🛑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

🛑 Is there any effect of Paracetamol use on blood pressure level?

✅ Yes. Regular daily intake of 4 g Paracetamol (acetaminophen) for chronic pain increases systolic BP in individuals with hypertension by 4.7 mm Hg and diastolic BP by =1.6 mm Hg. Effect of regular use of paracetamol on blood pressure (BP)is similar to that of nonsteroidal anti-inflammatories This rise in BP is seen both in those taking and not taking antihypertensive therapy.
✅ Short-term use of paracetamol for headaches or fever is fine. Start with a low dose of paracetamol, and increase the dose in stages, going no higher than needed to control pain.
✅ Keep a closer eye on BP in people with high BP
who newly start paracetamol for chronic pain.

🛑Treatment of Restless Legs Syndrome and Periodic Limb Movement Disorder


✅Obtain serum iron studies, including ferritin and transferrin saturation. Treat with oral or intravenous (IV) iron in adults with serum ferritin ≤75 ng/mL or transferrin saturation <20%, IV iron in adults with serum ferritin 75–100 ng/mL, and oral or IV iron in children with serum ferritin ≤50 ng/mL

✅Alpha-2-delta ligands (gabapentin, gabapentin encarbil, and pregabalin) are strongly recommended for those without contraindications.

✅IV ferric carboxymaltose is recommended if iron supplementation is warranted. IV low molecular weight iron dextran, IV ferumoxytol, or oral ferrous sulfate may be considered. (The lead guideline author reports serving on the steering committee for a company investigating ferric carboxymaltose for RLS.)




✅In end-stage renal disease gabapentin, IV iron sucrose (for those with ferritin <200 ng/mL and transferrin saturation <20%), and vitamin C can be considered; levodopa and dopamine agonists are not recommended.

✅Ferrous sulfate can be considered for children with appropriate iron status.

#NEJM watch 2024

اعادة نشر هذا الفهرس بعض أهم الأشياء في القناة يمكنكم الضغط ع الكلمه الزرقاء وسوف يتم تحويلكم إلى المنشور الخاص بها

وبقية الملفات الهامه يمكنكم إيجادها في معلومات القناة
https://t.me/Clinical_Notes/4084

🛑anticoagulants and drug adherence

✅It is also important to pay attention to drug adherence. A switch from warfarin to a DOAC or the addition of low-dose vitamin K may be appropriate in individuals taking warfarin who have significant INR variability despite good medication adherence.
✅In contrast, however, switching to a DOAC is not advised in individuals with poor INR control that is due to poor drug adherence, as one or two missed doses of a DOAC could reduce the efficacy of anticoagulation more than one or two missed doses of warfarin, and use of a DOAC eliminates the ability to monitor adherence effectively.

#UPTODATE

🛑inflammation and ICU-Related Anemia

✅Systemic inflammation is accompanied by iron sequestration in tissue macrophages, which is attributed to the actions of cytokines, and also to the hepatic release of hepcidin
✅ a small peptide that reduces plasma iron levels by promoting iron sequestration in tissue macrophages
✅ The sequestered iron cannot be transferred to developing red blood cells, and this results in a hypochromic microcytic anemia that resembles iron-deficiency anemia.

# ICU Book

🛑PLASMA FERRITIN:
✅ The ferritin level in plasma is used to evaluate tissue iron stores, and thus can distinguish between iron deficiency anemia (plasma ferritin <30 μg/L) and the anemia of inflammation (plasma ferritin >100 μg/L)

🛑Management hemodynamic in patient with Acute renal impairment

🉐Do not think that hypovolemia is the cause of AKI

✅1) If AKI develop suddenly in ICU patient without clear history of fluid/blood loss

✅2) If patient has AKI with normal/high pulse pressure
        ..............................

✅Fluid should be given until hypovolemia is corrected and NOT until AKI is resolved

✅Do not add maintenance fluid in patients with oliguria except after increase in urine output

✅Do not give fluid without looking to the status of the lung

#salah

🛑 role of corticosteroids in septic shock

✅ Corticosteroids have two actions that are potentially beneficial in septic shock
✅they have antiinflammatory activity,
✅and they facilitate the vasoconstrictor response to catecholamines.
✅ However, innumerable studies since the 1960s have failed to produce convincing evidence that corticosteroids improve outcomes in septic shock
✅Yet steroids continue to be popular in septic shock, as shown by the following recommendation from the most recent guidelines on septic shock  which is based on a single meta-analysis showing that corticosteroids hastened the resolution of septic shock (by 1.5 days), but without improving the survival rate

✅ Corticosteroid therapy is suggested for patients with septic shock who are receiving norepinephrine or epinephrine at a dose ≥0.25 μg/kg/min.
✅ The recommended regimen is IV hydrocortisone in a dose of 50 mg every 6 hours (200 mg daily). There is no recommendation for the duration of treatment, but most clinical studies use a treatment period of about 7 days

# ICU book