Kay Little

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  • in reply to: Erectile Dysfunction in HFrEF patients #49057

    Kay Little

    Recommendations for the use of sildenafil in patients with cardiovascular disease:
    1) Sildenafil is contraindicated in patients using long- and short-acting nitrates due to the possibility of developing potentially fatal severe hypotension.
    2) In patients with stable coronary artery disease treated with long-acting nitrates, one may consider the possibility of suspending the nitrate in accordance with the patient, so that sildenafil can be used.
    3) Patients not using long-acting nitrates but requiring nitrates sublingual for treatment of episodes of angina should be informed about the hazarg of using sildenafil, unless the nitrate can be replaced by an alternative medication with no risk of interaction with sildenafil.
    4) Any use of nitrate is contraindicated in the 24 hours following the use of sildenafil. Sildenafil is also contraindicated if any nitrate has been used in the preceding 24 hours.
    5) High-risk cardiovascular patients, including patients with :
    1- atherosclerotic disease
    2 – NYHA functional classes II and III
    3 – patients individuals above 65 years of age,
    4 – hypertensive and
    5 – diabetic patients
    6 – smokers
    7 – patients with moderate to severe dyslipidemia,
    8 – and obese individuals,
    >>> even if not having asked for sildenafil, should be informed about the potential severe risk of sildenafil-nitrate interaction.
    This should be done because patients may obtain sildenafil by other means without the recommendations necessary for its use.
    6) High-risk cardiovascular patients should be previously assessed through a treadmill stress test.
    The risk of ischemia during coitus is low if they do not develop clinical or electrocardiographic signs, of ischemia and or arrhythmia, until a load of 5 to 6 METs is reached.
    These load limits are valid for coitus with the usual partner, in a familiar environment, and without additional overload of excessive consumption of food and alcoholic beverages.
    Patients without sexual activity for a long period should be advised to moderate their physical activity and anxiety during their return to sexual activity.
    7) In patients without ischemia and or arrhythmia, or both, on the treadmill stress test with load lower than 5 to 6 METs, the use of sildenafil should be conditioned to the clinical situation of the patient.
    8) It is convenient that patients using vasodilators and diuretics simultaneously should be monitored for a hypotensive response to sildenafil.
    9) Physicians and allied health personal emergency departments should be instructed to routinely ask patients about the use of sildenafil.
    10) Patients using sildenafil should be instructed to tell about the use of sildenafil in case of an emergency.
    11) An initial dose of 25 mg should be recommended in all situations that may increase the plasma concentration of sildenafil or potentiate its vasodilating effect and that do not constitute a formal contraindication for its use.

    in reply to: Maximum daily dose of Ondansetron #49131

    Kay Little

    Can you give me the reference.

    in reply to: Premix TPN #48991

    Kay Little

    Recently, I have looked into the utilization of premix PN (three chamber bag system). Below steps may help in assessing the utilization of premix PN

    • Assess current PN utilization and patient population by performing utilization review
    • Retrospective or prospective PN utilization review. (looking at the below criteria)
      • Age group (Adult, pediatric, neonates)
      • Central or peripheral PN
      • Indications, comorbidity​​
      • Short term or long-term
      • Number of PN orders per day
    • You may also asses pros and cons of each customized versus premix

    1- Safety: Measured by ADR (Complication)

    2- Efficacy: Since there is no single indicator to assess nutritional status. Efficacy can be assessed by comprehensive evaluation of weight, electrolytes level, hydration status, prealbmuin etc.

    3- Cost: Direct (Cost of the PN bag customized versus premixed) and indirect (staffing and equipment)

    Usually, stable young patients with no co-morbidity will tolerate ready-made PN and it’s a cost saving to the institution. However, if the majority of patient population is pediatric and neonates then customized can’t be replaced by ready-made.

    Hope this will help

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