Lasix

Eric H. Awtry, MD, FACC

• Boston Medical Center
• Assistant Professor of Medicine
• Boston University School of Medicine
• Director of Education, Division of Cardiology
• Boston, Massachusetts

An evidence-based review of important issues concerning neonatal hyperbilirubinemia blood pressure medication restless leg syndrome lasix 100 mg line. Clinical Practice Guideline: Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation arrhythmia practice tests buy lasix 100 mg on-line. A decline in the frequency of neonatal exchange transfusions and its effect on exchangerelated morbidity and mortality hypertension unspecified buy generic lasix 40 mg line. Apnea arteria3d elven city pack lasix 100 mg order with visa, Sudden Infant Death Syndrome, and Home Monitoring Committee on Fetus and Newborn; Pediatrics Vol. American Academy of Pediatrics: Committee on Fetus and Newborn: Apnea, Sudden Infant Death Syndrome, and Home Monitoring. Intravenous immunoglobulin for suspected or subsequently proven infection in neonates. S Vergnano, M Sharland, P Kazembe, C Mwansambo, and P T Heath Neonatal sepsis: an international perspective. Remington and KleinTextbook of Infectious Diseases of the Fetus and Newborn Infant. Guidelines for the investigation and treatment of infants at risk of congenital syphilis in the Northern Territory, 2005. Patent ductus arteriosus ligation in premature infants: who really benefits, and at what cost? Royal Prince Alfred Hospital Department of Neonatal Medicine Protocol Book, 2001 3. Furosemide for prevention of morbidity in indomethacin-treated infants with patent ductus arteriosus. Prolonged versus short course of indomethacin for the treatment of patent ductus arteriosus in preterm infants. Intravenous midazolam infusion for sedation of infants in the neonatal intensive care unit. Persistent pulmonary hypertension of the newborn in the era before nitric oxide: practice variation and outcomes. Varicella exposure in a neonatal medical centre: successful prophylaxis with oral acyclovir. Definition · Chronic airway inflammation leading to increase airway responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing particularly at night or early morning. The possibility of those with negative index not becoming asthmatic by 6 years old was 95% whereas those with a positive index have a 65% chance of becoming asthmatic by 6 years old. A Clinical Index to define Risk of Asthma in young children with Recurrent Wheeze: Positive index (> 3 wheezing episodes / year during first 3 years) plus 1 Major criterion or 2 Minor criteria. Major criteria · Eczema1 · Parental asthma1 · Positive aeroallergen skin test1 Minor criteria · Positive skin test1 · Wheezing without upper respiratory tract infection · Eosinophilia (> 4%) Footnote: 1, Doctor Diagnosed · the child who presents with chronic cough alone (daily cough for > 4 weeks) and has never wheezed is unlikely to have asthma. These children require further evaluation for other illnesses that can cause chronic cough. The change is due to the fact that asthma management based on severity is on expert opinion rather than evidence based, with limitation in deciding treatment and it does not predict treatment response. Taking a -agonist prior to strenuous exercise, as well as optimizing treatment, are usually helpful. This group of patients need to be identified and closely monitored which includes frequent medical review (at least 3 monthly), objective assessment of asthma control with lung function on each visit, review of asthma action plan and medication supply, identification of psychosocial issues and referral to a paediatrician or respiratory specialist. Management of acute asthma exacerbations · Mild attacks can be usually treated at home if the patient is prepared and has a personal asthma action plan. On discharge, patients must be provided with an Action Plan to assist parents or patients to prevent/terminate asthma attacks. Clinical Features · Typically presents with a mild coryza, low grade fever and cough. The chest may be hyperinflated and auscultation usually reveals fine crepitations and sometimes rhonchi.

Succinylcholine is rapidly hydrolyzed by pseudocholinesterase in the plasma to succinylmonocholine blood pressure chart systolic diastolic pulse purchase 40 mg lasix with visa, a relatively inactive metabolite pulse pressure less than 10 lasix 40 mg buy with amex. In patients with low levels of pseudocholinesterase or atypical cholinesterase enzyme arrhythmia ekg purchase lasix 40 mg online, prolonged relaxation can occur arrhythmia pathophysiology lasix 100 mg sale. Furthermore, when very large doses of succinylcholine are used, a phase 2 competitive block, which is similar to nondepolarizer block, may develop. This drug is particularly useful in critically ill patients with a full stomach, for whom a rapid-sequence intubation technique is needed. Atracurium Atracurium is a nondepolarizing muscle relaxant with an intermediate duration of action. It has the unique property of being hydrolyzed through the Hoffman degradation mechanism. Renal or hepatic disease does not prolong its short elimination half-life (19 minutes). Laudanosine, its metabolite, causes cerebral irritation in high doses in several animal species. This has not been noted clinically, however, even after prolonged use of atracurium. The route of laudanosine elimination is not known for certain, but it seems that renal failure itself will not affect metabolic accumulation significantly. Administration of atracurium should be slow and adequate in amount because rapid intravenous injection with a large bolus may result in histamine release and hypotension. Clinically, in most instances, recovery is rapid and complete once the infusion is stopped. Because of its relatively mild cardiovascular and cumulative effects, atracurium by continuous infusion appears to be useful when prolonged neuromuscular blockade is required. Cisatracurium Cisatracurium is a stereoisomer of atracurium with higher potency and no histamine release and thus more cardiovascular stability. Like atracurium, it is particularly indicated in patients with compromised hepatic and/or renal functions. Nondepolarizing Neuromuscular Blocking Agents Nondepolarizing neuromuscular blocking agents bind in a competitive manner principally to postsynaptic cholinergic receptors at the neuromuscular junctions, where they prevent depolarization by acetylcholine. Mivacurium Mivacurium is the only short-acting nondepolarizing muscle relaxant currently available. In some procedures, mivacurium can replace succinylcholine if short duration of muscle relaxation is needed and succinylcholine is contraindicated. Renal and hepatic patients have prolonged action of mivacurium because of decreased plasma cholinesterase in those patients. It can cause histamine release and thus is not suitable for hemodynamically unstable patients. Both doxacurium and pipercuronium are obsolete in clinical use owing to their lack of titratability compared with other relaxants. Complications of Use of Muscle Relaxants Vecuronium Vecuronium is a shorter-acting monoquaternary steroidal analogue of pancuronium. Because it causes no vagolytic effects and does not provoke histamine release, its use is associated with marked cardiovascular stability. The metabolism and excretion of vecuronium are mainly through the liver, although about 15­25% is excreted by the kidneys. The metabolite 3-desacetyl vecuronium has about half the potency of the parent compound. Onset of action is 2­3 minutes, peak relaxation occurs within 3­5 minutes, and the duration of action is 25­30 minutes. Continuous infusion of vecuronium is recommended for prolonged paralysis in patients with cardiovascular instability. In patients with normal renal and liver function, recovery of neuromuscular function occurs rapidly when the infusion is stopped, even after large doses.

The вoenegativeв symptoms arrhythmia ecg quiz buy 100 mg lasix amex, such as blunted affect blood pressure medication nausea order 100 mg lasix overnight delivery, anhedonia (not getting pleasure from normally pleasurable stimuli) heart attack white sea acapella remix purchase lasix 100 mg visa, apathy sheer heart attack discount lasix 100 mg buy on line, and impaired attention, as well as cognitive impairment are not as responsive to therapy, particularly with the typical neuroleptics. Many atypical agents, such as clozapine, ameliorate the negative symptoms to some extent. All of the drugs also have a calming effect and reduce spontaneous physical movement. The antipsychotic effects usually take several days to weeks to occur, suggesting that the therapeutic effects are related to secondary changes in the corticostriatal pathways. Extrapyramidal effects: Dystonias (sustained contraction of muscles leading to twisting distorted postures), parkinson-like symptoms, akathisia (motor restlessness), and tardive dyskinesia (involuntary movements of the tongue, lips, neck, trunk, and limbs) occur with chronic treatment. Blocking of dopamine receptors in the nigrostriatal pathway probably causes these unwanted movement symptoms. Other effects: Blockade of О±-adrenergic receptors causes orthostatic hypotension and light-headedness. The neuroleptics also alter temperature-regulating mechanisms and can produce poikilothermia (body temperature varies with the environment). In the pituitary, neuroleptics block D2 receptors, leading to an increase in prolactin release. Sedation occurs with those drugs that are potent antagonists of the H1-histamine receptor, including chlorpromazine, olanzapine, quetiapine, and clozapine. Sexual dysfunction may also occur with the antipsychotics due to various receptorbinding characteristics. Treatment of schizophrenia: the neuroleptics are considered to be the only efficacious treatment for schizophrenia. Not all patients respond, and complete normalization of behavior is seldom achieved. The traditional neuroleptics are most effective in treating positive symptoms of schizophrenia (delusions, hallucinations, thought processing, and agitation). However, even the atypical antipsychotics do not consistently improve the negative symptoms of schizophrenia more than the older agents. Prevention of severe nausea and vomiting: the older neuroleptics (most commonly prochlorperazine) are useful in the treatment of drug-induced nausea (see p. Nausea arising from motion should be treated with sedatives, antihistamines, and anticholinergics, however, rather than with the powerful neuroleptic drugs. Other uses: the neuroleptic drugs can be used as tranquilizers to manage agitated and disruptive behavior secondary to other disorders. Neuroleptics are used in combination with narcotic analgesics for treatment of chronic pain with severe anxiety. However, risperidone and haloperidol are also commonly prescribed for this tic disorder. Also, risperidone is now approved for the management of disruptive behavior and irritability secondary to autism. Absorption and metabolism After oral administration, the neuroleptics show variable absorption that is unaffected by food (except for ziprasidone and paliperidone, the absorption of which is increased with food). Fluphenazine decanoate, haloperidol decanoate, and risperidone microspheres are slow-release (up to 2 to 4 weeks) injectable formulations of neuroleptics that are administered via deep gluteal intramuscular injection. These drugs are often used to treat outpatients and individuals who are noncompliant with oral medications. Adverse effects Adverse effects of the neuroleptic drugs can occur in practically all patients and are significant in about 80 percent (Figure 13. Although antipsychotic drugs have an array of adverse effects, their therapeutic index is high. Extrapyramidal side effects: the inhibitory effects of dopaminergic neurons are normally balanced by the excitatory actions of cholinergic neurons in the striatum. Blocking dopamine receptors alters this balance, causing a relative excess of cholinergic influence, which results in extrapyramidal motor effects.

Drug metabolism is significantly reduced in hypothyroidism arteria recurrens lasix 100 mg low cost, and administration of the usual doses of sedatives may depress ventilation significantly and compromise mental status pulse pressure greater than 80 100 mg lasix purchase otc. In critically ill patients blood pressure 50 0 cheap lasix 40 mg with amex, the diagnosis of hypothyroidism sometimes may be hard to make on clinical grounds arrhythmia after heart surgery discount lasix 100 mg with mastercard. Hypoglycemia may occur, particularly if there is deficiency of pituitary hormones as well. Chest x-ray may reveal an enlarged cardiac silhouette and pleural and pericardial effusions. It may be difficult at times to distinguish sick euthyroid syndrome from primary hypothyroidism by thyroid function tests. Adrenal Insufficiency-In patients with hypothyroidism, the manifestations of adrenal insufficiency may be masked. Development of an intercurrent illness such as an infection on top of the underlying severe hypothyroidism usually leads to this decompensation. While laboratory tests confirm hypothyroidism, the diagnosis is based on the constellation of clinical findings of myxedema, altered mental status, and hypothermia. The physician must remain alert for the possibility of myxedema coma because the consequences of missing the diagnosis can be devastating. In addition, the usual clinical signs of infection such as fever and leukocytosis may be masked in patients with severe hypothyroidism. Therefore, one also must actively search for infection or other precipitating factors and treat these illnesses aggressively. Pathophysiology Hypothyroidism is a common endocrinopathy, but myxedema coma is encountered much less commonly because of thyroid hormone replacement therapy. Patients with myxedema most often have a history of hypothyroidism, but the precipitating condition is almost always a combination of failure to take an adequate amount of thyroid replacement therapy and the presence of some comorbid condition. Because the serum half-life of T4 is quite long, hypothyroidism is a subacute condition characterized by decreased metabolic rate, accumulation of edema fluid, deterioration of cardiac function from structural and physiologic changes, hyperlipidemia, and inability to manifest an appropriate response to hypothermia. Ventilatory drive is diminished from central mechanisms and, because of respiratory muscle weakness and pleural effusions and ascites, can result in hypercapnia. First, in patients with autoimmune thyroid disease, there is a higher incidence of autoimmune adrenalitis and adrenal insufficiency than in the general population. These patients with secondary adrenal insufficiency lack the skin and mucosal hyperpigmentation that is characteristic of primary adrenal insufficiency. For these reasons, it is easy to miss adrenal insufficiency in this setting, and the clinician must keep alert to the possibility of concomitant adrenal insufficiency. Thyroid Hormone Replacement-While all commentators assert the need for prompt thyroid hormone replacement in myxedema coma, there is disagreement about what constitutes an optimal regimen. The major controversy relates to which regimen of thyroid hormone replacement to use: T4 alone, T3 alone, or a combination of T4 and T3. This is so because the activity of 5-deiodinase is diminished in hypothyroidism, and the conversion of T4 to T3 may be Table 25­2. Mechanism of Action Thyroid hormone replacement Treatment Levothyroxine (T4), 500 g by slow intravenous infusion, followed by 100­150 g every 24 hours. On the other hand, a rapid increase in T3 may be detrimental to the patient because of cardiac arrhythmias and too rapid an increase in myocardial oxygen demand. Because of its potential adverse effects, the use of this regimen has been discouraged by some. Intravenous administration of T4 is considered safe and has been the standard for the past three decades. One traditional regimen consists of 500 g of levothyroxine (T4) given slowly intravenously, followed by 100­150 g every 24 hours. The rationale for the large initial dose is that it restores the total thyroxine pool. However, it is not clear if this regimen is any better than 150 g given intravenously daily. In fact, a dose of 100­150 g levothyroxine given intravenously daily would correct the thermoregulatory, respiratory, cardiac, and mental status changes over 24­48 hours. It is suggested that 200­300 g T4 be given simultaneously with 25 g T3 intravenously. This is followed by administration of another 25 g T3 12 hours later and 100 g T4 at 24 hours. Starting the third day, 100 g T4 is given daily until the patient regains consciousness.

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Risk factors for catheter-associated bacteriuria include prolonged duration of catheterization blood pressure what is too low 100 mg lasix visa, older age hypertension lab tests buy lasix 100 mg mastercard, severe underlying illness pre hypertension natural cure 100 mg lasix with amex, diabetes mellitus arteria networks corporation buy lasix 100 mg online, absence of systemic antibiotic use, female sex, abnormal serum creatinine, errors in catheter care, and periurethral colonization with potential uropathogens. Once bacteriuria has occurred, it is difficult to prevent subsequent infection; thus prevention of the initial bacteriuria is critical. The only two factors shown to decrease the risk of nosocomial catheter-associated bacteriuria are maintenance of a closed catheter system with aseptic insertion of catheter and early removal of the urinary catheter. Chastre J et al: Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: A randomized trial. Symptoms and Signs-Diagnosis of catheter-related urinary tract infection is straightforward, although many patients with catheter-associated urinary tract infections are asymptomatic. Up to 30% of patients will have fever or other symptoms of urinary tract infection. Fever or other systemic signs of infection, as well as pain localized to the flank, suggest upper tract infection. Laboratory Findings-The white blood cell count may be elevated with serious infection. Direct examination of the urine continues to be valuable for early diagnosis of bacterial infections of the genitourinary tract. Pyuria indicates the presence of urinary infection rather than simple bacterial colonization of the urine; the presence of white blood cell casts suggests upper tract disease. The presence of one or two leukocytes per high-power field (400Ч) or bacteria seen under oil immersion (1000Ч) in unspun urine has a 95% correlation with the presence of more than 100,000 cfu/mL of urine. Thus microscopy is useful for identification of urinary tract involvement with a high urine bacterial count. The presence of bacteria in a concentration greater than 100,000 cfu/mL with accompanying pyuria is consistent with infection. In catheterized patients, bacterial counts of more than 1000 cfu/mL, if untreated, will increase to more than 100,000 cfu/mL within 24­48 hours. Urine culture for bacteria and fungi must be submitted to the laboratory with prompt processing. Alternatively, specimens may be refrigerated at 4°C, where bacterial counts will remain stable for up to 24 hours. Urine left at room temperature for over 2 hours after collection will have significantly higher urine bacterial colony counts, thereby confounding the diagnosis of urinary tract infection. Most microbiology laboratories routinely identify and perform antimicrobial susceptibility tests on microorganisms General Considerations A urinary (bladder) catheter provides a portal of entry into the urinary tract for microorganisms. Urinary catheter­associated infections account for up to 40% of all nosocomial infections. Fewer than 5% of patients who develop bacteriuria will become bacteremic; however, the tremendous frequency of nosocomial bacteriurias accounts for the observation that urinary catheter­associated infections account for 15% of all nosocomial bacteremias. The urinary catheter allows transit of microorganisms colonizing the perineum and the urethral meatus to pass through the urethra and enter the bladder. Bacterial also ascend intraluminally through the catheter because of failure of the closed drainage system or contamination of the collection bag. Bacteriuria occurs in catheterized patients at a rate of 3­10% per catheter-day, with 10­25% of these patient developing symptoms of local infection and bacteremia and sepsis occurring in 2­4%. If polymicrobial bacteriuria is anticipated (eg, chronic indwelling catheter or neurogenic bladder), the laboratory should be alerted to this possibility. Imaging Studies-Seriously ill patients presenting with a urinary tract infection, whether catheter-related or not, who have high fever, flank pain, or urosepsis require further evaluation for upper tract disease. Ultrasonography is useful to assess the anatomy of the genitourinary tract and to rule out an obstructed ureter. Complications-Complications of bladder and kidney infections are common and potentially serious. The urinary tract is the most common site of origin of gram-negative bacteremia and sepsis. Acute pyelonephritis, chronic pyelonephritis, emphysematous pyelonephritis, renal abscess, and urosepsis may complicate an untreated urinary tract infection.

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