Antibiotics AND INR..Be Careful

Most antibiotics can effect gut flora and effect vitamin K production with direct consequences on the anticoagulation therapy.

In short, within days of initiation of antibiotic treatment the

mean increase in INR with azithromycin was 0.5 with 31% of patients being increased to outside the therapeutic range.

Levofloxacin use raised the INR by a mean of 0.8 pushing 39% outside the therapeutic range.

TMP-SMZ increased INR levels by 1.8 pushing 69% outside the therapeutic range with 31% having an INR of 5 or higher and 13% having bleeding complications.
Although the 13% figure sounds very high, the point is that TMP-SMZs effects are substantial and consistent.

THE RISK OF OVERANTICOAGULATION WITH ANTIBIOTIC USE IN OUTPATIENTS ON STABLE WARFARIN REGIMENS
Glasheen, J.J., et al, J Gen Intern Med 20(7):653, July 2005

IMPACT OF PREEMPTIVE WARFARIN DOSE REDUCTION ON ANTICOAGULATION AFTER INITIATION OF TRIMETHOPRIM-SULFAMETHOXAZOLE OR LEVOFLOXACIN
Ahmed, A., et al, J Thromb Thrombolysis 26(1):44, August 2008

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The pressure volume loop...

In the pressure-volume loop below, cardiac work is best represented by: the area of the curve the slope of the line from points C to D the distance of the line from points C to D the slope of a line from points A to D .. .. ... .... ... .... .... .... In the pressure-volume loop below, cardiac work is best represented by: the area of the curve Cardiac work is the product of pressure and volume and is linearly related to myocardial oxygen consumption. Cardiac work is best represented by the area of the curve of a pressure-volume loop.

Driving Pressure in ARDS: A new concept!

Driving Pressure and Survival in the Acute Respiratory Distress Syndrome Marcelo B.P. Amato, M.D., Maureen O. Meade, M.D., Arthur S. Slutsky, M.D., Laurent Brochard, M.D., Eduardo L.V. Costa, M.D., David A. Schoenfeld, Ph.D., Thomas E. Stewart, M.D., Matthias Briel, M.D., Daniel Talmor, M.D., M.P.H., Alain Mercat, M.D., Jean-Christophe M. Richard, M.D., Carlos R.R. Carvalho, M.D., and Roy G. Brower, M.D. N Engl J Med 2015; 372:747-755 February 19, 2015 DOI: 10.1056/NEJMsa1410639 BACKGROUND Mechanical-ventilation strategies that use lower end-inspiratory (plateau) airway pressures, lower tidal volumes (V T ), and higher positive end-expiratory pressures (PEEPs) can improve survival in patients with the acute respiratory distress syndrome (ARDS), but the relative importance of each of these components is uncertain. Because respiratory-system compliance (C RS ) is strongly related to the volume of aerated remaining functional lung during disease (termed functional lung size)...

Anaphylaxis updates part 2- Empty Ventricle Syndrome

Patients with anaphylaxis should not suddenly sit, stand, or be placed in the upright position. Instead, they should be placed on the back with their lower extremities elevated or, if they are experiencing respiratory distress or vomiting, they should be placed in a position of comfort with their lower extremities elevated. This accomplishes 2 therapeutic goals: 1) preservation of fluid in the circulation (the central vascular compartment), an important step in managing distributive shock; and 2) prevention of the empty vena cava/empty ventricle syndrome, which can occur within seconds when patients with anaphylaxis suddenly assume or are placed in an upright position. Patients with this syndrome are at high risk for sudden death. They are unlikely to respond to epinephrine regardless of route of administration, because it does not reach the heart and therefore cannot be circulated throughout the body

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