規則
Rule number 1: Safety and ICF signing
Rule number Last: Efficacy
相信病人的主要抱怨 eg pulmonary thrombosis
Port A 儘量分開 procedure ,overnight
就像端午節吃粽子,有些粽子包的很簡單,但是很好吃,有些粽子包得很高級,裡面充滿干貝,蛋黃,蝦子,但是卻不一定好吃。簡單說:適合的就是最好吃,簡單的不一定不好吃。
Rule number 1:
青菜蘿蔔各有所好,適性看病。Every dog has his day.
千百會,再會,順毛。
$ Education and Safe >>>>Efficacy
$ Psycho evalutaion/ Goal/ End of life as Soon?
自殺無法預防,請親人確認,24小時陪伴,醫院醫護只能協助(請會精神科, most is famly issue)。
*** No Pushing treatment
Long stay 3+1
Port a if need 找麻醉
醫囑不確定,請問人。
開醫囑前,確認生化血球 (T bil and irinotecan toxicity) 。
只告知確定已知結果(不未來式)
If Unfitted keep palliation.
黃疸高(T.Bil high) 使用 irinotecan, 小心 WBC between 2-4 th course.
TB always/Influenza A( ER?/PCR/clinical(SAS))
三人同機,必有肺炎(influenza test)
CMV HSV PCP Legionella….
Neutropenia fever (GCSF /antibiotis)
Immunotherapy related adverse event:
Treatment related mortality 1-3%
hit: Hemolysis, LDH, ALT, Ca P….>> high dose steroid
Lung; Liver; endocrine …..
anti-VEGF: Perforation, CAD, dissection , wound ….
腸穿孔注意事項 有胃潰瘍風險者 阿斯匹靈 原發腫瘤未切除 ….
post procedure TRMM -,must visit
Port A 不順(不一定回血)
原因很多,有可能掉了(CXR),血栓(urokinase),針不正(長針)
Urokinase ,一般一次(5000IU - 6000 IU),注入 device 靜置 10-15 分鐘再反抽。
追蹤
For stage I IIA PNI LVSI late recurrence .C.T BETTER
If marker high x2 and CT no finding Arrange PET
Adjuvant C/T after Metastasectomy
Bio-C/T first if SD then stivarga
if stivarga from mid-way
Salvage regimen:
醫療不是商品,有其相對風險
通常 "怪別人較快", especially those did not actually a true caregiver
so not too hot-Heart
Standard in VIIP first
病人的規劃
共病症
治療的目標
常常是最優先的考量,一定要先確定病人的”治療目標”以及”共病症”狀況再安排後續的治療。
Poor organ function: s/p VATs xn, s.p liver op ….
lost of liver and lung volume might caruse immunosupression
Anti-VEGF
沒必要 不要超標 ( 80-90% is safe)
Avastin 350 mg (30% in PS2 due to easy bleeding; HTN/aortic dissection)
Zaltrap 240 mg (30% in PS2 due to easy bleeding; HTN/aortic dissection)
Irinotecan 300 mg (reduced if D/T bil ,High; 累加毒性 neutropenia day 14-21)
Oxaliplatin 130 mg (acute neuropathy)
HDFL
delirium
Stivarga
HFSR
some C.T to prevent no return points
Irinotecan
(Delay or timely) neutropenia and septic shock
WBC @ C3
BRAF mt:
BRAFi major and MEKi minor
consult oph better
treatment related skin cancer