Sept 30 Conference Notes

Dr Bernadoni Right Heart Failure

PULMONARY HTN +  RV SPIRAL OF DEATH-

Definition is mean pulmonary artery pressure >20mmHg (on R heart cath). This can be estimated based on PA pressure >35 on echo

  • In patients with acute PE or with chronic pHTN and an acute VQ mismatch (eg pneumonia)
  • This is translated as an increased afterload on the RV, which does not tolerate this well. Pt becomes hypotensive, shocky.
  • Of note the LV will appear underfilled and hypokinetic on XR- this does not represent hypovolemia and the heart will not respond well to fluid administration.
  • RV vs LV perfusion- LV gets perfused only during diastole, whereas under normal circumstances the RV gets perfusion throughout the cardiac cycle. When pHTN is present (and right heart pressures are subsequently high) the transmural pressure across the RV only allows perfusion during diastole, causing ischemia and reduced contractility. It can also leads to relative or bradycardia through hypoperfusion of the SA/AV node

This group of events is known as the RV spiral of death.

HOW TO AVOID IT-

Fluids-

These pts are rarely volume responsive in a good way. Fluid administration pushes them further into above spiral

(In the setting of PE or chronic RHF/pHTN) when patients have evidence of R heart failure on echo (dilated RV, Mcconell’s sign, low TAPSE) they will not respond well to further fluid administration.

If their RV looks small/empty too, may consider a very small fluid bolus and evaluate for effect.

Most patients will benefit from diuresis, even when they are hypotensive and have LV underfilling (diuresis improves RV function and allows the pt to better fill their LV and increase their CO

PRESSORS

Instead, aggressively support MAP with pressors-

Aim is to raised MAP without raising pulmonary blood pressure

  • Norepinephrine is go to- increases contractility, gives peripheral vasoconstriction and at low doses should increased pulmonary vascular constriction much
  • Vaso is next line- gives peripheral vasoconstriction but actually reduces pulmonary pressures- this is exactly what is wanted
  • Can consider dobutamine as third line- start at 5mcg/kg/min

AIRWAY MANAGEMENT (+INHALED MEDS)

  • Intubation should be avoided if at all possible.
  • Consider use of nitric oxide prior to intubation (via BIPAP/HFNC)- see below
  • Paralysis causes hypoxia and hypercarbia- leading to hypoxic vasoconstriction and worsened pulm HTN and RV afterload
  • PPV increases RV afterload and reduces output

SO:

  • Have push dose pressors ready and strongly consider placing an arterial line prior to intubation
  • Have atropine at bedside
  • Use etomidate for sedative (ketamine may increase pulmonary vascular resistance)
  • Do not use straight RSI- continue ventilation (bagging or BIPAP)
  • Can break from ARDS net protocols and consider high FiO2 without raising PEEP as much as normal. Keep plateau AND PEAK pressures low

If pt remains hypotensive/hypoxic use inhaled nitric oxide- start at 40ppm

Or consider inhaled epoprostenol

In the absence of the above nebulize 5mg of nitroglycerin

SYSTEMIC VASODILATORS

Many chronic pHTN pts have continuous vasodilator pumps running

If pt has pump failure/otherwise their systemic meds are stopped restart them at the same dose immediately. They can be given peripherally if necessary

MASSIVE PE

SBP <90 for 15mins (submassive PE is with RV strain based on trop, BNP, echo etc)

  • Thrombolysis if bleeding risk is acceptable (this is a case by case decision taking into account a large number of factors). Note that is unclear how much thrombolysis actually causes bleeding in acute PE (studies show similar rates of bleeding with heparin alone cf heparin and tpa)
  • In patients with a pulse typical is 100mg IV tPA over 2h. Can give 10mg as a push and the other 90 as an infusion over the 2 hours
  • In cardiac arrest 50mg IV push
  • Note above doses have minimal evidence base.
  • Run heparin concurrently

INTERVENTIONAL THERAPY + ECMO

Catheter directed therapy recommended in patients with high bleeding risk, tPA contraindicated. This should initially be percutaneous embolectomy, can use catheter directed thrombolysis (tPA) if unsuccessful.

ECMO- Extra-corporeal membrane oxygenation

In PE ECMO is run Venousà Arterial (VA ECMO).

This allows circulation to bypass the heart and lungs, bypassing the failing right heart and the elevated pulmonary pressures. Helpful with the R heart failure of PE (or the reduced CO in STEMI, myocarditis, low+slow poisoning etc)

In patients with pure lung pathology (ARDS, asthma, pulmonary contusion) it can be run Venous-Venous (VàV), which bypasses the lungs but still requires good cardiac function

Consider ECMO if non ECMO mortality is >50%, even more so if >80% (and has ECMO responsive pathology)

Reserve for pts likely to have benefit (reversable cause of current illness, no major life limiting comorbidities or advanced age) and less likely to have harm (pts require heavy anticoagulation so those with high bleeding risk are likely to be harmed)

———————————————————————————————–

Josh Senn- GU abx

  • Don’t treat asymptomatic bacteria (>105 CFU) without symptoms unless pregnant or a guy pending a urological procedure
  • Use nitro 100 bid (if CrCl >30) or cephalexin qid for 5 days for uncomplicated UTI in a male or female
  • Chlamydia- use 1g azithromycin PO one time. Use doxy 100mg BID for 7 days if PID. Second line levofloxacin, erythromycin, ofloxacin.
  • Gonorrhea- Ceftriaxone 250mg IM x1 (+azithro or doxy). Alternatives are cefixime or gentamicin + azithro
  • Trichomoniasis- metronidazole 500mg PO BID x7 days has higher cure rate than 2g one time. Topical gel does not have good cure rate. Alternative is tinidazole
  • BV- 500mg BID x 7 days, can use vaginal gel BID x 7 days. Alternatives are clinda or tinidazole
  • Benzathine penicillin 2M units for primary or early latent. More complex with neurosyphilis

2 thoughts on “Sept 30 Conference Notes

  1. Inside 5 minutes, I had almost killed myself when loading up means too much weight for a set of bench presses.
    Your training routine throughout a bulk must be targeted and intentional.
    Year-long bulking is a powerful strategy for
    severe lifters.
    That is, if you prepare on Monday, you’ll
    have Tuesday off, then practice once more on Wednesday.
    Nonetheless, you only have limited funds in your recovery account.
    Overdo the cardio exercise, and also you might overdraw that account and end up struggling to recover from and adapt
    to your strength training routine. For the muscle-gain specific practice, aim
    for a snack or meal wealthy in protein within an hour or so
    after your exercise.
    This is a true full-body train that instantly hits your hamstrings, lower again, lats, rhomboids,
    trapezius, deltoids and biceps. In this workout, you’ll be doing a twist on the traditional deadlift rep scheme that can ramp up the intensity over 6 sets of 6 reps.
    A exercise that includes heavy compound workouts with a combine of isolation exercises and
    general volume (more units and reps). I’ll explain why under, but first let’s
    check out what a simple bodybuilding workout appear to be.
    This section continues to employ a four-day break up, however bodyparts are paired differently—namely,
    chest and again are trained on the same day (Day 1),
    as are biceps and triceps (Day 4). This is little more
    than a method of fixing issues up, giving your muscles a
    barely totally different stimulus to spark new muscle
    progress.
    It automates your programming, adapts to your progress,
    and optimizes your workouts, so you don’t have
    to overthink it. However, while full body splits can maintain your muscle mass,
    they will not be optimal for long-term progress. The lack of
    specialization can lead to insufficient quantity for
    specific muscle groups. If your objective is to build muscle, consider this
    strategy a stopgap rather than a permanent solution.
    For occasion, many bodybuilders advocate for splits that allow for muscle recovery
    whereas maximizing tension. They typically argue that training a muscle group two to three occasions
    per week can improve growth.
    As somebody that already spends an excellent few hours per week within the health club you’re no
    stranger to hard work and heavy weights. Lastly, I’ll repeat what
    I stated about progressive overload. It is the lacking key in most people’s exercise routines, and
    without it, they spin their wheels for years with out
    making any progress. The purpose the long head of the triceps is labored
    so properly from the barbell lying tricep extension is that the muscle head passes each your elbow
    joint and your shoulder joint.
    Compound and isolation movements may be equally efficient at
    resulting in muscle hypertrophy when it comes to the best train sort for
    muscle building. If loading development isn’t attainable, attempt for a higher number of sets whereas maintaining the number of reps unchanged.
    It won’t be as effective as load progression for constructing energy, however it’s going to help you construct mass.
    This means you’ll do one set of the first carry, rest,
    then one set of the second raise, relaxation again, and repeat until
    sets are full. Or you can do a cardio session on your non-weight training days.
    This would allow you to stick to the true 30-minute exercise plan.
    Full Body training is efficient for beginners, however may
    limit muscle-specific focus compared to more specialised splits.
    If you want to take the guesswork out of your training and start constructing muscle smarter, not harder,
    take a look at Dr. Muscle. Bounce out of bed the subsequent day with excitement, knowing that you are going to
    smash your workout. As you head out the door, your psychological intensity stage must be
    at about 7 out of 10. Driving to the health club, see yourself
    efficiently completing your max lifts again, and dial it as a lot as a
    9. Then, as you emerge through the gym doorways you must be raring
    to assault the weights at a ten.
    Max-OT is a good program for someone who’s under a time schedule.
    If your time is restricted, look no farther than this program.
    The solely drawback is that you’ll need a spotter for plenty of your sets.
    You shall be working each set to failure — it
    wouldn’t be smart to do this and not utilizing a spotter.

    A major con with this program is the shortage of
    frequency and lack of quantity.
    The push pull legs (or PPL for short) break up is
    considered one of the hottest exercise applications for building muscle and
    energy positive aspects. Many athletes and bodybuilders,
    including superior lifters, swear by the PPL routine as
    one of the best ways to train for muscle mass. Not only is it effective for muscle progress, but you’ll find a way to tailor it
    to your schedule to reach your fitness objectives, whatever they may
    be.
    It will cowl all the most important things you have to know.
    Analysis exhibits that how many units you do per muscle group is strongly associated to how a lot muscle and energy you achieve.
    Now let’s go over a few of the finer details like sets, reps, and relaxation.
    This is the difference between your youthful days of
    lifting weights to how you want to train today,
    being over 40. In all actuality, being over 40 is a cause you should be much more disciplined
    and committed to figuring out. And in this post, I’m going to give you a complete workout
    routine that can assist you build muscle over 40.
    That is, alternating between low, medium and high reps will build muscle faster than sticking to the identical number of reps on an everyday basis.

    Whereas this isn’t essential, it has been proven (in some studies at least) to have
    a small but helpful impact on muscle progress [3].
    However there’ll come a point when the features
    slow down, or even grind to a halt utterly. Once you get to
    that point, likelihood is you’ll need to ramp up the amount of coaching you’re
    doing to continue making progress.
    Yet they have been milking each little bit of depth that they might from that poundage.
    For your last two sets of the incline bench press you’ll be doing drop units.
    You will start with the identical weight that you used for the earlier 3 sets.
    This will hold the strain on the pecs throughout the whole
    motion. These are isolation exercises that assist to develop the muscles you’re not necessarily hitting within the big three lifts.
    Since putting this workout routine on the market back in 2010, I’ve
    gotten tons of feedback from literally 1000’s of people.

    For anyone trying to optimize mass, boost strength or simply enhance their fitness and conditioning ranges, this provides a quick and efficient answer.

    It’ll take motivation and willpower to take per week off training
    after some solid work in the gym for the previous couple of weeks, but it’ll be price it
    if you see the outcomes. If you fall into the entice of skipping
    periods or having an ‘I’ll go tomorrow’ attitude, you’ll soon find that
    your fitness center membership collects mud
    and your gains are non-existent. It can take time for positive, but what we’re after is so that you just can achieve common and frequent workouts in the early phases
    of your program. In this detailed information we take you
    thru every step of the mass building course of.
    This is typically carried out on your last set and in direction of the top of your exercise.
    Both method, I do recommend taking no much less than 1 day of
    relaxation after four consecutive exercises. You’re going to wish to have restoration time with these intense exercises.
    Speaking of damage, you wish to try and shake up your routine every
    so often. If you progressively overload the same muscular tissues again and again in a brief amount of time, you run the chance of damage from overusing these muscular tissues.
    The finest training cut up is dependent upon your physique,
    goals, and restoration capability. Flexibility in your training schedule
    is important for long-term success.
    Sure, however it’s really helpful to begin with conservative weights and focus on studying
    correct form to avoid harm and actually get essentially the most out
    of every of your exercises. Whether you’re a
    seasoned lifter looking to break via those dreaded plateaus or an intermediate lifter seeking speedy positive aspects, this program is
    your information to attaining massive results in less time.
    You take the time to assess key markers of physique composition and efficiency.
    We’ve already calculated that a 200-pound male with
    10% body fats has a BMR of 2,332 cals. If he has a really energetic lifestyle, he’d multiply this figure by 1.725 to achieve a TDEE of four,022 cal.
    This is his energy balance—eat more and he positive aspects weight; eat less and he loses weight.
    To start, you need to have body fats of 14% or much less,
    have at least 18 months’ coaching expertise, and be willing to commit to 5
    hours’ training a week.
    In addition, they permit you to get a full vary of
    motion both on the bottom and prime of the movement.

    Attempt some push-ups and squats as we discussed in our
    energy coaching section. While you can’t spot reduce fat, you can choose to construct more muscle in particular areas, changing your body form.

    Let’s start with the 5 day break up that most individuals
    think of when it comes to a 5 day exercise plan – the 
    Standard 5-Day Cut Up. Whereas at some point
    you train decrease pulling and one other you prepare decrease pushing, you can’t isolate your quadriceps, hamstrings, and glutes when performing compound actions.
    You can target all muscle tissue in a week with comparatively shorter, centered periods, making it easier to take
    care of consistency and avoid fatigue. Plus, the routine allows for prime frequency
    with out overtraining any muscle group. For example, after a “push” exercise, your chest and triceps have time to
    get well when you focus in your back and biceps on the “pull” day, and your legs get a
    break on the “legs” day. Balancing your coaching
    helps forestall muscular imbalances, which in the end reduces the chance of damage and optimizes general energy
    and muscle development.
    In case you are performing intense weightlifting or compound workout routines, you might require barely extra
    rest between sets, which is totally acceptable.
    Guarantee that you do not relaxation excessively to the extent that your muscles settle
    down. Your coronary heart rate will point out when you are prepared for the next
    set. Nonetheless, problem your self as there could also be cases where you
    delay the remainder period greater than essential. With numerous exercise splits to choose from,
    the 5 day exercise split is among the many most popular choices, tested by pro bodybuilders for decades.

    But extra importantly, it’s going to assist keep good health and lessen the chance of many
    issues that plague older people. The fact is any exercise
    can cause injury should you do it incorrect
    and you’re not centered. For example, if you want to do this final workout on Friday to find a way
    to have the weekend off, that’s fine. This goes that will help you get
    in the best mindset to where you’ll be succesful of go in there and kill
    your exercise.
    This frequency permits you to stimulate
    muscle fibers more effectively while giving them sufficient restoration time.
    Understanding the method to manipulate volume is important for maximizing positive aspects.
    If you discover stagnation, think about adjusting the variety of sets or reps, and even the sort of
    workouts you carry out. This can provide the stimulus wanted for continued progress.
    When designing a coaching cut up, focus on a couple of key
    ideas. These rules ensure that your workouts are effective and that you could
    recuperate properly. Make positive your muscles have sufficient time
    to recuperate between sessions.
    Given a possibility and performed the proper means, you can expect to
    build muscles by utilizing it. It makes use of a 6-day split and can work for anybody
    who performs the workout routines appropriately, who’s in fairly healthy situation, and who eats
    proper and sleeps enough. If your fitness center has a comfortable decline press machine, like a plate-loaded hammer strength
    machine, use it.

    References:

    what are the types of steroids

Leave a Reply

Your email address will not be published. Required fields are marked *