Monday, March 16, 2009

Dietetic table of № 10

Posted By:Dr.Zharif


Dietetic table of № 10

Indication: diseases of cardiovascular system with Heart Failure NYHA I -II[a] degree.

Aim:

1. improvement in the blood circulation,

2. functions of cardiovascular system, liver and kidneys,

3. the normalization of exchange of substances,

4. protection of cardiovascular system and organs of digestion.

General characteristic: -

1. small reduction in the caloricity due to the fats and partly carbohydrates.

2. limitation of a quantity of sodium of chloride,

3. the decrease of the consumption of liquids.

4. The content of the substances, which excite cardiovascular and nervous system, which irritate the liver and nights, is limited superfluously burdening gastrointestinal tract, that facilitate meteorism.

5. increased the content of potassium, magnesium, lipotropic substances, products, which render the alkalizing action (milk, vegetables, fruits). Culinary working is performed with that moderated by mechanical .

6. Meat and fish they boil.

7. Food is prepared without the salt.

8. The temperature of food is usual.

9. Feed mode: 5 times a day by relatively uniform portions.

Chemical composition and energy-value (daily ration):

· the proteins 90[g] (55- 60% animals)

· the fats 70[g] (25 30% plant)

· the carbohydrates 350-400 g

· Energy-value 2500-2600 kcal.

· the common salt 6-7[g]

· the liquid 1,2[l]

Can

Can’t

• bread is wheaten from the flour the 1st and 2nd types, yesterday's baking or slightly dried slightly; dietetic salt-free bread, pastry and sponge cake;

• any vegetarian soups with different groats, milk soups;

• the nonfatty types of beef, veal, meat and trimming pork, rabbit, hen, turkey. they boil meat after cleaning from the tendons and fascias, and then bake or brown, dishes from the chopped or lump boiled meat, flood from the boiled meat, limited - doctoral and dietetic sausages, the nonfatty forms of fish - boiled or with subsequent roasting, dish from boiled sea products;

• milk, sour-milk beverages and cottage cheese;

• egg – 1per day, soft-boiled, the steam and baked omelettes, protein omelettes, in the dishes • dish from different groats; boiled macaroni articles;

• vegetables in the boiled and baked form potatoes, cauliflower, carrot, beet, summer squashes, pumpkin, tomatoes, lettuce, cucumbers, the cabbage and green peas – limited green bow, dill, parsley - in the dishes;

• lettuces from the fresh vegetables (ground carrot, tomatoes, cucumbers), vinaigrettes with vegetable oil, vegetable roe, lettuces are fruit, with sea products, fish the boiled flood

• soft ripe fruits and berry, honey, jam.

• Weak tea, coffee beverages with the milk, fruit and vegetable juices, the broth of sweetbrier, limited - grape juice.

• fresh bread, article made of the rich test and puff-pastry Guest, pancakes, fritter;

• soups from the bean, meat, fish and fungus bouillon;

• the fatty forms of the meat of goose, weft, the liver, kidney, the brains, smoked foods, sausage articles, meat canned foods, fish, bird;

• kidney, smoked foods, sausage;

• salt, the fatty forms of fish, roe, canned foods, salt and fatty cheeses;

• bean;

• the eggs hard-boiled, fried;

• the salt, and sour vegetables; fruits with rough cellulose tissue, spinach, sorrel, horseradish, radish, garlic, turnip-shaped bow, fungi;

• chocolate, strong tea, coffee and coco





You can download full description about Diet no.10 here

Диетический стол 10.docx

Ref:1.Russian Medical Portal
2. Russian Hospital Therapy Text Book


Monday, February 16, 2009

Management of Heart Failure By MOH


Posted by:Dr.Zharif




Investigation

Blood test – FBC, renal function, liver function, glucose, lipid profile

urinalysis – proteinuria, glycosuria

Other important investigations include:

• echocardiogram – to identify structural abnormalities and assess LV systolic

and diastolic dysfunction

natriuretic peptides or their precursors (especially BNP and NT-proBNP) – If available, this investigation is useful in the evaluation of patients presenting IIa.A with acute dyspnoea in the urgent care setting in whom the clinical diagnosis of HF is uncertain. A low-normal concentration of this marker in an untreated patient makes the diagnosis of HF unlikely.Thus it is a useful “rule–out” test in doubtful cases.

Additional investigations when indicated;

Blood tests:

– cardiac biomarkers – thyroid function tests

– C-reactive protein (to look for inflammation)

Tests for myocardial ischemia and/or viability: – treadmill exercise test

– stress echocardiography (exercise or pharmacological)

– radionuclide studies

– cardiac magnetic resonance imaging (CMR)

Invasive tests:

– coronary angiography – cardiac catheterization – endomyocardial biopsy

Others:

– Holter electrocardiography, loop recorders and long-time ECG recording – pulmonary function tests


Management

The principles of management are:

Rapid recognition of the condition

Stabilization of hemodynamics

Improvement in clinical symptoms and signs

Identification and treatment of the

– underlying cause

– precipitating / aggravating factors.

The initial management includes a combination of the following first line therapy:

Oxygen – 5 to 6 liters/minute, by mask with the aim of achieving oxygen saturation of more than 95% in order to maximize tissue oxygenation and to prevent end organ dysfunction or multi organ failure. Elective ventilation using non invasive positive pressure ventilation (Continuous Positive Airway Pressure [CPAP] or Bi-level Positive Airway Pressure [BiPAP])should be considered early if necessary Should the oxygen saturation be inadequate or the patient develop respiratory muscle fatigue, then endotracheal intubation and mechanical ventilation is necessary.

Frusemide – Intravenous (i.v.) frusemide 40 – 100mg. The dose should be

individualized depending on the severity of the clinical condition

Administration of a loading dose followed by a continuous infusion has been

shown to be more effective than repeated bolus injections alone .The

dose should be titrated according to clinical response and renal function.

Morphine sulphate – i.v. 3 – 5 mg bolus (repeated if necessary, up to a total maximum of 10mg). It reduces pulmonary venous congestion and sympathetic drive. It is most useful in patients who are dyspnoeic and restless. Intravenous anti-emetics (metoclopramide 10mg or prochlorperazine 12.5mg) should be administered concomitantly. Care must be exercised in patients with chronic respiratory diseases.

Nitrates - If the BP is adequate (SBP > 100 mmHg), nitrates are indicated as first line therapy in AHF. It should be administered sublingually or intravenously. The i.v. route is more effective and preferable. Patients should be closely monitored for hypotension. This commonly occurs with concomitant diuretic therapy. Studies have shown that the combination of i.v. nitrate and low dose frusemide is more efficacious than high dose diuretic treatment alone .

Extreme caution should be exercised in patients with aortic and mitral stenosis.

Nitrates are contraindicated in severe valvular stenosis



Route of

Dosages



Admin


Diuretics




Frusemide

IV

40mg – 100mg



Infusion

5 – 40mg/hour (better than very high bolus




doses)






Vasodilators




Nitroglycerin

Infusion

5ug/min increasing at intervals of 3 – 5 min




by 5ug/min increments up to 100 – 200




ug/min


Nitroprusside

Infusion

0.1 – 5ug/kg/min






Sympathomimetics




Dobutamine

Infusion

2 – 20ug/kg/min


Dopamine

Infusion

<2>




2 – 10ug/kg/min – inotropic doses




10 – 20ug/kg/min –




peripheral vasoconstriction


Noradrenaline

Infusion

0.02 – 1ug/kg/min till desired BP is




attained






Phosphodiesterase-




3- Inhibitors




Milrinone

Infusion

50ug/kg bolus then 0.375 – 0.75ug/kg/min








Grading of Recommendations of Therapies in the Management of AHF


Intervention

Grades of

Level of



Recommen-

Comments



Evidence



dation








INITIAL MANAGEMENT CONSISTS OF :





Maintain the oxygen saturation above


Oxygen

I

C


95%











Diuretics

I

B

Indicated for fluid retention







Nitrates

I

B

Contraindicated if SBP<>


with caution in valvular stenosis.











Morphine

IIb

C

Indicated in pts who are dyspnoeic and


restless











NOT RESPONSIVE TO INITIAL TREATMENT AND SBP≥100mmHg





continuous infusion; combination with






Diuretics

IIb

C

nitrates, dopamine, dobutamine or





thiazide


Dobutamine

IIa

C

Indicated for peripheral hypoperfusion +/-


pulmonary congestion











Dopamine

IIb

C

To improve renal perfusion and promote


(<2>µg/kg/min)

diuresis










Milrinone

IIb

C

Improves symptoms and hemodynamics.







Sodium

I

C

Indicated in hypertensive crisis and acute


Nitroprusside

valvular regurgitation










NOT RESPONSIVE TO INITIAL TREATMENT AND SBP<100mmhg





Indicated to increase the BP


Dopamine

IIa

C


(>2µg/kg/min)











Noradrenaline

IIb

C

Indicated to increase the BP










Indicated as a bridge till myocardial


IABP

I

B

recovery or heart transplant







Ventricular



Indicated as a bridge till myocardial


Assist Device




IIa

B

recovery or heart transplant


(VAD)









For more detail Information about Management of Heart Failure By MOH
u can download the pdf file HERE