Context-sensitive fluid administration : what, when and how much? : SASA refresher course text
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As with all drugs, fluid therapy must be regarded as context sensitive. If a drug is given in the wrong context to the wrong patient and without a proper indication, only the side-effects of the drug will be seen, with probable demonstrable harm. Fluids, as with all drugs, should only be administered in the proper context in which consideration is given to the pharmacological properties of the agent being administered, the condition for which the drug is being given, and the expected benefits and possible harm. Without clear consideration of the context, drug administration is negligent and harmful.Keywords:
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In favour of self-acupuncture, this is a useful way to prolong the effects of acupuncture when the response is only brief or patients cannot attend frequently. If the patient is capable and the condition is suitable for self-acupuncture, patients can be taught how to do it and then seen for review. Patients should be provided with complete information sheets, and one example is presented. Against self-acupuncture, patient safety is paramount and would be compromised by teaching them how to do acupuncture. In addition, serious accidents have happened with self-acupuncture, including a death. Other arguments against it are that it is less effective than standard acupuncture, the patient misses out on the therapeutic relationship, and safer alternative methods exist.
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One of the more important questions of the moment is whether specific antimicrobial agents should be prescribed for the patient ill with an infectious disease. The decision is complicated by a number of factors, not the least of which is the attitude of the patient or of his family. The average patient expects, and not infrequently demands, such treatment with no consideration of whether the causative agent of his particular infection is susceptible to any of the available therapeutic agents. Many physicians are currently choosing the easier course of prescribing supposedly specific therapy for practically all infections. Only when the disease is not terminated by the therapy or spontaneously in spite of it, is serious consideration given to more accurate diagnostic measures and in turn to truly specific therapy, if such is available. There are arguments to support such indiscriminate therapy, but in the opinion of most critical physicians the
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How often have you thought about the importance of and the processes involved in choosing the most effective drug for your patient? Claire Meager and Philip A Routledge help you find out
I will not provide treatments that are pointless or harmful, or which an informed and competent patient refuses. I will help patients find the information and support they want to make decisions on their care
A new Hippocratic oath, 2004
When it comes to choosing the most appropriate drugs for our patients, there unfortunately isn't a concept of a must have drug or indeed a one size fits all regimen of treatment. Instead, each decision about treatment is made according to a number of different factors, such as proved efficacy, cost effectiveness, and patients' preferences. Together these constitute the idea of rational prescribing. (This concept was introduced in article one of this series.) This article explains which drugs we should be giving to our patients, focusing on fundamental concepts while also giving a few specific examples.
In a perfect world patients would not need any drugs, and one stop treatments would be the answer. This is often the panacea of medical treatment-for example, the idea of islet cell pancreatic transplantation for diabetes mellitus rather than daily injections of insulin or multiple hyperglycaemia drugs. For most chronic conditions, however, such as ischaemic heart disease, hypertension, and diabetes, long term treatment with drugs is essential. And as the population ages, patients with multiple comorbidities will need ever increasing numbers of treatments.
Drugs are the mainstay of therapeutic interventions for acute and chronic conditions, whether intended to prolong life, treat symptoms, or cure disease. When making the decision about which class of agent or the most appropriate drug for your patient you should consider efficacy and clinical effectiveness, safety, and cost …
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First Do No Harm' is a series of 12 brief monthly articles with internet footnotes about harming and healing in general practice.Each article is based on one of the 12 RCGP competency domains, this month's being: 5. Clinical management: the recognition and management of common medical conditions in primary care. 1 'It is far better to predict without certainty, then never to have predicted at all.' 2
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As with all drugs, fluid therapy must be regarded as context sensitive. If a drug is given in the wrong context to the wrong patient and without a proper indication, only the side-effects of the drug will be seen, with probable demonstrable harm. Fluids, as with all drugs, should only be administered in the proper context in which consideration is given to the pharmacological properties of the agent being administered, the condition for which the drug is being given, and the expected benefits and possible harm. Without clear consideration of the context, drug administration is negligent and harmful.
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Aging incurs aortic stiffening and dilation, but these changes are less pronounced in peripheral arteries, resulting in stiffness and geometry gradients influencing progression of the forward and reflected pressure waves. Because premature arterial aging is observed in ESRD, we determined the respective roles of stiffness and aortic geometry gradients in 73 controls and 156 patients on hemodialysis. We measured aortic pulse wave velocity (PWV) and brachial PWV to evaluate the stiffness gradient [(brachial PWV/aortic PWV)0.5] and ascending aortic and aortic bifurcation diameters to assess aortic taper (ascending aortic diameter/aortic bifurcation diameter). The global reflection coefficient was estimated from characteristic impedance and vascular resistance. Cox proportional hazard models were used to determine mortality risk. The age-associated increase in aortic PWV was higher in patients (P<0.001). In controls, aortic ascending and bifurcation diameters increased with age, with an unchanged aortic taper. In patients on hemodialysis, age did not associate with increased ascending aortic diameter but did associate with increased aortic bifurcation diameter and decreased aortic taper, both of which also associated with abdominal aortic calcifications and smaller global reflection coefficient (P<0.001). In patients, multivariate models revealed all-cause and cardiovascular mortality associated with age, aortic PWV, and aortic bifurcation diameter with high specificity and sensitivity. Using stiffness gradient, aortic taper, or global reflection coefficient in the model produced similar results. Thus, whereas aortic stiffness is a known independent predictor of mortality, these results indicate the importance of also evaluating the aortic geometry in patients on hemodialysis.
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A clinical mistake is a preventable antagonistic impact of care, regardless of whether it is obvious or unsafe to the patient's. This may incorporate an incorrect or fragmented finding or treatment of an illness, injury, condition conduct, contamination, or other infirmity. Clinical mistakes can happen any place in the medical services framework: In clinics, facilities, medical procedure places, specialists' workplaces, nursing homes, drug stores, and patients' homes. Mistakes can include medications, medical procedure, conclusion, gear, or lab reports. These tips determine how you can deal with get more secure consideration. Clinical blunders prompting unfriendly occasions can happen in dentistry.
The writing demonstrates that such mistakes extensively include: blunders identified with the remedy of medicine, blunders dependent on disregarding current logical proof in regards to treatment, mistakes happening during treatment or related with ill-advised upkeep of hardware, mistakes dependent on inability to appropriately keep up quiet records, blunders emerging from the inability to obtain educated assent, the inability to set up and keep up fitting disease control gauges, the inability to appropriately analyze, the inability to forestall mishaps or confusions related with care or to seek after proper subsequent consideration when they happen, and the inability to adhere to legitimate directs reflecting momentum standard of care or practice rules or guidelines set up by singular state laws. This show surveys the most well-known clinical mistakes prone to happen in the act of dentistry; traces the proposals by ADA for avoidance of clinical blunder and portray how to foster an underlying driver examination and activity intend to forestall further clinical blunder
Under this classification there are clinical mistakes identified with wrong estimation of remedial measurement of sedative, absense of pain, or endorsed drugs; blunder in the genuine conveyance of a sedative or absense of pain; and mistake from inappropriate solution of prescription before, or following treatment. Blunder results from an absence of information or comprehension of the pharmacokinetic or pharmacodynamic standards related with drug treatment including drug retention, dissemination, digestion, and end, instrument of activity and general impacts dental medical care suppliers have a commitment to know about these likely mistakes and standards of medication conveyance and recommend medicine as needs be. As far as medication ingestion, consider that any drug applied topically to oral mucous layers will sidestep the entry dissemination, subsequently staying away from first-pass digestion by the liver. Consequently a drug conveyed through mucosal retention can have equivalent or more noteworthy intensity than oral or different courses of organization. For instance, indiscriminant utilization of a prescription, it ought to be valued that a few medications, like diazepam, are extremely dissolvable in lipid and stored into fat tissue, with later delivery during actual work; a thought that is significant when such a medication is given to a competitor or to the geriatric patient.
Additionally the hairlike dispersion in fetal tissue makes impressive openness even modest quantities of medicine. Solution of medicine during pregnancy (especially the main trimester) should be either deferred or thought about mindfully to forestall antagonistic fetal occasions. Medication change influencing circulation is another expected wellspring of blunder in endorsing as certain prescriptions change subsequent to being used, possibly causing harm2 For instance, meperidine (Demerol®) is changed over to normeperidine, a poisonous metabolite which is a focal sensory system energizer with a half-existence of 15-20 hours. Damage can emerge out of the incessant solution and utilization of meperidine from the amassing of this harmful metabolite.
Another part of conveyance is identified with the effect of microsomal action which has been involved in many medication communications and unfriendly impacts. It is accounted for that 90% of medications are utilized by cytochrome P450 compounds (the class contains in any event 50 chemicals). For instance, in the patient endorsed phenobarbital, which initiates creation of CYP3A4 catalyst (one of the 50 variations), other recommended prescriptions that are processed by this compound might be delivered less compelling. Diminished adequacy emerging from the coprescription (phenobarbital in addition to a prescription utilized by CYP3A4) would be viewed as an endorsing blunder. Two extra instances of this sort of mistake remember changed coagulation for the patient taking warfarin as a result of co-endorsed fluconazole (Diflucan®) for oral candidiasis and myopathy or rhabdomyolysis in patients taking simvastatin (Zocor®) or Tegretol® when co-recommended with erythromycin for a dental disease. In the patient taking Prozac® or Paxil® (which restrains the movement of the P450 catalyst - CYP2D6) endorsed torment relievers like codeine, hydrocodone, or oxycodone might be less compelling in giving post-careful help with discomfort these models establish clinical blunder.
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Polypharmacy is a commonly addressed problem in the elderly. It is the use of a minimum of four medicines simultaneously. However, the elderly population suffers not only from the overuse of the medicines but also from the underuse. Furthermore, not uncommonly, use of a minimum of four medicines designated as polypharmacy, may be rational in many clinical circumstances in the elderly. In this article, we review the principles of rational drug use in the elderly. The main aim of the geriatric management increasing the quality of life should also be the purpose of the drug therapy. The physiological changes that occur by aging should be taken into account. The patient or caregiver should be informed on the drug list, instruction on use, possible side effects and indication of the current regimen. The drugs taken by the patient should be checked against the recommended regimen. The regimen should be reviewed for indication, appropriateness and possible switch to a safer or cheaper agent, minimum effective dosage, timing, effectiveness, side effects and toxicity, and potential drug-drug interaction one by one. This checking should be performed in a periodical manner and also in any acute deterioration. The potentially useful drugs should not be underused. This approach may decrease both the overuse and underuse of medicines resulting in the rational drug use of the vulnerable elderly.
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