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These studies identify a large number of benefits to the health care delivery processes as well as a large number of barriers to uptake and use of the various systems studied generic kamagra oral jelly 100 mg visa. The strengths of the amalgam of evidence are that similar themes were identified across studies buy kamagra oral jelly 100mg fast delivery, health care settings were assessed by more than one study trusted 100mg kamagra oral jelly, studies were carried out in settings across the care continuum, study participants included physicians, pharmacists, nurses, other health care providers as well as some administrative management personnel, and multiple different types of qualitative data collection approaches including interviews, focus groups, observations, and document reviews were used across the set of studies evaluated. The following paragraphs provide descriptions of some of the more important qualitative studies and their findings. Many groups studied could be 727,729,733,740,748 described as hopeful but cautious while others, mainly physicians (although they 726,735,761,765 were who was studied most often), were skeptical. Their attitudes about the current paper-based system were generally positive and many had a mistrust of computer systems in general. Patients identified that an electronic system may be an advantage for staff when the first language is not English. The key themes that emerged were importance of computerized alerts, need to minimize spurious alerts making it difficult to override critically important alerts, having audit trails of such overrides, support for safe repeat prescribing, effective computer–user interface, importance of call and recall, and need for safety reports. User interface, repeat prescribing, need to be able to run safety reports, 738 and other safety issues were also agreed upon. Drug alerts, including drug interaction alerts, were stated to be beneficial to 547,632,666,767 improve patient safety. E-Prescribing triggered a variety of clinician behaviors (other 632 than terminating or changing a prescription) that may improve patient safety. These were grouped as (1) information errors generated by fragmentation of data and failure to integrate the hospital’s several computer and information systems, and (2) human-machine interface flaws reflecting machine rules that do not correspond to work organization or usual behaviors such as selecting the wrong patient because a list is alphabetical versus by team or floor, or unclear log on and log off procedures or processes so that the next person does work using the previous person’s permissions. The 761 multiple checks within the system also could lead to improved patient safety. They reported that this was because data were more legible, could be accessed remotely, and reminders provided helpful decision support. However, they also reported that at the same time as being helpful, the reminder system was considered time 763 consuming, redundant, and the speed of the system slow. Over time, and with experience of making the system work for them, attitudes changed to become more balanced and 439,676,761 the potential benefits of the system become clearer to most. Physician users tended to provide comments related to the culture of professional quality (feeling that the computer facilitated quality). Alternately, those physicians that chose not to use the system tended to provide comments that focused on human relations. For example, they reported on their relationships 751 with their patients that they felt were detrimentally affected by computer use. This cost savings however, only directly benefited insurers and not the clinicians, 751 patients, or health care facility. Effectiveness focused on the 745 positive effect of alerts on allergy awareness and patient education. Efficiency related to 742,745 ensuring that the alerts and reminders were efficient, useful, and did not waste time. Information content 742,745 was concerned with accurate, comprehensive, timely, rich, and accessible information. The user interface was felt to be important for smooth and efficient work and provision of valuable 742,745 information that was accurate and provided quickly. The value of e-Prescribing alerts was diminished by the quantity of irrelevant and 632 inappropriate alerts. Workflow issues related to the information being available when and only 742 745 when needed. Attitudes to evidence-based guidelines were also seen as an important factor as to how alerts would be taken up, with physicians preferring that alerts be severity-rated, that only substantial ones should 745 appear, and that user interface design be enhanced. The biggest surprise from a set of focus groups (reported in 2002) with a group of clinicians (physicians, physician assistants, and nurse 61 practitioners) was the considerable negative emotion associated with alerts and reminders 742 (feelings of being criticized, embarrassment, guilt, frustration, annoyance, and anger). More people from the successful hospitals group reported supportive administering and heads of medical sections, direct involvement of physicians, mandatory implementation, adequate training, and sufficient hardware facilitated success. In terms of barriers, only inadequate hardware and lack of ability to easily complete patient transfer and advance admission orders (medical records package) differentiated the successful compared with unsuccessful groups. User created strategies identified that information overload must be carefully managed and communication is vital and is often negatively affected by new systems. Patients on a general survey ward were interviewed after implementation of an e-Prescribing and administering system. Concerns were identified including loss of personal touch, not understanding the system, and perceived extra time needed if nursing staff had to check the drugs prescribed on the 748 computer. E-Prescribing has tremendous capacity to change and improve pharmacists’ professional work and 730 interactions. One study showed that overly ambitious expectations sometimes lead to failed 629 implementation. Organizational processes such as the limited resource of fax machines were also 732 identified. In the ambulatory setting limited electronic connectivity of e-Prescribing systems to pharmacies or pharmaceutical benefits managers (who administrate pharmacy prescriptions) meant that despite one-way electronic (non-fax) communication of prescription information from the practice there was still conventional communication (e. Factors associated with these issues related to product limitations, external implementation challenges (e. A system that appended alerts and comments to the bottom of e-Prescriptions and was designed to reduce pharmacy callbacks did not reduce the number of callbacks but did 540 change the nature of the callbacks. Some 746 expressed concern that poor design or implementation could lead to increased errors. Most believed the system would lead to improved efficiencies facilitating more time spent with 746 patients. All of these studies focused on evaluation of the process of care delivery before or after implementation of the systems. Themes derived from the survey done before implementation indicated that the nurses felt that medications would be given in a timely manner with less error, but may result in an increase in time with this increase in safety, along with more reported errors, but fewer errors in administering actual meds (near misses). The surveys collected after implementation indicated that the staff felt there were fewer medication errors with a smoother administering of 674 medication. In one study done in a hospital setting, these workarounds were categorized into omission of process steps (seven workarounds), steps performed out of sequence (one workaround), and unauthorized process 728 steps (seven workarounds). Probable causes for these workarounds included technology, task, 728 organizational, patient, and environmental related causes. Another study of a system put in place in a long term care institution identified workarounds 732 related to the technology itself and organizational processes. The workarounds occurred at 732 new medication order entry, communication with the pharmacy, and administering. Organization process blocks leading to workarounds included 732 the double checking of preparation and administration documents. After an automated medication dispensing system was installed interviews with all workers and managers who were affected (nurses, pharmacy managers, pharmacists, pharmacy technicians, hospital administrators, and patient care managers) resulted in themes of distrust, resistance, miscommunication, unrealistic expectations (skepticism that it reduced medication errors), speed and scale of implementation, concurrent changes, inadequate support, and social 744 factors. Furthermore, some patients showed an interest 635 when they saw the results from the electronic assessment. One ethnographic case study identified that the physician–nurse communications, mechanisms to ensure cooperation, and the procedures for preparing and administering the medications are the key process areas to address before implementing a system to augment the 762 nursing administering of medications. Patients with lung, breast, or colorectal cancer who used the system generally felt that, with training, the handset was straightforward and easy to use, entering data twice a day for 14 days was acceptable, the system did not impact on patients’ daily routines, and the set of six symptoms that were recorded on the handset were adequate (although some patients did indicate that they would have liked the opportunity to report other symptoms). They were very happy with the alerting facility of the system often reporting that they felt ‘secure’ in the knowledge that someone was being alerted about their symptoms, the real time, 633 quick response rate of the data collection and alerting facility was viewed positively. However, one patient viewed the alerting system negatively, as she felt this part of the system 633 was not sufficiently individually tailored. Patients felt that the system improved safety, feeling that the program ‘would catch something I might not recognize’ or help them ‘respond 760 quickly to a threat’ to their health. Population Level Outcomes Only one study met our inclusion criteria that assessed population level outcomes as a 712 primary endpoint (Appendix C, Evidence Table 11). Composite Outcomes Only one included study assessed a composite outcome as their primary endpoint (Appendix 771 C, Evidence Table 11). The main endpoint of process composite score for checks 65 of glycated hemoglobin, blood pressure, low density lipoprotein cholesterol, albuminuria, body mass index, foot surveillance, exercise, and smoking improved significantly more in the intervention group than in the control group (1. Variation in Impact Depending on Medication Type or Form Summary of the Findings Although most studies looked at medication management in general, regardless of drug 18,399,401,403­ families, types or forms, 135 articles dealt with one or a few drugs or drug classes. No included studies addressed the issue of sound-alike or look-alike drugs, and four dealt with 414,458,510,535 altering prescribing of generic drugs over name brand.

Although many systems have been developed purchase kamagra oral jelly 100mg with mastercard, very few have really tackled the overwhelming difficulty of delivering the medication to the eye order kamagra oral jelly 100mg on-line. At the front of the eye cheap kamagra oral jelly 100 mg mastercard, the efficient clearance mechanism and the nature of the precorneal and scleral barriers oppose retention of drug in periocular tissue. The penalty for prolonged delivery may be blurring of vision or the need to use an implant. Drug delivery to the back of the eye is fraught with difficulties and the poor penetration severely limits the treatment of sight-threatening diseases. Developments in the next century will have to focus on the need to provide prolonged release of disease modulators with less risk and easier access than the present generation of devices. Outline the structure and physiology of the cornea relevant to drug delivery and adsorption. List the various disperse systems which have been employed to enhance topical ocular drug delivery. Describe the use of liposomes, microparticulates and nanoparticulates in intraocular drug delivery. Outline the advantages and disadvantages of iontophoresis in ophthalmic drug delivery. However, drugs generally do not readily enter the brain from the circulating blood. Access to the brain is particularly difficult for the “new biotherapeutics” such as peptide, protein and nucleic-acid based biopharmaceuticals. The brain capillary endothelium comprises the lumenal and ablumenal membranes of capillaries, which are separated by approximately 300 run of endothelial cytoplasm (Figure 13. The structural differences between brain capillary endothelium and non-brain capillary endothelium are associated with the endothelial tight junctions. The non-brain capillaries have fenestrations (openings) between the endothelial cells through which solutes can move readily via passive diffusion. In brain capillaries, the endothelium has epithelial-like tight junctions which preclude movement via paracellular diffusion pathways. There is also minimal pinocytosis across brain capillary endothelim, which further limits transport of moieties from blood to brain. Extending from the sides of these cells are foot processes; or limbs, that spread out, and abutting one another, encapsulate the capillaries. There is a very close relationship between the endothelial cells and the astrocyte foot processes, they are separated by a distance of only 20 nm, or approximately the thickness of the basement membrane. The existence of the endothelial tight junctions means that passive diffusion between the cells is prohibited (paracellular route), so that passive diffusion is limited to the transcellular route. Lipid soluble drugs move across the lipid-rich 323 plasma membranes of the endothelial cells, down a concentration gradient according to Fick’s Law (see Section 1. The most common system is the one that mediates the transport of glucose, which provides the brain with virtually all its energy. Carrier-mediated mechanisms are also responsible for the absorption of two other energy sources: ketone bodies, which are derived from lipids, and lactic acid, a by-product of sugar metabolism. Carrier-mediated transport systems are also involved in the uptake of amino acids by the brain. The brain can manufacture its own small neutral and acidic amino acids; however, large neutral and basic amino acids are obtained from the bloodstream. When citrate, a tricarboxylic acid, chelates metals such as aluminum, the tetravalent citrate-aluminum complex leaves a free non-complexed monocarboxylic acid which is a substrate for the monocarboxylic acid or lactate carrier in the brain endothelium. This enzyme is localized in the astrocyte foot processes of the brain, with minimal localization in capillary endothelial cells. This astrocytic enzymatic barrier to adenosine movement into brain interstitial 324 fluid is an example of how the permeability barrier of the endothelium can work in tandem with the enzymatic barrier in astrocyte foot processes, to provide a multicomponent blood-brain barrier. In brief, a macromolecular drug combines with a membrane-bound receptor and is internalized into endocytic vesicles. Transcytosis is achieved if the endocytic vesicles containing the drug-receptor complexes can reach the basal membrane without fusion with lysosomes. This receptor is upregulated in development and downregulated in streptozotocin-induced diabetes mellitus. Physicochemical factors associated with the drug which facilitate this process have been discussed extensively in Chapter 1 (Section 1. However, this linear relationship is only applicable if the molecular weight of the molecule is under a threshold of 400–600 Da (Figure 13. Examples of decreased permeability due to high molecular weight include morphine-6-glucuronide (molecular weight=461 Da), somatostatin analog 201–995 (1,019 Da), vinblastine (814 Da), vincristine (825 Da), or cyclosporin (1,203 Da). Size exclusion is associated primarily with the molecular volume of the molecule and not strictly with the molecular weight (see Section 1. It is proposed that such an active efflux system is p- glycoprotein based (see Sections 1. For example, vinblastine, vincristine, and cyclosporin are all potential substrates for p-glycoprotein. Recent studies have shown that p-glycoprotein is located in the astrocyte membranes (and not in the brain capillary endothelium as previously accepted) and that it functions by reducing the volume of distribution of the drug in the brain. The unionized form of the drug is the lipophilic form which can cross membranes, whereas negligible transport occurs for the ionized form. In this process, the plasma” protein collides with the endothelial glycocalyx and this microcirculatory event triggers conformational changes in the plasma protein. These conformational changes may involve the drug binding site on the plasma protein, so that the drug undergoes enhanced dissociation from that binding site within the brain capillary. The enhanced dissociation of a drug from its binding site on plasma proteins in vivo in the brain capillaries has been demonstrated for a number of different drugs and ligands (Table 13. Strategies such as modifying the physciochemical properties of a drug to enhance uptake by specialized transport systems are described below. Following icv infusion, drug diffusion in the brain is limited by such factors as: • physical barriers such as synaptic regions protected by ensheathing glial processes; • catabolic enzymes; • high- and low-affinity uptake sites; • low diffusion coefficients of macromolecules. For example, within 30 minutes of administering cholecystokinin to the brain via icv infusion, the neuropeptide has reached the plasma and inhibits feeding via a peripheral rather than a central mechanism of action. The distribution of drug rapidly to the peripheral bloodstream following icv infusion has been demonstrated repeatedly for both large molecules, such as cytokines, and small molecules. These factors combine to limit drug delivery via icv to the surface of the brain, with minimal distribution of drug into brain parenchyma. This may be beneficial when target receptors are found on the surface, or for diseases confined to areas near the ventricle wall. The use of genetically engineered cells to secrete a drug is currently at a very preliminary stage of development. A wide variety of polymeric implants are available, with different rate-controlling mechanisms, degrees of biodegradability, shapes, sizes etc. The distribution of drug into the brain following the intracerebral implantation of a polymeric implant is also limited by diffusion, with a maximal penetration of drug into brain parenchyma of < 1 mm. Albumin is neurotoxic for astrocytes and normally exists at concentrations in brain interstitial fluid that are approximately 1,000-fold lower than the concentrations of albumin in the circulation. Newer strategies involving the use of drug delivery systems include the use of immunoliposomes to target vesicles to the brain, as discussed below (Section 13. One of the simplest methods of improving the uptake of a drug to the brain involves the conversion of the drug to a more lipophilic prodrug (see Section 1. If a drug possesses a molecular structure similar to that of a nutrient which is a substrate for carrier-mediated transport (Table 13. Due to the high structural specificity of the carriers, it is more advantageous to convert the drug into a structure similar to that of an endogenous nutrient, rather than conjugating the drug to the nutrient. A: transport vector; B: non-transportable drug; A-R: receptor for transport vector; B-R: Receptor for peptide 13. This strategy (essentially a prodrug strategy) involves coupling the drug to a peptide or protein “vector” which normally undergoes receptor-mediated transcytosis, to form a so-called “chimeric peptide” (Figure 13. The chemical linker joining the therapeutic agent to the transport vector is cleaved, freeing the therapeutic agent to bind to the appropriate target receptor. Design considerations in the development of effective chimeric peptides include vector specificity for the brain, vector pharmacokinetics, coupling between vector and drug, and intrinsic receptor affinity for the released drug.

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The line of experiment will be to determine its influence upon the reproductive organs discount kamagra oral jelly 100mg online, and upon the nervous system generic 100mg kamagra oral jelly otc. It is a specific in certain cases of rheumatism - with the indications above named - and will cure when other remedies fail order 100 mg kamagra oral jelly free shipping. But if we examine these cases we will find that one has a pallid tongue, the other a red tongue. Lemon juice may also be used in the treatment of enlarged tonsils and uvula; one or two applications a day being made with a camel’s hair pencil. Or the fresh plant is bruised and covered with ten parts of hot lard or mutton tallow. It forms an excellent soothing ointment, and has been extensively used for hemorrhoids. A tincture is prepared from the fresh plant, with alcohol of 98 per cent; of this, gtt. It may be used in scrofula, enlargement of spleen and liver, jaundice, disease of skin, and “bad blood. In some cases where the irritation is due to sexual excitement or abuse, Lupulin exerts a very good influence. A tincture of the hop, may be occasionally employed in dyspepsia, with restlessness and a disposition to brood over troubles. It may also be used, following a meal, when the food undergoes fermentation, giving rise to unpleasant eructations. The Lycopodium (sporules) is triturated dry in a porcelain mortar until it becomes a doughy mass, then placed in a percolator and covered with alcohol and allowed to macerate for four days, when it may be drawn off in the usual way. The tincture of the plant may be given in chronic disease of the kidneys, when there is blood in the urine; in cases of cough with bloody expectoration, congestive headache, dizziness and tendency to syncope. The tincture of the sporules may be given when there is extreme sensitiveness of the surface; sensitiveness of a part, and care to prevent its being touched; slow, painful boils, nodes or swellings; extreme sensitiveness of the organs of special sense, with pale, livid or dirty complexion. For years I have employed Macrotys as a specific in rheumatism, and with excellent success. Not that it cures every case, for it does not; neither would we expect this, for this would be prescribing a remedy for a name. Rheumatism may consist of varied pathological conditions, though in all there is the special lesion of the nervous system, which characterizes the disease. In one case we find the indications for the use of an acid prominent, and this becomes a remedy for rheumatism. In another there are symptoms showing the need of alkalies, and they prove curative. Thus in the milder cases, where the disease has not localized itself as an inflammation, Macrotys is very speedy and certain in action. In rheumatic fever it is also positive in its action, and with the special sedatives gives excellent results. Where rheumatism has localized itself in an inflammatory process, all the benefit we obtain from it is, that we remove the cause, and hence the reason for a long continuance of the inflammation. It is a remedy for all pain having a rheumatic character, and for this we prescribe it with the best results. Those cases which go under the name of rheumatic-neuralgia, are very speedily relieved by it. Whilst the continuance of the remedy will not unfrequently effect a cure in these cases, in many it will require the additional means necessary to give healthy functional activity to some organ or part especially impaired. This influence seems to be wholly upon the nervous system, relieving irritation, irregular innervation, and strengthening normal functional activity. For this purpose it is unsurpassed by any agent of our materia medica, and is very largely used. Its influence is very marked in functional disease of the reproductive organs of women. Associated with pulsatilla it is specific in many cases of dysmenorrhœa; it should be given for three or four days before the expected period, and continued until the flow is free. In rheumatism of the uterus, to relieve false pains, or the many unpleasant sensations attending pregnancy, it has no equal in the materia medica, and becomes a true partus preparator. The heavy, tensive, aching pains are sufficiently characteristic and need not be mistaken. So prominent is this indication for the remedy, in some cases (not rheumatic), that I give it with a certainty that the entire series of morbid processes will disappear under its use. In one case, the disease had continued through the first week, growing worse daily under the treatment adopted, until the remarks of a night-watcher called my attention to these pains. Questioning elicited the fact that muscular pains had been severe from the first - but the patient “thought it was part of the disease, and there was no use to complain. This will serve as an illustration of the fact, “that a certain condition of disease may have that prominence in a case that an entire series of morbid phenomena will pass away when it is removed;” or in other words, that a single remedy may prove curative when a disease is complex - removing the first in a series of morbid processes, the others disappear of themselves. We find in all that class of acute diseases which develop typhoid symptoms as they progress, a need for remedies which control the septic process in the blood. Most physicians will have employed sulphite of soda in these cases, and have found marked advantage from its use, yet in other cases, presenting somewhat similar general symptoms it has done no good, and in some has done harm. But we have need of the same antiseptic remedies in cases in which the tongue is deep-red or dusky, whether covered with a brown fur, or presenting the smooth glistening appearance noticed in some of the more severe cases of typhoid fever, or typhoid disease. Whenever the tongue is thus dark-red, we can not give the salt of soda, for there is present a prominent indication for the use of an acid. We may use sulphurous acid as the antiseptic, but frequently it is not well borne by the stomach. We may say that it may always be administered when the tongue is dark- red, and shows a dark fur, and there is need for a remedy to antagonize the septic process in the blood. The Magnolia Glauca and Accuminata possess tonic and stomachic properties, which may prove useful in medicine. Will some of our Southern readers prepare a tincture from the recent bark, and test it thoroughly. It may not prove better than a dozen similar articles, and yet supply a very good medicine to those who live where it is abundant. It may be used in bronchial catarrh, gastric catarrh, rheumatism, and in the convalescence from malarial fevers. But it evidently has an action beyond this, and influences the function of respiration. Let us have it thoroughly tried, and it may be another instance of a very valuable remedy in a common article. The direction of the investigation will be shown by reference to the Dispensatory or Materia Medica. It may also be used in jaundice, with enlarged liver, the patient complaining of fullness and weight in the hypogastrium. A pale, leaden tongue, dirty, with full stomach, pendulous abdomen and sluggish bowels, is sometimes benefited by small doses of this remedy. A first or second decimal trituration may be employed to very good advantage where tissues are old and feeble, the heart’s action feeble, and the circulation of the blood weak. It has given excellent results in the treatment of neuralgia, especially when associated with debility. It may be administered in colic, painful diarrhœa, dysuria with painful desire to urinate, in dysmenorrhœa associated with lameness in the hip, and along the course of the sciatic nerve, and in some cases of rheumatism where such lameness is a marked feature. Eclectics have always been opposed to the common use of mercury in the treatment of disease, because as commonly used it did very much more harm than good. In the United States it has been extensively employed in all the ills that flesh is heir to, and in all its preparations, from the one-twelfth of a grain of corrosive sublimate or protoiodide of mercury, to teaspoonful doses of calomel. The use of mercury to tap the liver, and touch the gums, and the fearful salivation and sore mouth that sometimes followed, the protracted sickness, the increased death-rate, and the lasting wrongs that were entailed by it, even when patients recovered, are all vividly in the minds of our people. In the light of to-day, it is no wonder that the Eclectic school of medicine opposed its use, and made such a vigorous fight against it for half a century, until even its advocates are obliged to use it secretly. The charges made against it have all been sustained, and respectable practitioners of medicine in the city use mercury very sparingly, if at all. The common use of mercury by the Homœopaths, though the dose is small, is to be deprecated, as I have known much harm to result from it. Two of the worst cases of salivation I ever saw (resulting in death) were the result of Homœopathic treatment.

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Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) buy discount kamagra oral jelly 100 mg on-line. Copyright 1996 The American College of Cardiology Foundation and American Heart Association Inc generic kamagra oral jelly 100 mg on-line. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) discount kamagra oral jelly 100 mg on-line. Copyright 1996 The American College of Cardiology Foundation and American Heart Association Inc. Summary of evidence-based recommendations for supplemental evaluation of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery, 1996. An elevated serum bicarbonate concentration suggests chronic respi- ratory acidosis, while polycythemia may suggest chronic hypoxemia. A room air blood gas may provide useful baseline information so that one is not surprised that the postoperative arterial blood gas findings are so abnormal. A room air arterial oxygen tension (Pao2) less than 60mmHg correlates with pulmonary hypertension, whereas a Paco2 greater than 45mmHg is associated with increased perioperative mor- bidity. If spirometric parameters improve by 15% or more after bronchodilator therapy, such therapy should be continued. For abdominal surgery, there is no indication for evaluation beyond spirometry and arterial blood gas analysis. Patients may be well served by a preoperative discussion with their surgeon or respiratory therapist regarding the role of post- operative incentive spirometry and pulmonary toilet procedures. The patients need to be informed of the need for their active involvement postoperatively if they are to avoid pulmonary complications such as atelectasis and pneumonia. They also should be reassured that, while they will have some postoperative discomfort, measures will be taken to assure that they will have adequate pain relief. Perhaps the most useful intervention is for the smoking patient to cease smoking prior to surgery. Cessation of cigarette smoking is very important for those who smoke more than 10 cigarettes per day. Short- term abstinence (48 hours) decreases the carboxyhemoglobin to that of a nonsmoker, abolishes the effects of nicotine on the cardiovascu- lar system, and improves mucosal ciliary function. Sputum volume decreases after 1 to 2 weeks of abstinence, and spirometry improves after about 6 weeks of abstinence. Nutritional There is a strong inverse correlation between the body’s protein status and postoperative complications in populations of patients undergoing elective major gastrointestinal surgery and, to a lesser extent, other forms of surgery. With this in mind, it would seem useful to assess the nutritional status of a patient prior to surgery and possibly intervene preoperatively if a deficit is unmasked. While this makes intuitive sense, there in not much evidence to support improved clinical outcome via aggressive nutritional supportive measures. While there are many clinical and laboratory measures that can help assess a patient’s nutritional status, there is no “gold standard. Ciocca ual markers may not accurately represent the nutritional status of the patient. Preoperative weight loss is an important historical factor to obtain, if possible. In general, a weight loss of 5% to 10% over a month or 10% to 20% over 6 months is associated with increased complica- tions from an operation. A more thorough history of weight loss in the patient in the case presented at the beginning of this chapter will be important. While no one marker is predictive of surgical outcome, combinations of measurements have been used to quantify the risk for subsequent complications. Because delayed hypersensitivity is uncommon in clinical practice, the equation has been simplified by substituting the lymphocyte score, using a scale of 0 to 2, where 0 is less than 1000 total lymphocytes/mm3, 1 is 1000 to 2000 total lymphocytes/mm3, and a score of 2 is more than 2000 total lymphocytes/mm3. The higher the score using either of these equa- tions, the greater the risk of postoperative complications. It is important to take the patient’s nutritional state into consideration after surgery. In the majority of well-nourished patients, little needs to be done other than to ensure that they resume a normal diet as soon as possible after surgery, preferably within 5 to 10 days. In patients who are severely malnourished, aggressive nutritional support may be of some benefit, with most of the benefit occurring in the early postoperative period. Hematologic An obvious concern for a surgeon who is about to induce iatrogenic injury to a patient is that of bleeding and the patient’s inherent ability to form clots. On the one hand, the surgeon depends on it so that the patient does not exsanguinate from the intervention (fortu- nately, an exceedingly rare event). Conversely, a patient in a hyper- coaguable state may suffer from a thromboemblic event that could be life threatening. In addition, a growing number of patients requiring surgical intervention are chronically anticoagulated for a number of reasons, e. Historical information of importance includes whether the patient or a family member has had a prior episode of bleeding or a throm- boembolic event, and whether the patient has a history of prior 1. Perioperative Care of the Surgery Patient 13 transfusions, prior surgery, heavy menstrual bleeding, easy bruising, frequent nosebleeds, or gum bleeding after brushing teeth. If the history is negative and the patient has not had a previous significant hemostatic challenge, then the like- lihood of a bleeding or thrombotic event is exceedingly rare and the value of preoperative coagulation testing is low. This underscores the importance of adopting a rea- sonable strategy of ordering only those diagnostic tests indicated by the patient’s history. If a clinically important coagulopathy is identi- fied, therapeutic strategies for management of various coagulation dis- orders in preparation for surgery are listed in Table 1. A good deal of the planning hinges upon how urgently the surgery needs to be performed and the indication for the anticoagula- tion. Most patients who take warfarin and who are to undergo ambu- latory or same-day admission elective surgery can be managed simply by having them discontinue their warfarin for several days prior to surgery. If there is concern that the patient should not be without anticoagulation, the patient can be systemically anticoagulated with unfractionated intravenous heparin. The heparin infusion is discon- tinued approximately 4 hours prior to surgery (the half-life of heparin is about 90 minutes), and surgery proceeds with good hemostasis. Antibiotic Prophylaxis This topic is discussed in greater detail in future chapters. Suffice it to say that surgery is an insult to the body’s immune system and infection is frequently an unwanted side affect. Antibiotic therapy must be used judiciously so as to avoid overuse and selection of resistant strains of bacteria. A type and screen or type and crossmatch should be requested for operations where blood transfusions are likely (Table 1. Levels should be maintained for 5–7 (moderate injury) or 7–14 days (severe injury), as delayed bleeding is typical. Levels should be maintained for 5–7 (moderate injury) or 7–14 days (severe injury), as delayed bleeding is typical. Tachyphylaxis can be restored by a 24-h drug holiday to allow repletion of endothelial stores. Platelet abnormalities Thrombocytopenia Transfuse platelets <50,000 if bleeding or invasive procedure is anticipated; <20,000 otherwise. Platelet infusion after ligation of the splenic artery during splenectomy if the response to immune globulin is poor. Transfuse platelets only if surgery cannot be delayed to allow spontaneous recovery. Summary of evidence-based guidelines for the prevention of surgical site infec- a tion (wound infection). Preparation of the patient Level I: Identify and treat all infections remote to the surgical site before elective operations. Do not remove hair preoperatively unless hair at or near the incision site will interfere with surgery. If hair is removed, it should be removed immediately beforehand, preferably with electric clippers. Indicated blood transfusions should not be withheld as a means to prevent surgical site infection. Patients should shower or bathe with an antiseptic agent at least the night before surgery. Scrub the hands and forearms up to the elbows for at least 2–5min with an appropriate antiseptic.

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