🛑Sickle cell disease  in pregnancy

✅Aspirin 75mg od should be considered for women with SCD from 12 weeks gestation, aiming to reduce the risk of pre-eclampsia.
✅ SCD carries a higher risk of VTE. This should be included in the VTE risk assessment for these women and thromboprophylaxis prescribed as appropriate.
✅ LMWH thromboprophylaxis will usually need to start at 28 weeks gestation but may need to be started prior to this if additional VTE risk factors exist.

✅Thromboprophylaxis should be administered (if not contraindicated) whilst in hospital and for minimum of 7 days following vaginal delivery or 6 weeks following C-section.

🛑thalassaemia in pregnancy
✅Women with thalassaemia major or intermedia have a prothrombotic tendency due to the presence of abnormal red cell fragments, especially if they have undergone splenectomy
. ✅Aspirin 75mg od should be offered to women with a plt count >600 or who have had a splenectomy.
✅If both plt count >600 and splenectomy then offer aspirin + LMWH thromboprophylaxis.
✅ All women should be offered LMWH thromboprophylaxis if admitted to hospital.

وصفه لمريض Febrile Neutropenia
IV Fluconazole
+Chlorphenamine
+Iv moxifloxacin
و
Serum K (2.3)

قلب المريض😅👇👇

🛑في ملاحظه مهمة بخصوص مريض العناية المركزة انه يحدث تغير فيسولوجي نتيجة الحاله المرضية ⬅️هذا بيغير في pharmacokinetics و pharmacodynamic للدواء مقارنه  بالمريض الغير متواجد في العناية

✅مثال بسيط مريض septic shock بيكون بحاجه الى larg volume fluid ⬅️هذا ممكن يزود peripheral edema أيضا بيكون بحاجه الى ادوية Vassopressors  وكل هذا راح يقلل من systemic absorption ل الادوية التي تعطي تحت الجلد مثل الهيبارين الذي يعطى لمريض septic shock عشان ال DVT prophylaxis ⬅️بتالي فرصه حصول DVT تكون أكثر على الرغم من استخدام الجرعه الوقائية من الهيبارين
✅طبعا الجرعه الوقائية للهبارين 5000 وحده تعطى مرتين الى ثلاث مرات في اليوم⬅️ ف هذا الحاله قد يكون خيار ثلاث مرات هو الأفضل مع مراعاة risk of bleeding ايضا


#Diprio

في دراسه حديثه كانت أنه
Preoperative oral antibiotic preparation
مع
preop IVAP
وخلال
24 h post-operation
تقلل من حدوث ال

Surgical site infection (SSI)
in intestinal surgery

Metronidazoles + quinolones or aminoglycoside might be the appropriate combo for OABP regimens
#massoud

#remember
#toxicity
✅Children with ibuprofen ingestions of less than 100 mg/kg can be observed at home
, but those who ingest greater than 400 mg/kg are at high risk for toxicity and require medical evaluation.

من المعروف أن داء السكري من الامراض المرافق معه أمراض أخرى
حسب اخر جايد لاين
للجمعية الامريكيه للأمراض المعديه
في معالجه القدم السكر فإن هناك توصيات حول المعالجة والتشخيص نذكر بعضها

Do not treat clinically uninfected foot ulcers with systemic or local antibiotic therapy when the goal is to reduce the risk of new infection or to promote ulcer healing.
بمعنا انه في حاله ان هناك تقرحات في الجلد غير المصابه سريريا م نعالجه ب مضادات حيويه موضعيه او غيرة
حتى نتأكد إذ كان مصاب او لا عبر المزرعه ونضرا لانه اغلب حالا ال Diabetic foot ulcers  لا تكون مصابه اصلا وهذا يعرض المريض لادويه غير ضروريه وخسارة ناهيك عن المقاومة للمضادات الحيويه
لكن هل هذا يشمل الحالات في العالم الثالث ؟؟؟!
ع سبيل المثال في اليمن نضرا لقله التوعيه واهمال المرضى، فإنه لا يذهب إلى المراكز الصحية الا بعد تفاقم الحالة !

بالنسبه لتوصيات الاخر
فإنه عند التاكد من العدوى نستخدم ادويه
Use any of the systemic antibiotic regimens that have been shown to be effective in published randomised controlled trials at standard (usual) dosing to treat a person with diabetes and a soft tissue infection of the foot
وتكون المدة كن اسبوع إلى اسبوعين
قد نستمر إلى ثلاثه او اربعه اسابيع في حاله كان فيه تحسن ولكن بشكل ابطىء او كان يعاني من
  severe peripheral artery disease

لكن بعد اربعه اسابيع اذا لم يتحسن ضروري انه نعيد تقييم المريض او فحوصات أخرى نحدد للمشاكل وقد يحتاج إلى
alternative treatments


بالنسبه لتوصية استخدام الدواء او كيف نختار
يعتمد ع الدراسات السابقه بحيث اكثر فعاليه وأقل اعراض جانبيه وتداخل
وتوافر الدواء والقدرة ع التكلفه

أيضآ
Target aerobic gram-positive pathogens only (beta- haemolytic streptococci and Staphylococcus aureus including methicillin-resistant strains if indicated)

Do not empirically target antibiotic therapy against Pseudomonas aeruginosa in cases of DFI in temperate climates, but use empirical treatment of P. aeruginosa if it has been isolated from cultures of the affected site within the previous few weeks,
#massoud

#remember
✅It should be appreciated that the IV formulation of acetaminophen has been associated with hypotension with a reduction in mean arterial pressure of greater than 15 mm Hg in as many as 50% of patients.
✅ The reasons for this remain unclear Daily dosing of acetaminophen for
acute short-term use should be limited to less than 4 gm in those with cirrhosis or a history of alcohol use disorder and for longer term use a maximum of 2 to 3 gm daily is recommended .
#Diprio

#remember
✅The risk of nephrotoxicity with aminoglycosides is significant (>50% incidence) and has been well reported. Higher incidence has been associated with higher trough concentrations, concomitant nephrotoxic medications, and hypotension
✅ Targeting troughs less than 2 mg/L for gentamicin/ tobramycin and less than 8 mg/L for amikacin are recommended to reduce this incidence.

🛑 piperacillin tazobactam

✅Based on PK data and the prescribing information, patients on IHD should receive 2.25 g every 8 hours for nosocomial pneumonia and 2.25 g every 12 hours for all other indications. There have been case reports of neurotoxicity in patients on IHD receiving 2.25 g every 6 hours
✅ In patients on CRRT, the risk of treatment failure in patients receiving ≤ 9 g/day is increased
✅Total daily doses should exceed this amount when the MIC <32 mg/L.

✅Recent studies have established a link between higher rates of AKI when piperacillin/tazobactam and vancomycin are given concomitantly

🛑 Vancomycin

✅When dosing vancomycin in IHD patients, there are two general dosing methods that are employed: using mg/kg (intermittent) dosing when pre-IHD concentrations are in the therapeutic range and using fixed doses after each IHD based on defined ranges of pre-IHD vancomycin concentrations or the patients weight. Although intermittent dosing may be more convenient in the inpatient setting, fixed hemodialysis dosing may be more convenient for outpatients

🛑heparin

✅Heparin Kinetics
Heparin is metabolized in the liver and reticuloendothelial system
✅After subcutaneous administration, 20–44% of the dose is absorbed systemically and largely remains in the intravascular space
✅. At therapeutic IV doses, heparin is eliminated via nonrenal mechanisms. However, at very high doses, heparin is renally eliminated and the half-life is increased in patients with renal impairment


✅ No dosage adjustments are required due to the nonrenal elimination at therapeutic doses. In patients who are receiving heparin for treatment of VTE, activated partial thromboplastin time (aPTT) should be monitored without concern for renal impairment impacting the level.

Cardiovascular drugs in renal impairment

🛑Routine maintenance fluid

✅25–30ml/kg/day of water and approximately 1 mmol/kg/day of potassium[3], sodium and chloride and approximately 50–100g/day of glucose to limit starvation ketosis.

✅When prescribing for routine maintenance alone, consider using 25–30 ml/kg/ day sodium chloride 0.18% in 4% glucose with 27 mmol/l potassiumon day 1 (there are other regimens to achieve this)
✅. Prescribing more than 2.5 litres per day increases the risk of hyponatraemia.

✅Consider prescribing less fluid (for example, 20–25 ml/kg/day fluid) for patients who:
✅are older or frail
✅have renal impairment or cardiac failure
✅ are malnourished and at risk of refeeding syndrome

#NIC

#remember
✅Folate supplementation may help prevent hepatotoxicity in patients taking methotrexate but does not substitute for ongoing monitoring and appropriate MTX dose adjustments if transaminase elevation occurs

Medication dose for H .pylori treatment in children

#remember
#Drug-induced thrombocytopenia
✅Severity of thrombocytopenia – The thrombocytopenia in.Drug-induced thrombocytopen(DITP) is often severe, with a nadir platelet count <20,000/microL
✅ An exception is heparin-induced thrombocytopenia (HIT), in which the median nadir platelet count is approximately 60,000/microL and platelet counts <20,000/microL are rare
#Uptodate

🛑كيف نفرق بأن Thermbocytopenia في مريض العنايه انه ممكن بسبب DIC او drugs؟؟
✅طبعا اشهر  سبب ل DIC اما sepsis او Malignancy

✅ال thermbocytopenia التي بسبب DIC غالبا تكون مرافقة ل زياده في PT و PTT و D dimer مع نقص في fibrinogen  اضافه إلى نقص في الصفائح يكون mildly to moderately نادرا مايكون sever (الصفائح تكون أقل من 20000 وهذا على العكس اذا كان thermbocytopenia بسبب ادويه غالبا تكون sever thermbocytopenia  بإستثناء الهيبارين طبعا
#UpTodate2023