🛑beta blockers and liver cirrhosis

✅we avoid the following beta blockers for patients with cirrhosis:
●Labetalol: Labetalol, a beta and alpha blocker, has been associated with fatal drug-induced liver injury.

●Nebivolol: Nebivolol, a beta 1 selective blocker, has been shown to increase portal pressures

#Uptodate

🛑azithromycin and liver cirrhosis
✅We avoid azithromycin because of increased risk of acute liver injury and mortality in patients with cirrhosis

#Uptodate

🛑Proton pump inhibitors and liver cirrhosis
✅ For patients with cirrhosis and an indication for PPIs, we typically use esomeprazole, when available, based on pharmacokinetic data

✅ For patients with decompensated cirrhosis, omeprazole, lansoprazole, and rabeprazole are generally avoided 

#Uptodate

🛑Tranexamic acid does not reduce bleeding during hepatectomy (October 2024)

✅Tranexamic acid (TXA) is used routinely during some types of surgery to prevent excessive bleeding; however, its effect during hepatectomy is unclear. In a randomized trial of over 1200 patients undergoing hepatic resection for cancer, administration of an intravenous bolus of TXA followed by an eight-hour infusion did not reduce blood loss or the need for blood transfusion compared with placebo [1]. Patients receiving TXA had more postoperative complications (44 versus 38 percent), with the largest difference in major complications. Venous thromboembolism was similar in the two groups, though the study may have been too small to detect a large difference. These results support our practice of avoiding routine administration of TXA during hepatic resection

#UPTODATE2024

🛑Mycophenolate mofetil and PPI drugs

✅PPIs can decrease absorption of mycophenolate mofetil (MMF) by 25 percent or more

Enteric-coated mycophenolate sodium (EC-MPS) formulation appears less likely to interact.

#UPTODATE2024

اعاده نشر للأهمية ❤️

🛑راح نتكلم عن موضوع مهم بخصوص 
bicarbonate therapy in patients with lactic acidosis  
طبعا ذا الموضوع في malpractice كثير

✅اولا راح اقتصر بالحديث عن اشهر نوع وهو ال
Type A lactic acidosis
الذي غالبا بيكون بسبب impaired tissue oxygenation نتيجه shock او sepsis

✅لطالما قلنا بأنه يجيب ان نعرف مخاطر الدواء قبل لأي غرض نستخدمه؟
✅اولا عشان تكون المعالجة ب sodium bicarbonate ناجحه ضروري اعالج السبب وحنا عرفنا فوق اهم سببين ل lactic acidosis او يمكن العلاج نفسه يفاقم  الحاله يعني يزيد من lactic acidosis كيف؟
✅عشان نجاوب نعرف كيفيه آلية عمل دواء Sodium bicarbonate  في خطوتين

✅First, it combines with a hydrogen ion to form carbonic acid (H2CO3)
✅H2CO3 dehydrates to carbon dioxide (CO2), and water (H2O). 

✅طيب CO2 لازم يطرد من خلال body  circulation ( يعني ضروري اصحح tissue hypoperfusion  واتأكد ان المريض adequate perfusion and ventilation لانه الهدف من المعالجة ب sodium bicarbonate المحافظه على arterial pH above 7.1 حتى نصلح السبب

✅طيب حتى لو كان في adequate perfusion  ممكن يحصل ارتفاع لحظي ل PCO2 لو أعطينا  infusion ب rat سريع   ⬅️لانه  CO2 readily penetrates cell membranes ⬅️مما يحصل worsen intracellular acidosis حتى لو ارتفع atrial blood pH

🛑طيب متى نعطي IV sodium bicarbonate?
✅هناك اختلاف متى بضبط ولكن اجمع اغلب الخبراء بأنه نعطيه في حالتين
✅severe lactic acidosis
ويعرف بانة يكون  PH اقل من 7.1 و serum bicarbonate  6 او اقل
✅less severe acidosis
لو كان PH مابين 7.1 إلى 7.2 مع وجود فشل كلوي حاد AKI

🛑طيب كم الجرعه ممكن في حاله sever acidosis نعطي
intravenous sodium bicarbonate bolus of 1 to 2 mEq/kg body weigh
✅اشهر تركيز موجود 8.4% طبعا بحجم 50ml؛يعني كل 1cc من تركيز 8.4% فيه 1mEq من sodium bicarbonate


✅The serum electrolytes and blood pH should be measured 30 to 60 minutes later, and the dose of sodium bicarbonate can be repeated if severe lactic acidosis (pH less than 7.1) persists.

🛑ماهي المشاكل التي قد تواجهنا أثناء المعالجة بIV sodium bicarbonate ??

✅اولا اذا كان PH  يساوي او اقل من 7.1 وكان bicarbonate level is greater than 6 mEq/L فهذا يشير إلى PCo2 ممكن يكون فوق 20 فهذا يدل انه المريض  inadequate ventilation وقد يكون لديه mixed metabolic and respiratory acidosis وإعطاء المريض infusion ب rapid rate ممكن يفاقم ال respiratory acidosis والحل انه ممكن mechanical  ventilation عشان إنقاص PCo2 ورفع PH

✅ثانيا مشاكل تتعلق ب rapid infusion bicarbonate
✅Effects on calcium, sodium, and extracellular fluid volume 

اي  ارتفاع في PH قد يصاحبه انخفاض في ionized calcium concentration و ارتفاع في serum sodium لان ال sodium bicarbonate بتركيز 8.4% يعتبر hypertonic solution

✅اي انخفاض في ionized calcium قد يصاحبه hemodynamic instability  لذا يجب قياس ionized calcium ومعالجته في حال كان هناك نقص ؛في حاله لم يتوفر ionized calcium  test  او تأخر في أخذه ممكن بأن انخفاض ضغط الدم او عدم تحسنه يعطيني مؤشر بانخفاض  ionized calcium وقد اخذ بعين الاعتبار اعطي المريض empiric calcium infusion

✅طيب في حاله إعطاء عده جرع من sodium bicarbonate  و PH لم يرتفع  فوق 7.1 وعالجات السبب الرئيسي ل lactic acidosis هنا ممكن اعطي المريض  continues infusions ولكن راح اخلي المحلول isotonic بدل ماكان hypertonic يعني راح أحضر 3 امبول من تركيز 8.4%  في 1 لتر من 5% dextrose 
في حاله حصول volume overload  او تدهورت وظائف الكلى اكثر هنا ممكن الجاء إلى الغسيل الكلوي


#UpTodate2023

🛑Asymptomatic candiduria  treatment
✅Asymptomatic candiduria rarely requires antifungal therapy unless it occurs in the setting of a condition that confers high risk of dissemination (neutropenia, very low birth weight infants (<1500 g), or urinary tract manipulation)

✅Antifungal therapy is not recommended unless the patient belongs to one of the groups listed above

#UPTODATE2024

🛑type  2 diabetes treatment  in hospitalized patients

✅For people with type 2 diabetes hospitalized with heart failure, it is recommended that use of a sodiumglucose cotransporter 2 inhibitor be initiated or continued during hospitalization and upon discharge, if there are no contraindications and after recovery from the acute illness. A
#ADA2025

🛑digoxin and   dialysis

✅We avoid digoxin use in patients with HF with reduced ejection fraction (HFrEF) who receive dialysis
✅In dialysis patients, we reserve use of digoxin for selected patients with atrial fibrillation who do not achieve adequate rate control by optimum doses of beta blocker and who can be closely followed to maintain a digoxin level <1.0 ng/mL. When digoxin is administered to a dialysis patient, dosing of digoxin should be adjusted for renal failure and close monitoring is require

#UPTODATE2024

Patients with Acute coronary syndrome should take High intensity statins
Atorvastatin 40-80mg or rosuvastatin 20-40mg

🛑General Principles of Therapy TOPICAL CORTICOSTEROIDS

✅Topical corticosteroids should be applied no more than twice daily. Increasing the application from twice daily to four times daily does not produce superior responses, is more expensive, and may lead to increased frequency of topical and systemic adverse effects.

✅Preparations should be rubbed in thoroughly and, when possible, applied while the skin is moist (e.g., after bathing)." Hydration of the skin increases percutaneous absorption and the resultant therapeutic effect of topical steroids.

✅Appropriate-strength preparations should be used to con- trol the condition. For maintenance, most dermatologic conditions requiring topical corticosteroids can be managed with medium- or low-strength corticosteroid preparations (i.e., 1% hydrocortisone or a low-strength fluorinated cor- ticosteroid such as triamcinolone acetonide 0.025%).

✅Occluded areas and certain, thin-skinned areas of the body, such as the face and flexures, are more prone to the develop- ment of side effects.
✅  If corticosteroids must be used on
the face or flexures, hydrocortisone or other nonfluorinated topical steroids should be used to reduce the probability of side effects.

✅Children, elderly patients, and patients with liver failure are at risk for systemic corticosteroid toxicities. In addi- tion, patients who use the highest-potency preparations for longer than 2 weeks are susceptible to percutaneous absorp- tion and systemic toxicity.

✅With chronic conditions such as atopic eczema or allergic contact dermatitis, it is best to discontinue therapy gradu- ally. This reduces the potential for rebound flares of topical lesions

#clinical use of drug

#remember

✅Anemia is highly prevalent among the critically ill; 60% of patients admitted to intensive care units (ICU) are anaemic and 20-30% have a first hemoglobin concentration (Hb) <9.0 g/dL

✅After 7 day . 80% of ICU patients have an Hb <9.0 g/dL and 30-50% of ICU patients receive red cell (RBC) transfusions

#remember

🛑Patients must meet the following criteria prior to initiation of the potassium, magnesium, or phosphorus protocols:

✅SCr < 2 mg/dL

✅Weight> 40kg

حسب عدة دراسات هناك ما بين
20%-50% of inpatient antibiotic use may be inappropriate and occur
ورجح اسباب حدوثها الى الاتي
اولا
broad-spectrum empiric therapy is continued throughout treatment when regimen could be narrowed after microbiologic data become available
بمعنى انه يستمروا في نفس المضادات واسعات الطيف رغم ضهور النتيجه في المزرعه وكأن من المفروض تضييق الاختيار
ثانيا
patient does not improve on initial therapy, and additional broad-spectrum antibiotics, antifungals, and antivirals are added without appropriate considerations
بمعنى انه يضاف ادويه اخرى مضادات ميكروبيه عندما لا يتحسن المريض في يتم اضافه واسعات الطيف من المضادات الحيوية ومضادات الفطريات والفيروسات دون الاعتبارات المناسبة لاستخدامها
ثالثا
antimicrobials are prescribed for patients without infection
صرف مضادات حيويه لمريض دون الحاجه إليها
رابعا
patients are treated longer than necessary to eradicate infection‌‌
يتم علاج المرضى لفترة أطول من اللازم للقضاء على العدوى‌‌
#Clinical_Note

#remember
✅Chest pain usually precedes skin rash in patients with herpes zoster.

#remember

✅Both hypokalaemia and hyperkalemia can lead to bradycardia.

🛑What is the possible explanation for fever post PCI?

✅ Coronary stent infection(CSI)is rare but life threatening complication post PCI.
✅The most common symptoms are chest pain and fever. Diagnosis is based on positive blood cultures and demonstration of the infective focus by transthoracic echo or TEE, coronary angiography, CT or MRI.
✅CSI is associated with formation of mycotic aneurysms and spontaneous coronary artery perforation.
✅The most common organisms are staphylococcus aureus followed by pseudomonas aeruginosa Medical therapy consists of parenteral broad-spectrum antibiotics to cover MRSA, MSSA, and gram- negative organisms and should be given for at least 4 weeks.
✅Surgical intervention includes stent removal if possible, and abscess drainage or perforation repair when indicated.

#Tips and Tricks Cardiology

🛑Can we administer 'injectable Vitamin K' orally?

✅ Previous studies have shown that intravenous vitamin K is well tolerated when administere orally and works quickly to correct supratherapeutic INRs. Injectable vitamin K can be given orlly ung the undiluted injectable formulation or compounded into an oral solution.
✅Orange juice can mask the unpleasant taste of undiluted vitamin K.

✅https://www.mja.com.au/journal/2013/198/4/update-consensus-guidelines-warfarin-reversal

كتاب
Naplex 2025

#Clinical_Note