title: headache during dialysis
this lecture is about the headache an acute complication during dialysis. it will cover all the aspects of headache like its prevention management and causes.
Establishing and maintaining normal extracellular volume (ECV) is required to achieve normotension. The achievement of an optimal fluid status, as expressed by "dry weight" (DW), should allow for controlling blood pressure (BP) in the large majority of HD patients
Renal Replacement Therapy: modes and evidenceMohd Saif Khan
Renal replacement therapy is a supportive care often required in critically ill patients who develop acute renal failure and its complications. Complexity arises when such patients become hemodynamically unstable and pose special challenge to critical care clinicians in ICU to carefully choose dialytic modality to tackle volume and solute overload. This presentation is about short description of modalities of RRT and current evidence regarding initiation, dose and type of modality.
A very simple yet comprehensive presentation to understand the concept of CRRT and its implementation in Intensive Care Unit. Intended for the very beginners in ICU. After going through the presentation you will be able to say "Now I know it!"
title: headache during dialysis
this lecture is about the headache an acute complication during dialysis. it will cover all the aspects of headache like its prevention management and causes.
Establishing and maintaining normal extracellular volume (ECV) is required to achieve normotension. The achievement of an optimal fluid status, as expressed by "dry weight" (DW), should allow for controlling blood pressure (BP) in the large majority of HD patients
Renal Replacement Therapy: modes and evidenceMohd Saif Khan
Renal replacement therapy is a supportive care often required in critically ill patients who develop acute renal failure and its complications. Complexity arises when such patients become hemodynamically unstable and pose special challenge to critical care clinicians in ICU to carefully choose dialytic modality to tackle volume and solute overload. This presentation is about short description of modalities of RRT and current evidence regarding initiation, dose and type of modality.
A very simple yet comprehensive presentation to understand the concept of CRRT and its implementation in Intensive Care Unit. Intended for the very beginners in ICU. After going through the presentation you will be able to say "Now I know it!"
as an oral and maxillofacial surgeon, we should know how to manage a patient with known bleeding disorders in our regular practice to avoid unfortunate incidents
The use of extracorporeal membrane oxygenation (ECMO), and ventricular assist devices (VADs) for both short-term and long-term management of advanced cardiac (and respiratory) failure is increasing. Both thrombotic and haemorrhagic complications are common in patients receiving mechanical support, and such complications are associated with increased morbidity and mortality. Risks of bleeding and of thrombosis vary over time, and according to technical and patient factors. Careful assessment of the risks and benefits of anticoagulation for each patient is therefore a critical component of successful mechanical support.
The approach to anticoagulation for patients receiving VADs varies according to stage of recovery and device. In the immediate post-operative period, bleeding is usually a greater risk than thrombosis and a period free from anticoagulation is usually used. Subsequent initiation of anticoagulation is usually with heparin, with the introduction of warfarin and aspirin over a period of days. Current recommendations include warfarin for all continuous flow devices, usually with the addition of aspirin, and in some cases an additional antiplatelet agent. Target INR and platelet inhibition varies with device, and institution. Testing varies according to device also. Potential pitfalls and problems exist, and these will be highlighted in this session, using a case-based approach.
The management of anticoagulation for patients receiving ECMO varies worldwide, and there are currently limited guidelines. Important factors in decision-making in regards to anticoagulation for ECMO include mode of ECMO, ECMO configuration, ECMO flows, and underlying patient pathology. Strategies for anticoagulation should take each of these factors into consideration. It is also important to recognise that other management techniques to avoid thrombosis are important, such as adequate intracardiac decompression, and promoting cardiac ejection to avoid stasis. Cases will be used to demonstrate important issues and practical management strategies.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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
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.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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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.
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4. CLOTTINGOF THE
EXTRACORPOREAL
CIRCUIT
leads to
➢ blood loss
➢ reduced solute clearance and ultrafiteration due to reduction in dialyser surface
area.
Hence it is important to prevent clotting and assess the adequacy of anticoagulation.
5. What does induce clotting??
The hemodialysis circuit represents a large extracorporeal
surface area and the simple passage of blood through the
circuit could potentially lead to the deposition and activation of
plasma coagulation proteins thus initiating clotting.
8. EUROPEAN BEST PRACTICE
GUIDELINES FOR
ANTICOAGULATION IN
HEMODIALYSIS
significant risk of bleeding
We recommend that systemic anticoagulation should be avoided or kept
to a minimum. This may be achieved by using a high blood flow rate and
regular flushing of the extracorporealcircuit with saline every 15-30 minutes or
regional citrate infusion. Low-dose unfractionated heparin may be used with
caution in patients with intermediate risk of bleeding. (1C)
Anticoagulation without added risk of bleeding:
We recommend that patients without increased bleeding risk should be given
unfractionated heparin or LMWH during HD to reduce the risk of clotting of
the extracorporealsystem. (1A)
NephrolDial Transplant 2002; 17: Supplement7 S1-S111
10. • Heparin enhance the anticoagulant
activity of antithrombin III which
inactivates thrombin and factor Xa and
to lesser extent IXa , XIa and XIIa.
• raises the blood clotting time,
monitoring with APTT
• Highly negatively charged and binds
non-specifically to endothelium,
platelets, circulating proteins,
macrophages and plastic surfaces.
• The effect of heparin is immediate and
has a short half-life (30 minutes to 2
hours after discontinuation).
• Protaminesulfate as antidote.
Guidelines for Anticoagulation of Extracorporeal
12. STANDARDHEPARINISATION
(routineanticoagulation)
• Those patients who do not have increased risk of hemorrhage or co
morbidities like CNS bleed, GI haemorrhage, uremic pericarditis and are
not currently taking oral anticoagulants
Delivery techniques
Intermittent boluses:
• Initial bolus followed by repeated intermittent maintenance boluses
• Initial bolus followed by bolus on demand
• Single dose
continuous infusions
Initial bolus followed by continuous infusions
13.
14. • Termination of heparin infusion
a. AV fistula-One hour before end of dialysis
b. Venous catheters- at the end of dialysis
• Reversal of over heparinisation: Injection protamine 1 mg for every 100
units heparin
• Target clotting times during dialysis
• Routine heparinisation: the clotting time at 1½ -2 times the baseline
clotting time.
• Tight heparinisation: the clotting time at 1¼ times the baseline clotting
time.
15. POTENTIALCOMPLICATIONSOF
USE OF HEPARIN
Heparin use may be associated with complications like
• heparin induced thrombocytopenia (HIT)
• drug drug interaction
• bleeding events
The long-term use of heparin has been associated with serious
side effects such as:
hair loss (alopecia)
Hyperkalemia due to Heparin induced suppression of aldosterone
synthesis
osteoporosis
Hyperlipidaemia (↑TG & Cholesterol,↓ HDL).
pruritis and rashes( anaphylactoid reaction ( first use yndrome)
The risk of
bleedng is
Related to the
level of APTT
not to the
heparin dose
19. Anticoagulation in patients with HIT type 2
We suggest that patients with HIT type 2 or HITTS should
not be prescribed unfractionated heparin or low molecular
weight heparin (LMWH) (2B).
20. There are multiple forms of LMWH
e.g. Enoxaparin, Dalteparin,
Nadroparin, Reviparin Tinzaparin
21. • shorter chain length
consisting of ≤ 15
saccharide units.
The results in:
1. less non-specific binding &
less bleeding
2. longer half-life
• Binds anti-thrombin III and inhibits
factor Xa
In most cases the affinity of LMWH for
Xa versus thrombin is of the order of
3:1.
• The anticoagulant effect of LMWH
can be monitored by the anti-factor
Xa activity in plasma:
25. EUROPEAN BEST PRACTICE
GUIDELINES FOR
ANTICOAGULATION IN
HEMODIALYSIS
significant risk of bleeding
We recommend that systemic anticoagulation should be avoided or kept
to a minimum. This may be achieved by using a high blood flow rate and
regular flushing of the extracorporealcircuit with saline every 15-30 minutes or
regional citrate infusion. Low-dose unfractionated heparin may be used with
caution in patients with intermediate risk of bleeding. (1C)
Anticoagulation without added risk of bleeding:
We recommend that patients without increased bleeding risk should be given
unfractionated heparin or LMWH during HD to reduce the risk of clotting of the
extracorporealsystem. (1A)
NephrolDial Transplant 2002; 17: Supplement7 S1-S111
26. Priming in some units with heparin (3000 IU/ L saline) (avoid in HIT)
Multiple flushes of 250 ml of saline every 30 min, in association with a
high blood flow rate
Periodic saline rinse allows inspection of dialyser for evidence of clotting
No Heparin Dialysis
27. Indication
a. Patient at slight risk of bleeding
b chronic & prolonged bleeding
c. Heparin free dialysis unsuccessful due to
frequent clotting
Delivery technique
constant infusion
Initial bolus dose : 750 IU
constant infusion rate : 600 IU/ hour, Monitor and
keep ACT at baseline +40% (170-190 seconds)
heparin infusion Continue till end of dialysis
Tight heparinisation
(Minimum dose heparin)
Intermittent boluses
bolus of 500 IU/60 minutes to
keep the ACT within target ??
Do not try
intermittent
boluses as it
will lead to
rising and
falling clotting
times XXX
28. Regional citrate Anticoagulation
(RCA)
• Continuous infusion of isosmotic trisodium citrate solution (102 mmol/L) into
the arterial side of the dialyzer.
• Citrate bind to plasma calcium fall in plasma calcium preventing
the coagulation cascade anticoagulation.
• Calcium disturbance (monitoring)
• Metabolic alkalosis (Metabolism of citrate to HCO3)
• Hypernatremia( Hypertonic sodium citrate solution)
• Contraindicated in patient can not metabolized citrate such as : liver failure
31. • Constant infusion of heparin into the
dialyzer inlet line and the simultaneous,
constant infusion of protamine prior to the
blood returning to the patient.
• Rebound bleeding 2-4 hours after the
end of dialysis as the reticuloendothelial
system releases free heparin from the
protamine-heparin complex back into the
general circulation.
Regional anticoagulation
with Protamine reversal
34. Clinicalpresentation
In patients with HIT Type II all heparin products must be avoided, including:
1.Topical preparations, coated products as well as intravenous preparations.
2.Systemic anticoagulation
Dialysis patients may have:
‘no heparin’ dialysis / switched to P.D/ RCA or anticoagulation with non- heparins
agents: commonly used include Danaparoid, Fonadparinux Hirudin, and Argatroban.
Venous catheters must not be heparin locked, but can be locked with recombinant
tissue plasminogen activator or citrate ( trisodium citrate 46.7%).
35. Conclusion
• Anticoagulation in Hemodialysis is an area in
dialysis that in continuous development and
evolution.
• UFH vs LMWH depend on your local practice and
resources
• good understanding for the Management of high
risk for bleeding on dialysis is mandatory