ECG - f f pe scurt

HR =  300 / Nr de casute mari dintre 2 QRS 

1 casuta mare = 0.2 sec

1 casuta mica = 0.04 sec

PR = 0.12 - 0.2 sec

  • > 0.2 sec BAV I
  • < 0.12 sec Preexcitatie 
    • LGL
    • WPW
QRS 0.1 sec

> 0.12 sec BR

QTc > 0.44 ⚣/ 0.46⚢



Ax QRS Normal Left Right N - W
D I + + --
D II + -
AVF
+ -

Indice Sokolov

R5/6 + S1/2 > 3.5 mV

Fungi

 - 𝛽 Glucan + perete celular chitina

- unicelular/ micelii

Colonizare pulmonara

  • Aspergilius
  • Cnadida
  • Penicillium
  • Clavispora
  • Pneumocistis

Fungile reprezinta 0.1% din microbiomul intestinal

  • Ascomycota
  • Bazidiomycota

MUCORALES

- ubicuitari

- hife

- afinitate crescuta pentru fier (PTR1)

  • Imunocompromisi - cancer, imunoterapie, malnutritie, administrarea de voriconazol, GVHD, MV
  • DZ cu glicemii necontrolate
  • Neutropenie severa
  • COVID 19 nonsever + glucocorticoid
  • Chelator fier
  • trauma
- Sinuzita severa → abces cerebral

- sediu pulmonar, gastrointestinal, cutanat

- Black Skin

Colonizare → invazie tisulara → angioinvazie → +++ tromboza →  necroza + diseminare

ASPERGILIUS

- trasnmitere - inhalare spori

- saprofit, oportunist

- forme:

  • ABPA - Aspergiloza Bronhopulmonara Alergica
  • CNPA - Pneumonie Cronica Necrotizanta cu Aspergilius
  • Aspergilom
  • Aspergiloza invaziva
  • IAPA - Influenza Associated Invasive Apergillosis
  • CAPA - Covid 19 Associated Pulmonary Apergillosis
                    - Covid 19 Associated Traheobronchittis
  • CPA - Chronic Pulmonary Aspergillosis
    • Neutropenic → angio invasive
    • Non-neutropenic → airway invasive

Colonizare → Invazie tisulara → Angioinvazie

Factori de risc:

- neutropenie (leucemii) →  profilazie Posaconazol

- pneumoniii virale severe (covid)

- leziuni structurale pulmonare

- imunosupresoare (transplant)

Factori de risc CAPA

- supresie cale Interferon

- fact clinici: Tocilizumab + Dexa

* Klebsiella inhiba formarea de hife si biofilm de catre Aspergillius


Aspergiloza invaziva - IPA (Invasive Pulmonary Aspergollosis) / TBA (tracheobronchial aspergillosis)

- biomarker: galactomanan (BAL > ser) / amplificare ADN 

- imagistic : halo/crescent sign Rx

  • 1 semn/simptom compatibil
    • febra > 3 zile sub antibioterapie corecta
    • reaparitie febra > 48 ore de la oprirea acesteia sub antibioterapie neintrerupta 
    • durere pleuretica
    • dispnee
    • hemoptizii
  • 1 criteriu clinic
    • ulceratii traheo-bronsice
    • noduli
    • infiltrate pulmonare
    • abcese
  • 1 criteriu ce tine de gazda
    • gripa
    • covid
    • BPOC moderat/sever
    • HIV CD4 < 200
    • cancer 
  • 1 criteriu micologic
    • galactomanan BAL > 1.0 ODI
    • galactomana ser > 0.5 ODI
    • culturi pozitive cu Aspergillius

CANDIDA SPP

- comensala

Candida

  • Albicans
  • Glabrata
  • Thropicalis
  • Parapsilosis
  • Krusei
  • Kefyr
  • Auris

- Candemie: 

  • neutropenie
  • hemodializa
  • cvc
  • chirugie abdominala

Candemie = Candida izolata din hemocultura crecoltata central/periferic (FUNDICU - vena periferica)

* Candemie → tratament timp de 14 zile dupa negatire culturi

- biomarker: 1,3 𝛽Dglucagon (BDG)

ALTI FUNGI

Pneumocystis Jiravecii Pneumonia

Antifungice

POLIENE

Amfotericina B deoxycholate PK (AmB - d)

Amfotericina B lizozomala (L -AmB)

Amfotericina B  Complex lipidic (ABLC)

Mecanism actiune

- legare de ergosterol

- leziuni oxidative

- stimularea celulelor fagocitare

! Se absoarbtie in tubulatura ECMO!

! Concentratii in plaman, ficat, spina!

AMB-D

- 0.7 - 1 mg/zi in 2-4 ore 

- 1.5 mg/zi in PEV timp de 6 h

- activitate dependeta de concentratie

- legare ↑ de proteine plasmatice

- 𝛥t1/2 = 24 ore, per de eliminare 15 zile

- concentratie ↑ in ficat, splina, maduva, peritoneu, plaman, rinichi

- concentratie ↓ in LCR, lichidul amniotic

Ef adverse

- legat de adminsitrare - febra, HTA, frison, greata ← elibereaza IL6, IL8, TNF𝛼, MCP1, IL10

- nefrotoxicitate

- ↓ K, ↓ Mg

- ANafilaxie

- Encefalita demielininzanta

- anemie normocromica

ABLC

- 1 - 5 mg/kg/zi

- nefrootoxicitate mai scazuta

- efecte secundare - reactii legate de administrare

L-AMB

- neutropenie febrila 1 - 3 mg/kg/zi

- aspergiloza 3 - 5 mg/kg/zi

- eficacitate crescuta > Aspergilius

- 6 mg/kg/zi Cryptococus

AZOLI

Imidazoli

  • Miconazol
  • Ketoconazol
  • Clotrimazol
Triazoli

- tinta - Ergosterolul
- inhiba - 14𝛼Demethylase = Fungal CYP
- efecte adverse: rash, cefalee, gastro-intestinale, insuficienta hepatica, ↓ QT, defecte congenitale

  • 1 generatie - IMIDAZOLI
    • Fluconazol (Diflucan)
- forma IV/OR 
- excretie urinara crescuta
- timp de injumatatire crescut - o doza/zi
- obezi - cresti doza
- interactiuni medicamentoase +
    • Itraconazol 
- piele
- forma OR
- timp de injumatatire crescut - o doza/zi 
- metabolizare hepatica
- interactiuni medicamentoase +++

  • 2 generatie - TRIAZOLI
    • Voriconazol (Vfend) 
- forma IV/OR
- Candida auris, Candida  krusei, Candida  glabrata, Aspergilius fumigatus
- excretie in LCR
- metabolizare hepatica
- timp de injumatatire scazut - bid
- efecte adv: modificari oftalmologice, fotosensibilitate, toxicitate osoasa, cancer piele
- interactiuni medicamentoase +++
    • Posaconazol 
- forma IV/OR
- Candida auris, Candida  krusei, Candida  glabrata, Aspergilius fumigatus, Mucorales
- timp de injumatatire crescut - o doza/zi
- excretie fecala
- metabolizare hepatica
- interactiuni medicamentoase +++
    • Isavuconazol (Cresemba) 
- forma IV/OR 
- Candida auris, Candida  krusei, Candida  glabrata, Aspergilius fumigatus, Mucorales
- prodrug - Isavuconazonium sulfat
- timp de injumatatire crescut - o doza/zi
- metabolizare hepatica
- interactiuni medicamentoase +++

ECHINOCANDINE

Caspofungin (Cancidas)
Micafungin
Anidulafungin (Ecalta) 

- inhiba sinteza de 𝛽 1,3 D glucagon

- efecte adverse: 

    - legate de adminsitrare flush facial, edem, prurit, bronhospasm

    - gastrointestinale, anemie, leucopenie, 

    - mai frecvente la Caspofungin

    - teratogen

- fungicide pentru Candida

- fungistatice depeendente de doza pentru Aspergilius

- metabolizare 

    • Caspofungin - citocromul P450
    • Micafungin - CYP
    • Anidulafungin - spontan in plasma

- penetranta minima in SNC

- eficiente in biofilm

- NU s emodifica doza pe ECMO

- EAGLE EYE EFFECT = scaderea eficacitatiila o doza mult peste MIC

ALTELE

Rezafungin 

- generatia a doua de echinocandine

Ibrexafungerp

- inhiba sinteza de glucagon
- OR

Fosmanogepix

- IV/OR
- sinergic cu AmB

Olorofim 

- OR
- Aspergilius

Odelconazol

- triazol inhalator

Volum lichid pleural

 Formula Balik

Volum lichid pleural (ml) = Distanta masurata ecografic (mm) x 20

pH lichid pleural < 7.2 = infectie

The fluid is considered an exudate if any of the following are found and a transudate if all are absent (Light’s criteria) –ratio of pleural fluid to serum protein > 0.5, ratio of pleural fluid to serum LDH > 0.6, pleural fluid LDH > two thirds of the upper limits of normal serum value. Pleural fluid cholesterol > 55 mg/dL (1.42mmol/L)may also be a useful in distinguishing an exudate from a transudate.

Pulmonary Arterial Hypertension / Pulmonary Venous Hypertension

Parametru PAH Pulmonary Arterial Hypertension PVH Pulmonary Venous Hypertension
RV ↑ ±↑
LA ↓ ↑
RA/LA
Size ratio		 ↑ N ( LA > RA)
Sept interatrial Impins spre stanga Impins spre stanga
RVOT  Frecvent Rar
E/A < 1 >1
Lat e' N ↓
Lat E/e' < 8 > 10
Ao pressure N / ↓ N / ↑
PCWP ⋜ 15 mmHg > 15 mmHg
PADP - PCWP > 7 mmHg < 5 mmHg
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