Daily goals

Intravenous lipid emulsion Typical intravenous lipid emulsion should provide -20-30% of total daily calories Can be an alternative source of calories in patients with diabetes or hyperglycemia—consider increasing calories from intravenous lipid emulsion in these patients (e.g., 30% of total daily calories) Total daily goal calories = 1 800 kcal/day I 800 kcal/day x 0.3 = 540 kcal/day 540 kcal/day to be provided from intravenous lipid emulsion kcaPmL3 mL 20°/° intravenous lipid emulsion/day (11.25 mL/hour x 24 hours, so round to 11 mL/hour) II mL/hour x 24 hours = 264 mL/day of 20% intravenous lipid emulsion = 528 kcal/day... 

Dextrose Dextrose infusion rate should be -3 1 mg/kg per minute, should comprise -50-60% of total daily calories Since this patient has type 2 diabetes mellitus, consider a goal of -3 mg/kg per minute Provide remainder of total daily calories as dextrose Total daily goal calories = 1 800 kcal/day 1 800 kcal/day -528 kcal/day (from intravenous lipid emulsion) 1272 kcal/day -440 kcal/day (from amino acids) 832 kcal/day to make up with dextrose. 3.4 kcal/g Y 245 8 dextrose/daY If using a 70% stock dextrose solution 245 g x 100 mL. 70 g 245 g/day x 3.4 kcal/g = 833 kcal/day As a double-check, convert to mg/kg/minute 245 g dextrose/day x 1000 mg/1 g x 1 day/1440 minute = 1 70.1 mg/minute 170.1 mg/minute -2.8 mg/kg per minute... 

Team interventions briefing, checklisting and daily goals... 

Watching teams and teamwork quickly reveals that a group of weU intentioned individuals does not make a team and furthermore, that teamwork has to be planned and organized. In this section we will review some apparently simple interventions, which turn out to have quite profound effects. Daily goals, preoperative and post-operative checklists seem mundane, and this partly accounts for clinicians resistance to their use. However, a checklist is not a piece of paper or even a list it is a team intervention which, used well, can affect the wider team functioning, the relationships across professions and hierarchies and even the values and safety culture of the team. To my mind, the impact of these simple tools on clinical processes and patient outcome suggests that their effect can only be fully understood by appreciating their wider impact on team performance. 

REPRINTED EROM JOURNAL OF CRITICAL CARE, PETER PRONOVOST, SEAN BEREN-HOLTZ, TODD DORMAN, PAM A. UPSETT, TERRI SIMMONDS AND CAROL HARADEN. "IMPROVING COMMUNICATION IN THE ICU USING DAILY GOALS". 18, NO. 2, [71-75], 2003, WITH PERMISSION FROM ELSEVIER)... 

The impact of this simple intervention was remarkable. Within eight weeks, the proportion of nurses and doaors who clearly understood the daily goals for the patient increased from 10 to 95 %. Staff found the short-term goals sheet to be a simple tool for setting priorities and guiding the daily work. Nurses felt that they were an active part of the team working in partnership with physicians, so this basic change to the clinical process also impacted on relationships within the team. 

Pronovost, P., Berenholtz, S., Dorman, T. etal. (2003) Improving communication in the ICU using daily goals. Journal of Critical Care, 18(2), 71-75. 

Setting daily goals with Sarah, team, and family. 

Narasimhan M, Eisen LA, Mahoney CD, et al. Improving nurse-physician communication and satisfaction in the intensive care unit with a daily goals worksheet. Am J Crit Cate 2006 15(2) 217-222. 

An initial assessment should review how the organization currently develops and designs jobs required meeting its daily goals and objectives.The JHA process must be customized to ensure that it fits within the current methods and concepts used to solve problems. 

In order to achieve the goals of making more efficient use of the information that is produced and of planning and performing better experiments, chemoinformatics will have to be more integrated into the daily work processes of the chemist, and into the work of the bench chemist. Certainly, many chemists still have to overcome high barriers to using the computer for assistance in the solution of their daily scientific problems. 

The U.S. Defense Logistics Agency (DLA), which maintains the U.S. National Defense Stockpile (NDS), sold 267 t of stockpiled mercury in 1992 (14). The DLA also sold 103 t of secondary mercury from the Department of Energy (DOE) stocks at Oak Ridge, Teimessee. The DLA accepts bids for prime virgin mercury on a daily basis, and for secondary mercury once a month. Inventories on December 31, 1992 were 4766 t of mercury in the NDS and 121 t of DOE mercury (14). The goal for both is zero. 

The goal of most scrap tire utilization projects is to find markets for scrap tires so that they do not end up in landfills or on stockpiles. Ironically, one potentially significant use of tires is in the constmction and management of landfills. Both shredded and whole scrap tires have been approved in various states for use in constmcting leachate beds in landfills. Approval has also been given in some states for the use of shredded tire material as a partial replacement for required daily cover (42). 

To help the reader keep abreast of these advances we present a list of useful WWW sites in this appendix. Realistically, this list should be updated on a daily basis as many of the tools offered on the Internet are made available not only by large organizations and research groups but also by individual researchers. The goal, therefore, has not been to provide a nearly complete guide to the WWW but rather to provide material representative of the tools useful to researchers in the fields of biochemistry and biophysics. 

Propofol 5-20 mcg/kg/min continuous IV infusion (in patients who require frequent neurological assessment) Reassess goals daily and titrate/taper dose to desired response (as patients may accumulate the medication or become tolerant)... 

Lactulose is the foundation of pharmacologic therapy to prevent and treat hepatic encephalopathy. It is a non-digestible synthetic disaccharide laxative that is hydrolyzed in the gut to an osmotically-active compound that draws water into the colon and stimulates defecation. Lactulose also lowers colonic pH, which favors the conversion of ammonia (NH3) to ammonium (NHf).48 Ammonium is ionic and cannot cross back into systemic circulation it is eliminated in the feces. Lactulose is usually initiated at 15 to 30 mL two to three times per day and titrated to a therapeutic goal of two to four soft bowel movements daily.20 49 50... 

Goals of therapy are to maintain a state of euvolemia with good urine output (at least 1 ml/kg per hour), to return serum creatinine and BUN to baseline, and to correct electrolyte and acid-base abnormalities. Vital signs, weight, fluid intake, urine output, BUN, creatinine, and electrolytes should be assessed daily in the unstable patient. 

Iron Supplementation Use of ESAs can lead to iron deficiency if iron stores are not adequately maintained. If serum ferritin and TSAT fall below the goal levels, iron supplementation is required. Oral iron supplements are less costly than IV supplements and are generally the first-line treatment for iron supplementation. When administering iron by the oral route, 200 mg of elemental iron should be delivered daily to maintain adequate iron stores. 

The goals of treatment are to maintain patient independence, activities of daily living (ADL), and quality of life (QOL) by alleviating the patient s symptoms, minimizing the development of response fluctuations, and limiting medication-related adverse effects. 

The primary goals of treatment are correction of the intraabdominal disease processes or injuries that have caused infection and drainage of collections of purulent material (abscess). A secondary objective is to resolve the infection without major organ system complications (e.g., pulmonary, hepatic, cardiovascular, or renal failure) or adverse drug effects. Ideally, the patient should be discharged from the hospital with full function for self-care and routine daily activities. 

Monitor for nonhematologic toxicity of the preparative regimen during its administration. Monitor these symptoms at least daily, with more frequent monitoring if the patient is experiencing these nonhematologic effects. The goal is to prevent or minimize these adverse effects. Specifically,... 

Goal calorie and protein requirements Perform a subjective global assessment Take into consideration the patient s current clinical status, diagnoses, medications, etc. Total daily calories -25-30 kcal/kg per day, or -1 500-1 800 kcal/day Protein -1.5-2 g/kg per day of ideal body weight (-89-11 8 g protein/day) This patient has sepsis, diffuse peritonitis, and recent surgical procedures, target -1800 kcal/day and -11 0 g protein/day... 

Amino acids Amino acids goal of -110 g/day 440 kcal/day (should provide -1 0-20% of total daily calories) If using a 10% stock amino acid solution 110 g x 100 mL 11 oo mL of 10% stock solution 10g... 

The goal is to transition the patient to enteral or oral nutrition and taper off PN as soon as feasible clinically. When initiating enteral or oral nutrition, monitor the patient for glucose, fluid, and electrolyte abnormalities. Perform calorie counts to determine the adequacy of nutrition via the oral or enteral route. When the patient is tolerating more than 50% of total estimated daily calorie and protein requirements via the oral or enteral route, wean PN by about 50%. PN can be stopped once the patient is tolerating more than 75% of total estimated daily calorie and protein requirements via the oral or enteral route, assuming that intestinal absorption is maintained. 

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