Fomepizole (Antizol®)
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Interaction Between Renal Replacement Therapy And
rren Cu t R y: es Romano, Surgery Curr Res 2014, 4:1 r e e a g r r c u h DOI: 10.4172/2161-1076.1000154 S Surgery: Current Research ISSN: 2161-1076 Review Article Open Access Interaction between Renal Replacement Therapy and Extracorporeal Membrane Oxygenation Support Thiago Gomes Romano* Assistant Teaching Professor for the Discipline of Nephrology, ABC Medical School Medical Intensivist at Hospital, Sírio-Libanês, Brazil Abstract Extracorporeal Membrane Oxygenation (ECMO) is one of the designations used for extracorporeal circuits capable of oxygenation, carbon dioxide removal and, eventually, circulatory support. Acute respiratory distress syndrome with severe hypoxemia or acidemia with high carbon dioxide levels in a scenario of low pulmonary tidal volume is its mainly indication. Acute Kidney Injury (AKI) and its complications such as volume overload and azotemia are common in this situation; some epidemiological studies have shown that around 78% of the patients demanding ECMO therapy develop AKI. Therefore, renal replacement therapy is required in about 50% of those cases. This papers aims to explain the concept of the ECMO circuit and the ways continuous renal replacement therapy (CRRT) can be instituted in critical ill patients who need ECMO. Keywords: ECMO; Renal replacement therapy; Dialysis internal jugular or femoral vein with the return placed in the femoral artery. Additionally, a jugular-carotid cannulation is one option despite Introduction the potential for neurological injury. In cases exclusively intended for Extracorporeal Membrane Oxygenation (ECMO) is one of the ventilatory support [venovenous (VV) ECMO], cannulation can be designations used for extracorporeal circuits capable of oxygenation, placed femoro-jugular, jugular-femoral or femoral-femoral depending carbon dioxide (CO ) removal and, eventually, circulatory support. -
Overview of Complications of Hemodialysis Access
Update on Hemodialysis Access Raymond J. Holmes, MD April 4th, 2019 Presenter Disclosure Information Raymond J. Holmes, MD The Cardiovascular Care Group FINANCIAL DISCLOSURE: Nothing to disclose UNLABELED/UNAPPROVED USES DISCLOSURE: No unlabeled and or unapproved off-label use of products or devices will be discussed in this presentation Update on Hemodialysis Access Surgery • Overview: K-DOQI and Fistula First • Strategy for sequential access placement • AV fistula, AV graft, basilic vein transposition, HeRO device • Endovascular Intervention • Complications In the Beginning… Belding Scribner 1921-2003 Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula Michael J. Brescia, M.D., James E. Cimino, M.D., Kenneth Appel, M.D. and Baruch J. Hurwich, M.D. NEJM 275:1089-1092, 1966. James E. Cimino (1928-2010) What is the best access for hemodialysis? • 53 years after initial description of the AV fistula, it still remains the best access for hemodialysis Michael J. Brescia, M.D., James E. Cimino, M.D., Kenneth Appel, M.D. and Baruch J. Hurwich, M.D. NEJM 275:1089-1092, 1966. DOQI Guidelines • Developed by National Kidney Foundation. (www.kidney.org) • Common sense, common practice • Some “evidence” based; some opinion based. • Careful disclaimers not to be “standard of care” – However, widely adapted as “standard of care”. Guidelines on topics for management of patients with chronic kidney disease including vascular access •Clinical Practice Guidelines for Vascular Access, Update 2006 •Guideline 1. Patient Preparation for Permanent Hemodialysis Access •Guideline 2. Selection and Placement of Hemodialysis Access •Guideline 3. Cannulationof Fistulae and Grafts and Accession of Hemodialysis Catheters and Port Catheter Systems •Guideline 4. -
Guideline on Antidote Availability for Emergency Departments January 2017
Royal College of Emergency Medicine and National Poisons Information Service Guideline on Antidote Availability for Emergency Departments January 2017 TOXBASE and/or the BNF should be consulted for further advice on doses and indications for antidote administration and, if necessary, the National Poisons Information Service (NPIS) should be telephoned for more patient-specific advice. Contact details for NPIS are available on TOXBASE. Additional drugs that are used in the poisoned patient that are widely available in ED are not listed in the table – in particular it is important to ensure that insulin, benzodiazepines (diazepam and/or lorazepam), glyceryl trinitrate or isosorbide dinitrate and magnesium are immediately available in the ED. The following drugs should be immediately available in the ED or any area where poisoned patients are initially treated. These drugs should be held in a designated storage facility* The stock held should be sufficient to initiate treatment (stocking guidance is in Appendix 1). Drug Indication Acetylcysteine Paracetamol Activated charcoal Many oral poisons Atropine Organophosphorus or carbamate insecticides Bradycardia Calcium chloride Calcium channel blockers Systemic effects of hydrofluoric acid Calcium gluconate Local infiltration for hydrofluoric acid Calcium gluconate gel Hydrofluoric acid Cyanide antidotes Cyanide Dicobalt edetate The choice of antidote depends on the severity of poisoning, certainty of diagnosis and cause Hydroxocobalamin (Cyanokit®) of poisoning/source of cyanide. Sodium nitrite - Dicobalt edetate is the antidote of choice in severe cases when there is a high clinical Sodium thiosulphate suspicion of cyanide poisoning e.g. after cyanide salt exposure. - Hydroxocobalamin (Cyanokit®) should be considered in smoke inhalation victims who have a severe lactic acidosis, are comatose, in cardiac arrest or have significant cardiovascular compromise - Sodium nitrite may be used if dicobalt edetate is not available. -
RCEM NPIS Antidote Guideline Appx 1
Royal College of Emergency Medicine and National Poisons Information Service Guideline on Antidote Availability for Emergency Departments (January 2017) Appendix 1. Stock levels & storage recommendations Doses and Clinical Advice on the Administration of Antidotes TOXBASE and/or the BNF should be consulted for further advice on doses and indications for antidote administration. If necessary, the National Poisons Information Service (NPIS) should be telephoned for more patient-specific advice. Contact details for NPIS are available on TOXBASE. Stock Levels The recommended minimum stocking levels (rounded up to full “pack-sizes” where necessary) are based on the amount of antidote required to initiate treatment for an adult patient in the ED and to continue treatment for the first 24 hours. Higher stock levels may be required and individual departments should determine the amount of each antidote they stock based on the epidemiology of poisoning presentations to their department. Additional drugs that are used in the poisoned patient that are widely available in ED are not listed in the table – in particular it is important to ensure that insulin, benzodiazepines (diazepam and/or lorazepam), glyceryl trinitrate or isosorbide mononitrate and magnesium are immediately available in the ED. The following drugs should be immediately available in the ED or any area where poisoned patients are initially treated These drugs should be held in a designated storage facility Recommended stock Drug Indication Presentation Special storage conditions -
Hemodialysis
The Ohio State University Veterinary Medical Center Hemodialysis What is hemodialysis? Hemodialysis is a method of blood purification that This is most commonly performed in the acute setting removes blood from the body through a catheter (acute kidney injury) for animals but may also be elected and filters it through a dialyzer (artificial kidney). for patients with chronic kidney dysfunction. Hemodialysis is used to purify the blood by eliminating While acute kidney injury is the most common reason toxic metabolites, balancing electrolytes, and removing for performing hemodialysis, it can also be used to treat excess water that builds up when the kidneys are acute intoxications to enhance elimination of a toxin. unable to excrete it. Indications for Hemodialysis Acute Kidney Injury This is the most common indication for hemodialysis. 10-14 days of hospitalization and treatment. With acute This procedure should be considered when clinical kidney injury, the kidneys typically start to regain some uremia, hyperkalemia, acid/base disturbances, and function within this time period, but a lack of response fluid overload cannot be managed with conventional does not mean the kidneys will never recover. medical therapy. The best time to start hemodialysis There are instances when it may take up to four weeks is still unknown (even in human medicine), but starting to become dialysis independent. Patients are generally treatment sooner means fewer side effects from uremia. transitioned after the 10-14 days to outpatient treatments Thus, hemodialysis should be considered sooner rather to continue to provide time for the kidneys to recover. than later. Outpatient treatments allow families to play an active When hemodialysis is performed, pet owners should role in facilitating recovery. -
UNDERSTANDING YOUR HEMODIALYSIS OPTIONS Hemodialysis Is a Treatment for Access People Whose Kidneys Are No Longer Involves Working
UNDERSTANDINGUnderstanding YOUR HEMODIALYSISYour OPTIONS Hemodialysis Access Options This educational activity is supported by a donation by Amgen, Inc UNDERSTANDING YOUR HEMODIALYSIS OPTIONS Hemodialysis is a treatment for access people whose kidneys are no longer involves working. The treatment removes making a waste products and fluid from the connection blood using an artificial kidney between an machine. It is the most common artery and a treatment for people who have end- vein under stage renal disease (ESRD), or whose the skin. A kidneys no longer work. surgeon will make There are four types of hemodialysis your fistula treatment options. AAKP created this or graft brochure to explain each of your by sewing treatment options, and to show you one of your the pros and cons of each option. arteries to Mayo Clinic Foundation for one of your Education and Research veins. It’s CREATING AN ACCESS a simple medical procedure. Your surgeon Before you begin hemodialysis chooses which artery and vein to treatment, a surgeon must create connect depending on how fast your an access for the machine. Don’t be blood flows through the artery and afraid. Access for the machine will vein. be at a place on your body close to a vein and artery. It allows access A catheter is the other type of to your blood stream. Blood goes access. A catheter is a thin, flexible from your body through the access tube that can be put through a small and to the dialysis machine. Once hole in your body. A surgeon inserts inside the artificial kidney machine, the catheter through your skin into the machine cleans the blood and a large vein in the neck, chest or returns the clean blood back to groin. -
Fomepizole for Acetaminophen Toxicity
Clinical Pharmacology & Toxicology Pearl of the Week Fomepizole for Acetaminophen Toxicity Mechanisms There are two ways that fomepizole works to help prevent hepatotoxicity in APAP overdose. The primary mechanism involves inhibition of CYP450 2E1. o When a toxic amount of APAP is ingested, the pathways that convert it into nontoxic metabolites become overwhelmed. o Thus, more APAP gets converted into NAPQI. o Fomepizole inhibits the 2E1 pathway, thus preventing conversion of APAP into NAPQI. The second mechanism of action is the JNK (“junk”) enzyme. o NAPQI-induced mitochondrial dysfunction leads to formation of reactive oxidant species. This oxidant stress leads to activation of c-jun N-terminal kinase, or JNK, enzyme. o This enzyme translocates to the mitochondria, amplifying oxidant stress, and ultimately resulting in the cessation of ATP production. o Additionally, the JNK enzyme can lead to the rupture of the outer mitochondrial membrane, causing release of intermembrane proteins, which can potentially lead to DNA fragmentation o Interestingly, it is thought that both metabolic acidosis, as well as elevated lactate levels, may be the result of alterations in mitochondrial respiratory function o Fomepizole works by preventing the APAP-induced activation of this enzyme. Role in Acetaminophen poisoning management In cases where fomepizole and NAC were administered together, evidence has shown that the combination has contributed to a decrease in both hepatotoxicity and mortality. Most of the evidence has come from case reports and animal models. Currently, fomepizole is recommended for massive APAP ingestions (as in, ingestions over 500- 600 mg/kg or in cases where 4-hour equivalent acetaminophen concentrations over 5000 umol/L). -
Ultrafiltration I Hemodialysis During Cardiopulmonary Bypass: a Case Report
THE jOURNAL OF EXTRA-CORPOREAL TECHNOLOGY Case Report Ultrafiltration I Hemodialysis During Cardiopulmonary Bypass: A Case Report Scott D. Niles, BA, Robin G. Sutton, MS, CCP, Richard P. Embrey, MD University of Iowa Hospitals and Clinics, Iowa City, Iowa Keywords: cardiopulmonary bypass; hemodialysis, concurrent; technique; ultrafiltration. ABSTRACT Patient demographics for elective cardiovascular surgery have shifted toward older patients with more profound disease states. Cardiopulmonary bypass is complicated when the patient presents with end stage renal disease. Hemodialysis during cardiopulmonary bypass has been successfully employed to reduce the postoperative sequelae associated with cardiopulmo nary bypass. A patient with end stage renal disease who presented for coronary artery bypass grafting serves as the subject of this case report. Utilizing a modified technique previously described by Wiggins and Dearing, we describe successful intraoperative use of hemodialysis during cardiopulmonary bypass. Our experience suggests that hemodialysis during cardiopulmo nary bypass is an effective alternative to ultrafiltration and may prolong the time interval for resumption of postoperative dialysis regimens. Address correspondence to: Scott D. Niles University of Iowa Hospitals and Clinics Perfusion Technology Program Department of Surgery Division of Cardiothoracic Surgery 1600 JCP Iowa City, lA 52242 104 Volume 27, Number 2, June 1995 THE jOURNAL OF EXTRA-CORPOREAL TECHNOLOGY INTRODUCTION helping to resolve elevated BUN and creatinine levels. A hemodialysis circuit was constructed in parallel with the Population demographics in patients undergoing elective cardiopulmonary bypass circuit (Figure 1). A purge port on top cardiovascular surgery have undergone dramatic changes over of the arterial filter served as the blood source for an ultrafiltration the past twenty years, With a trend toward older patients with hemoconcentrator which then emptied into a venous reservoir bag. -
Preparing for Vascular Access Surgery
Form: D-5134 Preparing for Vascular Access Surgery Information for patients and families Read this booklet to learn: • why you need vascular access for hemodialysis • what an AV graft and an AV fistula is • what to expect with this procedure • who to call if you have any questions Check in at: Toronto General Hospital Surgical Admission Unit (SAU), Peter Munk Building – 2nd Floor Date and time of my surgery: Date: Time: *Remember: You need to arrive at the hospital 2 hours before surgery Why do I need vascular access surgery? If you need hemodialysis, you need a vein that is easy to find and use. Vascular access surgery makes an access site for the hemodialysis. This is called an arteriovenous (AV) access. An AV access connects your artery directly to your vein. If this is not possible, a soft plastic tube will be used to connect your artery and vein. How does my AV access work during hemodialysis? Before hemodialysis (or dialysis), your nurse will put 2 needles into your AV access. One needle takes the blood from your body to the artificial kidney (dialyzer). This cleans your blood. The second needle returns the clean blood back to you. Only a small amount of blood (about 1 cup) is removed from your body at one time. At the end, your nurse removes both needles and puts bandages where the needles were put in. You can take the bandages off the next day. 2 Your AV access will usually be in your forearm or upper arm. There are 2 types of AV access your surgeon could give you. -
Uremic Toxins and Blood Purification: a Review of Current Evidence and Future Perspectives
toxins Review Uremic Toxins and Blood Purification: A Review of Current Evidence and Future Perspectives Stefania Magnani * and Mauro Atti Aferetica S.r.l, Via Spartaco 10, 40138 Bologna (BO), Italy; [email protected] * Correspondence: [email protected]; Tel.: +39-0535-640261 Abstract: Accumulation of uremic toxins represents one of the major contributors to the rapid progression of chronic kidney disease (CKD), especially in patients with end-stage renal disease that are undergoing dialysis treatment. In particular, protein-bound uremic toxins (PBUTs) seem to have an important key pathophysiologic role in CKD, inducing various cardiovascular complications. The removal of uremic toxins from the blood with dialytic techniques represents a proved approach to limit the CKD-related complications. However, conventional dialysis mainly focuses on the removal of water-soluble compounds of low and middle molecular weight, whereas PBTUs are strongly protein-bound, thus not efficiently eliminated. Therefore, over the years, dialysis techniques have been adapted by improving membranes structures or using combined strategies to maximize PBTUs removal and eventually prevent CKD-related complications. Recent findings showed that adsorption-based extracorporeal techniques, in addition to conventional dialysis treatment, may effectively adsorb a significant amount of PBTUs during the course of the sessions. This review is focused on the analysis of the current state of the art for blood purification strategies in order to highlight their potentialities and limits and identify the most feasible solution to improve toxins removal effectiveness, exploring possible future strategies and applications, such as the study of a synergic approach by reducing PBTUs production and increasing their blood clearance. -
Estonian Statistics on Medicines 2016 1/41
Estonian Statistics on Medicines 2016 ATC code ATC group / Active substance (rout of admin.) Quantity sold Unit DDD Unit DDD/1000/ day A ALIMENTARY TRACT AND METABOLISM 167,8985 A01 STOMATOLOGICAL PREPARATIONS 0,0738 A01A STOMATOLOGICAL PREPARATIONS 0,0738 A01AB Antiinfectives and antiseptics for local oral treatment 0,0738 A01AB09 Miconazole (O) 7088 g 0,2 g 0,0738 A01AB12 Hexetidine (O) 1951200 ml A01AB81 Neomycin+ Benzocaine (dental) 30200 pieces A01AB82 Demeclocycline+ Triamcinolone (dental) 680 g A01AC Corticosteroids for local oral treatment A01AC81 Dexamethasone+ Thymol (dental) 3094 ml A01AD Other agents for local oral treatment A01AD80 Lidocaine+ Cetylpyridinium chloride (gingival) 227150 g A01AD81 Lidocaine+ Cetrimide (O) 30900 g A01AD82 Choline salicylate (O) 864720 pieces A01AD83 Lidocaine+ Chamomille extract (O) 370080 g A01AD90 Lidocaine+ Paraformaldehyde (dental) 405 g A02 DRUGS FOR ACID RELATED DISORDERS 47,1312 A02A ANTACIDS 1,0133 Combinations and complexes of aluminium, calcium and A02AD 1,0133 magnesium compounds A02AD81 Aluminium hydroxide+ Magnesium hydroxide (O) 811120 pieces 10 pieces 0,1689 A02AD81 Aluminium hydroxide+ Magnesium hydroxide (O) 3101974 ml 50 ml 0,1292 A02AD83 Calcium carbonate+ Magnesium carbonate (O) 3434232 pieces 10 pieces 0,7152 DRUGS FOR PEPTIC ULCER AND GASTRO- A02B 46,1179 OESOPHAGEAL REFLUX DISEASE (GORD) A02BA H2-receptor antagonists 2,3855 A02BA02 Ranitidine (O) 340327,5 g 0,3 g 2,3624 A02BA02 Ranitidine (P) 3318,25 g 0,3 g 0,0230 A02BC Proton pump inhibitors 43,7324 A02BC01 Omeprazole -
ECMO) Machines
Converting Hemodialysis (HD) membranes to Extracorporeal Membrane Oxygenation (ECMO) machines Abhimanyu Dasa, Matthew L. Robinsonb, D. M. Warsingera a School of Mechanical Engineering and Birck Nanotechnology Center, Purdue University, West Lafayette, IN, 47907, USA b Division of Infectious Diseases, Center for Clinical Global Health Education, Johns Hopkins University School of Medicine, Baltimore, Maryland April 2020 ABSTRACT Crises like COVID-19 can create a massive unmet demand for rare blood oxygenation membrane machines for impaired lungs: Extracorporeal Membrane Oxygenation (ECMO) machines. Meanwhile, Hemodialysis (HD) machines, which use membranes to supplement failing kidneys, are extremely common and widespread, with orders of magnitude more available than for ECMO machines[1]. This short study examines whether the membranes for HD can be modified for use in blood oxygenation (ECMO). To do so, it considers mass transfer at the micro-scale level, and calculations for the macro-scale level such as blood pumping rates and O2 supply pressure. Overall, while this conversion may technically be possible, poor gas transport likely requires multiple HD membranes for one patient. INTRODUCTION Background on HD and ECMO HD and ECMO machines both operate by removing large volumes of blood from the body and passing them through membranes that rely on diffusion to transfer desirable or undesirable solutes. HD machines focus on adding and removing compounds to assist with kidney failure, including removing salts and small organic compounds like urea. Meanwhile, ECMO uses membranes to replace O2 and help remove CO2. Conversion approach requirements for HD for ECMO Custom HD machines made for blood oxygenation[2] have been successfully demonstrated in the past; the question is whether existing HD machines can be converted readily.