psa Flashcards
BNF guidance recommends that if INR > 1.5 on the day before surgery
phytomenadione (vitamin K) 1–5 mg orally, using the IV preparation
Non LMWH VTE thromboprophylaxsis
Apixiban 2.5 mg oral twice a day
Antiplatelets and surgery
usually stopped up to 7 days before surgery
Male UTI low GFR
trimethoprim 200 mg orally 12-hrly for 7 days
Starting ACEi what biochem can you expect
small rise <20% in creatinine
Side effects: ACEi – Amlodipine – Amiodarone – Carbamazepine – Clozapine – Gliclazide – Metformin – Statins –
ACEi – cough, hyperkalaemia Amlodipine – oedema Amiodarone – pulmonary fibrosis, thyroid dysfunction Carbamazepine – hyponatraemia Clozapine – agranulocytosis Gliclazide – hypoglycaemia Metformin – lactic acidosis Statins – myalgia
Enzyme inducers
PC BRAS –
phenytoin, carbamazepine, barbiturates, rifampicin, alcohol (chronic excess) sulphonylureas.
Others: topiramate, St John’s Wort, and smoking
Enzyme inhibitors
AO DEVICES – allopurinol, omeprazole, disulfiram, erythromycin, valproate, isoniazid, ciprofloxacin, ethanol (acute intoxication), sulphonamides.
Others: grapefruit juice, amiodarone, and SSRIs (fluoxetine, sertraline).
ACEi monitoring
Renal function and electrolytes should be checked before starting ACE inhibitors (or increasing the dose) and monitored during treatment (more frequently if side effects mentioned are present
Review in antidepressant
How long before consider change
After remission?
Key electrolyte
Patients should be reviewed every 1–2 weeks at the start of antidepressant treatment
4 weeks (6 weeks in elderly)
continued at the same dose for at least 6 months (about 12 months in the elderly), or for at least 12 months in patients receiving treatment for generalised anxiety disorder (as the likelihood of relapse is high). Patients with a history of recurrent depression should receive maintenance treatment for at least 2 years.
hypoNa - consider if drowsy
Satisfactory INR
Within 0.5
Warfarin and surgery
If INR>1.5 day before surg
When to resume if haemostasis adequate
should be stopped 5 days before elective surgery;
phytomenadione (vitamin K1) by mouth given the day before surgery if the INR is ≥1.5.
If haemostasis is adequate, warfarin sodium can be resumed at the normal maintenance dose on the evening of surgery or the next day.
LMWH and surgery ?
High risk of bleeding surgery?
The low molecular weight heparin should be stopped at least 24 hours before surgery;
if the surgery carries a high risk of bleeding, it should not be restarted until at least 48 hours after surgery.
Pt on warfarin and emergency surgery?
If cant be delayed ?
delayed for 6–12 hours can be given intravenous phytomenadione (vitamin K1) to reverse the anticoagulant effect.
If surgery cannot be delayed, dried prothrombin complex can be given in addition to intravenous phytomenadione (vitamin K1) and the INR checked before surgery.
Bisphosphonates monitoring
Correct disturbances of calcium and mineral metabolism (e.g. vitamin-D deficiency, hypocalcaemia) before starting treatment. Monitor serum-calcium concentration during treatment.
reduce vasomotor symptoms in women who cannot take an oestrogen,
Clonidine hydrochloride
monitoring HRT
at least annually and for osteoporosis alternative treatments considered
Insulin therapy perameters
In adults
between 4 and 9 mmol/litre for most of the time (4–7 mmol/litre before meals and less than 9 mmol/litre after meals).
In children
between 4 and 10 mmol/litre for most of the time (4–8 mmol/litre before meals and less than 10 mmol/litre after meals).
Methotrexate monitoring
have full blood count and renal and liver function tests repeated every 1–2 weeks until therapy stabilised, thereafter patients should be monitored every 2–3 months.
be advised to report all symptoms and signs suggestive of infection, especially sore throat
Local protocols for frequency of monitoring may vary.
Statin contraception
Adequate contraception is required during treatment and for 1 month afterwards.
statin monitoring
What if raised ALT ?
Before treatment
at least one full lipid profile (non-fasting)
triglyceride concentrations
thyroid-stimulating hormone
and renal function should also be assessed.
Liver function
NICE suggests that liver enzymes should be measured before treatment, and repeated within 3 months and at 12 months of starting treatment,
Those with serum transaminases that are raised, but less than 3 times the upper limit of the reference range, should not be routinely excluded from statin therapy. Those with serum transaminases of more than 3 times the upper limit of the reference range should discontinue statin therapy.
Creatine kinase
Before initiation of statin treatment, creatine kinase concentration should be measured in patients who have had persistent, generalised, unexplained muscle pain (whether associated or not with previous lipid-regulating drugs); if the concentration is more than 5 times the upper limit of normal, a repeat measurement should be taken after 7 days. If the repeat concentration remains above 5 times the upper limit, statin treatment should not be started; if concentrations are still raised but less than 5 times the upper limit, the statin should be started at a lower dose.
Diabetes
Patients at high risk of diabetes mellitus should have fasting blood-glucose concentration or HbA1C checked before starting statin treatment, and then repeated after 3 months.
when titrating drugs, for example, thyroxine to get TSH in range….
Make the smallest incremental change possible
When can you start POP
“You can start the pill at any time if you are sure you are not pregnant. You will need to use condoms for the first seven days of taking the pill.”
POP - If one pill is missed or a new pack is started more than three hours* late ¹
Take the missed pill straight away, if you have missed more than one pill, only take one pill.”
“Take the next pill at the usual time you would take it, this might mean you have to take two pills in one day. Don’t worry, this is not harmful.”
“Unfortunately, you are not protected from pregnancy and therefore you should use condoms for the next two days. Continue to take your pills as you normally would.”
“If you have had sex in the time you have missed your pill, you may need to seek advice for emergency contraception.”
POP - If one pill is missed less than three hours* late
“Take the pill as soon as you remember to take it and then take your next pill at the usual time you would take it. You will be protected from pregnancy.”
*12 hours if it is the desogestrel progesterone only pill
COCP - 1 pill missed
“Take the missed pill straight away and continue taking the rest of the pack as normal. Emergency contraception is not needed.”
COCP - 2 Pills missed
“Take the most recent pill you missed straight away and leave any of the pills you missed before then. Use condoms or avoid sex for the next 7 days. If you have had sex in the previous seven days you need to seek advice for emergency contraception.”
What to do with the rest of the pack after a missed pill
If seven or more pills left in the pack:
If less than 7
“If there are seven or more pills left, then you should finish the pack and have the usual 7-day break”.
“If there are less than seven pills left in the pack then the pack should be finished and a new pack should be started the next day. This means taking the pills back to back.”
Initial resus fluids
500 ml bolus of a crystalloid solution in <15mins
can repeat up to 2000ml
Daily maintenance fluid requirements ?
Who does it change for>
25-30 ml/kg/day of water
1 mmol/kg/day of potassium, sodium and chloride and
50-100 g/day of glucose to limit starvation ketosis
[Elderly patients
Patients with renal impairment or cardiac failure
Malnourished patients at risk of refeeding syndrome
=20-25 ml/kg/day]
Maintenance fluids in obese
When prescribing routine maintenance fluids for obese patients you should adjust the prescription to their ideal body weight.
When use heparin over LMWH
in severe renal impairment
Unconcious hypo in hospital inital Mx
15 g glucose IV using a 20% solution
Glucagon 1mg IM is second line
Monitor BB in AF
Rate - rate control
