Monthly Archives: March 2016

Hypercoagulable Panel

Checklist for hypercoagulable work-up

  • *Antithrombin III Activity
  • *Prothrombin Gene Mutation
  • *Factor V (5) Leiden Gene Mutation
  • Factor VIII (8) Activity
  • aPTT-LA (Lupus Sensitive Reagent)
  • Anticardiolipin Antibody (IgG, IgM, IgA)
  • Beta 2 glycoprotein
  • Russell Viper Venom Time (dilute)
  • *Homocysteine
  • *Protein C Activity
  • *Protein S Activity
  • ESR CRP ANA
  • MTHFR
  • SPEP
  • Lipoprotein A
  • Plasminogen activator inhibitor

*Shani list, also add Lupus anticoagulant, Vit B12 levels

Rarer causes:

  • Alpha-macroglobulin deficiency
  • Dysfibrinogenemia
  • Factor V deficiency, excess
  • Factor VII excess
  • Factor VIII excess
  • Factor XI excess
  • Heparin cofactor II deficiency
  • Hyperfibrinogenemia
  • PAI-1 excess
  • Plasminogen deficiency
  • tPA deficiency
  • TFPI deficiency
  • Thrombomodulin deficiency

 

References

“Hypercoagulability Panel – Machaon Diagnostics”. Machaon Diagnostics. N.p., 2016. Web. 30 Mar. 2016.

“Hypercoagulable States”. Clevelandclinicmeded.com. N.p., 2016. Web. 30 Mar. 2016.

Antiepileptic Medications

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SIADH

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  • Patients with severe symptoms or SAH at risk for vasospasm will receive hypertonic saline; otherwise the cornerstone of treatment for SIADH is fluid restriction.
  • Acute hyponatremia and/or severe symptoms should have 6 mmol/L corrected over 6 h or until severe symptoms improve.
  • The total correction of Na should not exceed 8 mmol/L over 24 h. Therefore, if 6 mmol/L is corrected in 6 h, the Na should not be increased more than 2 mmol/L in the following 18 h.
  • The total correction of Na is based on the Na deficit which is calculated conservatively with the formula depicted.
  • With improvement of symptoms, the patients can be moved to the less aggressive treatments in the algorithm, until Na reaches 131 mmol/L.

 

Reference

Layon, A. Joseph, Andrea Gabrielli, and William A Friedman. Textbook Of Neurointensive Care. Print.

CSW vs SIADH

Table compares clinical and laboratory findings in CSW vs SIADH.  Both conditions will present with low serum (osm and Na) and high urine (osm and Na).  The key to distinguishing between the two is extracellular fluid status (increased or normal in SIADH and decreased in CSW).

 

SIADH criteria proposed by Janicic and colleagues:

  1. Posm <275
  2. inappropriate urinary concentration (Uosm >100)
  3. clinical euvolemia (no orthostasis, tachycardia, dec skin turgor, dry mucous membranes or edema and ascites)
  4. elevated urinary Na excretion with normal salt and water intake
  5. absence of other causes of euvolemic hypoosmolality (hypothyroidism, hypocortisolism)

Reference:

Layon, A. Joseph, Andrea Gabrielli, and William A Friedman. Textbook Of Neurointensive Care. Print.

Prophylaxis for Acute Kidney Injury

Prevention of Acute Kidney Injury

  1. acetylcysteine 1,2000m g PO on day before and on the day of administration of the contrast agent, x 2 days PLUS
  2. saline 0.45% IV at 1ml/KgBW/h x12h before and 12h after administration of contrast agent
  3. for EMERGENCY procedures:  154 mEq/L NaHCO3 bolus of 3 ml/Kg/h x 1h before iopamidol contrast ffd by infusion of 1 ml/Kg/h x6h after procedure
  4. reduce contrast load

 

General Measures:

  1. maintain adequate BP
  2. optimize fluid balance
  3. adjust med dosage to renal function
  4. avoid NSAIDs

 

Reference:

Layon, A. Joseph, Andrea Gabrielli, and William A Friedman. Textbook Of Neurointensive Care. Print.

Antihypertensive Agents for Acute Stroke

Potential Approaches to Arterial Hypertension in Acute Ischemic Stroke Patients Who Are Candidates for Acute Reperfusion Therapy

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Eligible for tPA except BP 185/110 mmHg:

  • Labetalol 10–20 mg IV over 1–2 minutes, may repeat 1 time; or
  • Nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5–15 minutes, maximum 15 mg/h; when desired BP reached, adjust to maintain proper BP limits; or
  • Other agents (hydralazine, enalaprilat, etc) may be considered when appropriate

BP not maintained </=185/110 mmHg, do not administer rtPA

Keep BP during and after tPA <= 180/105 mmHg:

  • Monitor BP from start of tPA
    • every 15 minutes x 2 hours
    • every 30 minutes x 6 hours
    • every hour x 16 hours

If systolic BP >180–230 mmHg or diastolic BP >105–120 mmHg:

  • Labetalol 10 mg IV followed by continuous IV infusion 2–8 mg/min; or
  • Nicardipine 5 mg/h IV, titrate up to desired effect by 2.5 mg/h every 5–15 minutes, maximum 15 mg/h

If BP not controlled or diastolic BP >140 mmHg, consider IV sodium nitroprusside

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Reference:

Jauch, E. C. et al. “Guidelines For The Early Management Of Patients With Acute Ischemic Stroke: A Guideline For Healthcare Professionals From The American Heart Association/American Stroke Association”. Stroke 44.3 (2013): 870-947. Web. 22 Mar. 2016.

Checklist: Immediate Diagnostic Studies for Evaluation of Suspected Acute Ischemic Stroke

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*Although it is desirable to know the results of these tests before giving intravenous recombinant tissue-type plasminogen activator, fibrinolytic therapy should not be delayed while awaiting the results unless (1) there is clinical suspicion of a bleeding abnormality or thrombocytopenia, (2) the patient has received heparin or warfarin, or (3) the patient has received other anticoagulants (direct thrombin inhibitors or direct factor Xa inhibitors).

 

 

 

References

Jauch, E. C. et al. “Guidelines For The Early Management Of Patients With Acute Ischemic Stroke: A Guideline For Healthcare Professionals From The American Heart Association/American Stroke Association”. Stroke 44.3 (2013): 870-947. Web. 22 Mar. 2016.