This document discusses anticoagulants and their implications for regional anesthesia. It covers the coagulation cascade, classifications of anticoagulants including warfarin, heparin, LMWH, antiplatelets, and newer anticoagulants. Guidelines are provided for timing of regional anesthesia in relation to different anticoagulants. It emphasizes that coagulation defects are the principal risk factor for spinal hematoma from regional anesthesia.
K. thanavaro the indications and uses of the novel anticoagulantsAlysia Smith
Dr. Kristin Thanavaro, MD presents on "The Indications and Uses of the Novel Anticoagulants" at the March 4 -6, 2016 Cardiac and Thoracic Surgery Associates, Cardiovascular Summit at The Westin Riverfront Resort and Spa.
Epirubicin hydrochloride 2 mgml solution for injection or infusion smpc taj ...Taj Pharma
EPIRUBICIN HYDROCHLORIDE - Drug Information - Taj Pharma, EPIRUBICIN HYDROCHLORIDE dose Taj pharmaceuticals EPIRUBICIN HYDROCHLORIDE interactions, Taj Pharmaceutical EPIRUBICIN HYDROCHLORIDE contraindications, EPIRUBICIN HYDROCHLORIDE price, EPIRUBICIN HYDROCHLORIDE Taj Pharma Cancer, oncologyEpirubicin Hydrochloride 2mg/ml solution for injection or infusion SMPC- Taj Pharma . Stay connected to all updated on EPIRUBICIN HYDROCHLORIDE Taj Pharmaceuticals Taj pharmaceuticals Hyderabad.
Rivaroxaban is a Factor Xa inhibitor. This presentation covers in brief regarding need for NOACs, kinetics, effects, indications, dosage, toxity, and antidote of rivaroxaban. It also covers in brief all the published trials
K. thanavaro the indications and uses of the novel anticoagulantsAlysia Smith
Dr. Kristin Thanavaro, MD presents on "The Indications and Uses of the Novel Anticoagulants" at the March 4 -6, 2016 Cardiac and Thoracic Surgery Associates, Cardiovascular Summit at The Westin Riverfront Resort and Spa.
Epirubicin hydrochloride 2 mgml solution for injection or infusion smpc taj ...Taj Pharma
EPIRUBICIN HYDROCHLORIDE - Drug Information - Taj Pharma, EPIRUBICIN HYDROCHLORIDE dose Taj pharmaceuticals EPIRUBICIN HYDROCHLORIDE interactions, Taj Pharmaceutical EPIRUBICIN HYDROCHLORIDE contraindications, EPIRUBICIN HYDROCHLORIDE price, EPIRUBICIN HYDROCHLORIDE Taj Pharma Cancer, oncologyEpirubicin Hydrochloride 2mg/ml solution for injection or infusion SMPC- Taj Pharma . Stay connected to all updated on EPIRUBICIN HYDROCHLORIDE Taj Pharmaceuticals Taj pharmaceuticals Hyderabad.
Rivaroxaban is a Factor Xa inhibitor. This presentation covers in brief regarding need for NOACs, kinetics, effects, indications, dosage, toxity, and antidote of rivaroxaban. It also covers in brief all the published trials
Direct oral anticoagulants (DOACs) have quickly become attractive alternatives to the long‐standing standard of care in anticoagulation, vitamin K antagonist. DOACs are indicated for prevention and treatment of several cardiovascular conditions. Since the first approval in 2010, DOACs have emerged as leading therapeutic alternatives that provide both clinicians and patients with more effective, safe, and convenient treatment options in thromboembolic settings. With the expanding role of DOACs, clinicians are faced with increasingly complex decisions relating to appropriate agent, duration of treatment, and use in special populations. This review will provide an overview of DOACs and act as a practical reference for clinicians to optimize DOAC use among common challenging scenarios. Topics addressed include (1) appropriate indications; (2) use in patients with specific comorbidities; (3) monitoring parameters; (4) transitioning between anticoagulant regimens; (5) major drug interactions; and (6) cost considerations.
Direct oral anticoagulants (DOACs)—dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban (Savaysa), and betrixaban (Bevyxxa) are anticoagulation pharmacotherapy used for the prevention of thrombosis in several cardiovascular contexts.1 DOACs are categorized into 2 main classes: oral direct factor Xa inhibitors (ie, rivaroxaban, apixaban, edoxaban, and betrixaban) and direct thrombin inhibitors (ie, dabigatran). In 2010, the US Food and Drug Administration (FDA) approved its first DOAC, dabigatran, followed by rivaroxaban, apixaban, edoxaban, and betrixaban in the following years. DOACs are relatively new agents demonstrating superiority or noninferiority to prior standards of care, anticoagulation with vitamin K antagonists (VKA; ie, warfarin), or low‐molecular‐weight heparins (LMWHs), in reducing risk of thromboembolic complications with similar or reduced bleeding risk.2, 3, 4, 5 Advantages of DOACs compared with VKAs include fewer monitoring requirements, less frequent follow‐up, more immediate drug onset and offset effects (important for periprocedural and acute bleeding management), and fewer drug and food interactions.6 As a result, DOAC prescriptions exceeded those for warfarin by 2013, with apixaban being the most frequently prescribed DOAC for patients with nonvalvular atrial fibrillation (NVAF).7
Over the past decade, DOACs have been the subject of extensive investigation in many clinical scenarios. Though guidelines and review articles have provided detailed and in‐depth analyses of the immense literature base, these can be too cumbersome and challenging to integrate into everyday clinical use
In general, FDA‐approved indications for each of the DOACs are comparable (see Table 1). Dabigatran, rivaroxaban, apixaban, and edoxaban are approved for the lowering the risk of stroke and embolism in NVAF as well as deep vein thrombosis and pulmonary embolism treatment/prophylaxis.8, 9, 10, 11 Unique indications
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
3. Spinal hematoma is a rare but potentially
devastating complication of regional
anesthesia( approximately 0.1 per 100,000
patients per year)
Coagulation defects are the principal risk
factors for regional anesthesia
Trauma to epidural veins in the presence of
coagulopathies may result in large
hematoma.
4. Patient with spinal hematoma presents
with severe back pain and neurological
deficit.
Diagnosis is confirmed by MRI.
Decompression laminectomy is required to
preserve neurologic functions.
Neuraxial blockade should be performed
cautiously in the presence of prophylactic
anticoagulation.
8. Mechanism of action:
Interferes with the synthesis of Vit K
dependant clotting factors
1. II, VII, IX and X.
2. Anticoagulation of proteins C, and S.
9. Half life: 40 hours
Dosage: 2-15 mg / day
Monitoring: PT and INR
10. Caution should be made in performing
neuraxial block in patients recently
discontinued warfarin therapy.
The anticoagulant therapy must be
stopped (ideally 4 – 5 days before
performing the block).
Monitor PT/INR prior to initiation of the
block. INR value of ≤1.4 acceptable for
the performance of neuraxial blocks.
No Regional Anesthesia if in combination
of other drugs affecting the clotting.
11. If the first dose given 24 hrs earlier- check
PT/INR
PT/INR on daily basis in case of epidural
analgesia.
Check PT/INR before catheter removal if
initial doses of warfarin are given more
than 36 hours preoperatively.
Epidural catheters can be removed if INR
is < 1.5.
12. Neurological testing of motor and sensory
functions should be done.
Minimize the degree of motor and sensory
block.
If INR > 3, Hold warfarin
Reduced doses of warfarin in patients with
enhanced drug response.
14. Mechanism of action:
Accelerates the inactivation of factors IIa,
IXa, Xa, XIa, and XIIa by the serine protease
inhibitor, Antithorombin III (AT III).
15. Half life:1 to 1.5 hours.
Dose:
Bolus: 80 units / kg or 5000 units
Maintenance: 15 units / kg / hr or 700
to 2000 units / day
Monitoring: aPTT.
16. For mini dose prophylaxis :
No contraindication. Hold morning dose.
Check platelet count
17. In pts with combined neuraxial blocks and
intraoperative anticoagulation,
Avoid regional anesthesia(RA) with other
coagulopathies.
Avoid RA in patients with medications of
clotting inhibitors in combination.
Delay Heparin dose up to 1 hour after
needle placement.
18. Remove catheter 4 hours stopping the dose
and start the dose again after 1 hour.
Check for motor and sensory blockade.
Consider minimal dose of local anesthetics
for early detection of spinal hematoma.
19. Combining neuraxial techniques with full
anticoagulation of cardiac surgery
Insufficient data and experience to
determine the risk of hematoma.
Postoperative monitoring of neurological
functions.
20. Mechanism of action: Inhibit clotting factor Xa
more than IIa.
Examples
Deltaparin
Enoxaparin
Tinzaparin
21. Half-life: Three to four times more than
Haparin
Doses:
Deltaparin: 2500-5000 u / day
Enoxaparin: 30-40 mg / day
Tinzaparin:175 u / day
22. Monitoring of anti – Xa level is not
recommended.
No RA in patients taking other clotting
inhibitors in addition.
In the presence of blood during needle and
catheter placement.
Delay LMWH therapy for 24 hours
Should be discussed with the surgeon.
23. Preoperative LMWH:
1. Thromboprophylaxis: Needle placement
should be delayed up to 10 – 12 hours.
2. Treatment doses: A delay of at least 24 hours
is recommended.
3. No RA if the dose is given in morning
preoperatively.
24. Postoperative LMWH: may undergo RA
technique, but removal of the catheter
depends upon total daily dose and
timing.
a. Twice daily dose:
increased risk of spinal hematoma.
First dose of LMWH should not be
administered 24 hours postoperatively.
Catheters should be removed prior to
initiation of thrombo-prophylaxis.
LMWH dose should be started after 2 hours
removing the catheter.
25. b. Single daily dose:
First dose should be administered 6 – 8 hours
postoperatively.
Second dose after 24 hours and catheters may be
safely maintained.
Catheters should be removed after 12 hours of last
LMWH dose.
LMWH dose can be started after two hours.
27. MECHANISM OF ACTION:
Blocks cyclooxygenase. Which is responsible
for the production of thromboxane A2 which
inhibits platelet aggregation and causes
vasoconstriction.
DURATION OF ACTION:
Irreversible effect on platelets. Effect of
aspirin lasts for the life of the platelet which
is 7-10 days. Long term use of aspirin may
lead to a decrease in prothrombin production
and result in a lengthening of the PT.
28. MECHANISM OF ACTION:
Inhibits cyclooxygenase by decreasing tissue
prostaglandin synthesis.
DURATION OF ACTION:
Reversible. Duration of action depends on
the half life of the medication used and can
range from 1 hour to 3 days.
30. Either medication alone does not increase
risk.
Need to scrutinize dosages, duration of
therapy and concomitant medications
that may affect coagulation.
No wholly accepted laboratory tests. A
normal bleeding time does not indicate
normal homeostasis. An abnormal
bleeding time does not necessarily
indicate abnormal homeostasis.
31. History of bruising easily
History of excessive bleeding
Female gender
Increased age
33. MECHANISM OF ACTION:
Interfere with platelet membrane function
by inhibition of adenosine diphosphate (ADP)
induced platelet-fibrinogen binding.
DURATION OF ACTION:
Thienopyridine derivatives exert an
irreversible effect on platelet function for
the life of the platelet.
34. D/C ticlopidine for 14 days prior to a
neuraxial block.
D/C clopidogrel for 7 days prior to a
neuraxial block.
There is no accepted laboratory tests for
these medications.
Epidural catheters can be removed safely
and neuraxial injections can be performed 5
days (not 7 days, as once advised) after
clopidogrel is discontinued.
36. Mechanism of action: Non peptide inhibitors
of GP IIb / IIIa receptor
Doses:
Abciximab. Dose:250 micrograms / kg
Eptifibatide. Dose:180 microgram / kg
Tirofiban. Dose: 10 micrograms / kg
37. No wholly accepted test including the
bleeding time.
Careful preoperative assessment is
necessary,
Easy bruisability
Excessive bleeding
Female gender
Increasing age
38. Platelet GIIb/IIIa Inhibitors:
RA should be avoided 2 days for abciximab and 4-
8 hours for eptifibatide and tirofiban therapy.
If administrated postoperatively following RA,
the patient should be monitored neurologically.
40. Activates plasminogen to form plasmin which
digest fibrin and dissolve clot.
Although the plasma half life of
thrombolytic drugs is mainly hours, it may
take days for the thrombolytic effect to
resolve
41. No RA in the presence of these drugs.
In patients with catheters already in and
with sudden initiation of these drugs,
Neuraxial monitoring is necessary which should not be
more than 2 hour interval.
Infusion should be limited to drugs minimizing sensory
and motor blockade.
Fibrinogen level measurement.
No definite recommendation regarding the removal of
catheters.
42. Patients scheduled for thrombolytic therapy
must be inquired for history of neuroaxial
block.
Patients who received thrombolytic therapy,
neuroaxial block is contraindicated, no time
interval is outlined.
43.
44. Antithrombotic medication for DVT
prophylaxis
Binds with antithrombin III which
neutralizes factor Xa.
Peak effect in 3 hours with half life of 17-
21 hours
Irreversible effect
Time for initial catheter placement is 72
hrs and 12 hrs delay required to restart.
Need further clinical experience to
formulate guidelines
45. Bivalirudin- thrombin inhibitor used in
interventional cardiology.
Lepirudin used to treat heparin-induced
thrombocytopenia.
Caution advised. No recommendations
related to limited clinical experience.
46. Dabigatran etexilate
Is a prodrug that inhibits both free and clot-
bound thrombin.
The drug is absorbed from the
gastrointestinal tract with a bioavailability of
5%.
The half-life is 8 hrs after a single dose and
up to 17 hrs after multiple doses.
Prolongs the aPTT
47. Rivaroxaban
Is a potent selective and reversible oral
activated factor Xa inhibitor.
Inhibition is maintained for 12 hrs.
Monitored with the PT, aPTT.
Initial catheter placement time- 24 hrs.
Time to restart- 6 hrs
Longer holding time required in renal
impairment.
48. For patients undergoing deep plexus or
peripheral block, recommendations regarding
neuraxial techniques, should also be applied
similarly.
49. These consensus statements represent the collective
experience of recognized experts in neuraxial
anesthesia and anticoagulation.
Alternative anesthetic and analgesic techniques
should be used for the patients.
Indwelling catheters should not be removed
Vigilance in monitoring
Protocols must be in place for urgent magnetic
resonance imaging
The patient's coagulation status should be optimized
at the time of spinal or epidural needle/catheter
placement.