Monthly Archives: August 2015

Caprini Risk Assessment Model for DVT

Caprini Risk Score

  • a tool to assess risk of VTE among surgical patients
  • includes 20 variables
  • derived from a prospective study of 538 general surgery patients




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Status Epilepticus Treatment Algorithm

Status Epilepticus Algorithm

Brain Death Declaration


Intraventricular Antibiotics for Ventriculitis

Prepare the following:

1.  Three 3-way stopcocks

2.  One sterile saline flush (preservative-free)

3.  2-4 10cc syringes

4.  sterile gloves, sterile towels

5.  gauze with betadine

6.  cap, gown, mask

7.  antibiotic in 2cc syringe

Put drape underneath shunt access port.  Clean shunt access port with betadine thoroughly, paint line and port with betadine.  Prepare sterile field (won’t be completely sterile), put on gown, mask and sterile gloves.  Prepare stopcock, flush, empty syringe and antibiotic – connect in series as shown in photograph.  Maintain one hand as sterile and another hand as “dirty.”  Lock CSF drain to patient.  Connect free end of stopcock to shunt access port.  and open empty syringe (distal port) to patient.  Withdraw CSF into empty syringes – draw fluid slowly, to max of 20 cc. (volume equal to or slightly more than amount of antibiotic and sterile flush to be infused).  Close empty syringe (now filled with CSF) to patient.  Open antibiotic port (proximal port) to patient and push antibiotic slowly.  Close antibiotic port and open sterile flush port (middle port) to patient.  Flush enough saline to push antibiotic in tubing into patient, and then push an extra 1-2 ml more.  Close sterile flush port and disconnect intraventricular infusion set up from shunt access port.  Maintain EVD clamped x 1 hour.


Empiric treatment:

Vancomycin 15mgkg q8-12h (max 2g) plus one of the following

  1. ceftazidime 2g IV q8h
  2. cefepime 2g IV q8h
  3. meropenem 2g IV q8h

Gram positive:

  • Vancomycin for MRSA
  • Nafcillin or Oxacillin for MSSA
  • Add rifampin if refractory
  • Linezolid 600mg IV q12h if VRE or vancomycin allergy

Duration of treatment:

  1. normal CSF and CONS (+) – possible contaminatin, replace shunt on day 3 if cultures negative
  2. if CONS(+) and abnormal CSF – ABx while device in plus 1 week; document sterile CSF prior to shunt placement
  3. if virulent organism then >10d for staph or 14-21d for GNB; document sterile CSF x 10d prior to shunt
  4. if device cannot be removed, cont ABx until 7-10d after sterile CSF


  • best experience with gentamicin and vancomycin
  • may use colistin for MDROs (i.e. acinetobacter)
  • no PCN or cephalosporins (neurotoxic!)
  • goal is INHIB QUOTIENT of <10-20  … INHIB QUOTIENT is trough of CSF ABx / MIC

CHOICES: vanc 5-20mg/d; gent 4-8mg/d; ampho 0.1-1mg/d


  • IDSA recommends cefazolin but UPTODATE prefer vancomycin over cefazolin (pred CONS)
  • vancomycin 15mgkg (<2g) IV 2h prior (since vanc requires 60 minute infusion)
  • if al, then cefazolin 1-2g IV 1h prior



Intraventricular application of antibiotics to reach effective concentrations within the CNScapture



Nau, R., F. Sorgel, and H. Eiffert. “Penetration Of Drugs Through The Blood-Cerebrospinal Fluid/Blood-Brain Barrier For Treatment Of Central Nervous System Infections”. Clinical Microbiology Reviews 23.4 (2010): 858-883.


10 basal cisterns and fissures



HIJDRA Illustration in Powerpoint



  1. Grade each of the 10 basal cisterns and fissures separately on a scale according to the amount of extravasated blood:
    1. No blood = 0
    2. Small amount = 1
    3. Moderately filled = 2
    4. Completely filled = 3
  2. Grade clots that expanded the original size of a cistern or fissure as 3
  3. Calculate total amount of subarachnoid blood [sum score] by adding the 10 scores;  range = 0-30
  4. Use average score for inadequately visualized cisterns or fissures
  5. Grade the amount of blood in the four ventricles
    1. No blood = 0
    2. Sedimentation in posterior part = 1
    3. Partly filled = 2
    4. Completely filled = 3
  6. Calculate total amount of intraventricular blood [sum score] by adding the 4 scores; range = 0-12


Utility of Hijdra Score:

In one study, Hijdra sum score and history of smoking was noted to be the strongest predictors of cerrebral vasospasm on angiography.  This score was noted to be superior to the modified Fisher score as a tool to predict vasospasm after SAH.

Combined history of smoking and HSS >23 had positive and negative predictive values of 37 and 88%, respectively, for prediction of cerebral vasospasm after aneurysmal hemorrhage.


Dupont, Stefan A. et al. “Prediction Of Angiographic Vasospasm After Aneurysmal Subarachnoid Hemorrhage: Value Of The Hijdra Sum Scoring System”. Neurocritical Care 11.2 (2009): 172-176. Web.

Hijdra, A. et al. “Grading The Amount Of Blood On Computed Tomograms After Subarachnoid Hemorrhage”. Stroke 21.8 (1990): 1156-1161. Web.