鎮静・鎮痛 (ICU)
＜鎮痛＞
Mild pain (pain score 1-3)
- Fentanyl 25mcg IV q2h prn
- Hydromorphone 0.25mg IV q4h prn
- Morphine 2mg IV q2h prn
- Ketorolac 15mg IV q6h prn
Moderate pain (pain score 4-6)
- Fentanyl 50mcg IV q2h prn
- Hydromorphone 0.5mg IV q4h prn
- Morphine 4mg IV q2h prn
- Ketorolac 15mg IV q6h sch
Severe pain (pain score 7-10)
- Fentanyl 75mcg IV q2h prn
- Hydromorphone 1mg IV q4h prn
- Morphine 6mg IV q2h prn
[Continuous infusion for analgesia]
Fentanyl 2500mcg/NS 200ml
Start at 25 mcg/hr; titrate by 10 mcg/hr q5 min to PAIN Score 3/10; or to GOAL RASS Score 0 to -1; to a maximum of 200 mcg/hr
(Adjust in opioid tolerant patients. No max when used for comfort measures)
Morphine 100mg/NS 90ml
Start at 1 mg/hr; titrate by 1mg/hr q5min to PAIN Score 3/10; or to GOAL RASS Score 0 to -1; to a maximum of 20 mg/hr.
(Adjust in opioid tolerant patients. No max when used for comfort measures)
Hydromorphone 50mg/NS 50ml
Start at 0.2 mg/hr; titrate by 0.2 mg/hr q30 min to Pain Score 3/10
or GOAL RASS Score 0 to -1; to a maximum of 2 mg/hr
(No max when used for comfort measures)
＜鎮静＞
Propofol 1000mg/100ml
Start at 5 mcg/kg/min; titrate by 5 mcg/kg/min q 10 min
to GOAL RASS Score 0 to -1; to a maximum of 70 mcg/kg/min
Dexmedetomidine 200mcg/NS 50ml
Loading dose of 1 mcg/kg over 10 min
THEN Start at 0.2 mcg/kg/hr; titrate by 0.1 mcg/kg/hr q30 min to GOAL RASS Score 0 to -1; to a maximum 1.4 mcg/kg/hr as tolerated.
Midazolam 100mg/NS 80ml
Start at 1 mg/hr titrate by 1 mg/hr q5 min to GOAL RASS Score 0 to -1; to a maximum of 10 mg/hr
[Neuromuscular blocker]
Cisatracurium 200mg/NS 200ml
Loading dose 0.15 mg/kg = [ ]mg
Start at 3 mcg/kg/min; titrate by 0.5 mcg/kg/min q 20 min
to a maximum of 10 mcg/kg/min to a train of four (TOF)
of at least 1-2/4 to maintain ventilator synchrony
＜Delirium＞
- Quetiapine 25mg PO q8h sch
- Haloperidol lactate 2mg IV q8h sch
(HOLD if QTC greater than 25% increase from baseline QTC or absolute corrected QT of 0.48)
- Dexmedetomidine iv (the same protocol above)
(dexmedetomidine is the sedation medication of choice in hemodynamically stable patient with significant delirium)
(米国一施設基準)
ICU持続静脈注射薬
Amiodarone
[bolus]
amiodarone 150mg in 100ml D5W at 618ml/hr iv x 1
[continuous]
amiodarone/D5W 750mg/500ml
Start at 1 mg/min x 6 hours, then 0.5 mg/min
Maximum rate 1.5 mg/min
Diltiazem
diltiazem/NS 100mg/100ml
Loading dose 0.25mg/kg over 2 min
Start at 5 mg/hr
titrate by 5 mg/hr q10 min
Titrate to Goal Ventricular Rate <100
Hold for HR<50 or SBP <90
to a maximum of 15 mg/hr
(Usual range 5 mg/hr to 15 mg/hr)
Dobutamine
dobutamine/D5W 250mg/250ml
Start at 2 mcg/kg/min
titrate by 2 mcg/kg/min every 5 min
Titrate to Goal parameter:
to a maximum of 20 mcg/kg/min
(Usual range 1 mcg/kg/min to 20 mcg/kg/min)
Dopamine
dopamine/D5W 400mg/250ml
Start at 2 mcg/kg/min
Titrate by 1 mcg/kg/min every 5 min
To a Goal MAP > or = 65 mmHg to a maximum of 25 mcg/kg/min
(Usual range 1 mcg/kg/min to 25 mcg/kg/min)
Epinephrine
epinephrine 1mg/NS250ml
Start at 0.01 mcg/kg/min
Titrate by 0.01 mcg/kg/min every 5 min
To a maximum of 1 mcg/kg/min or MAP > 65 mmHg
(Usual range 0.01 mcg/kg/min to 1 mcg/kg/min)
Esmolol
esmolol/NS 2500mg/250ml
Start at 50 mcg/kg/min
titrate by 50 mcg/kg/min q5 min
Titrate to Goal to keep HR <100
Hold for HR <50 or SBP <90
to a maximum of 300 mcg/kg/min
(Usual range 50 mcg/kg/min to 300 mcg/kg/min)
Furosemide
furosemide 1000mg/100ml
Start at 5 mg/hr
titrate by 5 mg/hr q60 min
Titrate to Goal Urine Output 0.5 ml/kg/hr
to a maximum of 40 mg/hr
(Usual range 5 mg/hr to 40 mg/hr)
Isoproterenol
isoproterenol/D5W 1mg/250ml
Start at 0.01 mcg/kg/min
titrate by 0.01 mcg/kg/min every 5 min
Titrate to Goal parameters:
to a maximum of 0.4 mcg/kg/min
(Usual range 0.01mcg/kg/min to 0.4 mcg/kg/min)
Labetalol
labetalol/NS 200mg/200ml
Loading dose 10 mg IV
Start at 2 mg/min
titrate by 1 mg/min every 5 min
Titrate to Goal SBP [ ] mmHg
Hold for HR <50
to a maximum of 8 mg/min
(Usual range 2 mg/min to 8 mg/min)
Lidocaine
lidocaine/D5W 2000mg/250ml
Start at 14 mcg/kg/min
titrate by 7 mcg/kg/min
Titrate to eliminate Ventricular Tachycardia
to a maximum of 57 mcg/kg/min
(Usual range 14 mcg/kg/min to 57 mcg/kg/min)
Milrinone
milrinone/D5W 20mg/100ml
Loading dose 50 mcg/kg over 10 min
Start at 0.375 mcg/kg/min
titrate by 0.05 mcg/kg/min q30 min
Titrate to Goal parameter:
to a maximum of 0.75 mcg/kg/min
(Usual range 0.375 mcg/kg/min to 0.75 mcg/kg/min)
Nicardipine
nicardipine/NS 20mg/200ml
Start at 5 mg/hr
titrate by 2.5 mg/hr every 5 min
Titrate to Goal SBP [ ] mmHg
Hold for HR <50
to a maximum of 15 mg/hr
(Usual range 5 mg/hr to 15 mg/hr)
Nitroglycerin
nitroglycerin/D5W 100mg/250ml
Start at 0.1 mcg/kg/min
titrate by 0.2 mcg/kg/min q3 min
Titrate to eliminate chest pain
Maintain SBP > 100 mmHg
to a maximum of 5 mcg/kg/min
(Usual range 0.1 mcg/kg/min to 5 mcg/kg/min)
Nitroprusside
nitroprusside/NS 100mg/250ml
Start at 0.5 mcg/kg/min
titrate by 0.5 mcg/kg/min every 2 min
Titrate to Goal SBP [ ] mmHg
to a maximum of 10 mcg/kg/min
(Usual range 0.5mcg/kg/min to 10mcg/kg/min)
Norepinephrine
norepinephrine/NS 8mg/250ml
Start at 0.01 mcg/kg/min
Titrate by 0.02 mcg/kg/min every 5 min
To a Goal MAP > or = 65 mmHg to a maximum of 3 mcg/kg/min
(Usual range 0.01 mcg/kg/min to 3 mcg/kg/min)
Phenylephrine
phenylephrine/NS 50mg/250ml
Start at 0.3 mcg/kg/min
Titrate by 0.1 mcg/kg/min every 5 min
To a Goal MAP > or = 65 mmHg to a maximum of 10 mcg/kg/min
(Usual range 0.3 mcg/kg/min to 10 mcg/kg/min)
Procainamide
procaineamide/NS 1000mg/250ml
Start at 1 mg/min;
titrate by 1mg/min q 20 min
Titrate to Goal parameter:
to a maximum of 6mg/min up to 24 hr
(Usual range 1 mg/min to 6 mg/min)
Vasopressin
vasopressin/NS 50units/250ml
Start at 0.01 units/min
Goal MAP > or = 65 mmHg
(Usual range 0.01 units/min to 0.04 units/min)
(米国一施設基準)
疼痛コントロール
This order set is based on the WHO Analgesic Ladder
Directions:
1. Assess pain severity
2. Begin treatment at the appropriate step of the Ladder
3. If starting at Step 2 or 3 ensure the all appropriate medications from Step 1 are administered in addition to the current step
4. Progress through the steps until pain is controlled
STEP 1
- Acetaminophen 650mg PO Q4H PRN for mild pain
plus celebrex (with higher risk of bleeding)
- Celecoxib 200mg PO Q12H SCH
or ketorolac (with lower risk of bleeding)
- Ketorolac 15mg IV Q6H SCH
(maximum dose of 120mg/day for 5 days. avoid in renal dysfunction, GI bleeding, Platelet abnormality, concomitant administration of ACEI, CHF, cirrhosis, asthma)
Mild pain (pain score 1-3)
- oxycodone IR 5mg PO Q4H PRN
- oxycodone oral solution (5mg/5ml 5mg) 5mg PO Q4H PRN
STEP 2
Moderate pain (pain score 4-6)
(hydromorphone or oxycodone preferred option)
- Hydromorphone 2mg PO Q4H PRN
- Oxycodone IR 10mg PO Q4H PRN
- Oxycodone oral solution (5mg/5ml 5mg) 10mg PO Q4H PRN
- Morphine IR 15mg PO Q4H PRN
Unable to take PO
- Hydromorphone 0.5mg IV Q3H PRN
- Morphine 2mg IV Q3H PRN
STEP 3
Severe pain (pain score 7-10)
(hydromorphone preferred option)
- Hydromorphone 4mg PO Q4H PRN
- Morphine 30mg PO Q4H PRN
Unable to take PO
- Hydromorphone 0.5mg IV Q2H PRN
- Morphine 4mg IV Q3H PRN
(米国一施設基準)
譫妄
検査
- Fingerstick Glucose
- Urine drug screen
- UA + Culture
- CBC/CMP
- Digoxin level PRN
- ABG
- EKG
- Chest portable X-ray
コンサルテーション
- psychiatry consult
- speech language consult
Medication
All Medications should be used only when non-pharmacologic interventions have failed and caution should be used when dosing these medications in the elderly
Caution:
* If QTc>450ms, highly recommend to discuss treatment options with psychiatry prior to ordering any medications below
* Please observe for the following: extrapyramidal symptoms
* If differential diagnosis is alcohol withdrawal or benzodiazepine withdrawal, initiate CIWA protocol
For hyperactive delirium with agitation, confusion, restlessness, sleep disturbance x 24 hours
- Haloperidol 0.5／1mg PO Q2H PRN for hyperactive delirium
(total IV or PO maximum: not to exceed 10mg/24hours)
- Risperidone 0.5mg PO BID PRN for hyperactive delirium
- Quetiapine 12.5mg PO Q6H PRN for hyperactive delirium
For hyperactive delirium with combative behavior, spitting, throwing x 24 hours
- Haloperidol 2mg IV Q2H PRN for hyperactive delirium
(total IV or PO maximum: not to exceed 10mg/24hours)
- Risperidone 1mg PO BID PRN for hyperactive delirium
- Quetiapine 25mg PO Q6H PRN for hyperactive delirium
(米国一施設基準)
End of Life Comfort Care
Nurse order
Provide private room
Visitor okay pre-post normal hours
食事
Regular diet（持ち込み可）
コンサルテーション
Pain management consult
Social service consult
Spiritual care consult
疼痛コントロール
- Morphine (20mg/1ml solution) 10／20mg sublingual Q1H PRN for pain
- Morphine 1／2／4mg IV Q1H PRN for pain
- Morphine IV (100mg/NS100cc) 持続
start at 1mg/hr, titrate by 1mg/hr every 5 minutes, maximum dose: none
- Hydromorphone 0.2／0.4mg IV Q4H PRN for severe pain
- Hydromorphone IV (50mg/NS50cc) 持続
start at 0.2mg/hr, titrate to patient comfort
- Fentanyl Patch 12／25／50／75／100mcg/hr Q3D SCH
- Acetaminophen 650mg PO Q4H PRN
- Acetaminophen 650mg PO Q6H SCH
掻痒時
- Diphenhydramine 25mg PO Q4H PRN for pruritis
- Diphenhydramine 25mg IV Q4H PRN for pruritis
便秘時
- Senna-Docusate 2 tab PO HS PRN for constipation
- Bisacodyl Suppository 10mg PR DAILY PRN for constipation
口腔内分泌過多時
- Scopolamine 1.5mg/72hr Patch 1 patch TD Q72H PRN for excess secretions
- Hyoscyamine 0.125mg PO Q4H PRN for excess secretions
不安時
- Lorazepam 1mg PO Q4H PRN for agitation
- Lorazepam 1mg IV Q2H PRN for agitation
不眠時
- Haloperidol 1mg PO HS PRN for sleep
嘔気時
- Prochlorperazne 10mg PO Q6H PRN for nausea/vomiting
- Ondansetron 4mg IV Q6H PRN for nausea/vomiting
- Prochlorperazine 25mg PR Q12H PRN for nausea/vomiting
(米国一施設基準)
Insulin Sliding Scale
インスリンスライディングスケール
Low dose protocol (インスリン1日量が40単位以下の患者)
70-100 no insulin
101-150 no insulin
151-199 1単位／no insulin
200-249 2単位／no insulin
250-299 3単位／1単位
300-349 4単位／2単位
350以上 5単位 call MD／2単位 call MD
（insulin aspart：食前／眠前）
Medium dose protocol (インスリン1日量が40-80単位の患者)
70-100 no insulin
101-150 no insulin
151-199 2単位／no insulin
200-249 4単位／no insulin
250-299 6単位／3単位
300-349 8単位／4単位
350以上 10単位 call MD／5単位 call MD
（insulin aspart：食前／眠前）
High dose protocol (インスリン1日量が80単位以上の患者)
70-100 no insulin
101-150 no insulin
151-199 3単位／no insulin
200-249 6単位／no insulin
250-299 9単位／4単位
300-349 12単位／6単位
350以上 15単位 call MD／7単位 call MD
（insulin aspart：食前／眠前）
絶食・TPN投与時
血糖測定６時間ごと
インスリン：insulin regular
投与量は食事摂取時と同じ
眠前投与量の変更なし
低血糖プロトコール
経口可能時
軽度～中等度 (40-69mg/dl) グルコース15 gram 経口
重度(40mg/dl以下) グルコース30 gram 経口
経口不能、IV accessある時
軽度～中等度 (40-69mg/dl) 50%ブドウ糖液12.5 gram IV
重度(40mg/dl以下) 50%ブドウ糖液25 gram IV
IV accessなしかつ経口不能
グルカゴン 1mg IM, 続いてグルコース経口投与あるいは5%ブドウ糖液100m/hrで開始
インスリン持続静脈投与（not for DKA）
Insulin regular 100units/NS100cc
Goal: Fingerstick blood glucose 110-150mg/dl
Initiate IV Insulin Infusion
(Bolus/Infusion)
< 150 No bolus ／ No infusion
150-180 2 units ／ 1 unit/h
181-210 3 units ／ 2 units/h
211-250 4 units ／ 4 units/h
251-300 5 units ／ 6 units/h
> 300 call MD
Further titration
Fingerstick blood glucose check every 1 hour
(Bolus/Infusion)
< 70 hypoglycemic protocol
<110 No bolus ／ stop infusion
110-150 No bolus ／ no change
151-180 No bolus ／ increase by 1 unit/h
181-210 2 units ／ increase by 2 units/h
211-250 3 units ／ increase by 3 units/h
251-300 5 units ／ increase by 4 units/h
301-400 8 units ／ increase by 5 units/h
>400 call MD
If FSBG decrease >40mg/dl regardless of range, decrease rate by 50%
If FSBG decrease 2 consecutive readings in 110-150 range, decrease rate by 50%
(米国一施設基準)
Job Search for J1 VISA Holder
Timeline (my experience)
4/2015 Registration to job search websites
5/2015 Start contacting recruiters
8-9/2015 Interview / contract (the earlier the better for J1 waiver spots)
12/2015 Application to FCVS
2/2016 Application to American Board of Internal Medicine
2/2016 Submission of application to state medical license
3/2016 Application to J1 extension
4/2016 Notification of J1 waiver selection
4/2016 Preparation for graduation (medical procedures, evaluation sheets, ...)
6/2016 Submission of the rest of medical license application once residency is finished
8/2016 American Board of Internal Medicine Exam
① How to search job positions
First, you make a new e-mail account exclusively for job search
Then register to websites below
And you start receiving e-mails every day
When you find programs you are interested in, then you call the recruiters to ask about more details. If you are eligible for the programs, they will set up interviews
Practice match https://www.practicematch.com/
Career MD https://www.careermd.com/
Practice link http://www.practicelink.com/
3R Net https://www.3rnet.org/ (for J1 VISA holder)
(Contract better to be reviewed with experienced attending physicians before signed)
② Medical license application
☆FCVS (Federation Credentials Verification Service) (the earlier the better)
https://www.fsmb.org/licensure/fcvs/
(some of the documents require notarization which can be done by program secretaries)
☆Initial full license application (MA) (the earlier the better)
http://www.mass.gov/eohhs/gov/departments/borim/physicians/licensing/forms/full-license/initial-full-licenses.html (MA state license)
Documents require to be filled out and be sent
Opioid and Pain Management Training www.opioidprescribing.com. (online training)
Training to Recognize and Report Suspected Child Abuse or Neglect
http://middlesexcac.org/51A-reporter-training/ (online training)
National Practitioner Data Bank http://www.npdb.hrsa.gov/ (online registration)
AMA Physician Profile https://commerce.ama-assn.org/amaprofiles/ (online registration)
③ Application to American Board of Internal Medicine
https://www.abim.org/certification/exam-information.aspx
Application from 12/1/2016 through 3/1/2017 (exam fee cheaper if applying by 2/15/2017)
④ Extension of J1 VISA (optional)
J1 VISA expires when residency training is finished
By applying to IM board exam, J1 VISA can be extended to the end of the month when the exam is taken (end of August)
Go to OASIS -> J1 VISA sponsorship -> Board application
