV access* as far as possible
3. Cardiac monitor & pulse oximeter
4. Oropharyngeal / nasopharyngeal airways
5. Direct laryngoscope (Macintoch) with functioning light bulb and
blade of appropriate size (start with size 3, usually size 3-4 for
adults)
6. Endotracheal tube (Male 8-8.5 mm, female 7-8 mm internal
diameter) with low pressure cuff
with syringe for cuff inflation, check cuff for leakage
(Inflate with 10 ml syringe, then deflate completely)
If stylet used, lubricate and insert into ETT. Its tip must be
recessed > 1 cm from distal end of tube
7. End-tidal CO2 monitor if available
8. Yankauer sucker
9. Bougie if indicated
10. A spare endotracheal tube with size 0.5 1mm smaller
Note
1. Consult anaesthetists in expectedly difficult case
2. In patients with suspected unstable cervical spine, leave intubation
to expert hands if possible, otherwise, do in-line stabilization during
intubation
3. Do not attempt intubation for >15 sec at a time. Achieve adequate
oxygenation before the next attempt

Procedures

Pr 2
Procedure
1. Position patient supine
2. Place patient in sniffing position (neck flexed and head extended),
Open airway by head tilt-chin lift / jaw thrust
3. Remove dentures and other foreign bodies
4. Fit a face mask tightly on patients nose and mouth and ventilate
using a BMV connected to O2 (bag should be inflated with O2)
5. Pre-oxygenate for 5 minutes
6. (Optional) Apply cricoid pressure (Sellicks manoeuvre)
7. Perform Rapid Sequence Induction (RSI)
Give a short acting sedative (e.g. midazolam or propofol)
followed immediately by a paralytic agent such as
suxamethonium or rocuronium
8. Insert direct laryngoscope: Push tongue to the left, expose larynx by
pulling jaw towards ceiling (Do not lever laryngoscope at the teeth)
9. Gently slide ETT in between cords and immediately remove stylet.
Advance ETT till marking at incisor is 22-24 cm for males, 20-22
cm for females (Or visualizing the thick black line in ETT entering
vocal cord)
10. For more difficult case, consult anesthetist / senior. In selected case,
may consider the use of bougie or McCoy blade for assistance:
insert bougie as a guidewire, then thread ETT through afterwards
11. Inflate cuff (4-6 mls air to achieve cuff pressure 20 - 24 cm H2O)
12. Connect ETT to BMV
13. Confirm ETT position by end-tidal CO2 device if available. Observe
lung expansion, auscultation (bilateral chest and epigastrium (for
the absence of gurgling sound)).
14. Off cricoid pressure AFTER endotracheal intubation is confirmed if
using Sellicks manoeuvre
** In case of failed intubation, maintain mask ventilation and summon
help. DO NOT inject second dose of muscle relaxant for another
attempt.
After-care
Urgent CXR to check ETT position (ETT tip 4 2cm from carina,
exclude pneumothorax/pneumomediastinum)

Pr 3

SETTING CVP LINE

Procedures

Indications
1. Haemodynamic monitor
2. Administration of TPN, vasopressors
Contraindications
1. Bleeding tendency
2. Ipsilateral carotid artery aneurysm
Internal Jugular Vein (IJV) Puncture
- Aseptic technique, use Gauge 14 or 16 angiocatheter
- Preferably US-guided
- IJV runs behind the sternocleidomastoid (SCM) close to the lateral
border of the carotid artery
- Place patient in a 20 head-down position with the head turned to the
opposite side
- Right side preferred to avoid injury to the thoracic duct
(1) Anterior approach: Insert angiocath 0.5cm 1cm lateral to carotid
pulse at midpoint of the sternal head of SCM.
(2) Central approach: Insert angiocath at apex of triangle formed by
two muscle bellies of SCM and clavicle.
- Advance angiocath towards ipsilateral nipple with the syringe at
30-45 above the skin. Maintain gentle aspiration till a gush of blood
(dark red) is aspirated
- Gently withdraw stylet of angiocath while pushing angiocath into
position, connect infusion set to angiocatheter
- If the artery is punctured (bright red blood), withdraw everything and
apply firm pressure for at least 5 minutes
- (Never advance beyond clavicle. Pneumothorax can kill)

Always make sure that the catheter is in vascular space

(Check siphoning: Venous blood backflows upon lowering
infusion set below the patient &blood level should oscillate with
respiration)

Read the first CVP reading yourself

Always take a CXR afterwards to exclude pneumothorax

Maintain catheter patency with infusion of fluid

Pr 4

DEFIBRILLATION
The speed with which defibrillation performed is the major determinant
of the resuscitation success. Rapid diagnosis of VF and pulseless VT
followed by immediate defibrillation is important.

Procedures

1.
2.
3.
4.

CPR before defibrillator available.

Attach and turn on defibrillator when available.
Check rhythm and identify shockable rhythm (VF and pulseless VT).
Apply appropriate conductive material to hand-held paddles or use
defibrillator electrode pads. Do not rub the 2 paddles together.
5. Select energy level
Monophasic defibrillator 360J
Biphasic defibrillator device specific; if waveform type unknown,
use 200J
(150J to 200J for biphasic truncated exponential waveform or 120J
for rectilinear biphasic waveform).
6. Press charge button on machine or paddle.
7. Apply firm pressure with one paddle at cardiac apex, the other over
base of heart (if paddles are used)*
8. Warn everybody to stay clear of the patient.
9. Deliver the shock by pressing both discharge buttons simultaneously.
10. Resume CPR immediately after the shock and give 5 cycles of CPR
(one cycle of CPR: 30 compressions then 2 breaths). Then check
rhythm.
* For patient with permanent pacemaker, anterior-posterior orientation is
preferred or with paddles > 10cm from pacemaker. Interrogate pacemaker
after defibrillation to ensure normal functions.

Pr 5

TEMPORARY PACING
1. Equipment: Venous puncture set, temporary pacing wire and
pacemaker, cardiac monitor, defibrillator/transcutaneous pacing
standby.
2. Select venous access (femoral, internal jugular or subclavian).
3. Give local anaesthesia and perform venipuncture under aseptic
technique.
4. Manipulate pacing wire to RV apex fluoroscopic guidance.
5. Connect pacing wire to temporary pacemaker.
6. Test pacing threshold with a pacing rate above the patients own rate.
Accept site if threshold <1 volt. Set output at >3x threshold or 3V
whichever is higher.
7. Test for sensing threshold with pacing rate less than patients own
rate if clinically feasible. Set sensitivity to 1/2 of sensing threshold
(i.e. more sensitive than the sensing threshold).
8. Set desirable pacing rate, eg. 70-80/min.
9. Secure pacing wire at insertion site and cover with dressing.
10. Record the rhythm.

Transcutaneous Pacing (TCP)

As interim measure before transvenous pacing.
Anterior TCP patch at cardiac apex and posterior patch over left
infrascapular region. Turn the pacer ON consider analgesia.
Set the rate to ~60/min (adjusted to clinical condition). Set the
current output 2mA above the level with consistent mechanical
capture (safety margin). (Do not assess carotid pulse to confirm
mechanical capture as muscular jerking may mimic carotid pulse.)

Procedures

Aftercare
Full lead ECG and portable CXR.
Continue cardiac monitoring.
Check pacing threshold daily and adjust output accordingly.
Watch out for complications (infection, bleeding, haematoma,
pneumothorax, thrombophlebitis, etc).

Pr 6

LUMBAR PUNCTURE
Indications
1. To check intracranial pressure (ICP) and obtain cerebrospinal fluid
(CSF) for diagnosing a wide variety of neurological and
neurosurgical conditions
2. To drain CSF
3. To give intrathecal injection

Procedures

Precautions
Always examine the patient for evidence of raised intracranial
pressure and focal cerebral lesion before performing LP
(papilloedema, false localising signs)
1. LP may be performed in some exceptional circumstances if such
evidence is present. Always consult the Neurology Team
(Medicine) or Neurosurgery Department before making a decision
under such circumstances.
2. In case of doubt, a CT scan of the brain should be performed first to
exclude contraindications of LP. Perform blood culture and start
antibiotic for bacterial meningitis if such diagnosis is suspected and
CT brain cannot be done shortly.
3. Do not perform LP if there is uncorrectable bleeding tendency or
local infection in the area of needle insertion.
Procedures
1. Lie patient in left lateral position with back and knees flexed (may
try sitting position if failure after 2-3 attempts)
2. Aseptic technique
3. Infiltrate skin with local anaesthetic
4. Advance LP needle between spinous processes of L3/4 or L4/5.
Use fine-bore (# 23) needle if raised ICP suspected
5. At about 4-5 cm, a give sensation indicates that the needle has
pierced through ligamentum flavum
6. Remove stylet to allow CSF fluid to come out
7. Note the appearance of the CSF and measure CSF pressure

Pr 7
8. Lie patient flat for 4-6 hours after LP (24 hours if ICP increased)
9. Depending on provisional clinical diagnosis, send CSF fluid for:
- Biochemistry (use fluoride bottle for CSF glucose, check
simultaneous blood glucose)
- Microscopy and cell count, cytology
- Gram stain and culture, CIE for bacterial antigen (patient already
on antibiotics)
- AFB smear and culture PCR, VDRL / FTA
- Indian Ink preparation, fungal culture and cryptococcal antigen
- Viral isolation and antibody titre PCR
- IgG / albumin ratio and oligoclonal bands (with serum)

Procedures

Pr 8

Procedures

BONE MARROW ASPIRATION &

TREPHINE BIOPSY
Bone Marrow (BM) Aspiration & Trephine Biopsy
1. Obtain informed consent
2. Use either a reusable BM Biopsy needle supplied by CSSD or a
disposable one e.g. Jamshidi or J style BM Biopsy needle
3. Site: Posterior superior iliac crest (patient in lateral recumbent or
prone position)
4. Clean the skin overlying the posterosuperior iliac crest with aseptic
technique
5. Infiltrate overlying skin and periosteum with local anesthetics.
6. Incise skin with a scalpel (2-3 mm incision)
BM Aspiration
1. Hold needle at right angle to iliac crest
2. Advance needle with firm pressure in a clockwiseanticlockwise motion till a decrease in resistance is felt
3. Remove the stylet
4. Apply gentle suction with a 10-20 ml syringe, aspirate 0.2 to 2ml
bloody fluid, reinsert the stylet
5. Make marrow smear on clean slides before the specimen clots, and
send marrow clot in a EDTA specimen bottle for section
6. Put additional material in appropriate media for special tests e.g.
cytogenetic study, microbiological culture
BM Trephine Biopsy
1. Following the BM aspiration, with the stylet locked in the needle,
push out the needle to the periosteal surface, and advance needle
with firm pressure in a clockwise-anticlockwise motion in a
slightly different angle (not the same track as that of BM aspiration)
till a decrease in resistance is felt
2. Push, rotate and advance the needle till the needle reaches the
trabecular bone

Pr 9
3.

4.
5.
6.
7.

Remove the stylet, advance further for 1-1.5 cm using a circular

rotating motion of the needle along its long axis to include a core
of marrow within the needle. The biopsy specimen should measure
at least 1.6cm.
Withdraw needle by 2-3 mm, then with less pressure advance 23 mm in a different direction to break specimen
Withdraw needle by rotation with quick full twists
Imprints from biopsy specimen can be obtained ( by gently
touching glass slides to specimen ), epseically if no bone marrow
aspirates obtained ( dry tap )
Push the specimen from needle by inserting the stylet at the tip and
put the specimen in a formalin bottle

N.B. For patients with hematological malignancies or myelodysplastic

syndrome, arrange with laboratory haematologist beforehand for
cytogenetic, cytochemistry and immunophenotyping studies (if
available)

Procedures

Pr 10

CARE OF HICKMAN CATHETER

Procedures

Hickman Catheter Irrigation & Heparin Lock

1. Wash hands thoroughly with anti-microbial soap and water.
2. Put on non-sterile latex gloves.
3. Draw 5 ml of heparin-saline (50unit / 5 ml) into a 10ml syringe and
10 ml Normal Saline in another 10 ml syringe. Eliminate air from
the syringes.
4. Swab end one-inch of catheter and the junction (catheter with
Heparin cap or with IV tubing) with alcohol wipe vigorously with
friction for at least 3 times. Allow the antiseptic to air dry.
5. Ensure that the catheter clamp is closed.
6. Disconnect the heparin block or IV tubing and swab the hub
vigorously with friction for at least 3 times with Alcohol wipe.
Allow the antiseptic to air dry.
7. Perform each catheter irrigation and catheter cap:
Weekly heparin-saline flushing
Connect an empty 10 ml syringe.
Release clamp, and aspirate 5 ml of blood (3 times the catheter
volume) to clear the catheter.
Reclamp catheter. Remove and discard the blood syringe
Inject 10ml normal saline, then 5ml heparin saline
Swab the hub with Alcohol wipe and insert a new catheter cap
Clearing of Blocked Hickman Catheter
Stage I If infusion rate is slow:
1. Wash hand thoroughly with soap and water.
2. Put on non-sterile latex gloves.
3. Prepare 10ml Normal Saline in a 10ml syringe.
4. Wipe end one-inch of catheter and the junction (catheter with
Heparin block or with IV tubing) with alcohol wipe vigorously
with friction for at least 3 times. Allow the antiseptic to air dry.
5. Ensure catheter clamp is closed.

Pr 11
6.

Disconnect the heparin block or IV tubing. Swab the hub

vigorously with friction for at least 3 times with alcohol wipe.
Allow the antiseptic to air dry.
7. Verify catheter occlusion by attaching an empty syringe to catheter
and attempt to aspirate. If all clots in the catheter can be aspirated
successfully, follow with catheter irrigation and heparin block or
resume IV infusion.
8. If catheter is still occluded, attempt clearing by using a gentle
alternating irrigation and aspiration (push and pull) with a 20 ml
syringe half filled with normal saline. If this fails, try with
heparinised-saline.
N.B. 1. Do not force fluid as catheter damage may result.
2. If necessary, obtain an X-ray image of catheter to check it is
in-situ
Stage II If the first procedure has failed or the catheter has been
blocked for over 2 hours:
Repeat procedure in stage I but with 3 ml pure heparin (1000 units/ml)
by Doctor
Stage III If stage I & II have failed:
A fibrinolytic agent e.g. Urokinase can be used. Please contact
haematologist or haematology nurse

Procedures

Pr 12

RENAL BIOPSY
Relative contraindications:
1. Active infection e.g. acute pyelonephritis
2. Very small kidneys (<8 cm)
3. Single kidney
4. Uncontrolled hypertension
5. Bleeding tendency
Preparation:
1. Check CBP, platelets, PT, aPTT, bleeding time
2. Type and screen/X-match 1 pint packed cells
3. Trace film / report of USG or IVP
4. USG for localization

Procedures

Biopsy:
(Preferably done in early morning on a weekday)
1. Platelet count should be >100 x 109 /L, PT, aPTT normal
2. Check baseline BP/P
3. Fresh biopsy specimen put into plain bottle with NS and send for
histology, immunofluorescence electron microscopy
Post-Biopsy Care:
1. Encourage fluid intake
2. Complete bed rest for 24 hours
3. BP/P monitoring at least hourly for 4 hrs (every 15 mins for one
hour), then q4h if stable
4. Save all urine samples for inspection and for RBC
5. Appropriate oral analgesics
6. Inform if gross haematuria, falling BP (SBP<100 mmHg),
increasing pulse rate (>100/min), oozing of blood or severe pain at
biopsy site

Pr 13

INTERMITTENT PERITONEAL DIALYSIS

I. Tenckhoff catheter in-situ
1. Use automatic peritoneal dialysis machine
- Regular Rx once to twice a week
- Heparinisation (optional): during IPD 100 - 500 units/L
Post-dialysis up to 5,000 units IP
2.
Duration of

Medication
(per litre
fluid)

PD

PD
Dialysis
programme

Drain

1st 20-80 L

1L/cycle

30 mins

20 mins

Heparin
100-500 units
(optional)

Subsequently 2L/cycle

30 mins

20 mins

Optional

Procedures

II. Acute PD catheter insertion for patients without a Tenckhoff

Catheter
1. Empty bladder
2. Prime abdomen with 2 litres 1.5% PD Fluid via a #16
angiocatheter at 2 cm below umbilicus
3. Ensure smooth flow. Watch out for extraperitoneal infusion in
obese patients
4. Give local anaesthesia
5. Aseptic technique
6. Insert catheter for acute PD at 2-3 cm below umbilicus in
midline, with catheter tip towards rectovesical pouch
7. Bed cage to protect catheter after insertion

Pr 14
8. IPD order: Total duration 40 hours
2 litres 1.5%* PD fluid per shift
Add heparin 100-500 units/litre
Add 4 mEq KCl /litre if serum K < 4 mmol/l
Inflow + indwelling 40 mins; outflow 20 mins
(* may adjust % of PD fluid as required e.g. use 4.25% PD
fluid if fluid overload)
(* Use 1 litre exchanges if in respiratory distress)
9. Monitor inflow/outflow, if poor, reposition patient / give
laxatives/ adjust or replace catheter
10. Add soluble insulin (4-6 units/bag for 2L of 2.5% PD fluid) for
diabetics. Monitor h'stix q4-6 hours, aim at sugar 10 mmol/l

Procedures

Relative contraindications to peritoneal dialysis:

1. Severe bleeding tendency
2. Multiple lower abdominal scar, recent abdominal surgery
3. Suspicion of abdominal pathology
4. Respiratory failure
5. Pleuroperitoneal leak
6. Aortoiliac graft
7. Burns or other hypercatabolic state or life threatening
hyperkalaemia (not efficient enough)
Preparation for Tenckhoff Catheter Insertion
1. Give laxatives the night before T.C. insertion
2. Transfuse if Hb <8 g/dl, or Hct <0.26
3. Give dDAVP to correct bleeding tendency
4. Antibiotics prophylaxis (optional) :
Regime 1 :
Ampicillin 500 mg iv + cloxacillin 500 mg iv before insertion, then
Ampicillin 500 mg and Cloxacillin 500 mg qid
Regime 2 :
Vancomycin 1 g in 100 ml NS, infuse over 1 hr
5. Empty urinary bladder before Catheter insertion

Pr 15

PERCUTANEOUS LIVER BIOPSY

Before liver biopsy, educate the patients about their liver disease and
investigations other than liver biopsy. Carefully inform the patients
about the procedure, risks and benefits, limitations and alternatives (if
any) before obtaining consent
Contraindications
1.

2.
3.
4.
5.
6.
7.

PT > 3 secs prolonged; platelet count < 60x 109/L; bleeding time >
10 mins; haematocrit < 25%
(Consider safer approach like USG-guided plugged liver biopsy or
transvenous liver biopsy)
Gross ascites
Patient unable to hold breath or cooperate
Extrahepatic biliary obstruction, cholangitis
Vascular tumour, hydatid cyst, subphrenic abscess
Amyloidosis
Morbid obesity

Procedure
(Biopsy preferably done on a weekday in the morning)
1.

3.
4.

Procedures

2.

If no contraindication, discontinue anti-platelet agents, warfarin or

new oral anticoagulants for adequate period before procedure.
Consider bridging therapy with heparin in high thrombotic risk
patients. Risk of stopping antiplatelet agents or anticiagulants
should be weighed against the benefit of liver biopsy. Consult
relevant specialist(s) if indicated. In general, stop warfarin for 5
days prior to liver biopsy. Withold heparin for 12-24 hours.
Check CBP, platelet, INR, APTT +/- bleeding time in patients with
renal impairment or chronic liver disease
X-match 2 pints whole blood for reserve and consider antibiotic
prophylaxis in selected cases
Check BP/P before procedure

Pr 16
5.

Instruct patient on how to hold breath in deep expiration for as long

as he can
6. Palpate the abdomen and percuss for liver dullness in the
mid-axillary line
7. Perform ultrasound for guidance immediately before the liver
biopsy, with marking of the optimal biopsy site. Ultrasound
examination by the individual performing biopsy is preferred
8. Choose rib space with maximum liver dullness (ascertain puncture
site with USG is preferred if available)
9. Aseptic technique, anaesthetise skin, make a small incision
10. Use the Hepafix needle or spring loaded cutting needle. Follow
instructions in the package.
Make sure that the patient is holding his breath in deep
expiration before introducing the biopsy needle into liver.
Avoid lower border of ribs.
11. Send specimen for histology in formalin or formalin-saline
12. One pass is usually enough
Post-biopsy Care
1.

Procedures

2.
3.
4.
5.
6.
7.
8.

BP/P every 15mins for 1 hr, then every 30mins for 1 hr then hourly
for 4 hrs, then q4h if stable
Watch out for fall in BP, tachycardia, abdominal pain, right
shoulder pain, pleuritic chest pain or shortness of breath
Complete bed rest for 8 hrs; patient may sit up after 4 hrs.
Simple analgesics prn
Diet: full liquid for 6 hrs, then resume regular diet
Avoid lifting weights greater then 5 kg in the first 24 hours.
Anti-platelet agents may be restarted 48-72 hours after biopsy
Warfarin may be restarted the day following biopsy

Pr 17

ABDOMINAL PARACENTESIS
1.

2.

3.
4.
5.
6.

7.

Routine prophylactic use of fresh frozen plasma or platelets before

paracentesis is not recommended because bleeding complications
are infrequent.
* However, abdominal paracentesis should be avoided in patient
with disseminated intravascular coagulation and hyperfibrinolysis
Site: left lower quadrant preferred - 2 finger breaths (3cm) cephalad
and 2 finger breaths medial to the anterior superior iliac spine. Right
lower quadrant is suboptimal in the setting of dilated caecum or an
appendectomy but it is preferred in case of gross splenomegaly.
Aseptic technique
May infiltrate with 1% lignocaine
Insert needle (#19 or 21) and aspirate fluid or use commercial
paracentesis set
Send for microscopy and C/ST (use blood culture bottle), white cell
count (total and PMN), biochemistry (albumin and protein) for
initial screening. Check serum albumin and calculate SAAG
serum-ascites albumin gradient
Albumin infusion may not be necessary for a single paracentesis of
less than 4-5L. On the other hand, for large volume paracentesis,
consider albumin infusion of 6-8 g/litre after every 5L ascitic fluid
removed
Procedures

Pr 18

PLEURAL ASPIRATION
Review latest CXR to confirm diagnosis, location and extent of
effusion. (Pitfall: Be careful NOT to mistake bulla as pneumothorax
or collapsed lung as effusion). Correct side marking is essential
before procedure.
Patient position: A) 45o Semi-supine with hand behind head. Or B)
Sitting up leaning over a table with padding
Use ultrasound guidance if available
Best aspiration site guided by percussion. Aseptic technique.
Puncture lateral chest wall, preferably at safety triangle, along midor posterior axillary line immediately above a rib. (The triangle
of safety is bordered anteriorly by the lateral edge of pectoralis
major, laterally by the lateral edge of latissimus dorsi, inferiorly by
the line of the fifth intercostal space and superiorly by the base of
the axilla)
Anaesthetise all layers of thoracic wall down to pleura
Connect a fine-bore needle (21G)/angiocath to syringe for simple
diagnostic tap. 3-way tap may be used if repeated aspiration is
expected.
Avoid large bore needle.
Throughout procedure, avoid air entry into pleural space. (If 3-way
tap is used, ensure proper sealing of all joints of the tap)
Withdraw 20-50 ml pleural fluid and send for LDH, protein, cell
count & D/C, cytology (yield improves if larger volume sent),
gram stain & C/ST, AFB smear & culture. Check fluid pH & Sugar
(contained in fluoride tube) if infected fluid/empyema is suspected.
Check concomitant serum protein and LDH
For therapeutic tap, connect 3-way tap (+/- connect to bed side bag)
and aspirate slowly and repeatedly. Do not push any aspirated
content back into pleural cavity. DO NOT withdraw more than
1-1.5 L of pleural fluid per procedure to avoid re-expansion
pulmonary oedema.
Take CXR and closely monitor patient to detect complications

Procedures

Pr 19
Complications
1. Commonest: Pneumothorax(2-15%), Procedure failure,
Bleeding(haemothorax, haemoptysis), Pain, Visceral damage(liver
and spleen)
2. Others: Re-expansion pulmonary oedema from too rapid removal of
fluid, pleural infection/empyema, vagal shock, air embolism,
seeding of mesothelioma (avoid biopsy if this is suspected)

Procedures

Pr 20

PLEURAL BIOPSY

Procedures

Contraindications:
1.
Uncooperative patient
2.
Significant coagulopathy
Procedure:
Correct side marking is essential before procedure.
1. Ensure there is pleural fluid before attempting biopsy. Assemble
and check the Abrams needle before biopsy. A syringe may be
connected to the end hole of Abrams needle.
2. Preparation as for Steps 1 to 4 of Pleural Aspiration
(NB: If fluid cannot be aspirated with a needle at the time of
anesthesia, do not attempt pleural biopsy)
3. After skin incision (should be made right above a rib), advance a
CLOSED Abrams needle (with inner-most stylet in situ) through
soft tissue and parietal pleura using a slightly rotary movement
4. Once the needle is in the pleural cavity, rotate the inner tube
counter-clockwise to open biopsy notch (spherical knob of inner
tube will click into position in the upper recess of the groove of the
outer tube)
(Aspiration of fluid by the connected syringe confirm pleural
placement of the Abrams needle)
5. Apply lateral pressure on the notch against the chest wall anteriorly,
posteriorly or downwards (but NOT upwards to avoid injuring the
intercostal vessels and nerve) with a forefinger, at the same time
slowly withdraw the needle till resistance is felt when the pleura is
caught in the biopsy notch
6. Hold the needle firmly in this position and sharply twist the grip of
inner tube clockwise to take the specimen
7. Repeat Steps 4 to 6 above in the remaining two directions, totally
take at least 3 specimens if possible
8. Firmly apply a dressing to the wound and quickly remove the
needle when the patient is exhaling

Pr 21
9.

While an assistant presses on wound, remove stylet of needle, open

inner tube and flush specimen(s) out with NS
10. If tapping is necessary, aspirate as for Steps 5-8 of Pleural
Aspiration
11. Take CXR to detect complication(s)
Complications: As for Pleural Aspiration

Procedures

Pr 22

CHEST DRAIN INSERTION

Correct side marking is essential before procedure.
Preparation as for Pleural Aspiration. (Preferred patient position in
BTS guideline: Semi-supine on the bed, slightly rotated, with arm
on the side of the lesion behind his/her head to expose axillary
area.)
2. Always check the number of rib space from sternal angle.
Re-confirm insertion site by percussion, incise skin right above the
rib at anterior or mid-axillary line in 5th or 6th intercostal space.
(Alternate site: 2nd intercostal space, mid-clavicular line, is
uncommonly used nowadays)
3. USG guidance is strongly recommended if available
4. Insertion site should be within the safe triangle. (A space
bordered by anterior border of latissimus dorsi, lateral border of
pectoralis major and a horizontal line superior to nipple or 5th
intercostal space.)
5. Anaesthetise all layers of thoracic wall including pleura. (Do not
proceed if needle for anaesthesia cannot aspirate free gas/ fluid).
6. Proceed with blunt dissection of intercostal muscle with artery
forceps down to parietal pleura.
7. Preferred insertion method: Double-clamp outer end of Argyle
drain (24 Fr to drain air/fluid, 28 Fr to drain blood/pus). Apply
artery forceps in parallel with tip of drain. Breach pleura with
finger. Insert drain tip, release forceps & use them to direct drain
into place.
8. Alternate method: Insert Argyle drain with inner trocar.
Withdraw trocar by 1 cm into drain immediately after puncturing
pleura. Match every 1 cm advancement of drain with 1-2 cm
trocar withdrawal. Double-clamp chest drain when trocar tip
appears outside chest wall
9. Direct drain apically to drain air and basally to drain fluid
10. Attach chest drain to 2 cm underwater seal. Ensure fluid level
swings with respiration and coughing.

Procedures

1.

Pr 23
11. Apply a skin suture over the wound and make a knot, leaving
appropriate length on both sides. Form a 2 cm sling by tying
another square knot 2 cm from previous knot. Tie the sling to
the drain; make several knots using remaining threads to prevent
slipping.
12. Apply dressing.
13. Take CXR to confirm tube position and detect complication(s)
Complications: As for Pleural Aspiration

Procedures

Acknowledgement

Acknowledgement

The Editorial Board would like to thank the Coordinating

Committee (COC) in Internal Medicine for their support and
generous contribution to the publication of this Handbook.
We would also like to extend the heartfelt thanks to all the
colleagues who have made invaluable suggestions to the contents
of Seventh Edition of this Handbook.
Finally, we express our special gratitude to the following
colleagues for their efforts and contribution to the Handbook
Dr Edwin Hui*
Dr KF Hui
Dr WM Hui*
Dr YT Hui*
Dr Bonnie Kho*
Dr Emily Kun
Dr Patrick Kwan
Dr MS Lai *
Dr WC Lao*
Dr TW Lam*
Dr ST Law*
Dr WS Leung *
Dr YY Leung
Dr L Li
Dr KK Li*
Dr Herman Liu*
Dr Patrick Li
Dr HY Lo
Dr YT Lo*

Dr KL Lui*
Dr Colin Lui*
Dr WF Luk*
Dr Flora Miu*
Dr CC Mok
Dr Carmen Ng*
Dr PW Ng
Dr WL Ng
Dr Winnie Sin*
Dr Loletta So*
Dr SF Sze*
Dr Owen Tsang*
Dr Doris Tse
Dr Winnie Wong
Dr TC Wu*
Dr Jonas Yeung*
Dr CW Yim
Dr Shirley Ying
Prof MF Yuen*

Hong Kong Poison Information Centre : Dr Fei Lung Lau*, Dr Yiu Cheung
Chan*

* Doctors involved in updating contents for the 7th edition.

Acknowledgement

Prof Anthony Chan

Dr KH Chan*
Dr KK Chan
Dr KH Chan
Dr KS Chan*
Dr NY Chan*
Dr YH Chan*
Dr TN Chau
Dr KS Cheng*
Dr CM Cheung
Dr Nelson Cheung*
Dr Tommy Tang*
Dr CH Choi*
Dr KW Choi*
Dr CC Chow
Dr MY Chu*
Dr WC Fong*
Dr James Fung*
Dr CP Ho*

COPYRIGHT RESERVED

Quality Assurance Subcommittee

of the
Coordinating Committee in Internal Medicine