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

🛑Dengue fever

✅if symptoms appear more than 2 weeks aftar returning from a dengue-endemic region, it is very unlikely that dengue is the cause.

#ambosis

🛑Listeria meningitis

✅Ampicilin is added if patients are at risk of Listeria spp. infection ( newborns, pregnant women, adults > 50 years  of age, or immunocompromised patients)

✅because céphalosporins are ineffective against Listeria spp

#ambosis

#remember
✅The most important risk factors for developing diabetic retinopathy are a long duration of diabetes, inadequate glucose control, and elevated blood pressure

🛑Describe diabetes related to cystic fibrosis (CF)??

✅Diabetes mellitus occurs in approximately 50% of people with CF after age 35.
✅ People with CF-related diabetes tend to produce adequate amounts of basal insulin but have reduced or delayed insulin secretion in response to meals, causing them to have significant postprandial hyperglycemia.
✅Therefore an oral glucose tolerance test is usually employed to diagnose this condition.
✅Because of their tendency to have pulmonary infections and require glucocorticoid treatment, many individuals have concomitant insulin resistance.

#remember
✅Diabetes mellitus should be suspected in patients with recurrent cellulitis, candidiasis, dermatophyte infections, gangrene, pneumonia (particularly tuberculosis reactivation), influenza, genitourinary infections (UTIs), osteomyelitis, and/or vascular dementia

#ambosis

🛑Ten rules for Acute kidney injury in critically ill patients.

✅ If a patient has rising kidney functions without oliguria, it is impossible that this AKI is due to pre-renal cause. PLEASE do not push fluids in such patients.

✅2- If a patient developed oliguria after staying inside the ICU for several days, and is receiving adequate fluid volume every day without any clear loss (no bleeding - no stomas - no surgical complications), it is very unlikely that this AKI is due to pre-renal cause. Thus, be very careful if you decided to push fluids in this patient.

✅3- If a patient developed oliguria and his cardiac output is high (distributive shock), this AKI is not pre-renal. Do not push fluids in this patients.

✅4- When you evaluate the volume status in an oliguric patient, low CVP is not a good indicator for hypovolemia
.
✅5- If a patient is clearly edematous (limbs - lungs - abdominal wall), this patient is not hypovolemic (not pre-renal), even if the CVP is low. No more fluids in this patient.

✅6- Even if you do not have any advanced monitor for hemodynamic assessment, having a clinical look on the patient using your EYES + patient history would give you information which are more valuable than the CVP.

✅7- In AKI, Once you settled the diagnosis and excluded pre-renal pathology, you MUST DECREASE fluid intake and not INCREASE it. Pushing fluid in a pathological kidney would not force them to work; it would indeed harm the kidneys, promote congestion,
and hasten dialysis.

✅8- In AKI, once you settled the diagnosis and excluded pre-renal pathology, do frusemide stress test (1-1.5 mg per kg). If the patient did not respond within 2 h, he is unlikely to respond to diuretics and would probably proceed to higher stages of AKI

✅9- The target MAP to maintain renal perfusion is 65-70 mmHg. Higher values are NOT indicated, even in patients with chronic hypertension. Even if you want to do a "vasopressor test" by elevating the MAP transiently, this test is NOT related to chronic hypertension and can be done in any patient
.
✅10- We can wait for dialysis in patient with AKI as long as there is no (congestion - hyperkalemia - acidosis - encephalopathy related to uremia). we can wait for 48 h even if the patient is oliguric. Most of the patients will recover without the need to dialysis. However, if you pushed too much fluids in these patients, you are increasing the likelihood for the need to dialysis.
.
Ahmed Hasanin
Professor of Anesthesia and Surgical critical care medicine.

#remember
✅Start empiric anticoagulation for PE if clinical suspicion is high unless there is a high risk of bleeding (e.g., recent surgery, hemorrhagic stroke, active bleeding).
#ambosis

🔴 SGLT2I inhibitors and acute decompensate Heart failure

🛑Before starting SGLT2I Inhibitors during an Acute Heart Fallus(AHF)

✅The patient should be clinically and hemodynamically stable and able to tolerate oral intake. According to recent clinical trials regarding in-hospital initiation of SGLT2 inhibitors, five criteria have to be fulfilled

1❇️-Patients should have a systolic blood pressure above 100 mmHg. and should not have developed any symptoms of hypotension in the preceding 6 hour

2-❇️Progressive and effective decongestion must have been verified, with no need of increasing

the intravenous diuretic dose during the last 6 hours

3-❇️No prescription of intravenous vasodilators including nitrates within the last fi hours

4❇️-No administration of intravenous Inotropic drugs in the last 24 hours is required

5-❇️Patients should have a minimally preserved renal function, with an eGFR superior to 20
mL/min/m

✅تذكر
أعلى جرعه ل Ampicillin-sulbactam قد نشوفها في حاله الاصابه ب Acinetobacter infection الجرعه قد تصل إلى 27 جرام في اليوم في حاله كانت العدوى Moderate to severe infections
#UPToDate

#remember
✅COPD is a major risk factor for CVD, especially ASCVD, stroke, and HE

✅COPD patients are prone to antythmias AF and ventricular tachycardia) ant cardiac death

✅All COPD patients should be investigated for CVD.

✅Common COPD medications are usually safe in terms of CV adverse events

#tips and tricks in cardiology