🛑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

#remember
✅Presence of migraine with aura should be considered in CVD risk assessment (class lla)

✅Avoidance of combined hormonal contraceptives may be considered in women with migraine with aura (class lib).

#tips and tricks in cardiology

🛑Do not use NOAC (ex rivaroxaban)in the following conditions

✅Prosthetic heart valves or moderate to severe mitral stenosis

✅Pediatric patients (age < 18 years)

✅Pregnant or lactating

✅Antiphospholipid syndrome

✅Active GIT malignancy

بنسبه ل رقم واحد من خلال الدراسات وجدوا بأن المرضى الذين ياخذون NOAC
highest risk of thromboembolic events
مقارنه ب warfarin لذا مازال warfarin الخيار الأول هنا


رقم اثنين وثلاثه مافيش دراسات كافيه بخصوص efficacy and safety

رقم اربعه

increased risk of recurrent thrombotic events 
مقارنه ب warfarin
لذا يظل ال warfarin مع الهيبارين الخيار الأول هنا



رقم خمسه
Increase risk of GIT bleeding

🛑Use of erythropoiesis-stimulating agent in Management of anemia in critically ill patient

✅Erythropoiesis-stimulating agents are reommended to be used in critically ill anemic (Hb≤ 10.0-12.0 g/dL) and/or trauma patients in the absence of contraindication.

✅The recommended dose is 40,000 IU by subcutaneous injection once weekly in combination with an iron supplement

✅It is not recommended to administer iron to reduce red blood cell utilisation
or morbidity and mortality in critical care patients, except in combination with erythropoiesis-stimulating agents.

🛑Recommendations for the management of venous thromboembolism (VTE) in patients receiving anticancer treatment

✅Apixaban, edoxaban, or rivaroxaban are recommended for the treatment of symptomatic or incidental VTE in patients with cancer without contraindications (class 1).

✅Low molecular weight heparin (LMWH) are recommended for the treatment of symptomatic or incidental VTE in patients with cancer with platelet count>50 000/μL (class I).

✅In patients with cancer with platelet counts of 25 000-50 000/μL, anticoagulation with half-dose LMWH may be considered after a multidisciplinary discussion (class Ilb).

✅Prolongation of anticoagulation therapy beyond 6 months should be considered in selected patients with active cancer including metastatic disease (class lla).

#tips and tricks in cardiology

🛑Vasopressors in septic shock

✅After the first two boluses of fluid challenges assess the diastolic pressure (DP) and/or mean arterial pressure

✅If DP < 50 mmHg or MAP < 65 mmHg start norepinephrine within the first hour of resuscitation @ 0.1 ug/kg/min

✅If central access is not available, consider initiating vasopressor peripherally

✅Vasopressors peripherally should be administered for short period not more than 6 hours

❇️The concentration should not exceed 60 ug/ml

✅Consider echocardiography to assess cardiac function

🛑Assess MAP

✅If MAP < 65 mmHg, titrate norepinephrine up to 0.7 ug/kg/min

✅Consider adding vasopressin @ 0.03 units/min if MAP < 65 mmHg and norepinephrine dose reached 0.25-0.5 ug/kg/min

✅Consider adding epinephrine if MAP<65 mmHg despite norepinephrine and vasopressin

❇️If MAP cannot be achieved with vasopressors, the following measures can be used

✅Minimize sedation and use of midazolam instead of propofol

✅IV hydrocortisone 50 mg every 6 hours or as continuous infusion. Hydrocortisone is suggested to be initiated when the dose of norepinephrine or epinephrine ≥ 0.25 ug/kg/min at least 4 hours of initiation.

✅Terlipressin is NOT recommended as a vasopressor in septic shock patient

#ICU basic

الكمية محدودة Goodman_&_Gilman's_The_Pharmacologi
cal_Basis_of_Therapeutics_14th
مكتبة دار الثقافة
+967 772 608 622

🛑Bicarbonate therapy in septic shock

✅For adults with septic shock, severe metabolic acidemia (pH s 7.2) and AKI (AKIN score 2 or 3), NaHCO3 can be given

✅75-125 ml NaHCO3 8.4% in 30 min, maximum 500 ml in 24 hours.

✅NaHCO3 should not be used to improve hemodynamics or to reduce vasopressor requirements.

من مشاركه الزميل الدكتور مسعود في اول مؤتمر للصيادلة السريرية في اليمن مناقشه case report كانت بعنون
Medication-Related Challenges in Managing Diabetic Foot Complications: A Case Report

الحاله التي تم مشاركتها المؤتمر
الوقت كان ضيق وفيه نقص اشياء وكانت تركز على ال
Drugs Related Problems