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Where relevant hypertension vitamins generic 25 mg toprol xl visa, test for parasitic infection arrhythmia electrolyte imbalance buy toprol xl 50 mg on line, and treat if present blood pressure medication generic cheap 100mg toprol xl with amex, before commencing Type 2 targeted treatment (see section 5) blood pressure chart nih buy toprol xl 25mg line. Provide the patient with advice about what to do if they experience any adverse effects, including hypersensitivity reactions. There is an urgent need for head-to-head comparisons of different biologics in patients eligible for more than one biologic. Eligibility criteria: these vary by product and between payers, but usually include: Asthma Control Test, Asthma Control Questionnaire; frequency and severity of exacerbations. Base the order of reduction or cessation of add-on treatments on the observed benefit when they were started, patient risk factors, medication side-effects, cost, and patient satisfaction. Continue to assess for presence of osteoporosis, 244 and review need for preventative strategies including bisphosphonates. Patients should be reminded of the importance of continuing their inhaled controller. There are limited studies of cessation of biologic therapy, in these studies, symptom control worsened and/or exacerbations recurred for many (but not all) patients after cessation of the biologic. Consider intravenous magnesium sulfate for patients with severe exacerbations not responding to initial treatment. This should include starting controller treatment or stepping up the dose of existing controller treatment for 2?4 weeks, and reducing reliever medication to asneeded use. For management of asthma exacerbations in children 5 years and younger, see Chapter 6, p. Exacerbations may occur in patients with a preexisting diagnosis of asthma or, occasionally, as the first presentation of asthma. Severe exacerbations can occur in patients with mild or well9,169 controlled asthma symptoms. Such epidemics have been reported in association with springtime thunderstorms and either rye 485 482 grass pollen or fungal spores, and with environmental exposure to soy bean dust. Identifying patients at risk of asthma-related death In addition to factors known to increase the risk of asthma exacerbations (Box 2-2, p. The presence of one or more of these risk factors should be quickly identifiable in the clinical notes, and these patients should be encouraged to seek urgent medical care early in the course of an exacerbation. Management of worsening asthma and exacerbations 103 Terminology about exacerbations the academic term exacerbation is commonly used in scientific and clinical literature, although hospital-based studies more often refer to acute severe asthma. However, the term exacerbation is not suitable for use in clinical practice, as 489,490 it is difficult for many patients to pronounce and remember. The term flare-up is simpler, and conveys the sense that asthma is present even when symptoms are absent. The term attack is used by many patients and health care 489,490 providers but with widely varying meanings, and it may not be perceived as including gradual worsening. In pediatric literature, the term episode is commonly used, but understanding of this term by parent/carers is not known. In the acute setting, these measurements are more reliable indicators of the severity of the exacerbation than symptoms. A minority of patients perceive airflow limitation poorly and can experience a significant decline in lung function without a 124,125,133 change in symptoms. This especially affects patients with a history of near-fatal asthma and also appears to be more common in males. Severe exacerbations are potentially life threatening and their treatment requires careful assessment and close monitoring. Patients with severe exacerbations should be advised to see their health care provider promptly or, depending on the organization of local health services, to proceed to the nearest facility that provides emergency access for patients with acute asthma. Treatment options for written asthma action plans A written asthma action plan helps patients to recognize and respond appropriately to worsening asthma. The criteria for initiating an increase in controller medication will vary from patient to patient. This is particularly important if there has been a lack of response to increased use of beta2-agonist therapy. The recommended maximum total dose of formoterol in 24 hours with this regimen is 72 mcg. The benefit of this regimen in preventing exacerbations appears to be due to intervention at a very early 493,494 stage of worsening asthma. This regimen was also effective in reducing exacerbations in children aged 4?11 217 years, (Evidence B), but it is not approved for this age group in many countries. Patients should be advised about common side-effects, including sleep disturbance, increased 503 appetite, reflux, and mood changes. Management of worsening asthma and exacerbations 105 Reviewing response Patients should see their doctor immediately or present to an acute care unit if their asthma continues to deteriorate despite following their written asthma action plan, or if their asthma suddenly worsens. Follow up after a self-managed exacerbation After a self-managed exacerbation, patients should see their primary care health care provider for a semi-urgent review. Maintenance controller treatment can generally be resumed at previous levels 2?4 weeks after the exacerbation (Evidence D), unless the history suggests that the exacerbation occurred on a background of long-term poorly controlled asthma. In this situation, provided inhaler technique and adherence have been checked, a step up in treatment is indicated (Box 3-5, p. Adult and adolescent patients with more than 1-2 exacerbations per year despite Step 4-5 therapy should be referred to a specialist center for assessment (see decision tree in Chapter 3E, p. Maintenance and reliever regimen is not approved for children <12 years in many countries. Milder exacerbations can usually be treated in a primary care setting, depending on resources and expertise. Saturation levels <90% in children or adults signal the need for aggressive therapy. The aim is to rapidly relieve airflow obstruction and hypoxemia, address the underlying inflammatory pathophysiology, and prevent relapse. Because of the static charge on plastic spacers, they should be pre-washed with detergent and air-dried to be ready for immediate use. Controlled oxygen therapy (if available) Oxygen therapy should be titrated against pulse oximetry (if available) to maintain oxygen saturation at 93?95% (94 98% for children 6?11 years). Controlled or titrated oxygen therapy gives better clinical outcomes than high-flow 100% 507-509 oxygen therapy (Evidence B). Oxygen should not be withheld if oximetry is not available, but the patient should be monitored for deterioration, somnolence or fatigue. The recommended dose for adults is 1 mg prednisolone/kg/day or equivalent up to a maximum of 50 mg/day, and 1?2 mg/kg/day for children 6?11 years up to a maximum of 40 510,511 mg/day). Patients should be advised about common 503 side-effects, including sleep disturbance, increased appetite, reflux and mood changes. Controller medication Patients already prescribed controller medication should be provided with advice about increasing the dose for the next 2?4 weeks, as summarized in Box 4-2 (p. An exacerbation requiring medical care indicates that the patient is at increased risk of future exacerbations (Box 2-2, p. Antibiotics (not recommended) Evidence does not support a role of antibiotics in asthma exacerbations unless there is strong evidence of lung infection 512. Aggressive treatment with corticosteroids should be implemented before antibiotics are considered. Reviewing response During treatment, patients should be closely monitored, and treatment titrated according to their response. Patients who present with signs of a severe or life-threatening exacerbation (Box 4-3, p. A decision can then be made whether to send the patient home or transfer them to an acute care facility. Patients should be advised to use their reliever inhaler only as-needed, rather than routinely. A follow-up appointment should be arranged for about 2?7 days later, depending on the clinical and social context.
Reversing the fasting state of the patient by administration of an oral carbohydrate drink pre-operatively can increase insulin sensitivity by 50% blood pressure medication kidney pain discount toprol xl online amex, a state which continues into the post-operative period arrhythmia or anxiety buy toprol xl 25 mg. There have been no studies to arterial blood gas cheap toprol xl 100mg mastercard date looking at the effect of insulin resistance in donor nephrectomy; however prehypertension symptoms buy toprol xl american express, extrapolating the results achieved from gastrointestinal surgery, it would seem reasonable to consider pre-operative carbohydrate loading in patients undergoing donor nephrectomy. The pre-operative dosing regimen is 4 x 200 mL cartons between 9 pm and midnight before the operation with a further 2 x 200 mL 2 hours pre-operatively. In addition, allowing clear fluids up to 2 hours pre-operatively improves patient comfort by reducing thirst and allows black tea or coffee to be consumed by habitual caffeine drinkers who may be susceptible to withdrawal headache. Post-operative fasting should be avoided and early and unrestricted resumption of fluid and solid food is recommended in the immediate post-operative period. Peri-operative complications in gastrointestinal surgery increase when the post-operative weight gain exceeds 2. Evidence from one randomised control trial (46) and one series has demonstrated improved cardiovascular stability and reduced sub-clincal renal injury respectively when such pre-operative hydration strategies are applied (47). However, balancing the level of analgesia with the unwanted side effects of analgesic agents requires thought, observation and an individual, tailored approach to each patient. Epidural Anaesthesia Epidural anaesthesia can achieve excellent post-operative analgesia as well as significantly attenuate the surgical stress response. In early Enhanced Recovery protocols, epidural anaesthesia was the preferred method of choice to minimise the use of opiates in the peri-operative period. However, the side effects (hypotension, headache, potential for infection, urinary retention, reduced mobility) are well documented and other opiate sparing strategies have now superseded epidural use. There is now little place for epidural use within the domain of donor nephrectomy, especially when performed laparoscopically (48,49). In-Dwelling Nerve Catheters the anatomical basis of the nerve supply to the abdominal wall has been well described. Blockade of the nerve supply to the wound with local anaesthesia is therefore a very straightforward and attractive option as an opiate sparing technique. Indwelling nerve catheters have been in use for around 15 years and can provide safe and effective analgesia to a variety of surgical wounds in the thorax and abdomen as well as upper and lower limbs. Their use as a potential opiate sparing strategy within Enhanced Recovery programs is gaining popularity. Their use in donor nephrectomy surgery is novel but they have been shown to reduce opiate requirements in hand assisted laparoscopic donor nephrectomy (using an upper abdominal transverse extraction scar) and in fully laparoscopic donor nephrectomy (using a Pfannenstiel incision to extract the donor kidney) (50-55). Correct anatomical placement of the catheter is paramount to achieving success and there is a short learning curve to achieve expertise of use. The infusion can be administered via an elastomeric pump or a battery run infusion pump (52). Opiates Opiates are an effective analgesic and remain a common treatment of postoperative pain control worldwide. Drowsiness, nausea, vomiting, pruritis and lack of appetite all work against the principles of Enhanced Recovery surgery aiming for early mobilisation and return to oral intake. More recently, multimodal strategies have been attempting to introduce opiate sparing regimens to ameliorate the early unwanted side effects of these drugs (55). Opiates also have an effective role for breakthrough pain when opiate sparing strategies have not been effective. Impact of renal artery multiplicity on outcomes of renal donors and recipients in laparoscopic donor nephrectomy. Living donor kidney transplantation using laparoscopically procured multiple renal artery kidneys and right kidneys. A prospective study of the predictive power of spiral computed tomographic angiography for defining renal vascular anatomy before live-donor nephrectomy. Can magnetic resonance angiogram be a reliable alternative for donor evaluation for laparoscopic nephrectomy? Arevalo Perez J, Gragera Torres F, Marin Toribio A, Koren Fernandez L, Hayoun C, Daimiel Naranjo I. Morbidity and mortality after living kidney donation, 1999-2001: survey of United States transplant centers. Chronic pain following donor nephrectomy a study of incidence, nature and impact of chronic post nephrectomy pain. Towards evidence-based guidelines for the prevention of venous thromboembolism: systematic reviews of mechanical methods, oral anticoagulation, dextran and regional anaesthesia as thromboprophylaxis. General Medical Council: Good medical practice and consent: patients and doctors making decisions together. Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. A meta-analysis of randomised controlled trials on preoperative oral carbohydrate treatment in elective surgery. A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0. Major complications, mortality, and resource utilization after open abdominal surgery. A meta-analysis of randomised controlled trials of intravenous fluid therapy in major elective open abdominal surgery: getting the balance right corrigendum. Comparison of three perioperative fluid regimes for laparoscopic donor nephrectomy: a prospective randomized dose-finding study. Evidence basis for regional anesthesia in multidisciplinary fast-track surgical care pathways. Continuous preperitoneal infusion of ropivacaine provides effective analgesia and accelerates recovery after colorectal surgery. Outcomes after hand-assisted laparoscopic donor nephrectomy can be improved by an enhanced recovery after surgery programme. Use of wound infiltration catheters for enhanced recovery in fully laparoscopic live donor nephrectomies. The changing role of non-opioid analgesic techniques in the management of postoperative pain. This is important for younger recipients where repeat transplantation may be required. The results of these investigations provide an immunological risk assessment, which together with clinical information provide guidance on the suitability of a particular living kidney donor-recipient pair for transplantation. Initial assessment of donor and recipient histocompatibility status should be undertaken at an early stage in the donor work-up to avoid unnecessary and invasive clinical investigations. Histocompatibility assessments and interpretation of test results should only be undertaken in an appropriately accredited laboratory. The onus is on the referring centre to provide accurate information and donor and recipient samples necessary to fulfil these guidelines. Informed consent must therefore be obtained by the referring centre from both the recipient and all genetically related potential donors before these tests are undertaken (see section 4. In these cases there is the risk of an anamnestic response that is often refractory to baseline induction immunosuppression. Recent and past potential allosensitisation events, including recent infections, must be documented by the referring clinical team and reported to the histocompatibility laboratory. Potential recipients listed for repeat transplantation who are receiving immunosuppression while under assessment for living kidney transplantation are at high risk of de novo sensitisation, particularly if the baseline immunosuppression is changed, reduced or withdrawn. These discussions should take place at the earliest opportunity, to avoid delay and unnecessary investigation. In many cases, the living donor kidney transplant work-up may be prolonged and it is not uncommon for a year or more to elapse between the initial histocompatibility assessment and the planned operation. The recipient must have contemporary antibody screening results available using samples obtained within three months of the transplant operation. Any potential alloantibody priming events that occur within one month of the latest antibody screening sample, or after the sample collection date could change the donor-recipient antibody compatibility status and will obviate all previous results. Because of the opportunity for planned living donor transplant work-up, a virtual crossmatch is not acceptable. Living donor crossmatch testing is usually carried out at the time of first referral.
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The sural nerve biopsies showed signs of axonal degeneration and numerous endoneurial macrophages hypertension guidelines buy 100mg toprol xl with mastercard, but not the typical signs of demyelination like thinly myelinated nerve fibres or onion bulbs prehypertension lisinopril buy discount toprol xl on-line, although the patients had clear demyelinating features in nerve conduction studies blood pressure chart symptoms purchase toprol xl from india. In 1 patient blood pressure monitor walgreens order toprol xl overnight delivery, a follow-up skin biopsy available 6 years later showed complete depletion of myelinated fibres. Furthermore, in the patients with contactin-1 antibodies, the nodal and paranodal architecture was profoundly altered. Several immunological markers have been identified, some of which are strong candidates as pathogenic factors. At various meetings, the indication for nerve biopsy has been discussed between experts in the field. Unfortunately, postmortem examinations have become so rare that clinical-neuropathological correlations have become an exception. We also thank the international experts who founded the Peripheral Nerve Study Group in the mid1970s, which became the Peripheral Nerve Society in 1994, for fostering a face-to-face exchange of data and hypotheses that moved the field forward. Handbuch der speziellen pathologischen Anatomie und Histologie; Erkrankungen des peripheren Nervensystems. Miyakawa T, Murayama E, Sumiyoshi S, Deshimaru M, Kamano A (1971) A biopsy case of Landry-Guillain-Barre syndrome. Roberts M, Willison H, Vincent A, Newsom-Davis J (1994) Serum factor in Miller-Fisher variant of Guillain-Barre syndrome and neurotransmitter release. Querol L, Illa I (2015) Paranodal and other autoantibodies in chronic inflammatory neuropathies. Presently, we can distinguish a traumatic tap from any intracranial bleed, and those who believe that a small yellow drop cannot readily be seen in a large red puddle make use of calibrated spectrophotometry to this purpose [2]. Quincke himself gave credit to Essex Wynter for publishing the first description of the technique of lumbar puncture [1]. Heinrich Quincke was present at the ninth Jubilee of the University of Glasgow (1901) as a German delegate and received an honorary degree. The first time Essex Wynter tried the technique was in a 3-year-old boy with tubercular meningitis in February 1889. Such traces were found in the next 3 cases, none of whom survived due to the primary disease, tuberculosis. Based on the results of the meticulous post-mortem examinations, Essex Wynter summarises though none of these cases were ultimately successful, no harm in any one resulted from interference. Retrospectively, this was most likely related to the analytical sensitivity of the tests used at the time, but his observation is a good reminder that absence of evidence is not evidence for absence. He came from the famous French Sixth Armee, a corps composed of various disparate French armies. The summer is sorely remembered by the Battles of the Somme with more than one million soldiers killed on both sides between the 1st of July and 18th of September 1916. The Sixth Armee was under the command of General Fayolle, who was joined by the British forces. Fifty-nine days after his first symptoms he was able to walk again and was sent home as a convalescent soldier on the 30th of September. About a week later, 28th August, another soldier felt unusually tired and weak after a 15-km march. He was aged 33 years and seen by the neurologist on 5th September, at which time there was clear weakness of the lower limbs. He started to improve 31 days after his first symptoms and was evacuated behind the battle lines on 1st October. He believes this to be such a consistent feature of the disease that he states, I refuse to recognize radioculoneuritis with hyperlymphocytosis or hypernucleosis as belonging to the syndrome [5]. He concludes that because the virus of polyradiculoneuritis with albuminocytologic dissociation does not destroy nerve paths, progressive improvement and eventual recovery of the patient will be observed [5]. The perceived relevance of all the Top 10 described in this monograph will change over time. Some observations will slowly fade into oblivion; others will be rediscovered as being of core relevance. The dissociation albumino?cytologique deserves to remain in the Top 10 because it was the first reproducible biomarker discovery of its kind, made by 3 neurologists under exceptional circumstances on the 20th of September 1916. Therefore, and in contrast to blood sampling and electrophysiological tests, it will remain extremely difficult to obtain valuable longitudinal data. There might be other advantages and disadvantages to both time points we are not necessarily aware of yet. These patients were not able to walk without problems and were classified as having a poor outcome. For independent interpretation of these data one needs to remember that tau protein is expressed not only in neurons and their axons, but also in glial cells. It will be interesting to learn if future studies will investigate post-translational modifications and proteolytic breakdown products of this fascinating protein. After 4 years of work with neurofilament proteins I finally had completed collecting the reference population data for the neurofilament heavy chain (NfH). Did I have to accept the null hypothesis and did this mean that the test I had spent the last 4 years on developing was of little value? In those cases where the motor neuron is lost, trans-synaptic retrograde axonal degeneration might follow and should be demonstrable by longitudinal structural imaging evidence of localised atrophy in the pyramidal tracts and corresponding area of the primary motor cortex. But, it took over a decade to better understand the bimodal distribution of the data [22,26?28]. As with all measurements, there is a need to be careful that good laboratory standards are followed [31,32]. Conceptually, this has been related to presence of anti-myelin protein antibodies. Findings of auto-antibodies directed against myelin proteins have been regarded as nonspecific, because they are also found in many other diseases. It will be interesting learning about the longitudinal pattern of such auto-antibodies in, for example, patients who do not follow a monophasic disease course. Over half a century of research for a diagnostic auto-antibody in multiple sclerosis has not yet brought a result [35]. The Future: A Cocktail from Glasgow Post-translational modifications govern the interface between protein transcription and translation. Glycosylation mainly targets Asp>Asp-glycan, Ser>Ser-glycan, Thr>Thr-glycan, Hyl>Hyl-glycan, Hyp>Hyp-glycan. Therefore post-translational modifications which only occur in vivo, such as glycosylation, phosphorylation, citrullination, Nand C-terminal modifications will be in my future Top 10. In those cases where axonal sprouting does not occur, distal axonotemesis may continue to develop to retrograde axonal degeneration. Once the motor neuron is lost, trans-synaptic retrograde axonal degeneration may follow. There is also the possibility for a relapsing or chronic disease course to develop, which should be paralleled by a persistent or intermittent rise of blood peripherin levels. Guillain G, Mollaret P (1936) Valeur comparative de la ponction lombaire et de la ponction sous-occipitale. Eberle E, Brink J, Azen S, White D (1975) Early predictors of incomplete recovery in children with Guillain-Barre polyneuritis. Billard C, Ponsot G, Lyon G, Arthuis M (1979) Polyradiculonevrites aigues de l?enfant. Castaigne P, Brunet P, Nouailhat F (1966) Enquete clinique sur les polyradiculonevrites inflammatoire en France. Brettschneider J, Petzold A, Sussmuth S, Tumani H (2009) Cerebrospinal fluid biomarkers in Guillain-Barre syndrome?where do we stand? Petzold A (2005) Neurofilament phosphoforms: surrogate markers for axonal injury, degeneration and loss. The rapid onset of symptoms and the frequently observed early recovery of weakness can be attributed to the development and reversal of conduction block. For the 3 of us, understanding the clinical and pathophysiologic nature of conduction block has played a prominent role in our careers.
Amoxicillin Cefixime (3rd generation) Benzylpenicillin (Penicillin G) Cefotaxime (3rd generation) Co-amoxiclav (Amoxicillin + Clavulanic acid) Ceftazidime (3rd generation) Flucloxacillin Ceftriaxone (3rd generation) Phenoxymethylpenicillin (Penicillin V) Cefuroxime (2nd generation) Piperacillin + Tazobactam (Tazocin ) Meropenem (carbapenem) Cefalexin (1st generation) Primaxin (Imipenem + Cilastatin) (carbapenem) Ertapenem (carbapenem) the route of administration recommended in the table is the most appropriate if available hypertension prognosis toprol xl 100mg low cost. General wards can normally use ceftriaxone to blood pressure chart height and weight order toprol xl with paypal ease nursing time and patient intervention hypertension high blood pressure safe toprol xl 50 mg. No child should be denied immunisation without serious thought as to hypertension of the knee discount toprol xl online the consequences, both for the individual child and the community. Where there is any doubt, advice should be sought from a Consultant Paediatrician or Consultant in Communicable Disease Control. Immunity can be induced, either (long term) or (short term), against a variety of bacterial and viral agents. Children with certain conditions which increase the risk of complications from infectious diseases should be immunised as a matter of priority. Neonates of all gestational ages should be immunised according to the standard protocol from two months of age. Children with no spleen or with functional hyposplenism are at increased risk of bacterial infections especially those caused by encapsulated bacteria. In addition to antibiotic prophylaxis and standard vaccination schedule, such children should receive Hib vaccine (irrespective of age), meningococcal A and C vaccine and influenza vaccine. Where possible, immunisation should be given at least two weeks before splenectomy. Children suffering from an acute illness should have immunisation postponed unless the child has a minor infection without fever or systemic upset. Immunisation should not be carried out in individuals who have a definite history of a local or general reaction to a preceding dose. Hypersensitivity to egg contraindicates influenza vaccine; previous anaphylactic reaction to egg contraindicates influenza and yellow fever vaccines. Surgery is not a contraindication to immunisation, nor is recent immunisation a contraindication to anaesthesia or surgery. These children include: x All those receiving cytotoxic chemotherapy or generalised radiotherapy, or within 6 months of terminating such treatment. Postpone live vaccines for at least 3 months after stopping treatment or after non-immunosuppressive doses have been reached. Lower doses of steroids given in combination with cytotoxic drugs should also be considered to cause immunosuppression. Furthermore, haemodialysis patients are at an increased risk of hepatitis B and hepatitis C. These children should be screened for serological evidence of hepatitis B vaccine (ideally before dialysis commences). For vaccines that require booster doses for full immunisation, dosing at less than the recommended intervals may result in sub-optimal antibody response. Intervals between doses that are longer than recommended do not impair final antibody levels. Immunisation Intervals: x Different vaccines can usually be given simultaneously although live vaccines (unless a combination product) should be given at different sites, except in the case of varicella and measles vaccines where there should be an interval of one month between them. No interval is required between the administration of live and inactivated vaccines. Live vaccines (except yellow fever) should not be given during the three months after immunoglobulin injection, as the response is likely to be impaired. In infants, the antero-lateral aspect of the thigh or upper arm are recommended sites. If the buttock is used, injection into the upper outer quadrant avoids the risk of sciatic nerve damage. C causes freezing which can lead to deterioration of the vaccine and breakage of the container. If vaccines have been stored at an inappropriate temperature, advice should be obtained from a paediatric pharmacist before they are used. Specific immunoglobulins are prepared from plasma pooled from donors with high titres of the required antibody as a result of, for example, recent infection or vaccination. Immunoglobulins may interfere with the immune response to live vaccines, which should therefore be given at least 3 weeks before or three months after an injection of immunoglobulin. Immunocompromised children who come into contact with measles and infants (<12 months) in whom there is a particular reason to avoid measles. Special formulations for intravenous administration are available for replacement therapy for patients with congenital agammaglobulinaemia, for the treatment of idiopathic thrombocytopenic purpura and Kawasaki syndrome, and for the prophylaxis of infection following bone marrow transplantation. Intravenous immunoglobulin is also used in the treatment of Guillain-Barre Syndrome and is now preferred to plasma exchange. Other indications include cardiomyopathy and post-transfusional hyperhaemolysis in sickle cell patients. The following are considered tetanus-prone wounds: a) Any wound or burn sustained more than six hours before surgical treatment. Children with an unacceptable immunisation history should also receive appropriate tetanus toxoid treatment. Children who are accidentally inoculated, or who have contaminated their eyes or mouth or fresh cuts or abrasions of the skin, with blood from a known HbsAg positive person may require post exposure prophylaxis. Casaer, Michael Hiesmayr, Konstantin Mayer, j k l m Juan Carlos Montejo, Claude Pichard, Jean-Charles Preiser, Arthur R. When to Keywords: start and how to progress in the administration of adequate provision of nutrients is also described. The Intensive care best determination of amount and nature of carbohydrates, fat and protein are suggested. Particular conditions frequently observed in Enteral Parenteral intensive care such as patients with dysphagia, frail patients, multiple trauma patients, abdominal surGuidelines gery, sepsis, and obesity are discussed to guide the practitioner toward the best evidence based therapy. For now, a gap exists between and later conduct of studies does not necessarily guarantee higher nutritional practices and the previous guidelines [6] and many quality, we chose this approach for the reason that major relevant available studies address only one or at most some of the speci? In the current guidelines, the able around the start of the new millennium regarding timing, route, dose and composition of nutrition will be discussed and recommendations will be made recognizing that acute Composition of medical feeds metabolic changes as well as calorie and protein de? Outcome e are requested if possible, a systematic literature search has to be performed, including evaluation of recent other relevant 2. High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal 2? Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal 2Case control or cohort studies with a high risk of confounding or bias and a signi? The updated reccontain information on study design, detailed assessment of the ommendations and the? Evidence levels, grades of recommendation and consensus studies and systematic reviews published between 2000 and June process 2017 using a broad? Onlyarticles published in English or with an English abstract, and studies in the grading system relies primarily on studies of high quality, human adults were considered. Evidence levels were then translated into and systematic reviews were hand-searched for studies that were recommendations, taking into account study design and quality as missing in the initial database search. The search for literature was well as consistency and clinical relevance (Tables 2 and 3). The updated several times during the working process for the last time highest grade (A) is assigned to recommendations that are based on in August 2017. Meta-analysis strategy possible within the context of the available data and expert clinical experience. Some of the recommendations of these guidelines are When applicable, we used meta-analytic techniques to generate based on expert opinion because randomized studies are not pooled estimates across eligible studies. Recommendations are formulated in terms of a strong statisticalheterogeneitybetweenstudiesusingthec2andI2statistics (?Shall?)or?(conditional (?should or can?) and for or against the [9]. The intervention based on the balance of desirable and undesirable meta-analysis are available online as Supplemental Materials. Quality of evidence only based on the evidence levels of the studies but also on the judgment of the working group taking consistency, clinical releWe de? We completed consensus within the working group in April 2018 according to this process in two steps: 1) initially by assessing the quality of evTable 4 (from strong consensus to no consensus). Majority agreement Agreement of >50e75% of the participants Ebb phase and Flow phase.