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In a comparative trial xanax medications for anxiety buy genuine risperidone online, hydro-alcoholic extracts of chamomile produced antiinflammatory actions when applied topically in the croton ear test in the mouse medicine names generic 4 mg risperidone amex. The hydro-alcoholic extract reduced oedema in a dose-dependent manner and was equivalent in effectiveness to medications ordered po are order risperidone discount benzydamine at twice the usual clinical dose treatment internal hemorrhoids buy generic risperidone from india, but hydrocortisone was found to be the most effective treatment (Tubaro et al 1984). Another comparative study investigated the anti-inflammatory effects of an extract prepared from dried flowers, an extract based on fresh flowers, and the volatile oil, in croton oil-induced dermatitis of mouse ear. The activity of fresh chamomile equalled the activity of the reference drug (benzydamine). The anti-inflammatory activity of the herb appears to be due to several different constituents, chiefly apigenin, matricin, chamazulene and alpha-bisabolol, although others may also exist. The previous study determined that apigenin exerts the strongest anti-inflammatory action, which is ten times greater than matricin, which is ten times greater than chamazulene (Della Loggia et al 1990). Alpha-bisabolol has demonstrated anti-inflammatory and analgesic effects in a number of experimental inflammatory models: rat paw oedema, adjuvant arthritis of the rat, ultraviolet erythema of the guinea pig, and yeast fever of the rat (Jakovlev et al 1979). Most studies have investigated the effects of topically applied chamomile or isolated constituents; however, one study using the carrageenan inflammation test Chamomile 205 on rat paws showed that orally administered matricin produces anti-inflammatory © 2007 Elsevier Australia activity that was greater than chamazulene and almost as effective as (-)-alpha-bisabolol (Jakovlev et al 1979, Shipochliev 1981a). Chamazulene has been found to inhibit leukotriene B4 formation and blocks chemical peroxidation of arachidonic acid (Safayhi et al 1994). Additionally, the antipuritic effects of the antihistamine H1 antagonists, oxatomide and fexofenadine, were significantly increased by the ethyl acetate extract. The extract of chamomile also has a good spasmolytic activity (Achterrath-Tuckermann et al 1980). Apigenin showed antianxiety and sedative activity with intraperitoneal injection in mice (Viola et al 1995). In contrast, extracts of chamomile have demonstrated antimicrobial activity against E. Alpha-bisabolol promotes granulation and tissue regeneration in burns and ulcers, and protects against their formation (Szelenyi et al 1979). The polysaccharides (heteroglycans) showed significant immunostimulating activities according to the granulocytes and carbon clearance tests (Wagner et al 1985). It inhibits lipid peroxidation in vitro (Goeters et al 2001) in a dose-concentrationand time-dependent manner (Rekka et al 1996). Chamomile reduced frequencies of behaviours associated with withdrawal (paw tremor, rearing, teeth chattering, body shakes, ptosis, diarrhoea and urination) and weight loss (Gomaa et al 2003). Endothelin-1 is a cytokine responsible for stimulating melanocyte function leading to hyperpigmentation. Chamomile has been shown to interrupt the endothelin-1 induced signalling, thereby reducing the ability of melanocytes to proliferate and to synthesise melanin (Ichihashi et al 1999). In clinical practice, the oral dose form most often used is a concentrated extract, in order to produce stronger therapeutic effects. Wound healing According to a double-blind trial, external application of a chamomile extract improves wound healing. In the study, chamomile extract significantly decreased weeping and improved wound healing after dermabrasion of tattoos (Glowania et al 1987). Eczema In one comparative study, 161 patients with eczema on the arms and lower legs were treated with 0. The chamomile cream was as effective as hydrocortisone and was superior to the other two treatments (Aertgeerts et al 1985). Chamomile cream (Kamillosan) has Chamomile 208 been shown to be slightly less effective than 0. Commission E approves the external use of chamomile for inflammation of the skin and mucous membranes, as well as for bacterial skin diseases, including those of the oral cavity and gums (Blumenthal et al 2000). A placebo-controlled study involving 22 volunteers found that inhalation of chamomile oil produced sedative effects and improved mood (Roberts & Williams 1992). Chamomile tea (two teabags in 175 mL of hot water) given to 12 patients during cardiac catheterisation induced a deep sleep in 10 patients, even though the procedure usually causes pain and anxiety (Gould et al 1973). The herb’s antispasmodic and relaxant effects provide a theoretical basis for its use in these conditions. In an open, multicentre study, 104 patients with gastrointestinal complaints, including gastritis, flatulence and minor spasms of the intestines, were treated for 6 weeks with 5 mL/day of an oral chamomile preparation (standardised to contain 50 mg alpha-bisabolol and 150–300 mg apigenin-7-glucoside per 100 g). Diarrhoea in children In Europe, chamomile is widely used to treat a variety of paediatric complaints. A prospective, double-blind, randomised trial was used to document the efficacy of a preparation containing chamomile extract and pectin in children aged 6 months to 5. The chamomile preparation reduced the duration and severity significantly faster than placebo (de la Motte et al 1997). Commission E approves chamomile for gastrointestinal spasms and inflammatory diseases of the gastrointestinal tract. The specific indication is for gastrointestinal disturbance with nervous irritability in children and for teething and colic in infants. Commission E approves the use of inhalations for inflammation and irritation of the respiratory tract and baths and irrigations for anogenital inflammation (Blumenthal et al 2000). The mouthwash consisted of 8 g of flower heads steeped in 1000 mL of boiling water for 15 minutes and then used as a gargle four times daily. Thirty-two patients were randomly assigned to receive either the antibiotic cotrimoxazole (trimethoprim/sulfamethoxazole) alone or with a chamomile extract administered on day one as a bladder instillation, followed by daily hipbath use. Symptoms were evaluated after 10 days and indicated that the chamomile group experienced more rapid alleviation of symptoms than the group treated with only cotrimoxazole. The product used was Kamillenextrakt, an ethanolic extract of chamomile flowers (Barsom et al 1993). However, a bibliographic review of 50 reports of ‘chamomile’ sensitivity revealed that in only five papers was the botanical identification of the plant material correlated with Chamomilla recutita. In the majority of other instances, the effects were caused by species of the genus Anthemis, frequently also called chamomile. The suspected allergen is the sesquiterpene lactone, anthecotulide, found in Anthemis cotula L. Allergic conjunctivitis has been reported with the use of chamomile tea eyewashes, and the pollens contained in the teas have been identified as the allergens responsible. The reaction occurred after first exposure and was thought to be due to cross-reactivity to Artemesia pollen (Subiza et al 1989). Pollens are not likely to be present or active in aqueous alcohol extracts of chamomile. German chamomile is thought to be less allergenic than Roman chamomile, but any variety of chamomile can potentially cause allergic reactions. An enema made from German chamomile (Kamillosan) given during labour to a 35-year-old woman with no history of atopy resulted in life-threatening anaphylaxis and fatal asphyxia of the newborn (Jensen-Jarolim et al 1998). The clinical significance of this is unknown; however, drugs that are metabolised by these enzymes could theoretically be affected. Comparative studies show it has an anti-inflammatory effect equivalent to low-dose hydrocortisone preparations. Chamomile is taken to relieve stomach spasms and flatulence, to induce relaxation and promote sleep. It is also popular for children with teething pain and digestive complaints such as colic or diarrhoea. Applied externally as a cream, ointment or poultice, it is used to reduce skin irritation and inflammation. While there have been reports of allergic reactions, the majority have been due to adulteration with other herbs. Chamomile tea is more likely to cause allergic reactions than either extracts or essential oil. Chamomile should not be used by persons with hypersensitivity or known allergy to chamomile or other members of Asteraceae family. V: Investigations on the spasmolytic effect of compounds of chamomile and Kamillosan on the isolated guinea pig ileum. The effect of controlled release fertilizer and earthworm compost on Chamomile (Matricaria chamomilla L. Ethnobotanical survey in the Palestinian area: A classification of the healing potential of medicinal plants. Behandlung der Hamorrhagischen Cystitis (harnblasenschleimhautblutungen) mit Kamillenextrakt.

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In vitro effect of fenugreek extracts on intestinal sodium-dependent glucose uptake and hepatic glycogen phosphorylase A medicine cards discount risperidone line. Effect of Trigonella foenum-graecum (fenugreek) seeds on glycaemic control and insulin resistance in type 2 diabetes mellitus: a double blind placebo controlled study medicine 3601 order genuine risperidone. Inhibition of triiodothyronine production by fenugreek seed extract in mice and rats medicine wheel teachings discount risperidone american express. Gastroprotective effect of fenugreek seeds (Trigonella foenum graecum) on experimental gastric ulcer in rats medications when pregnant cheap 4mg risperidone otc. Steroid saponins from fenugreek seeds: extraction, purification, and pharmacological investigation on feeding behavior and plasma cholesterol. Influence of dietary spices or their active principles on digestive enzymes of small intestinal mucosa in rats. Influence of dietary spices and their active principles on pancreatic digestive enzymes in albino rats. Trigonella foenum graecum (fenugreek) seed powder improves glucose homeostasis in alloxan diabetic rat tissues by reversing the altered glycolytic, gluconeogenic and lipogenic enzymes. Effect of fenugreek and lupine seeds on the development of experimental diabetes in rats. Use of fenugreek seed powder in the management of non-insulin dependent diabetes mellitus. The effect of an ethanol extract derived from fenugreek (Trigonella foenum-graecum) on bile acid absorption and cholesterol levels in rats. Evaluation of anti-hyperglycemic and hypoglycemic effect of Trigonella foenumgraecum Linn, Ocimum sanctum Linn and Pterocarpus marsupium Linn in normal and alloxanized diabetic rats. Fenugreek 415 © 2007 Elsevier Australia Feverfew Historical note Feverfew has been used for centuries in Europe to treat headaches, arthritis and fever and used as an emmenagogue and anthelmintic agent. In the 1970s it was ‘rediscovered’ by the medical establishment and subjected to clinical studies, which produced encouraging results that suggested feverfew was an effective prophylactic medicine for migraine headache. Until recently, the sesquiterpene lactone parthenolide was thought to be the major biologically active constituent. However, in vitro and in vivo research suggests others are also present (Brown et al 1997, Pugh & Sambo 1988). Clinical note – Natural variations in parthenolide content the amount of parthenolide present in commercial preparations of feverfew leaves varies significantly, with some exhibiting levels as high as 1,7% dry weight and others as low as 0. The study by Cutlan et al measured the parthenolide content in plants produced from seeds taken from over 30 different sources and germinated under identical conditions. Similarly, when feverfew extracts and parthenolide from Tanacetum vulgare was administered orally in a rat model, gastric ulcer index was significantly reduced (Tournier et al 1999). Jain and Kulkarni (1999) demonstrated that the antinociceptive effect was not mediated through the opiate pathway and was not associated with sedation. In regards to the anti-inflammatory effect, several mechanisms appear to be responsible. Direct binding and inhibition of I-kappa B kinase beta, an important subunit involved in cytokine-mediated signalling, has been demonstrated for parthenolide in test tube studies (Kwok et al 2001). Several test tube studies and animal models have observed inhibition of platelet aggregation (Heptinstall et al 1988, Jain & Kulkarni 1999, Makheja & Bailey 1982). However, no significant effects were seen in a clinical study of 10 patients receiving feverfew (Biggs et al 1982). Therapeutic effect was maintained when capsules containing freeze-dried feverfew powder were continued, whereas those allocated placebo capsules experienced a significant increase in the frequency and severity of headache, nausea, and vomiting during the early months of withdrawal. Since then, numerous clinical studies have been conducted to determine the role of feverfew in the prevention of migraine headache. In 2000, Ernst and Pittler published a systematic review of six randomised, placebo-controlled double-blind trials of feverfew as a prophylactic treatment and concluded that the current evidence favours feverfew as an effective preventative treatment against migraine headache, and is generally well tolerated. Clinical note — Migraine Migraine is a common episodic familial headache disorder characterised by a combination of headache and neurologic, gastrointestinal, and autonomic sympFeverfew 418 © 2007 Elsevier Australia toms. It has a 1-year prevalence of approximately 18% in women, 6% in men, and 4% in children before puberty (Silberstein 2004). Several underlying mechanisms are considered responsible for the onset of migraine. Migraine aura is now thought to be caused by neuronal dysfunction, not ischaemia, and headache begins while cortical blood flow is reduced. In clinical practice, the three goals of migraine-preventive therapy are to reduce attack frequency, severity, and duration, improve responsiveness to treatment of acute attacks, and improve function and reduce disability. Ultimately, choice of treatment should be based on efficacy, adverse effects and coexistent conditions with a full therapeutic trial taking 2–6 months. A more recent Cochrane systematic review of five placebo-controlled, randomised, double-blind trials (n = 343) concluded that there was insufficient evidence to determine whether feverfew was superior to placebo in reducing migraine frequency or incidence, severity of nausea or severity of migraines (Pittler & Ernst 2004). A closer look at the studies reveals that results were mixed, methodological quality varied and various dosage regimens, administration forms and extracts were used. Interpretation of test results is made even more difficult when one considers the naturally occurring chemical variations among the preparations. The authors have offered several explanations for the inconsistent clinical findings and point out that previous negative studies used extracts standardised for parthenolide concentration; however, it is possible that other compounds found in whole-leaf preparations may also be important for pharmacological activity. Additionally, the negative results obtained by some studies may be due to under-dosing. Other in vitro tests have revealed that parthenolide-free feverfew extract reduces inflammation through several mechanisms and is being investigated further as a novel non-steroidal extract for irritated skin (Martin et al 2005). It is still controversial as to whether standardised extracts are best for migraine prophylaxis or not. Symptoms were most frequently reported by long-term users and were predominantly mouth ulceration and gastrointestinal symptoms. Contact dermatitis, mouth soreness and lip swelling has also been reported when leaves are chewed. Further research is required to determine its place in practice for this indication. Feverfew 421 © 2007 Elsevier Australia · Tincture or solid-dose preparations may be better tolerated than chewing the fresh leaves, which have been associated with mouth ulcers and lip swelling in some individuals. Some evidence suggests that feverfew may reduce the frequency and severity of migraine headaches; however, test results are inconsistent. Of those studies producing positive results, it appears that approximately 4 months’ continual use may be required; however, in practice, some patients experience benefits within the first 4 weeks. Feverfew extracts and parthenolide irreversibly inhibit vascular responses of the rabbit aorta. A chloroform extract of the herb feverfew blocks voltage-dependent potassium currents recorded from single smooth muscle cells. Feverfew and vascular smooth muscle: extracts from fresh and dried plants show opposing pharmacological profiles, dependent upon sesquiterpene lactone content. Intra-specific variability of feverfew: correlations between parthenolide, morphological traits and seed origin. A comparison of the effects of an extract of feverfew and parthenolide, a component of feverfew, on human platelet activity in-vitro. The activity of compounds extracted from feverfew on histamine release from rat mast cells. Inhibition of platelet behaviour by feverfew: a mechanism of action involving sulphydryl groups. The anti-inflammatory natural product parthenolide from the medicinal herb Feverfew directly binds to and inhibits IkappaB kinase. A platelet phospholipase inhibitor from the medicinal herb feverfew (Tanacetum parthenium). Pathenolide-free feverfew: an extract with effective anti-irritant activity in vitro. Randomised double-blind placebo-controlled trial of feverfew in migraine prevention. Modulation of lipopolysaccharide-induced proinflammatory cytokine production in vitro and in vivo by the herbal constituents apigenin (chamomile), ginsenoside Rb1 (ginseng) and parthenolide (feverfew). Effect of the chloroform extract of Tanacetum vulgare and one of its active principles, parthenolide, on experimental gastric ulcer in rats.

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The goals of therapy will include reduction in core symptoms medicine images order 2mg risperidone visa, psycho-education medicine ball slams generic risperidone 4mg without a prescription, relapse prevention medications definition order risperidone australia, and facilitating normal growth and development medications heart failure generic risperidone 2 mg without prescription. Neither the effectiveness nor the safety of anti-manic (this term is used as there is no agreed denition of mood stabilizer), antipsychotic and anticonvulsant medications in early and adolescent onset bipolar disorder is not yet established. This is predicted by: • depressive episode of rapid onset with psychomotor retardation and psychotic features; • family history of affective disorder especially mania; • history of mania or hypomania following antidepressant treatment. Occasionally, you must decide ‘who has the anxiety’, the child not wanting to go to school or the parent. Medication is usually reserved for when there is either no response or only an incomplete response to psychological therapy. Short-term outcome of treatment is positive, especially in conjunction with parental support. Prevalence varies from 100% of children taken hostage to 10% after natural disasters. Diagnostic criteria A range of psychopathology may be experienced following an emotionally traumatic event, dependent on pre-existing vulnerabilities, event exposure, and related loss and grief. And either: • Inability to recall, either partially or completely, some important aspects of the period of exposure to the stressor, or; • Persistent symptoms of increased psychological sensitivity and arousal. Age-specic symptoms Younger children often present as regressed with altered sleep and feeding routines; exhibiting clingy, anxious, or aggressive behaviour; or engaging in post-traumatic play. Young children cannot report emotional numbing or detachment; parents report these symptoms as a ‘personality change’. If trauma is repetitive expect disruptive behaviours in boys and early evidence of personality dysfunction in teenagers. Interventions include cognitive strategies such as identifying and modifying dysfunctional schema, behavioural strategies including prolonged re-exposure, skills acquisition such as relaxation techniques, supportive therapy, and family interventions to monitor for secondary impairment and altered family functioning. A history of chronic, repetitive trauma, such as sexual abuse, is overrepresented in other mental health presentations including drug and alcohol abuse, bulimia. Young people recognize these thoughts as their own, and perceive them as unhelpful and at times senseless. This is lower than in the general population where estimates of prevalence vary between 1 and 3%. These patterns persist into later childhood and adolescence in spite of changes in the child or young person’s environment. Two patterns of attachment disorders are described; Disinhibited attachment disorder Associated with an ‘institutional’ style of care in early life, with care being provided by a number carers and the absence of a specic primary care giver. The child is unduly friendly with strangers, does not seem to mind who looks after her/him, and forms supercial relationships easily. Such children may be overactive, aggressive, show emotional liability, or poorly tolerate frustration. The incidence of disinhibited attachment disorder is not well characterized, but is relatively low in the general population. Signicant rates of disinhibited attachment disorder are however, reported in children raised in institutional care from birth. Reactive attachment disorder these children fail to respond appropriately to social interactions and display a fearfulness and hypervigilance which is not responsive to reassurance. Parental abuse, neglect, and severe maltreatment are highly signicant aetiological factors. The severity and duration of abuse or neglect inuences the severity of the disorder. The prevalence of inhibited attachment disorder is low and not all children who experience signicant abuse and neglect will develop an inhibited attachment disorder. Treatment the focus of interventions is to ensure a secure nurturing care setting which provides consistent behavioural management and emotional responses. Infants and young children often have the capacity to alter their behaviour in response to sensitive and emotionally responsive parenting. Children with severe attachment disorders may require placement in a therapeutic residential unit. Prognosis Children with attachment disorders have signicant difculties with interpersonal relationships and are at greater risk of developing mental health problems in adolescence and adulthood. Children who are placed with appropriate carers before age two have a better outcome. Schizophrenia is very uncommon in the pre-pubertal child, when it does occur in this age group it is more common in boys. Causes There is a signicant genetic contribution with heritability estimates as high as 82 and rst-degree relatives having a 12-fold increase in risk of developing the illness. These include maternal infections, stressful events during pregnancy and obstetric complications. Refer to a standard adult psychiatric text for a more complete description of terms and their meaning. Core features of schizophrenia include the following: • Thought disorder: thoughts inserted or removed from one’s head or broadcast to others or disorganized with abnormal speech patterns. Differential diagnosis Important differential diagnoses include affective psychosis (bipolar disorder/psychotic depression), drug-induced psychoses, and psychoses secondary to other organic conditions (see also b pp. Assessment As a schizophrenia-type psychosis can be caused by organic conditions, it is essential that signs of these be sought. Include full neurological examination, and check for thyroid, adrenal, or pituitary dysfunction, and drug screen. Children and adolescents will require both: • Specic therapies, aimed at reducing the core symptoms. The aim is usually to deliver treatment on an out-patient basis, but it may occasionally be necessary to consider day or in-patient treatment. Antipsychotic medication, most commonly the newer atypical antipsychotics with preferable side-effect proles, is often effective. The acute phase can progress to a chronic state with poor motivation and inactivity. Clozapine (an atypical antipsychotic drug) may ameliorate this, but can cause agranulocytosis so ongoing blood monitoring is essential. Prognosis Prognosis is relatively good for a single acute episode in a previously well functioning teenager. However, it is worse for insidiously developing illness particularly in a child with pre-existing developmental difculties. The differentiation between schizophrenia and affective psychosis may be particularly difcult and it is not uncommon for patients’ diagnoses to switch between the two. Some of the terms in common usage are: • Psychosomatic: a very general and rather unhelpful term that can include both illnesses brought on by stress. These are subdivided into: • conversion disorders; • chronic fatigue syndrome; • pain syndromes, hypochondriasis; • somatization disorder. Whilst many of these terms are entrenched, and so unlikely to disappear, the concept of somatoform disorders has been much criticized on the following grounds: • It implies a cause that is not demonstrable and often intuitively does not appear to be correct. Proposed underlying mechanism is transformation of emotional conict into mental or physical symptoms. The postulated splitting off of mental processes from each other is referred to as dissociation. Treatment Principles of treatment include attempts to resolve any apparent emotional difculties, avoidance of unnecessary physical investigation, removal of secondary gain, and help in returning to normal life. The child’s complaints of recurrent abdominal pain are not found to have a physical basis. Features that may help include the diffuseness of the pain, the tendency not to be woken by it, pains elsewhere in the body, anxiety, and depression in child and parent, and the lack of positive ndings on physical examination. Treatment Generally a combination of reassurance, education about the links between stress and the body, psychological treatment where appropriate and avoidance of unnecessary physical investigation and treatment. Prognosis Short-term outcome is usually favourable though it is not known whether this is due to or in spite of treatment. In the longer term further episodes of non-organic pain are found in a large minority of cases. Selective eating this is a condition of younger children that in most, though not all, resolves in the teenage years. It is surprising that most children seem to ingest all the required nutrients in their very limited diet. To treat, a mixture of reassurance and encouragement seems to be the best approach.

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The catheter should exit facing downward and laterally and the exit site should not be placed near the midline treatment 3 phases malnourished children order risperidone canada, belt line or near any prior scars symptoms magnesium deficiency cheap risperidone online american express. For children with ostomies 20 medications that cause memory loss generic 3 mg risperidone with visa, fecal incontinence or obesity medicine x xtreme pastillas order cheapest risperidone and risperidone, the presternal exit site is preferred. Bicarbonate and acetate are rarely used as they commonly produce calcium precipitation and changes in the structure of the peritoneum, respectively. Dialysis is usually started 2 weeks after catheter placement to allow for adequate healing, incorporation of the cuffs and avoid leaks. For children with no other access, low volume dialysis in the supine position may be started in the first 24 hours without a significant risk of leak or subsequent infection and survival of the catheter. Exchange volume the exchange or “fill” volume is approximately 600-800 mL/m2 in children <2 years and 100-1200 mL/m2 in children >2 years old. With this technique, one empty bag is used to drain the peritoneal cavity and the other contains the dialysate solution (1. Both Gramnegative and Gram-positive organisms are responsible for the majority of episodes of peritonitis. Typically, vancomycin and a third generation cephalosporin are the antibiotics of choice. Catheter site infections are prevented with appropriate handling of the catheter and the use of local mupirocin in some series. Bleeding due to erosion of mesenteric vessels by the catheter is rare complication. Nephrol Dial Transplant 20:1416–1421 208 [10] Bellomo R, Cass A, Cole L, et al (2009) Intensity of continuous renalreplacement therapy in critically ill patients. N Engl J Med 359:7–20 [12] Sutherland S, Zappitelli M, Alexander S, et al (2010) Fluid overload and mortality in children receiving continuous renal replacement therapy: the prospective pediatric continuous renal replacement therapy registry. Am J Kidney Dis 55:316–325 [13] Fernandez C, Lopez-Herce J, Flores J, et al (2005) Prognosis in critically ill children requiring continuous renal replacement therapy. Demographic characteristics of pediatric continuous renal replacement therapy: a report of the prospective pediatric continuous renal replacement therapy registry. Clin J Am Soc Nephrol 2:732–738, 2007 [17] Annick Pierrat, Elisabeth Gravier, Claude Saunders, Marie-Veronique Caira. Randomized, double-blind trial of antibiotic exit site cream for prevention of exit site infection in peritoneal dialysis patients. Defining acute kidney injury: further steps in the right direction but can detente be maintained Canadian Association of Radiologists: consensus guidelines for the prevention of contrast-induced nephropathy. Laparoscopic insertion with tip suturing, omentectomy, and ovariopexy improves lifespan of peritoneal dialysis catheters in children. An amino acid-based peritoneal dialysis fluid buffered with bicarbonate versus glucose/bicarbonate and glucose/lactate solutions: an intraindividual randomized study. J Pediatr 2006; 148:770-778 213 Chapter 11 Transfusion and Anticoagulation Robert L. Introduction the oxygen carrying capacity of hemoglobin and its role in oxygen delivery is well understood. Transfusion of packed red blood cells has, therefore, become an important tool in the armamentarium of intensivists, and surgeons alike, in an attempt to reduce the oxygen debt associated with an underlying disease process. Currently no absolute value of hemoglobin concentration below which transfusion is mandated exists. There are multiple physiologic variables that dictate the necessity of transfusion. Defining this transfusion level has been the centerpiece of most recent literature on transfusion medicine. The impetus for these studies was the complication profile seen after transfusions including transmission of infectious disease, fluid overload and acute lung injury seen in patients post-transfusion. The underlying immunosuppression seen in many of our pediatric patients due to malignancy or 214 prematurity may complicate therapy with an increased risk of graft-versus-host disease in this population. This study showed a decreased in-hospital mortality rate and no difference in 30-day mortality in critically ill patients who had a more restrictive transfusion threshold (7g/dL). Guidelines, therefore, have been proposed and instituted at many centers to standardize transfusion medicine. These guidelines vary from institution to institution and rely upon critical review of the current literature as well as local transfusion policies and expert opinion. Neonatal Transfusion Premature infants are among the most commonly transfused patients in the hospital setting. Nearly 50% of infants will receive their first blood transfusion within two weeks after birth, and almost 80% of infants will receive at least one blood transfusion during their hospital stay [2,6]. Anemia in the preterm infant is most commonly due to either acute blood loss from multiple laboratory draws or due to inadequate marrow production – anemia of prematurity. Defining which patients will benefit from transfusion of blood components is difficult as the 216 symptoms of poor oxygen delivery or increased oxygen demand are vague and nondescript consisting of poor weight gain, tachycardia, apnea, persistent oxygen requirement or prolonged mechanical ventilation and lactic acidosis. Common practice in the 1970’s and 1980’s were to maintain a hematocrit of 40% in premature infants [6]. A trend towards more restrictive policies has been seen over the last several decades. Additionally, more severe consequences of transfusion of packed red blood cells have been described including the development of bronchopulmonary dysplasia [7,8], retinopathy of prematurity [9] and necrotizing enterocolitis [10]. It is felt that these outcomes may be due to the inflammatory modulators that are found from presence of leukocytes in non-irradiated red blood cells. There was no difference in the associated mortality, presence of retinopathy of prematurity or bronchopulmonary dysplasia between the two groups. Additionally, there was no statistically significant difference in the rates of intracranial hemorrhage or brain injury (18. This study supported previous thoughts that a high transfusion threshold subjects the infant to more risks of transfusion but does not confer any physiologic benefits. None of these guidelines have been compared in a prospective trial and many rely upon clinical expertise. Recombinant erythropoietin has been used to stimulate marrow and reduce the need for transfusion of autologous blood cells. One study showed a statistically significant reduction in number and volume of transfusions in preterm infants treated with erythropoietin. Additionally reticulocyte counts were higher with a higher hematocrit value at the end of the study in treated patients [12]. Erythropoietin appears to be a safe and important part of a conservative transfusion practice in neonates. Only the latter of these were concerning for increased oxygen demand and oxygen debt that would be treated by increasing the hemoglobin level [15]. Bateman et al, looked prospectively at 977 children admitted to an intensive care unit. Children who did receive a transfusion had longer days of mechanical ventilation, increased nosocomial infection and increased mortality. Interestingly, the most common reason for transfusion was low hemoglobin and the average pre-transfusion hemoglobin was 9. Hemoglobin levels were significantly lower in children in the restrictive arm during the study (8. There was no difference in the rate of new or progressive multiple organ dysfunction between the two groups (12% in each 220 arm). This study added support to the theory that children will tolerate a more restrictive transfusion threshold without an increase in adverse events, similar to the results seen in adults [1]. Overall, children appear to have better outcomes with a more restrictive transfusion protocol. Set transfusion thresholds of 7 g/dl similar to adult trials appear to be tolerated well in the pediatric population although the diverse patient population seen in pediatric intensive care units prevents one from making a single threshold that is all inclusive. Certain subsets of patients, such as sickle cell patients who have better postoperative outcomes when transfused to a hemoglobin of 10 g/dl, require the surgeon to treat each patient individually and consider the underlying pathophysiology that is treated when deciding upon an appropriate transfusion threshold [17]. Transfusion of Platelets Transfusion of platelets and other factors typically follow the recommended guidelines from adult surgical practice.

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