1. Kidney trauma grading: 
-Grade I: contusion
-Grade II: <1 cm cortex laceration
-Grade III: >1 cm cortex laceration
-Grade IV: laceration through cortex, medulla; renal aa/vv damage
-Grade V: shattered kidney, significant hilum injury leading to ischemia
2. Kidney trauma surgical management: 
-Attempt salvage surgery whenever possible: cut out damaged parts, approximate remaining viable tissue, omental overlay.
-Indications for nephrectomy: bleeding leading to hemodynamic instability (be careful in kids-- they can lose a lot of blood without hemodynamic compromise, and decompensate very quickly), shattered/completely devascularized kidney. Watch out for single kidney!
3. Bariatric surgery: two mechanisms of weight loss.
-Restriction, i.e. gastric sleeve: decreases the size of stomach, reduces amount of food it can hold. Good for people who are not as heavy, or for people who are very heavy but are not healthy enough for a more extensive surgery. Gastric sleeve procedures are also an excellent treatment for reflux, since it both reduces acid-secreting cell content and
-Malabsorption, i.e. roux en y, duodenal switch: bypass absorptive segments of bowel.
Gastric bands do not work.
4. AV fistulas in hemodialysis: because both the intake and output lines of dialysis are into veins (too risky to stick an artery), AV fistulas are made to increase volume flow across the source vein. Up to 10-20% of patients will have vascular steal phenomena (i.e. distal ischemia due to decreased blood flow to capillary bed), but the rate of serious ischemia requiring intervention (i.e. bypass graft) is much lower, <5%. Patients with peripheral artery disease (arteriolosclerosis, advanced DM) are more predisposed because of more stenotic vessels as well as decreased collateral formation.
5. Criteria for kidney transplant in an HIV-positive person:
-Undetectable viral load
-CD4>200-250
6. HIV+ patients have a higher kidney rejection rate than non-HIV infected patients, according to this 2010 non-randomized prospective trial in the NEJM, which at n=150 is the largest study to date of kidney transplant in HIV+ people. They chose people that met the above criteria, and found 1- and 3- year survival rates (97 and 88% respectively) and graft survival rates (90% and 74%) that were comparable with the general population of kidney recipients, however they found a significantly increased graft rejection rate-- 31% and 41% at 1 and 3 years, respectively. From the discussion:
"The main finding of concern in this study...was the unexpectedly higher rejection rates (by a factor of 2 to 3) in the HIV-infected kidney recipients, as compared with recipients who did not have HIV infection. About half these episodes were glucocorticoid-resistant, which is characteristic of aggressive rejection. Aggressive acute rejection within 6 months after transplantation suggests an inherently enhanced response to donor antigens. The subsequent gradual and steady increase in rejection despite low CD4+ T-cell counts may represent a memory response. Multiple explanations for this type of response can be hypothesized. First, HIV contains human leukocyte antigen molecules of the host, and their transmission to another host may induce allosensitization. Second, the homeostatic expansion of T cells in HIV infection is often coupled with the acquisition of memory phenotype, which in turn is associated with increased responsiveness of the T cell and nonspecific enhancement of alloimmunity. Third, prior infections can lead to the generation of memory alloreactive T cells as a result of cross-reactivity" Additionally, since many HAART drugs inhibit the cyp-450 system, dosing of immunosuppressive drugs had to be less frequent. Although monthly trough levels of these drugs were therapeutic, there is still a possibility there was inadequate immunosuppression.
7. Most common infectious agents after liver transplant: enterococcus, citrobacter, klebsiella, fungus. Cefepime generally covers citro/kleb, try amp or vanc for the enterococcus if its not VRE. If it's VRE, go to linezolid or daptomycin; linezolid has better lung penetration but carries the risk of anemia (via erythrosuppression) and thrombocytopenia (via consumption/autoimmune) and serotonin syndrome. So if someone's platelets are low, don't use it.
8. Sequelae of immobilization:
-Muscle: atrophies: 1-3% in a day, 10-15% in a week, 50% in a month in young healthy males; in older, frailer people it's probably even faster.
-Bones: Contractures and disuse osteoporosis
-Pulm: lying down decreases breath movement into lower lobes and increases atelectasis. Increased risk of aspiration. Prone positioning in patients with ARDS increases oxygenation (PaO2) and decreases needed FiO2, may decrease mortality in very ill patients. {Crit Care Med, 2008, meta-analysis total N>1000}
-CV: initially, increased venous return, leading to diuresis and volume depletion, orthostatic hypotension
-Heme: hypercoagulable state
-GI: increased GI motility dysfunction, diarrhea/constipation. Increased acid production, decreased appetite.
-GU: increased risk of UTI, stones, urosepsis
-Extremities: bedsores
9. Early exercise/PT intervention in clinically ill ventilated patients results in faster recovery and decreased morbidity and mortality, according to a 2009 RCT in the Lancet. This study randomized people who were in the ICU, on ventilators, to be woken up out of sedation daily and given whole-body PT. Return to functional status at discharge: 59% (intervention) vs 35% (control); duration of delirium: 2 days (intervention), 4 days (control); ventilator-free days: 23.5 days (intervention), 21.1 days (control).
10. Digoxin levels are usually targeted for between 0.8 and 2.0 depending on the intervention. Levels should be checked, often to monitor for toxicity rather than efficacy, especially if the patient is in renal failure. If the kidneys are fine, levels checked once per week is OK. If they have renal impairment, empirical spacing of dosing may be appropriate, to once every 48-72 hours, since constant checking also carries risk.