The document discusses various methods for weaning patients off mechanical ventilation, including SIMV, T-piece trials, CPAP/BiPAP, and pressure support. It notes major factors to consider for each patient such as their primary illness, ventilatory support needs, and other medical conditions. Key criteria for determining readiness for weaning trials and extubation include respiratory rate, vital capacity, gas exchange values, hemodynamic stability, and underlying disease improvement. Factors that could lead to weaning or extubation failure are also outlined.
Mvss part v weaning & liberation from mechanical ventilationSanti Silairatana
Slides accompanying the Lecture/Review Mechanical Ventilatory support series part V/V: Weaning and liberation from mechanical ventilatory support. For medical students and residents in Internal medicine. Contents are including rationale of weaning, predictors of weaning success and failure, methods of weaning, and detection and management of weaning failure
Inadequate respiratory drive
Inability to maintain adequate alveolar ventilation
Hypoxia
Decision to provide MV should be based on clinical examination and assessment of gas exchange by blood gas analysis. The principal goal of MV in the setting of respiratory failure is to support gas exchange while underlying diseased process is reversed.
Mvss part v weaning & liberation from mechanical ventilationSanti Silairatana
Slides accompanying the Lecture/Review Mechanical Ventilatory support series part V/V: Weaning and liberation from mechanical ventilatory support. For medical students and residents in Internal medicine. Contents are including rationale of weaning, predictors of weaning success and failure, methods of weaning, and detection and management of weaning failure
Inadequate respiratory drive
Inability to maintain adequate alveolar ventilation
Hypoxia
Decision to provide MV should be based on clinical examination and assessment of gas exchange by blood gas analysis. The principal goal of MV in the setting of respiratory failure is to support gas exchange while underlying diseased process is reversed.
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.
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.
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stockrebeccabio
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stock
Telegram: bmksupplier
signal: +85264872720
threema: TUD4A6YC
You can contact me on Telegram or Threema
Communicate promptly and reply
Free of customs clearance, Double Clearance 100% pass delivery to USA, Canada, Spain, Germany, Netherland, Poland, Italy, Sweden, UK, Czech Republic, Australia, Mexico, Russia, Ukraine, Kazakhstan.Door to door service
Hot Selling Organic intermediates
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
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
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
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
3. Before titration is begun, the method for weaning
should be considered. Titration should be patient
specific, taking into consideration the patient's
primary illness, length of ventilatory support, and
other confounding medical conditions. Four
major modes of titration are commonly used:
1. SIMV
2. T-piece
3. CPAP / BiPAP
4. Pressure Support
4. T-piece trials are usually used with resting periods
of assist control (AC) ventilation. The advantage to
this approach is that while weaning the patient is
doing all the work of breathing, and while on AC
the patient is allowed to rest.
AC with T-piece trials may work best in the patient
with COPD or other chronic lung conditions that
cause respiratory muscle weakness.
5. Synchronized intermittent mandatory ventilation
(SIMV) is most useful in patients whom a rapid
change in intrathoracic pressure would cause
hemodynamic instability.
Patients with cardiovascular disease can suffer
from congestive failure due to increased venous
return that occurs with rapid changes in thoracic
pressure.
SIMV allows for gradual change from positive
pressure ventilation to spontaneous (negative)
pressure ventilation.
6. Continuous positive airway pressure (CPAP) and
bi-level positive airway pressure (BiPAP) are
effective in providing expiratory support to
maintain oxygenation and prevent alveolar
collapse during titration.
They also maintain a level of positive intrathoracic
pressure that may be helpful in the cardiovascular
patient.
BiPAP adds inspiratory support to CPAP, which may
be helpful in preventing respiratory muscle
fatigue.
7. Pressure support (PS) provides inspiratory support
to help overcome airway resistance and decrease
respiratory muscle fatigue.
PS may be helpful in retraining respiratory muscles
in a patient who has been on long-term
ventilation.
8. Usually sedation is discontinued when weaning is
begun. This often results in a wide-awake,
frightened patient who is "bucking" the ventilator
and pulling on the tube.
Most patients say that mechanical ventilation is
extremely uncomfortable, and moderately painful.
Therefore, it would make sense to manage the
patient's pain and discomfort for the best
outcome.
Include sedation, pain control, and anxiety control
in modest amounts to keep the patient
comfortable but conscious during weaning.
9. Once the previous planning has been done, Check
the patient's nutritional status.
Assure adequate rest the night before weaning.
Shortly before weaning, suction the patient and
allow several minutes for his oxygenation to
return to normal. Using 100% FiO2 during
suctioning helps to accomplish this
10. Start the weaning trial at the appropriate time of
day.
Mornings can be difficult for several reasons:
1. Preload may be higher in the morning
2. Respiratory function is worse in the morning
(circadian effects)
3. Interruptions are more frequent (rounds, shift
change, etc.)
11. Determination of assessment parameters for continued
weaning (Go), cautious weaning (Caution), weaning
discontinuation (Stop) should be made before the trial is
begun.Some general guidelines are below:
1. Go:
No respiratory distress
Hemodynamically stable
2. Caution:
Mild respiratory distress
Hemodynamic changes
3. Stop:
Respiratory distress, respiratory acidosis
Vital sign changes: increased RR, HR, B/P
12. RR<30
VC>15ML/KG
Rapid shallow breathing index(RR/TV)>100
Max inspiratory force>-20cm h20
VD/VT<0.6
Pao2>80 with fio2 0.4
Paco2<45
Ph>7.3
PAo2-Pao2<300 on Fio2 1
Qs/Qt<15%
Conscious pt
Cardiovascular stability
Metabolically stable
Underlying disease process should have improved
13. The Cuff leak test during MV:
Set a tidal Volume 10-12 ml/kg
Measure the expired tidal volume
Deflated the cuff
Remeasure expired tidal volume (average of 4-6 breaths)
The difference in the tidal volumes with the cuff inflated
and deflated is the leak
A value of 130ml 85% sensitivity
95% specificity
Extubation Criteria
14. Cough / Leak test in spontaneous breathing
Tracheal cuff is deflated and monitored for the first 30
seconds for cough.
Only cough associated with respiratory gurgling (heard
without a stethoscope and related to secretions) is taken
into account.
The tube is then obstructed with a finger while the patient
continues to breath.
The ability to breathe around the tube is assessed by the
auscultation of a respiratory flow.
Extubation Criteria
15. Daily SBT
<100
Mechanical Ventilation
RR > 35/min
Spo2 < 90%
HR > 140/min
Sustained 20% increase in HR
SBP > 180 mm Hg, DBP > 90 mm Hg
Anxiety
Diaphoresis
30-120 min
PaO2/FiO2 ≥ 200 mm Hg
PEEP ≤ 5 cm H2O
Intact airway reflexes
No need for continuous infusions of vasopressors or inotrops
RSBI
Extubation
No
> 100
Rest 24 hrs
Yes
Stable Support Strategy
Assisted/PSV
24 hours
Low level CPAP (5 cm H2O),
Low levels of pressure support (5 to 7 cm H2O)
“T-piece” breathing
16. Gas flow to the inspiratory limb should be atleast
twice that of pt. minute ventilation in order to
meet pt peak respiratory rate
An extension piece of at least 12 inches should be
added to expiratory limb to prevent entrainment
of room air
If a patient is comfortable without signs of
detioration of gaseous exchange for 2 hrs , pt can
be safely extubated
17. Increase in RR by > 10 breath/min or to > 40
breath/min
Increase or decrease in BP by >20mmhg
Increase or decrease in HR by >20 beat/min
SaO2 <90% or PaO2<60mmhg
Increase in PaCO2>5mmhg and/or decrease in
Ph<7.3
Development of cardiac arrythmias
Signs of increased work of breathing(e.g. accessory
muscle use, nasal flaring, intercostal recession,
paradoxical respiration
Diaphoresis, complaints of dyspnoa, fatigue or pain
not relieved by reassurance
Detoriation of ABG is a late indication
18. Failure of SBT
Increased resistance
Decreased compliance
Increased WOB and exhaustion
Auto-PEEP
Respiratory
Backward failure: LV dysfunction
Forward heart failure
Cardiovascular
Poor nutritional status
Overfeeding
Decreased Mg and PO4 levels
Metabolic and respiratory alkalosis
Metablic/Electrolytes
Infection/fever
Major organ failure
Stridor
19. Start with 80% of RR of A/C
Reduce SIMV rate in steps of 1-3 breath/min at each
step
Moniter pt clinically and do the ABG
If Ph >7.3 reduce the rate further in steps of 1-3
breath/min
Reduce till a rate of 2-4 breath/min is reached
If deterioration develops in any step, increase the
SIMV rate again
Extubate the pt
Allow the pt muscle to rest at night by increasing the
SIMV rate
20. Set SIMV rate 2 breath/min less then in A/C plus
PSV15-20 cm H20
Reduce SIMV rate in steps of 1-3 breath/min plus
PSV 15-20cm h20
When SIMV reaches 2-4 breath/min, stop SIMV and
continue with PSV 15-20 cm H20
Reduce PSV in steps of 2cm H20 until PSV until PSV
is 5-6 cm H20
Extubate the pt.
If deterioration develops in any step, increase the
SIMV/PSV rate again
Allow the pt muscle to rest at night by increasing the
PSV rate
21. Start with PSV 15-20 cm H20
Reduce PSV in steps of 2cm H20 until PSV until
PSV is 5-6 cm H20
Extubate the pt.
If deterioration develops in any step, increase the
PSV rate again
Allow the pt muscle to rest at night by increasing
the PSV rate
23. It is defined as a need of reintubation within 7
days
Predisposing conditions
1. Increased resistive loads
2. Increased chest wall elastic loads
3. Increased lung elastic loads
4. Decreased drive
5. Muscle weakness
6. Impaired neuromuscular transmission
30. Candidates for early tracheotomy:
High levels of sedation
Marginal respiratory mechanics
Psychological benefit
Mobility may assist physical therapy efforts.
30
31. The benefits of tracheotomy include:
improved patient comfort
more effective airway suctioning
decreased airway resistance
enhanced patient mobility
increased opportunities for articulated speech
ability to eat orally, and
more secure airway
31
32. Patient at high risk of extubation failure who have
passed SBT, transition to NIV has reduced ICU stay
and short and long term mortality.
Initial SBT be conducted with inspiratory pressure
augmentation rather than T piece or CPAP was
associated with lower ICU mortality.
Cuff leak test should be used only in patient with
high risk of stridor.
Patients who failed cuff leak test but are otherwise
ready for extubation, systemic steroid 4 hr before
extubation should be used.
Marginal mechanics: in whom a tracheostomy tube having lower resistance might reduce the risk of muscle overload
psychological benefit from the ability to eat orally, communicate by articulated speech, and experience enhanced mobility