🅿️Key Points

Managing Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome
🛑Ascites

✅Diagnostic paracentesis should be performed in all patients with new-onset ascites and in all patients with cirrhosis and pre-existing ascites who are admitted to the hospital.

✅Recommended initial peritoneal fluid tests are cell count and differential total protein, and albumin (to enable calculation of the serum albumin–ascites gradient [SAAG]).

✅Minimal ascites (i.e., detected only by ultrasound) does not require treatment. Moderate ascites should be treated with dietary sodium restriction and diuretics (spironolactone, furosemide, or both), and large or tense ascites often requires large-volume paracentesis (LVP).

✅To prevent postparacentesis circulatory dysfunction (PPCD), a potentially dangerous complication of LVP, administer 6 to 8 g intravenous (IV) albumin per 1 L of fluid removed above 5 L. Risk for PPCD increases with LVP of >8 L in a single session.

🛑Spontaneous Bacterial Peritonitis (SBP):

✅Empirical treatment for SBP is recommended for all patients with ascitic fluid polymorphonuclear leukocytes >250 cells/mm3, even in the absence of symptoms; such treatment consists of an intravenous third-generation cephalosporin plus IV albumin (1.5 g/kg on day 1, followed by 1 g/kg on day 3). Cultures should be obtained prior to starting antibiotics.

✅All patients who recover from SBP should receive daily norfloxacin or ciprofloxacin for prophylaxis.

✅All patients with ascites and upper gastrointestinal hemorrhage should receive prophylaxis for SBP with IV ceftriaxone for as long as 7 days.

🛑Hepatorenal Syndrome (HRS):

✅Vasoconstrictors in combination with IV albumin are the mainstay of treatment for HRS. Terlipressin (a vasopressin analogue, not available in the U.S.) is the preferred first-line agent; norepinephrine is an alternative. Midodrine plus octreotide can be used, but their efficacy is low.

✅If creatinine does not decline after 4 days on maximal doses of vasopressors, further improvement is unlikely and treatment can be stopped.

✅Liver transplantation should be considered for patients with HRS


#AASLD
#salah

The Sanford guide 2022
كتاب يختص في مضادات الميكروبات كتاب جميل جدا
شكرا لدكتور حسن يونس والدكتور اسلام وكل من ساهم في ذالك
👇🏼

🛑patients with AF and hemodynamic instability undergoing urgent cardioversion (electrical or pharmacologic), after successful cardioversion to sinus rhythm,
✅we suggest therapeutic anticoagulation (with VKA or full adherence to NOAC therapy) for at least 4 weeks rather than no anticoagulation, regardless of baseline stroke risk (weak recommendation, low quality evidence).

✅patients with AF and hemodynamic instability undergoing urgent cardioversion (electrical or pharmacologic), we suggest that therapeutic-dose parenteral anticoagulation be started before cardioversion, if possible, but that initiation of anticoagulation must not delay any emergency intervention (weak recommendation, low quality evidence).
#salah

✅Anticoagulation with a VKA is indicated to achieve an INR of 3.0 in patients with a mechanical AVR and additional risk factors for thromboembolic events (AF, previous thromboembolism, LV dysfunction, or hypercoagulable conditions) or an older-generation mechanical AVR (such as ball-in-cage).
#American Heart Association
#salah

✅Continuation of VKA anticoagulation with a therapeutic INR is recommended in patients with mechanical heart valves undergoing minor procedures (such as dental extractions or cataract removal) where bleeding is easily controlled.
#American heart Association
#salah

طبعا بنسبه ايهما افضل من عائله SGLT2I في مريض HFrEF
دواء Dapagliflozin و empagliflozin

✅Reduce hospitalization
✅ Reduce CV mortality
✅Reduce All causes mortality
✅Improvement in symptoms ( reduce salt retention)
✅Control blood sugar in DM patients

يتفوق empagliflozin ع Dapagliflozin انه عليه دراسه انه ممكن
Empagliflozin Reduce the incident of hyperkalamia without significant increase in hypokalemia
وهذا قد بيساعد انه ماخفش كثير من صرف Aldactone للمريض

بينما Dapagliflozin بيكون افضل لو ترافق HFrEF مع CKD
#salah

Different formulations on ACEi and ARB

#Practice_Point
✅ If a patient is at risk for hypovolemia, consider decreasing thiazide or loop diuretic dosages before commencement of SGLT2i treatment, advise patients about symptoms of volume depletion and low blood pressure, and follow up on volume status after drug initiation.
#salah

As new study
For drugs resistance in TB patents we can use
bedaquiline-pretomanid-linezolid (BPaL)
نفضل جرعه تكون
600mg for 26 weeks
#massoud

#New recommendation ESC 2022
🛑Guidelines on cardiovascular
assessment and management of patients undergoing non-cardiac surgery (NCS)

1🔴Patients aged ,65 years without signs, symptoms, or history of CVD
🅰In patients with a family history of Patients aged ,65 years without signs, symptoms, or history of CVD In patients with a family history of genetic cardiomyopathy, it is recommended to perform an ECG and TTE before NCS, regardless of age and symptoms., it is recommended to perform an ECG and TTE before NCS, regardless of age and symptoms (class 1 recommendation)
.❇️بالعربي كذا اي مريض عمره اقل من 65 سنه وماعندش اي مرض من امراض CVD بعمل له ايكو وتخطيط قبل اي عمليه جراحيه (غير عمليات القلب ) فقط اذا كان عنده تاريخ اسري مع امراض genetic cardiomyopathy
🅱In patients aged 45–65 years without signs, symptoms, or history of CVD, ECG and biomarkers should be considered before high-risk NCS. (Class 2a recommendation)
❇️بالعربي كذا اي مريض عمره مابين ٤٥ الى ٦٤ وماعندش اي مرض من امراض القلب بعمل له تخطيط قلب وانزيمات القلب اذا كان بيخضع الر عمليه جراحيه تصنيف الخطوره مرتفع مرفق لكم تصنيف خطوره العمليات الجراحيه ف صور طبعا التصنيف قائم ع حسابه CV death ,MI ,stroke خلال 30 يوم

2🔴Pre-operative assessment in patients with a newly detected murmur, chest pain, dyspnoea, or peripheral oedem
🅰In patients with a newly detected murmur and symptoms or signs of CVD, TTE is recommended before NCS. (Class 1 recommendation)
💹بالعربي كذا اي مريض سمعت صوت murmur وعنده اعراض CVS مثل صعوبه التنفس تورم في الاطراف و chest pain هنا يتوجب نعمل له ايكو قبل اي عمليه جراحيه

🅱In patients with a newly detected murmur, but without other signs or symptoms of CVD, TTE should be considered before moderate and high-risk NCS. (Class 2a recommendation)

❇️بالعربي لو كان سمعت انه في new murmur بس مافيش اعراض CVD التي ذكرتها هنا ناخذ بعين الاعتبار عمل ايكو لو المريض خاضع لعمليه جراحيه تصنيف 30day CV death،MI متوسط الى مرتفع
3🛑Cardiovascular risk factors and lifestyle interventions
🅰Smoking cessation .4 weeks before NCS is recommended to reduce post-operative complications and mortality.(class 1 recommendation)
❇️بالعربي كذا قبل العمليات الجراحيه ننصح المريض بانة يجب علية إيقاف التدخين قبل العمليه باربعه اسابيع لتقليل من مضاعفات مابعد العملية الجراحيه

🅱Control of CV risk factors—including blood pressure dyslipidaemia, and diabetes—is recommended before NCS (class 1 recommendation)
❇️بالعربي كذا لو كان المريض عنده ارتفاع في ضغط الدم او ارتفاع في كوليسترول الدم او سكري يجب ان نتحكم بهم قبل اجراء العمليه الجراحيه
4🔴 Pharmacological treatment

1⃣For patients on diuretics to treat hypertension, transient discontinuation of diuretics on the day of NCS should be considered. (Class 2 a recommendation)
❇️بالعربي كذا لو المريض يستخدم مدرات اي نوع لمعالجة الضغط ناخذ في عين الاعتبار ايقافها قبل العملية الجراحيه
2⃣It should be considered to interrupt SGLT-2 inhibitor therapy for at least 3 days before intermediate- or high-risk NCS. (Class 2 a recommendation)
💹بالعربي نوقف ادويه SGLT2I مثل Dapagliflozin قبل العمليه الجراحيه بثلاثه ايام عشان نتجنب Euglycemic DKA

3⃣For patients undergoing high bleeding risk surgery (e.g. intracranial, spinal neurosurgery, or vitreoretinal eye surgery), it is recommended to interrupt aspirin for at least 7 days pre-operatively (class 1 recommendation)

#⃣ملاحظة كل هذه الاجراءات المذكوره هيا خاص بالعمليات الجراحيه التي Elective: surgery/intervention يعني التي مخطط لها من قبل ايام وليست عمليات مستعجله😁😁
✅نكتفي بذكر هذه الملاحظات نكمل الباقي في منشور اخر
#ESC2022
#salah