Coagulation cascade

SYNDROMES

Wyburn–Mason syndrome:  This congenital, nonhereditary disorder stems from a developmental abnormality of the vascular mesoderm in the optic cup and neural tube.  This constellation of ipsilateral–intraorbital and cerebral arteriovenous malformations, which is often associated with facial nevi,

Pradaxa

Dabigatran (Pradaxa in Australia, Europe and USA, Pradax in Canada, Prazaxa in Japan) is an anticoagulant from the class of the direct thrombin inhibitors. It is being studied for various clinical indications and in some cases it offers an alternative to warfarin as the preferred orally administered anticoagulant ("blood thinner") since it does not require frequent blood tests for international normalized ratio (INR) monitoring while offering similar results in terms of efficacy

fondaparinaux

One potential advantage of fondaparinux over LMWH or unfractionated heparin is that the risk for heparin-induced thrombocytopenia (HIT) is substantially lower. Furthermore, there have been case reports of fondaparinux being used to anticoagulate patients with established HIT as it has no affinity to PF-4. However, its renal excretion precludes its use in patients with renal dysfunction.

Unlike direct factor Xa inhibitors, it mediates its effects indirectly through antithrombin III, but unlike heparin, it is selective for factor Xa.^[1]

Heparin

An IV heparin protocol

When intravenous UFH is initiated for DVT anticoagulation, the goal is to achieve and maintain an elevated activated partial thromboplastin time (aPTT) of at least 1.5 times control. Heparin pharmacokinetics are complex, and the half-life is 60-90 minutes. A protocol for IV heparin use is as follows:

• Give an initial bolus of 80 U/kg.
• Initiate a constant maintenance infusion of 18 U/kg.
• Check the aPTT or heparin activity level 6 hours after the bolus, and adjust the infusion rate accordingly.
• Continue to check the aPTT or heparin activity level every 6 hours, until 2 successive values are therapeutic.
• Monitor the aPTT or heparin activity level, hematocrit, and platelet count every 24 hours.

management of Heart failure guidelines

http://content.onlinejacc.org/cgi/content/full/j.jacc.2008.11.009#SEC6c

sedation vacation

http://staugustine.com/living/health/2009-12-17/sedation-vacation-valuable-medical-procedure

FiO2 CALCULATIONS

For every 1 L/min of oxygen by NC, you add 3% to the estimated FiO2. So someone on 4L NC is getting about 33% FiO2 (21 + 12). Of course the FiO2 when you are talking about nasal canula is always an estimate, as people are variable in how much they breathe through their mouth. The actual FiO2 can vary quite a bit.

nails

http://reference.medscape.com/features/slideshow/rashes

Rashes

http://reference.medscape.com/features/slideshow/rashes

INfective Endocarditis: Acute

So today I got one pt with IE..so lets discuss lil bit abt IE management:

Treatment:
Empiric treatment:

• for native valve endocarditis: Pen G+ genta--for synergistic coverage for strep
• for prosthetic valve: have to cover MRSA and Coag negative Staph aureus : so have to use Vanco+genta
• For IVDA: have to cover staph aureus: Nafcillin/vanco+ Genta
• rifampin can be added if pt has any foreign body: like prosthetic valve..as Rifampin can penetrate biofilm  of most of the pathogen ...shoud be added to Vanco+gentaan 
• can use Linezolid in place of vanco if renal function is not good and have difficulty in achieving trough level.
• if vanco resistance: then can use linezolid or Daptomycin
• have to give ABX for almost 4-6 weeks and Only IV  treatment not oral ..Oral should be used only as suppressive for inoprable Prosthetic valve Endocarditis.
• 
  

If pt has vagetation then it is difficult to eradicate oragnism as antibiotic had dofficulty in penetrating fibrin/platelet rich thrombi

specific Treatment:
Usually Native valve endocariditis is caused by Strep Viridans and Bovis : can use
-Pen G alone If no other complication but require Continous IV infusion 12-18u/day or 6times a day for 4 weeks  so has very poor pt compliance
- or ampicillin 12 gm/day as continous IV infusion or 6 equally divided doses iv
- can Use ceftriaxone in place of Pen G, and it requires only twice a day dose   for sick and Once a day dose for Stable pt  so has good pt compliance..sometimes can be given IM if IV access is difficult.
-cefazolin 6gm/day can be also used in 3 equally divided doses for 4 weeks
-if allergic to penicillin ; use vanco 30 mg/kg/day , but not more then 2gm/day q12hrly for 4 weeks
-for sick/complicated pt ahve to use 2 drugs so have to add genta 1 mg/kg with Pen G or Ceftriaxone


For enterococcal Infection:
same treatment can be used
if PVE: then 6 weeks of treatment is used
-A combination of an inhibitor of cell wall synthesis (ie, penicillin, vancomycin) with an aminoglycoside (ie, gentamicin, streptomycin) is necessary to achieve bactericidal activity against the enterococci. Tobramycin or amikacin does not act synergistically with antibiotics active against the bacterial cell wall.
-if resistnace to Beta lactmase then : use Ampi-sulbactam/vanco/cipro/imipenam  +  genta




For VRE:

• can use Quinupristin/dalfopristin
• ampi+ceftriaxone
• ampi+ imipenam
• linezolid
• chloramphenical

For MSSA:

• Nafcillin/oxacillin 2gm/day q4hrly
• cefazolin 2gm IV q 8hrly
• if allergic to pen: use Vanco 30 mg.kg /day

Id staph with MIC for vanco> 1.5-2 mcg/ml ---use other ABX---linezolid/daptomycin

If PVE +MSSA:

use Cefazolin/nafcillin/oxacillin for 4-6 week

add Genta+ rifampicin for 2 week

PVE+MRSA:

use Vanco+ genta+rifampin

Linezolid had better outcome then Vanco: but have to monitor blood count

or daptomycin

HACEK:

use ampicillin or cefazolin

VAlve replacement Surgery:

if IE cause

• CHF
• >1cm vegetation
• perivalvular or myocardial abscess
• valve dysfunction
• >1 embolic episode

Fungal IE:

Surgical excision+ Amphotericin B

Daptomycin

Recently we discussed New drug Daptomycin...so I m Gonna post few facts regarding it:

MOA: cause Cell wall depolarization--> inhibit DNA, RNA and Protein synthrsis

Organism suscetibility: only gm +ve cocci--> staph-->MRSA too, Strep, ENterococci --also GRE

Used for MRSA, Rt sided endocarditis, soft tissue Infection...

Side effect:
Renal Failure
rhabdomyolysis---> so be careful while using dapto and statin together.

Limitation:
Cant be used in Pneumonia as It binds to surfactant ..

Pulmonary HTN

Based upon a Doppler echocardiographic study, it can be determined if PH is likely, unlikely, or possible [8]:

• PH is likely if the PASP is >50 and the TRV is >3.4
• PH is unlikely if the PASP is ≤36, the TRV is ≤2.8, and there are no other suggestive findings
• PH is possible with other combinations of findings

• Pulmonary hypertension (PH) defined as a mean pulmonary arterial (PA) pressure of greater than 25 mm Hg at rest or greater than 30 mm Hg during exercise, is characterized by a progressive and sustained increase in pulmonary vascular resistance that eventually leads to right ventricular (RV) failure. 

• Diagnosis of PAH requires the presence of pulmonary hypertension with two other conditions. Pulmonary artery occlusion pressure (PAOP or PCWP) must be less than 15 mm Hg (2000 Pa) and pulmonary vascular resistance (PVR) must be greater than 3 Wood units (240 dyn•s•cm⁻⁵ or 2.4 mN•s•cm⁻⁵).

Thyroid Nodule

Today I got case of Thyroid Nodule...She has < 1 cm nodule 1 year back and now it's 1.6 cm. , was solid, Normal TSH and T4. so biopsy was recommended..I m just posting algorithm for management of tHyroid nodule