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mg to ml 在 Adrian Lo Dejavu Facebook 八卦

Adrian Lo Dejavu By Adrian Lo Dejavu

2020-08-10 02:25:53 有 1,041 人按讚
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🐄MILF MILK🐄
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mg to ml 在 加護病房查房日誌 Facebook 八卦

加護病房查房日誌 By 加護病房查房日誌

2018-01-12 12:33:00 有 450 人按讚
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加護病房查房日誌20180112
昨天看到有位過去共事過的腎臟科醫師，在臉書上發表xyzal(levocetirizine)這個抗組織胺藥品在腎臟功能不全的病患，需要減量使用，而在腎絲球過濾率小於10 ml/min以及接受透析的病患，這顆藥物是禁止使用的！！
老師心有戚戚焉阿，我相信每位醫療專業人員應該都知道某些大部分由腎臟排除的藥品，在腎功能不全的情況下，可能需要調整劑量或是不建議使用。但是因為臨床忙碌的關係，不注意的情況下，仍有可能開立過量或是不小心使用，或許多數的情況下，病人沒有異狀，但是有可能是我們無法察覺，或是機率很低，但我想真的被我們遇到一次，就有可能吃不完兜著走。
老師分享一下本身的經驗，大家看看臨床上有沒有類似的情境。
1. 就像昨天腎臟科醫師說的，xyzal這個藥品，CrCl 30 to 50 mL/minute: 2.5 mg once every other day，甚至在CrCl <10 mL/minute, hemodialysis patients: Use is contraindicated. 但有時候老師甚至在腎臟科本科的醫師在ESRD的病人開立此藥品。
2. Baclofen，老師真的遇過在腎功能不全，禁用的病人，一吃結果昏迷不醒的。
3. Metoclopramide，也就是primperan，在腎功能不好的病人也要減半使用，以避免出現EPS等情況，尤其是帕金森氏症的病人。
4. Benzbromarone，這個降尿酸的藥品，文獻上是說在腎功能不好的病人，使用這個藥品是很低甚至沒有降尿酸的效果，但同樣的老師還是有看到醫師這樣使用。
5. H2-blocker, famotidine or cimetidine，其實也是一樣要減半的。
OK，我想大家應該都知道抗生素尤其是vancomycin等有腎毒性的藥品，腎不好要減量，但相對的在一些比較安全的藥品來說，就常被忽略。
有的時候，我們必須去看仿單或文獻上面寫要調整劑量，或禁用或不建議使用的原因為何?
不外乎是
1. 在過往藥物動力學的實驗中發現，當腎功能不全時，有可能藥物排不出體內，所以血中濃度上升，建議不要用常規的劑量，因為有可能會增加濃度相關的副作用。
2. 曾有案例或從臨床試驗中發現，腎功能不全使用常規劑量，可能會增加某類的副作用。
3. 最後還有一種是，在臨床試驗時，將腎功能不全的病人排除，所以我們無法得知這樣使用的問題何在，是有毒性或沒有?但其實若在臨床試驗會考慮排除，通常也是因為在前期的試驗中，可能看到某些不好的結果。
總而言之，不管怎樣，老師的建議是應先以實證為基礎，再以病人實際的反應進行調整，若真能確定這樣使用病人無大礙，在與病人溝通良好，達到共識的前提下，我想應該是還OK，只不過，若有其他可以選擇的藥品，還是建議選用相對安全的藥品，不需要冒險。
歡迎大家分享自己的使用經驗，例如: 是否有遇過使用primperan在腎功能不全的病人，無調整劑量出現EPS等。

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這是一個分享加護病房中查房心得，醫藥新知的地方。以簡單的方式呈現給大家，希望對大家有所幫助。
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2021-09-01 17:17:34 有 367 人按讚
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急性心衰竭 (心衰竭指引 ESC guidelines, 2021)

Part 2~~

key words:
AHF: 急性心衰竭(Acute heart failure)
ADHF: 急性失償心衰竭(Acute decompensated heart failure)
Cardiogenic shock: 心因性休克
MCS：機械式循環輔助 (Mechanical circulation Support)
RRT：腎臟替代療法(Renal replacement therapy)
Natriuretic peptides (BNP, NT-proBNP, MR-proANP)
MR-proANP = mid-regional pro-atrial natriuretic peptide
NT-proBNP = N-terminal pro-B-type natriuretic peptide

AHF流行病學、診斷和預後

AHF 是指 HF 的症狀和/或癥兆迅速或逐漸發作，嚴重到足以使患者尋求緊急醫療照護，導致意外入院或急診就診。AHF患者需要緊急評估，隨後開始或積極治療，包括經由靜脈治療或裝置步驟。AHF在院內死亡率為4%-10% 。出院後一年死亡率: 25–30%，死亡或再入院率高達 45% 以上。

AHF 可能是 HF第一次發作，或者是由於慢性 HF 的急性失償。與急性失償心衰竭相比，新發HF患者的院內死亡率可能較高，但出院後死亡率和再住院率較低。

AHF的診斷檢查包括心電圖、心超、胸部X光、檢查和肺超檢查。尤其無法檢測Natriuretic peptides(NP)時。如果診斷無法確定是否心因性心衰竭時，則檢驗血漿 NP數值（BNP 或 NT-proBNP 或 MR-proANP）。

NPs正常：排除AHF 的診斷。
急性 HF 的臨界值是：
BNP <100 pg/mL、
NT-proBNP <300 pg/mL
MR-proANP <120 pg/mL。

但NP值升高與多種非心臟疾病相關， 在一些患有晚期失償末期HF、肥胖、突發性肺水腫(flash pulmonary edema)或右側AHF的患者可測得低值NP。有AF和/或腎功能異常，其NP數值較高。

AHF診斷流程
• 初步驗血檢驗包括肌鈣蛋白(troponin)、血清肌酐、電解質、血尿素氮或尿素、TSH、肝功能檢查及D-dimer(疑似肺栓塞)；和procalcitonin (感染)，動脈血氧分析(呼吸窘迫)，以及lactate(低灌注的情況)。(註：procalcitonin降鈣素原可用於肺炎的診斷，數據 >0.2 μg/L 時，可能有使用抗生素治療的適應症。)
• 特定檢查包括冠狀動脈造影（疑似 ACS）和 CT（疑似肺栓塞）。
• 急性心衰診斷的NT-proBNP臨界值：
<55歲：> 450 pg/mL
55 -75 歲：> 900 pg/mL
> 75 歲> 1800 pg/mL

AHF臨床表現

AHF呈現四種主要的臨床表現，主要根據充血和/或外周血流灌注不足的原因所呈現出來不同的臨床表現。(參考表21)

四種臨床表現分別是：
1.急性失償心衰竭
2.急性肺水腫
3.孤立性右心室衰竭
4.心因性休克

各種急性心衰竭的臨床表現：

1.急性失償心衰竭(Acute decompensated heart failure, ADHF)
急性失償心衰竭 (ADHF) 是 AHF 最常見的形式，佔臨床表現的 50-70%。它發生在有HF病史和心臟功能異常，包括 RV 功能異常。與急性肺水腫表型不同，發作時程呈現漸進，主要變化是導致全身充血，液體滯留。
治療：
a. 使用環利尿劑，減少水份滯留。
b. 強心增壓劑(Norepinephrine)：於周邊低灌注時使用。
c. 短暫使用機械式循環輔助(MCS)：於周邊低灌注，器官受損時使用
c.腎臟替代療法(RRT: Renal replacement therapy)：如果利尿劑無效或腎病末期時，可考慮使用RRT (Class IIa)

2.急性肺水腫
急性肺水腫診斷的臨床標準包括:
呼吸困難合併端坐呼吸、
呼吸衰竭（低血氧症-高碳酸血症）、
呼吸急促、
>25 次/分鐘和呼吸功增加。

治療：
a. 給予氧氣，持續氣道正壓通氣、非侵入性正壓通氣和/或高流量鼻管。
b. 給予靜脈利尿劑。
c. 如果收縮壓 (SBP) 高，可以給予靜脈血管擴張劑，以減少 LV 後負荷。在少數晚期 HF 病例中，急性肺水腫可能與低心輸出量有關，在這種情況下，需要使用強心劑(Inotropics)、血管加壓藥(vasopressors)和/或MCS 來恢復器官灌注。

3. 孤立性右心衰竭 (Solitary RV Failure)
a. RV 衰竭是由於 RV 和心房壓力增加以及全身充血。RV 衰竭也可能損害 LV 填充功能，最後導致心輸出量減少。
b. 利尿劑通常是治療靜脈充血的首選藥物。
c. Norepinephrine，強心劑、血管加壓劑：適用於低心輸出量和血流動力學不穩定。可能優先選用能降低心臟充填壓的強心劑, 如，levosimendan, phosphodiesterase type III inhibitors。
d. 由於強心劑可能會使動脈低血壓更嚴重，必要時，可以與norepinephrine合用。

4.心因性休克
心因性休克是由於原發性心臟功能異常導致心輸出量不足的症候群，包括危及生命的組織低灌注狀態，可導致多器官衰竭和死亡。

心因性休克的診斷要件：

灌注不足的臨床症狀：例如四肢冷汗、少尿、精神錯亂、頭暈、脈壓變窄、低灌注。血清肌酐升高、代謝性酸中毒和血清乳酸升高，反映出組織缺氧和細胞代謝改變導致器官功能障礙。低灌注並不常合併低血壓，因為可以通過代償性血管收縮（使用/不使用升壓劑）來維持血壓。

應儘早開始治療心因性休克：早期識別和治療潛在原因。
尋找病因(口訣：CHAMPIT)：(see photo)
包括急性冠心症，高血壓急症，快速心律不整，嚴重心搏過慢，傳導阻滯，機械性原因(如，急性瓣膜返流，急性肺栓塞，感染，心肌炎，心包填塞)

嚴重休克病人則需要考慮將MCS(Class IIa)作為移植的過渡時期使用。

急性心衰竭的藥物治療：

利尿劑
靜脈利尿劑是AHF治療的基本。它們增加鈉和水份的排泄，適用於治療大多數AHF患者的體液過度負荷和充血。
a. Furosemide: 起始劑量為 20-40 mg，或靜脈推注 10-20 mg。Furosemide可以每天 2-3 次推注或連續輸注。由於給藥後，會有鈉滯留的可能性，因此不鼓勵每日單次推注給藥。連續輸注時，可使用負荷劑量以更早達到穩態。
b. 利尿劑治療開始後應立即評估利尿反應，並可通過在2或6小時後進行當時尿鈉含量(urine sport sodium) 和/或通過測量每小時尿量來評估。
c. 適當的利尿反應可以定義為2小時後，尿鈉(urine spot sodium) >50–70 mEq/L and/or
d. 前6小時尿量 >100–150 mL/h。
e. 如果利尿反應不足, 環利尿劑IV劑量可以加倍，並進一步評估利尿反應。
f. 如果利尿反應仍然不足，即使利尿劑劑量加倍，但每小時利尿量<100 mL，可以考慮同時使用其他作用於不同部位的利尿劑，即thiazides, metaolazone, acetazolamide。但需要仔細監測血清電解質和腎功能。

血管擴張劑
a. 靜脈血管擴張劑，如nitrate，可以擴張靜脈和動脈，因此減少靜脈返回心臟，充血減少，後負荷降低，增加心搏出量，因此緩解症狀。
b. Nitrate主要作用於靜脈，而nitroprusside則是動靜脈擴張。由於它們的作用機制，靜脈注射後，血管擴張劑可能比利尿劑更有效。急性肺水腫是由於後負荷增加和液體重新分配到肺部，而沒有周邊積液。
c. 當 SBP > 110 mmHg 時，可以考慮使用靜脈血管擴張劑來緩解AHF症狀。它們可以以低劑量開始並逐漸增加以達到臨床改善和血壓控制。應注意避免因前負荷和後負荷過度降低而導致的低血壓。因此，對於 LVH 和/或嚴重主動脈瓣狹窄的患者，應謹慎地使用。

強心升壓劑 (Inotropes)
a. 低心輸出量和低血壓患者的治療需要強心升壓劑（見表 22）。使用於左室收縮功能障礙、低心輸出量和低收縮壓（例如 <90 mmHg）導致重要器官灌注不良的情況。必須從低劑量開始謹慎使用，並在密切監測下逐漸增加。

b. Inotropes其是那些具有腎上腺素能機制的藥物，可引起竇性心動過速，增加 AF 患者的心室率，可能誘發心肌缺氧和心律異常，增加死亡率。

血管加壓藥(Vasopressors)
a. Norepinephrine具有顯著動脈收縮，適用於嚴重低血壓患者。主要目的是增加對重要器官的灌注。但會增加 LV 後負荷。因此，可以考慮同時併用Intropes + Norepisnephrine，特別是對於晚期 HF 和心因性休克的患者。

a. 休克患者第一線血管加壓藥的比較：Dopamine vs Norepinephrine，顯示在心因性休克患者Dopamine發生較多的心律不整，和死亡率。但低血容量或敗血性休克則沒有。

b. 在另一項前瞻性隨機試驗中，在急性 MI 引起的心因性休克患者中比較了Epinephrine vs Norepinephrine，由於頑固性心因性休克發生率較高，該研究提前終止。

c. Epinephrine會有較快的心率和乳酸中毒。儘管存在樣本量相對較小、追蹤時間短以及缺乏有關最大達到劑量的數據，但該研究表明Norepinephrine有較好的療效和安全性。這些數據與一項包括 2583 位心因性休克患者的綜合分析一致，顯示與Norepinephrine相比，心因性休克患者使用Epinephrine的死亡風險增加了三倍。因缺乏有關劑量、持續追蹤時間，和病因，使這些結果仍需進一步探討。

鴉片類製劑(Opoid)
a. Opoid類藥物可緩解呼吸困難和焦慮，在非侵入性正壓通氣期間用作為鎮靜劑，以改善患者的適應能力。 副作用包括噁心、低血壓、心搏過緩和呼吸抑制。
b. Morphine給藥與會使機械通氣頻率更多、住院時間延長、重症監護病房入院次數增加和死亡率增加。因此，不推薦在AHF中常規使用opoid類藥物。嚴重頑固性疼痛或焦慮治療的情況下，亦可考慮使用opoid類藥物。
c. SBP <90 mmHg時，勿用Morphine.
d. Morphine會抑制呼吸，使用時特別注意呼吸狀況及保持呼吸道通暢。

Digoxin
a. AF患者使用了乙型阻斷劑，但仍有心室心率過快(AF with RVR) (>110 b.p.m.) ，可考慮使用Digoxin。
b. 如果未曾使用過Digoxin，可以靜脈推注 0.25–0.5 mg。
對於CKD或影響Digoxin代謝的其他因素（包括其他藥物）和/或老年人，維持劑量可能難以理論上估計，應檢查血清Digoxin level。

血栓栓塞預防
a. 推薦使用肝素（例如低分子量肝素）或其他抗凝劑預防血栓栓塞。
c. 若正服用服抗凝劑或禁忌，則不需使用肝素。

短期機械式循環輔助(MCS)
a. 心因性休克可能需要短期 MCS 以增加心輸出量和維持器官灌注。
b. 短期 MCS 可用作恢復前(BTR, bridge to recover)，治療策略決定前(是否繼續積極治療或視為無效醫療, BTD, Bridge to decision) 暫時過渡期的使用。臨床研究證據仍然很少。因此，不支持在心因性休克患者中未經選擇地使用 MCS。
c. 心因性休克 II (IABP-SHOCK-II) 研究中的IABP-SHOCK-II顯示，主動脈內球泵浦 (IABP) 和合適藥物治療之比較，於心因性休克患者接受早期血管再灌注的急性 MI 後之休克中，30天和長期死亡率沒有差異。根據這些結果，不推薦 IABP常規用於 MI後的心因性休克(Class III)。然而，其他非ACS引起的心因性休克，對藥物治療無效，IABP作為BTD、BTR ，仍有幫助(Class IIb)。
d. 在小型隨機試驗和傾向匹配分析中將其他短期 MCS 與 IABP 進行了比較，但結果不確定。ECMO與 IABP或 MT進行比較的RCT亦無確定結果。
e. 一項僅包括觀察性研究的綜合分析顯示，與對照組相比，接受靜脈-動脈 (VA-ECMO) 治療的心因性休克或心臟驟停患者的預後良好。 VA-ECMO 也可用於治療暴發性心肌炎和其他導致嚴重心因性的疾病。
f. 根據心肌功能異常和/或合併二尖瓣或主動脈瓣閉鎖不全的嚴重程度，VA-ECMO 可能會增加 LV 後負荷，同時增加 LV 舒張末期壓力和肺充血。在這些情況下，可以通過經中隔/心室心尖通氣口或使用解除LV 負荷（例如 Impella 裝置） 。

本文出處：
https://reurl.cc/VEy9Gn

Ref:
European Heart Journal (2021) 00, 1-128
https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehab368/6358045#292214341

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mg to ml 在 Nami Channel Youtube 的評價

Nami Channel By Nami Channel

2018-05-04 18:15:01 有 456,271 人看過 有 3,814 人喜歡
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mg to ml 在 Joanna Soh Official Youtube 的評價

Joanna Soh Official By Joanna Soh Official

2019-03-15 19:30:00 有 113,264 人看過 有 2,442 人喜歡
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This video is in partnership with iHerb. New and Existing Customers can get a discount off their iHerb order at: http://www.iherb.com/?rcode=AOR2642 For shipping outside of the US: https://www.iherb.com/shipping

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This is not something I often share, in fact it took me a lot of courage to share my ACNE journey with you. I went through an episode of really bad acne when I was 20 - 22 years old. Then it completely went away for 4 years, and I never thought I'd have to go through this phase again. Guess what? I started having terrible breakouts 3 years back, and that lasted for another 2 years.

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mg to ml 在 วุ้นแฟนซี Youtube 的評價

วุ้นแฟนซี By วุ้นแฟนซี

2017-04-26 14:23:50 有 60,570 人看過 有 492 人喜歡
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วุ้นแฟนซีสวัสดีจ้า เราจะมาแนะนำวิธีทำวุ้นที่รสชาติเปรี้ยวนิดๆ อมหวานหน่อยๆ และวัตถุดิบหาได้ง่ายๆ ในครัวเรือน เป็นวุ้นมะนาวน้ำผึ้งนั่งเอง ทานคลายร้อนชื่นใจมากๆเลยค่ะ เหมาะสำหรับสาวๆที่กำลังไดเอท และยังเป็นอีกหนึ่งเมนูที่สามารถทำขายเพื่อเพิ่มรายได้ได้อีกด้วย


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Dec 25, 2019 - MG to ML Conversion Calculator -Milligram to Millilitre Calculator Converter | 10 mg to ml syringe | dosage calculator medicine | 10250,75. ... <看更多>

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