Hyperthyroidism in pregnancy

Women with moderate to severe overt hyperthyroidism require treatment of hyperthyroidism. Thionamides are recommended. Available thionamides include propylthiouracil (PTU), methimazole (MMI), and carbimazole (CBZ), which is completely metabolized to MMI. All 3 antithyroid drugs (ATDs) have been associated with possible teratogenic effects. Compared with PTU, the effects are more common and more severe with MMI and CBZ.

Thyroid function should be monitored monthly to maintain serum free T4 concentrations in the high-normal range and serum TSH concentrations in the low-normal range. The dose of PTU should be limited to 50 mg twice daily or less becase higher doses may result in fetal goiter and hypothyroidism.

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Hyperkalemia

Tall peaked T waves with a shortened QT interval are usually the first findings

Progressive lengthening of the PR interval and QRS duration

P wave may disappear, and ultimately the QRS widens further to a sine wave pattern

Ventricular standstill with a flat line on the ECG ensues with complete absence of electrical activity.

Beta blockers interfere with the beta-2-adrenergic facilitation of potassium uptake by the cells, particularly after a potassium load. An increase in serum potassium is primarily seen with nonselective beta blockers (such as propranolol and labetalol). In contrast, beta-1-selective blockers such as atenolol have little effect on serum potassium since beta-2 receptor activity remains intact

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Coumardin interaction

MONITOR: Isoniazid may increase the anticoagulant effect of warfarin, perhaps by inhibition of warfarin metabolism. This effect has been reported with an isoniazid dose of 600 mg per day. Other oral anticoagulants may interact with isoniazid in a similar fashion. The proposed mechanism is inhibition of CYP450 2C9 hepatic metabolism by isoniazid.

MANAGEMENT: The patient's INR should be monitored, and the anticoagulant dosage should be adjusted if necessary, whenever isoniazid is initiated, discontinued or the dosage is changed. Patients should be advised to promptly report any signs of bleeding to their physician, including pain, swelling, headache, dizziness, weakness, prolonged bleeding from cuts, increased menstrual flow, vaginal bleeding, nosebleeds, bleeding of gums from brushing, unusual bruising, red or brown urine, or red or black stools.


GENERALLY AVOID: Rifampin may decrease the anticoagulant effect of warfarin by enhancing CYP450 hepatic microsomal enzyme metabolism of warfarin.

MANAGEMENT: Concurrent use should be avoided unless no alternatives are available. The INR or prothrombin time should be monitored closely during concomitant therapy and after rifampin is discontinued. Adjustments in warfarin dosage may be needed when rifampin dosage is added, discontinued, or changed. This interaction may occur with other oral anticoagulants and with rifabutin.

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血腫 1

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Complication of ATEMI

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Insulin pump

1. N/S 500 ml + HRI 50 U iv run 50 ml/hr, and
2. Check blood sugar by Glucometer Q2h without HRI:
If blood sugar    > 600 mg/dl,  run 60 ml/hr
If blood sugar  551-600 mg/dl,  run 55 ml/hr
If blood sugar  501-550 mg/dl,  run 50 ml/hr
If blood sugar  451-500 mg/dl,  run 45 ml/hr
If blood sugar  401-450 mg/dl,  run 40 ml/hr
If blood sugar  351-400 mg/dl,  run 35 ml/hr
If blood sugar  301-350 mg/dl,  run 30 ml/hr
If blood sugar  251-300 mg/dl,  run 25 ml/hr
If blood sugar  201-250 mg/dl,  run 20 ml/hr
If blood sugar  151-200 mg/dl,  run 15 ml/hr
If blood sugar  101-150 mg/dl,  run 10 ml/hr
If blood sugar   85-100 mg/dl,  run  5 ml/hr
If blood sugar     < 85 mg/dl,  run  0 ml/hr
If blood sugar     < 70 mg/dl,  50% G/W 2 Amp iv stat

# If blood sugar < 100 mg/dL, inform doctor

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Surestep Q4H
normal saline 100cc + HRI 100u keep rate as:

BS<90  hold 2 hr and follow up eyetone 2 hr later
101-130          0.5cc/hr
131-160          1cc/hr
161-190          2cc/hr
191-220          3cc/hr
221-250          4cc/hr
251-280          5cc/hr
281-310          6cc/hr
311-340          7cc/hr
341-370                    8cc/hr
371-400          9cc/hr
401-430                   10cc/hr
431-460         11cc/hr
>460  HRI 5u iv  st and run 10 cc/hr
eyetone q4h for 1 day then qid without HRI

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Amiodarone

Amiodarone 6amp + D5W (glass bot.) 1 bot IVD, run 34ml/hr x 6 hrs, then 17ml/hr x 18 hrs  
Loading Amiodarone 150mg in D5W IVF 10min.

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