Some notes on Hepatic encephalopathy taught to me by @DelviseF and @KhushbooSGala

#1: HE is a sedated state. If hyperactive, suspect acute withdrawal (impt because Ativan worsens HE but should be used to prevent life-threatening withdrawals); PMID: PMID: 35598629 #2: West Haven Criteria
0: no encephalopathy
1: short attention span, euphoria/depression, sleep-wake disturbance ± asterixis (Ddx: OSA)
2: lethargy/apathy, disorientation, asterixis
3: somnolent but responsive to verbal commands, severe disorientation, no asterixis
4: coma

UGIB. Hold low dose ASA or not?
1. Primary prev: stop indefinitely
2. Secondary: AGA guidelines rec continuing (conditional, very low certainty). When to restart: AGA rec on day hemostasis endoscopically confirmed (conditional, very low certainty)

🧵 : 1/3 Evidence for continuing (RCT small sample size)
- non significant increased risk of rebleeding in aspirin group
- significantly lower all cause mortality (and mortality 2/2 cardiovasc, cerebrovasc, GI complications) in aspirin group

Approach to conjugated hyperbilirubinemia taught to us by @dunleavy_katie.
1. Definition: T.bili elevation + >20% conjugated
2. Obtain RUQ US to look for ductal dilation
3. No dilation = intrahepatic cholestasis
- rule out non-ICU vs ICU causes
4. MRCP, ERCP, liver biopsy Bilirubin thresholds:
- indirect bilirubin usually < 5-6 in massive hemolysis (if > 5-6, something else is going on)
- acute complete CBD obstruction: max bilirubin elevation usually around 15 (with time, hepatocyte dysfunction may cause higher elevations)

Summary of oxygen delivery devices taught to me by Mayo RT

Source of oxygen
- Wall taps by bedside: 0–15L/min
- Home concentrator: 0–10L/min

Oxygen delivered at 100%, put through different devices at different rates to adjust the oxygen concentration that the patient inspires TLDR
- Low oxygen (<35%): nasal prongs
- Moderate oxygen (35-60%): venturi (high flow but mix with room air)
- High oxygen (>60%): non rebreather or HFNC
- PEEP needed (e.g., ADCHF, OSA): CPAP
- Hypercapnic: BiPAP
- Failure, unable to protect airway: mechanical ventilation

Differentials for hypoxemia based on Aa gradient ABG vs VBG:
- pH: VBG
- pCO2: VBG (not accurate in shock or hypercapnia); ABG for severe shock or if precise pCO2 needed in hypercapnia
- PO2: ABG (but SpO2 generally good enough)
- CO or methemoglobin: co-ox

Quantifying proteinuria has confused me for the longest time so I wanted to revisit some definitions. A thread. 1. Proteinuria =/= albuminuria
- Glomerular prot: mostly albumin
- Tubular prot: LMW proteins (e.g., B2M)
- Overflow prot: light chains, myoglobin, hb
- Postrenal prot: inflammation, bleed, malignancy

Summary tweet on my approach to anemias. credit to @n_gangat, @RichGodby, @zhuoerxie, Dr Ron Go, @VincentRK for teaching. Comments/critiques welcome!

1. Approach to anemia 2. Approach to iron deficiency anemia