Guidelines For Monitoring Of Patients Research Articles

Fluidoterapia en cirugía cardiaca. Puesta al día

The anesthetist has 2 major tools for optimizing haemodynamics in cardiac surgery: Vasoactive drugs and the intravascular volume. It is necessary to identify which patients would benefit from one or the other therapies for a suitable response to treatment. Hemodynamic monitoring with the different existing parameters (pressure, volumetric static, volumetric functional and echocardiography) allows the management of these patients to be optimized. In this article a review is presented on the most recent and relevant publications, and the different tools available to control the management of the fluid therapy in this context, and to suggest a few guidelines for the haemodynamics monitoring of patients submitted to cardiac surgery. A systematic search has been made in PubMed, limiting the results to the publications over the last five years up to February 2012.

Rectosigmoid Pouch (Mainz Pouch II) in Children

Continent anal urinary diversion is a therapeutic option in bladder exstrophy. We report our long-term results with the rectosigmoid pouch (Mainz pouch II), a modification of the classic ureterosigmoidostomy. A total of 38 children with a mean age of 5 years (range 0.5 to 17) underwent a Mainz pouch II procedure between 1991 and 2004. Most patients (33) had bladder exstrophy or incontinent epispadias. In 14 children (37%) urinary diversion was performed after failed primary reconstruction. In 6 children conversion was performed from an incontinent type of urinary diversion. Renal function, continence and metabolic changes were analyzed. A total of 35 children were followed for a mean of 112 months (range 5 to 147). All children were continent during the daytime but 3 (8.6%) suffered from nighttime incontinence requiring pads. With respect to the upper urinary tract, 6 children (15.8%) had development of pyelonephritis, mostly with stenosis of the ureterointestinal anastomosis. Reimplantation of the ureter was required in 10 of 69 RU (14.5%), of which 7 (10.1%) were due to ureterointestinal stenosis and 3 (4.3%) were due to reflux. Serum creatinine was within normal limits in all children. During followup acid-base balance was monitored, and early alkali supplementation was initiated in 24 of 35 children (69%) when the base excess was less than -2.5 mmol/l. One child had development of clinical acidosis requiring hospitalization. After followup of more than 10 years annual rectosigmoidoscopy was performed in 16 children/young adults without pathological findings. The Mainz pouch II procedure for children with genitourinary anomalies promises excellent continence rates. However, periodic followup studies are important to check the upper urinary tract and prevent metabolic acidosis. Due to the risk of malignancy at the ureterointestinal anastomosis, endoscopy should be performed annually beginning at postoperative year 10. The Mainz pouch II procedure is safe in the long term. Without stoma, appliance or catheterization this type of continent urinary diversion is specifically suitable for children.

Oral glucose tolerance tests in treated patients with schizophrenia.: Data to support an adaptation of the proposed guidelines for monitoring of patients on second generation antipsychotics?

Objective. – A recent consensus conference has proposed guidelines for the monitoring for diabetes in patients with schizophrenia and also identifies the need of long-term prospective studies. Method. – A large scale prospective study on metabolic risks of antipsychotic medication is currently ongoing. At baseline, patients get a full laboratory screening, ECG and an oral glucose tolerance test (OGTT). Baseline data on 100 non-diabetic patients at study inclusion and stable on medication for at least 6 months are presented. Results. – Glucose abnormalities are found in 22% of patients at baseline. A monitoring protocol based only on fasting glucose would not have detected 63.6% of these patients with classifiable glucose abnormalities in our sample. Fasting insulin and measures for insulin resistance have a high predictive value for abnormalities late in the OGTT. Conclusion. – Already at baseline, metabolic problems are frequently present in patients with schizophrenia treated with antipsychotics. Adding assessment of fasting insulin in a monitoring protocol improves detection of glucose abnormalities late in an OGTT.

Sedation and analgesia in the pediatric patient.

The administration of sedation and analgesia for pediatric gastrointestinal procedures has become routine but is not standardized. For the most part, pediatric endoscopists are encouraged to use their clinical judgment to select between using intravenous (IV) sedation or general anesthesia on an individual patient basis. Commonly administered IV sedation regimens in children combine benzodiazepines with narcotics, but anesthesiologist administered propofol sedation is gaining acceptance among pediatric gastroenterologists. Guidelines for patient monitoring and new technologic advances may help to ensure patient safety for children undergoing endoscopic procedures, no matter what sedation regimen is used.

Monitoring by rheumatologists for methotrexate-, etanercept-, infliximab-, and anakinra-associated adverse events.

To determine what monitoring protocols rheumatologists use to identify adverse events in rheumatoid arthritis (RA) patients treated with methotrexate (methotrexate), etanercept (etanercept), infliximab (infliximab), and anakinra (anakinra), how often rheumatologists encounter treatment-altering adverse events in their RA patients receiving these treatments, and how they feel about and comply with the current monitoring guidelines. Three hundred ten physician members of the American College of Rheumatology (ACR) were notified by e-mail of a survey that was posted on our rheumatology Web site. Questions were closed-ended and multiple choice in format. One hundred twenty-three responses were received (40%). Most rheumatologists reported that they utilize the ACR recommended screening tests at baseline before methotrexate treatment is initiated. Seventy-nine percent reported that treatment-altering abnormalities had occurred in <5% of their methotrexate-treated RA patients, and 88% reported that such abnormalities had occurred in <10% of such patients, in the previous 3 years. Forty-one percent believed liver function monitoring guidelines need to be changed; 59% said they would agree with new guidelines that would include a recommendation for liver function monitoring every 3-4 months. Most rheumatologists were not aware of any guidelines for monitoring by blood tests in RA patients treated with biologic agents, yet the majority reported that they order blood tests before patients start these therapies and on followup. Our survey indicates that treatment-altering liver function abnormalities in methotrexate-treated RA patients are rare, and more than half of rheumatologists agree that a less stringent monitoring regimen should be considered. Rheumatologists and pharmaceutical companies might work together to develop guidelines for monitoring of patients treated with biologic agents.

Aerobic exercise and the post myocardial infarction patient: a review of the literature

Meta analyses of randomized controlled tests of cardiac rehabilitation after myocardial infarction demonstrate that regular exercise reduces the risk of overall mortality and cardiovascular mortality. In patients with established coronary artery disease, exercise is associated with improved activity tolerance, modification of risk factors, and improvement in quality of life. Randomized controlled tests demonstrate that whereas older patients after coronary events are substantially less fit than younger patients, they obtain a similar relative improvement of aerobic capacity with a graded conditioning program. However, older adults are enrolled in such programs at a lower rate than other age groups. Despite similar clinical profiles to men, women are less likely to participate in exercise rehabilitation. In this article we discuss the principles of program development, guidelines for monitoring of patients, and facilitation of exercise programs in the Australian context.

Intradialytic Parenteral Nutrition: Evolution and Current Concepts

A historical review of nutrition supplementation of the renal patient documents the evolution of nutritional support as an accepted mode of therapy. The purpose of this study was to examine the role of intradialytic parenteral nutrition (IDPN) as it exists today as well as to offer patient selection criteria, clarification of administration, and patient monitoring guidelines. The pilot study results and established IDPN protocol offer an opportunity to assess individual patient requirements and administer appropriate nutritional support when indicated. Clinical indices for IDPN patient selection are discussed along with suggested solutions for common problems encountered with IDPN.