Es ist nicht klar, wie groß die Rolle von Antibiotika https://antibiotika-wiki.de/ in den Wettbewerbsbeziehungen zwischen Mikroorganismen unter natürlichen Bedingungen ist. Zelman vaxman glaubte, dass diese Rolle minimal ist, Antibiotika werden nicht anders als in reinen Kulturen auf reichen Umgebungen gebildet. Anschließend wurde jedoch festgestellt, dass bei vielen Produzenten die Aktivität der antibiotikasynthese in Gegenwart anderer Arten oder spezifischer Produkte Ihres Stoffwechsels zunimmt.

Dazed and confused how can i prevent my patient from becoming delirious when having surgery?

Dazed and Confused
How can I prevent my patient from
becoming delirious when having surgery?
Learning Objectives
1. To identify which surgical patients are at highest risk of becoming delirious post- operatively 2. To understand ways to prevent delirium in Overview
What is delirium?
z Acute confusional statez Disturbance of consciousness with reduced z Develops over a short period of timez Evidence of medical cause from history, Epidemiology
z Often seen in patients with underlying – Up to 75% among surgical patients (Dyer Arch Int Med 1995) Preoperative Delirium Risk Factors
After Non-cardiac Surgery:
Preoperative psychotropic drug use (e.g. benzos,
narcotics, mood stabilizers)
Cognitive Impairment
Preoperative Delirium Risk Factors
Validated Clinical Prediction Rule (developed among patients > 50 undergoing elective non-cardiac surgery) • Poor cognitive status (TIC score <30) • Poor functional status (SAS class IV) Preoperative Delirium Risk Factors
Outcomes of Postoperative Delirium
Higher rates of discharge to long-term care or Poor functional recovery among hip fracture pts (Marcantonio JAGS 2000; Gustafson JAGS 1988) Diagnosing Delirium
Confusion Assessment Method (CAM)
Diagnosis of delirium if 1, 2, and either 3 or 4 Diagnosing Delirium-CAM
Diagnosing Delirium- CAM
Results for Systematic Review of Delirium Screening Tools:Summary measures from all studies (9 studies): Summary measures when CAM performed by an MD (4 studies): Summary measures when CAM performed by an RN (3 studies): Preventing Delirium
Multi-component Prevention Strategies
3 trials involving hip fracture pts (N = 646) Summary RR 0.75 (95% CI 0.64-0.88)
NNT= 7 (95%CI 4-20)
Multi-component Prevention Strategies
Targeted Risk Factors
Prevention Strategies
High risk medications
- Discontinue/minimize benzodiazepines,
anticholinergics, antihistamines, merperidine
- Modify/eliminate drugs to minimize drug interactions,
adverse effect and redundancies
Fluid and electrolyte
- Restore serum lytes (Na, K, glucose) to normal limits
imbalances
- Detect and treat dehydration or fluid overload
Malnutrition
- Ensure proper use of dentures, proper positioning,
assistance with eating if required, and consider
supplements
Multi-component Prevention Strategies
Targeted Risk Factors
Prevention Strategies
Cognitive Impairment
- Orientation protocols
- Provision of clocks and calendars
Functional Impairment - Early mobilization including out of bed regularly and
as tolerated
- Physiotherapy/Occupational therapy as needed
Impaired Vision &
- Appropriate use of glasses, hearing aids and adaptive
equipment
- If pain is an issue (especially post-op) consider standing
orders for Acetaminophen rather than prn
- Treatment of breakthrough pain starting with low dose
narcotics; avoiding meperidine
Multi-component Prevention Strategies
Targeted Risk Factors
Prevention Strategies
Iatrogenic
- D/C urinary catheters
complications
- Screen for urinary retention and incontinence
- Skin care program
- Appropriate bowel regiments
Sleep Deprivation
- Unit wide noise reduction strategies
- Scheduling of medications/procedures to allow for
proper sleep
- Use of nonpharmacologic measures to promote sleep
such as warm milk or herbal tea
Pharmacological Prevention Options
5 trials:z Epidural vs. General anesthesia (N = 57) z Pre-op Intrathecal Morphine vs. Saline (N = 59) z Prophylactic Haldol vs. placebo (N= 430) Pharmacological Prevention Options
Epidural (N=28) vs. General (N=29) Anesthesia Pharmacological Prevention Options
Pre-op Intrathecal Morphine (N=29) vs. Saline (N=30) Pharmacological Prevention Options
Pharmacological Prevention Options
Pharmacological Prevention Options
- benzodiazepines and narcotic continuously from 2000h – 0400h Management of Delirium
assessment and multi-component, targeted management strategies Multi-component Delirium Management
Strategies
Interventions focused on - Optimizing sensory input - Provision of familiar items and family presence - Use of atypical antipsychotics were indicated - Nutritional supplements where indicated Multi-component Delirium Management Strategies
Summary WMD 3.25 days (95%CI -2.58 – 9.34) Delirium - Clinical Bottom Line
z Limited evidence for delirium prevention and z Evidence supports implementation of multi- component prevention strategies (NNT = 7) z Insufficient evidence to support use of any What should be done for my frail
surgical patient?
z Weigh risks and benefits of surgery with z Considering using the validated clinical prediction rule to better determine risk of delirium z No clear evidence that drugs prevent delirium What should be done for my frail
surgical patient?
z Use multi-component management strategies z No clear evidence that drugs alter course z To control behavioral issues that are disturbing to patient, or – Trial of atypical neuroleptics (after weighing the risks) Risks with Atypical Antipsychotics
z Atypical antipsychotics have the best evidence for use in managing the neuropsychiatric symptoms of dementia (and ?delirium) – Increased risk of stroke (1-2% absolute increase) – Increased risk of death (1% absolute increase) Local Initiatives
Delirium Prevention Among Hip Fracture Pts
z Pragmatic KT intervention among hip fracture patients at
z Interrupted time-series designz Examining the impact of an electronic care pathway on post-op delirium rates and associated outcomes Future Initiatives
z Part of an NCE grant application designed to promote
elder friendly acute care hospitals within Canada z Implementation of the CAM screening tool on SCMz Geriatric-focused order sets ??? QUESTIONS???
403-944-1771jayna.holroyd-leduc@albertahealthservices.ca

Source: http://www.departmentofmedicine.com/rounds/presentations/2009/dazed_and_confused.pdf