🛑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

الحمدلله الزميله Hadeel Hlayel بخير ربنا يحفظهم
شكرا للجميع

#remember
🛑in patients with IE in whom a decision is made to continue anticoagulant therapy (eg, for a mechanical valve), we generally replace direct oral anticoagulant (DOAC) or vitamin K antagonist (VKA) therapy (eg, warfarin) with unfractionated heparin or low molecular weight heparin therapy at the time of presentation while stability and the potential need for an invasive procedure is assessed.

#remember
✅ with high dose intravenous methotrexate, serum ALT levels can rise to 10 to 20 times the upper limit of normal (ULN) within 12 to 48 hours, but levels then fall rapidly to normal with only rare instances of jaundice or symptoms of liver injury.

✅With long term, low-to-moderate dose methotrexate therapy, elevations in serum ALT or AST values occur in 15% to 50% of patients, but are usually mild and self-limiting

#Pediatric

🛑Hypercalcemia associated with malignancy is much less common in children than adults where it is one of the two most common causes of hypercalcemia
🛑Malignancy associated hypercalcemia is often severe (total calcium >14 mg/dL) and can be life threatening

🛑هناك بعض الادوية ممكن تسبب ارتفاع في درجه الحراره عند استخدامها وعند التوقف عنها تنخفض درجه الحراره للطبيعي ،طبعا يتم تشخيص ذلك باستبعاد الاسباب الأخرى ل ارتفاع درجه الحراره ،هذه قائمة الادوية التي ممكن ترفع من درجه الحراره وبعد كم من الاستخدام
#UpTodate2023

🛑من المعروف بأن اغلب  المضادات الحيوية الشكل الوريدي تستخدم في المستشفى أو مركز صحي ولكن قد نلجأ  إلى صرفها لمريض خارج المستشفى(outpatient) لبعض الحالات مثل
✅endocarditis,
✅ osteomyelitis
✅,and prosthetic joint infection
من أجل تقليل cost الذي قد يترتب عليها وجود المريض في المستشفى،المهم هناك جدول يوضح المضادات الحيوية ذو الشكل الوريدي كيفيه استخدامها وماهي test monitoring التي قد يحتاجها المريض و infusion time

الجدول الخاص used for outpatient parenteral antibiotic therapy

🛑عند عمل فحص vitamin D قد نلجأ إلى عمل فحوصات اخرى في حاله كانت نسبه serum vitamin D25(OH) اقل من 12 لان المريض بيكون risk for developing osteomalacia الفحوصات التي قد نحتاجها موضحه في الصوره

#remember
🛑Contraindications to computed tomography pulmonary angiography (CTPA)
التي تستخدم ل تأكيد وجود Pulmonary embolism
✅include allergy to intravenous contrast,
✅high risk of contrast nephropathy (eGFR <45 mL/min/1.73 m2,
✅ known diabetic nephropathy,
✅ hypotension,
✅advanced heart failure,
✅multiple myeloma)
#UpTodate2023

🛑treatment insomnia in palliative care
✅If a patient has insomnia due to delirium (eg, accompanied by restlessness, agitation, or psychosis), prescribing zolpidem or benzodiazepines or using the over-the-counter agent diphenhydramine to treat insomnia may worsen the delirium.
✅Patients with end-stage chronic obstructive pulmonary disease (COPD) may experience worsened respiratory function when prescribed benzodiazepines.

✅. For patients with insomnia related to pruritus, doxepin may help treat the pruritus as well
✅Mirtazapine  mirtazapine is associated with sedative side effects (at least at doses of 7.5 to 15 mg), which may be useful for the treatment of the depressed or anxious patient also experiencing insomnia