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Atrial fibrilation-guidelines

MANAGEMENT OF ATRIAL FIBRILLATION IN ADULT PATIENTS
A. VENTRICULAR RATE CONTROL
RATE CONTROL
AF secondary to sympathetic stimulations (ie. Sepsis, post-op…) Calcium antagonists: diltiazem, verapamil USUAL SUGGESTED IV DOSES
Loading IV/PO: 10-15mcg/kg (lean body weight) in 3-4 divided doses during the 1st 24hrs Maintenance: 0.125-0.5mg per day (adjust dose per renal function, levels, heart rate) Loading IV: 15-20mg (0.25mg/kg) over 2min, may repeat 20-25mg (0.35mg/kg) in 15min X 1 to control rate Infusion: 5-15mg/h titrate to heart rate and BP (mix 100mg/100mL D5W) IVP 2.5-5mg over 2 min initially, may repeat 5-10mg in 15-30min if needed (maximum 20mg) OR 5mg q15min to total dose of 30mg IVP 5mg slow q5min up to 3 doses (maximum 15mg) Infusion: 0.05-0.2mg/kg/min titrate to heart rate and BP (2.5gm/250mL NS) B. PHARMACOLOGIC CARDIOVERSION AND MAINTENANCE OF SINUS RHYTHM:
ANTI-ARRHYTHMIC AGENTS
CARDIOVERSION OF
HEMODYNAMICALLY STABLE AF
MAINTENANCE OF SINUS RHYTHM
WITHOUT WPW
DURATION
DURATION > 48
IMPAIRED HEART
HEART FUNCTION
48 HOURS
HOURS OR UNKOWN
CHF or EF < 40%
PRESERVED
Delayed cardioversion:
Early cardioversion: begin

* Note: only one of the above agents should be used at a time
♥ For patients who are hemodynamically unstable (ie. hypotensive), suggest DC cardioversion (start at 200 Joules). ♥ For patients with WPW, avoid adenosine, beta-blockers, calcium antagonists, digoxin and may use DC cardioversion,
amiodarone, procainamide, flecainide, propafenone, sotalol. USUAL SUGGESTED DOSES
♥ Loading infusion: 150mg/100mL IV D5W over 10 min (15mg/min). ♥ Infusion: 1mg/min X 6hrs then 0.5mg/min (mix 900mg/500mL D5W). Max cumulative dose is 2.2g/day. ♥ Maintenance: 200mg qd PO ♥ Cardioversion: 200mg q4h (maximum 800mg) ♥ Maintenance: 100-300mg q12h Oral (SR product) (reduce doses in renal dysfunction) ♥ 500mcg q12h PO (adjust doses based on renal function and QT intervals) for conversion and maintenance ♥ Initiation of therapy requires hospitalization X 3 days ♥ MD must be certified to order, use standing order sheet for Dofetilide, follow Dofetilide guidelines ♥ Maintenance: 50-100mg bid up to 400-600mg/day (reduce doses in renal dysfunction) ♥ ≥ 60kg : 1mg IV over 10min, may repeat same dose in 10min X 1 (mix dose in 50mL D5W) ♥ < 60kg : 0.01mg/kg over 10min, may repeat same dose in 10min X 1 (mix dose in 50mL D5W) ♥ Loading infusion: 20mg/min (maximum total dose 17mg/kg). Loading infusion can /should be D/C when 1) arrhythmias are suppressed, 2) hypotension occurs, 3) QRS is prolonged by 50% of baseline, 4) QTc > 500msec ♥ Maintenance infusion: 1-3mg/min (mix 1g/250mL D5W or NS). ♥ Maintenance oral: 1-4gm/day (q4-6hr with immediate release products, q6-12h with SR products) ♥ Maintenance: 150-300mg q8h (adjust dose in hepatic dysfunction) ♥ Cardioversion: 200mg quinidine sulfate PO, followed 1-2 hours later by 400mg ♥ Maintenance: 324-468mg quinidine gluconate q8h, or quinidine sulfate 200-400mg qid PO ♥ Maintenance: 160-320mg per day in 2 divided doses (adjust doses in renal dysfunction) ♥ Initiation of therapy requires hospitalization C. ANTICOAGULATIONS FOR STROKE PREVENTION:
RISK STRATIFICATION
DEFINITIONS
RECOMMENDATIONS
High-Risk Patients
Prior stroke/TIA or systemic embolus, h/o HTN, poor ♥ 1st choice: warfarin (INR 2-3, target 2.5) LV systolic function, age > 75yrs, rheumatic mitral ♥ 2nd choice: ASA (if warfarin is contra- indicated or poor candidate for warfarin) Moderate-Risk Patients
Age 65-75 yrs, DM, CAD with preserved LV systolic Low-Risk Patients
Age < 65 yrs lone AF (no cardiovascular disease)
Anticoagulation for elective cardioversion:
1. AF < 48hrs: Heparin during the peri-cardioversion period, even though the risk of embolism is low 2. AF ≥ 48hrs: a) Preferred: Warfarin (INR= 2-3, target= 2.5) for 3 weeks before and at least 4 weeks after cardioversion b) Alternative: Heparin then TEE before cardioversion; if there is no thrombi, followed by warfarin until normal sinus rhythm has been maintained for at least 4 weeks Anticoagulation upon discharge:
1. Anticoagulation with Low-molecular-weight heparin can be considered in eligible patients for early discharge followed by oral anticoagulation.
REFERENCES:
1. A symposium: atrial fibrillation: advances for the new millennium. Am J of Cardiol 2000;85(10A): 1D-52D 2. Albers GW et al. Antithrombotic therapy in AF. Chest 2001;119(1): 194S-206S 3. Falk, R. Atrial fibrillation. N Engl J Med 2001;344(14):1067-1978 4. ILCOR Member Organizations. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care – An international consensus on science. Circulation 2000;102(suppl I):I-1−I-11 5. Prystowsky EN et al. Management of patients with AF. Circulation 1996;93:1262-1277 Jennifer Bui, Pharm. D., Critical Care John Zimmerman, MD, Chief EPS AF guidelines(3/25/01,4/17/01,4/30/01,5/8/01,5/11/01,5/22/01,6/8/01)

Source: http://www.humcmd.net/documents/pinf/glos/atrial%20fibrilation-guidelines.pdf

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