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A prediction rule to identify low-risk patients with community-acquired pneumonia. Hospitalization decision in patients with community-acquired pneumonia: a prospective cohort study. Validation of a pneumonia prognostic index using the MedisGroups Comparative Hospital Database. Aetiology, outcome and prognostic factors in community-acquired pneumonia requiring hospitalization. Assessing prognosis and selecting an initial site of care for adults with community-acquired pneumonia. Effect of increasing the intensity of implementing pneumonia guidelines: a randomized, controlled trial. Community acquired pneumonia: aetiology and usefulness of severity criteria on admission. Use of prognostic scoring and outcome assessment tools in the admission decision for community-acquired pneumonia. Assessment of illness severity in community acquired pneumonia: a useful new prediction tool? Validation of a predictive rule for the management of community-acquired pneumonia. A prediction rule to identify allocation of inpatient care in community-acquired pneumonia. Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia. Hospitalization for community-acquired pneumonia: the pneumonia severity index vs clinical judgment. Cost and incidence of social comorbidities in low-risk patients with community-acquired pneumonia admitted to a public hospital. Validation of the 2001 American Thoracic Society criteria for severe community-acquired pneumonia. Severe community-acquired pneumonia: use of intensive care services and evaluation of American and British Thoracic Society Diagnostic criteria. Understanding physician adherence with a pneumonia practice guideline: effects of patient, system, and physician factors. Testing strategies in the initial management of patients with community-acquired pneumonia. Etiology, reasons for hospitalization, risk classes, and outcomes of community-acquired pneumonia in patients hospitalized on the basis of conventional admission criteria. Community-acquired pneumonia: etiology, epidemiology, and outcome at a teaching hospital in Argentina. Clinical aspects and prognostic factors in elderly patients hospitalised for communityacquired pneumonia. Process of care performance, patient characteristics, and outcomes in elderly patients hospitalized with community-acquired or nursing home-acquired pneumonia. A five-year study of severe community-acquired pneumonia with emphasis on prognosis in patients admitted to an intensive care unit. Validation of predictive rules and indices of severity for community acquired pneumonia. Initial microbiologic studies did not affect outcome in adults hospitalized with community-acquired pneumonia. The clinical features of severe community-acquired pneumonia presenting as septic shock. Severe community-acquired pneumonia: assessment of microbial aetiology as mortality factor. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Causes and factors associated with early failure in hospitalized patients with community-acquired pneumonia. Causes of death for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team cohort study. Risk factors of treatment failure in community acquired pneumonia: implications for disease outcome.

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The examination can be expanded as needed, or the use of special examination techniques can be employed if the findings indicate possible additional areas of involvement or if they are necessary to eliminate some possible diagnoses. In making the diagnosis in orthopedics, an intimate knowledge of anatomy and functional aspects of an area are crucial to making the diagnosis. Knowledge of pain referral patterns and 298 Plan Sports-Specific Rehabilitation structures and joint spaces intact. Pain was elicited at the end range of active flexion over flexor carpi ulnaris and with passive flexion and radial deviation of the wrist. Eight weeks after the operation the patient was asymptomatic and able to resume activity involving the wrist at a preinjury level. The patient was able to return to professional football following a successful functional rehabilitation program. The response to the treatment can provide feedback for eliminating or confirming a diagnosis. Sometimes, in patients with some response to a treatment, a subtle change in the prescribed therapy may allow further differentiation of the diagnosis. Such an approach requires the clinician to use critical evaluation of treatment information along with his or her own knowledge base (clinical experience and education) to identify a more precise diagnosis. Several different tests are available to assist in making a difficult diagnosis in orthopedics. Laboratory analysis of blood, urine, and fluid can be helpful in ruling out or establishing the diagnosis of such common orthopedic problems as rheumatoid arthritis, systemic lupus erythematosus, infections, and trauma. Serum analysis; a complete blood count; rheumatologic screen, which includes a complete metabolic profile; rheumatoid factor; acetylneuraminic acid; and C-reactor protein, sedimentation rate, and then a urinalysis are tests that help pinpoint medical conditions that present as orthopedic problems. Although this is not a complete set of all tests, it gives the clinician a basis for ruling in or out many diagnoses. Case 4 Tennis Player the following case study demonstrates the importance of the continued use of diagnostic skills throughout treatment. A 34-year-old, right-handed female presented for orthopedic examination and treatment of right wrist pain. History While playing tennis the patient reported falling and landing on her outstretched right arm 4 weeks before presenting for an orthopedic examination. She denied previous injury to the wrist and reported that activities requiring her to use her wrist increased her pain. Physical Examination Pulses and neurovascular and musculoskeletal systems were intact. Six days after falling from a vault, a Appendix A Approach to Differential Diagnosis in Orthopedics 25-year-old male presented for orthopedic evaluation and treatment of his left ankle. History the patient reports falling approximately 12 feet from vaulting in a track meet. He landed with the majority of his weight on the left foot and ankle on a hard surface. He was evaluated and treated in the emergency department for a lateral ankle sprain and a lateral malleolus avulsion fracture. He was placed on crutches and in an air cast ankle stirrup support and referred for an orthopedic evaluation. Physical Examination the patient, on crutches, was not bearing weight on the left ankle. Impression the therapist suspected a left ankle sprain with a possible occult fracture of the talus and calcaneus. Plan the patient was placed in a fracture walker boot, and a compression sock was applied to the foot and ankle. The patient was treated conservatively, having to use crutches without bearing weight and being in a boot for 6 weeks. Then he was started on progressive weight bearing and physical therapy and was functional after an additional 4 weeks.

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Dizziness, headache, edema, nausea, vomiting, heart block, and arrhythmias may occur. Monitor heart rate with concurrent clonidine use (sinus bradycardia has been reported). May increase levels and effects/toxicity of buspirone, cyclosporine, carbamazepine, fentanyl, digoxin, quinidine, tacrolimus, benzodiazepines, and -blockers. Cardizem immediate-release tablets should be swallowed whole because crushing or chewing may alter its pharmacokinetics. Side effects include sedation, nausea, vomiting, xerostoma, blurred vision, and other reactions common to antihistamines. Pregnancy category is "X" when used for migraine prophylaxis and is a "D" for all other indications. Dobutamine has been shown to increase cardiac output and systemic pressure in pediatric patients of every age group. A few drops of the 10 mg/mL oral liquid may be used in the ear as a cerumenolytic. Common side effects include dizziness, headache, sedation, blurred vision, fever, chills, and sleep disorders. Tachyarrhythmias, ectopic beats, hypertension, vasoconstriction, and vomiting may occur. Use with caution with phenytoin because hypotension and bradycardia may be exacerbated. Children aged <2 yr clear dopamine faster and exhibit high variability in neonates. Safety and efficacy has not been demonstrated in patients >1 yr of continuous use. The following nebulizer compressor systems have been recommended for use: Pulmo-Aide, Pari-Proneb, Mobilaire, Porta-Neb, or PariBaby. Use of the "Sidestream" nebulizer cup can significantly reduce the medication administration time. Do not use with general anesthetic agents that can sensitize the heart to catecholamines. Do not initiate doxapram until the general anesthetic agent has been completely excreted. May also cause tachycardia, arrhythmia, seizure, hyperreflexia, hyperpyrexia, abdominal distension, bloody stools, and sweating. Generally not recommended for use in children aged <8 yr because of risk for tooth enamel hypoplasia and discoloration. Rifampin, barbiturates, phenytoin, and carbamazepine may increase clearance of doxycycline. Use with caution in heart disease, seizures, and hepatic disease (reduce dose if severe). Side effects: euphoria, dizziness, difficulty concentrating, anxiety, mood change, sedation, hallucinations, ataxia, paresthesia, hypotension, excessively increased appetite, and habit-forming potential. Side effects include hypotension, tachycardia, extrapyramidal side effects such as dystonia, feeling of motor restlessness, laryngospasm, and bronchospasm. Hypersensitivity to test dose (fasciculations or intestinal cramping) is an indication to stop giving drug. Reported doses for reversing neuromuscular blockade in children have ranged from 0. Antagonism of nondepolarizing neuromuscular blocking drugs is more rapid in children than in adults.

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However, the committee does feel that therapy should be administered as soon as possible after the diagnosis is considered likely. Conversely, a delay in antibiotic therapy has adverse consequences in many infections. For critically ill, hemodynamically unstable patients, early antibiotic therapy should be encouraged, although no prospective data support this recommendation. Data from the Medicare database indicated that antibiotic treatment before hospital admission was also associated with lower mortality [109]. Important for discharge or oral switch decision but not necessarily for determination of nonresponse. Patients should be switched from intravenous to oral therapy when they are hemodynamically stable and improving clinically, are able to ingest medications, and have a normally functioning gastrointestinal tract. Patients should be discharged as soon as they are clinically stable, have no other active medical problems, and have a safe environment for continued care. Subsequent studies have suggested that even more liberal criteria are adequate for the switch to oral therapy. One study population with nonsevere illness was randomized to receive either oral therapy alone or intravenous therapy, with the switch occurring after 72 h without fever. The study population with severe illness was randomized to receive either intravenous therapy with a switch to oral therapy after 2 days or a full 10-day course of intravenous antibiotics. Time to resolution of symptoms for the patients with nonsevere illness was similar with either regimen. Among patients with more severe illness, the rapid switch to oral therapy had the same rate of treatment failure and the same time to resolution of symptoms as prolonged intravenous therapy. The need to keep patients in the hospital once clinical stability is achieved has been questioned, even though physicians commonly choose to observe patients receiving oral therapy for 1 day. Even in the presence of pneumococcal bacteremia, a switch to oral therapy can be safely done once clinical stability is achieved and prolonged intravenous therapy is not needed [270]. Such patients generally take longer (approximately half a day) to become clinically stable than do nonbacteremic patients. The benefits of in-hospital observation after a switch to oral therapy are limited and add to the cost of care [32]. Discharge should be considered when the patient is a candidate for oral therapy and when there is no need to treat any comorbid illness, no need for further diagnostic testing, and no unmet social needs [32, 271, 272]. Although it is clear that clinically stable patients can be safely switched to oral therapy and discharged, the need to wait for all of the features of clinical stability to be present before a patient is discharged is uncertain. For example, not all investigators have found it necessary to have the white blood cell count improve. This finding may reflect the fact that elderly patients with multiple comorbidities often recover more slowly. Arrangements for appropriate follow-up care, including rehabilitation, should therefore be initiated early for these patients. In general, when switching to oral antibiotics, either the same agent as the intravenous antibiotic or the same drug class should be used. Switching to a different class of agents simply because of its high bioavailability (such as a fluoroquinolone) is probably not necessary for a responding patient. Available data on short-course treatment do not suggest any difference in outcome with appropriate therapy in either inpatients or outpatients [276]. Duration is also difficult to define in a uniform fashion, because some antibiotics (such as azithromycin) are administered for a short time yet have a long half-life at respiratory sites of infection. Results with azithromycin should not be extrapolated to other drugs with significantly shorter half-lives. Patients with persistent clinical instability are often readmitted to the hospital and may not be candidates for shortduration therapy. Studies of duration of therapy have focused on patients receiving empirical treatment, and reliable data defining treatment duration after an initially ineffective regimen are lacking. Subsequent data have suggested that the benefit appears to be greatest when the treatment is given as early in the hospital admission as possible.

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Dosing of Renal Replacement Therapy the dose or amount of renal replacement therapy prescribed is equal to the amount of blood "purified" per unit time. In practice, the effluent (ultrafiltrate and/or spent dialysate) flow rate is used as a surrogate of clearance and is expressed in milliliters per kilogram of body weight per hour (mL/kg/hr). Occasionally, higher doses are used (25-30 mL/kg/hr) to account for the decreased efficiency of the filter with increased use and downtime if clotting occurs. Although more intense dosing was initially thought to decrease mortality; it is now generally accepted that doses above 25-30 mL/kg/hr have no additional benefit. This is performed via a double-lumen (11-14 French) central venous catheter placed percutaneously. The catheter has two ports corresponding to each lumen; the proximal port removes blood from the patient, while the distal port returns blood from the dialysis machine. In order of preference, the catheter is placed in the right internal jugular, femoral, or left internal jugular veins. The arterial cannula removes blood from the patient, while blood is returned via the venous cannula. The needle nearest the artery diverts blood to the dialysis machine, while the other needle returns blood to the patient. Osmotic demyelination syndrome is a neurologic disorder caused by damage to the myelin sheath of neurons (particularly in the brainstem) from rapid correction of hyponatremia. Adjustment of dialysate or replacement fluids with lower sodium 315 concentration as well as frequent monitoring of sodium levels is warranted. Acute liver failure is frequently associated with hyponatremia, cerebral edema, increased intracranial pressure, and acute or chronic kidney disease (hepatorenal syndrome). Dialysis disequilibrium syndrome is a neurologic disorder characterized by nausea, headache, and mental status changes that is thought to be secondary to abrupt changes in serum osmolarity resulting in cerebral edema. The mechanism is likely due to rapid serum clearance of urea during dialysis with slower equilibration of intracerebral urea concentration promoting influx of free water. Preventive measures include decreasing the dose of dialysis, slowing treatment time, and initiation of ultrafiltration prior to hemodialysis. Water-soluble drugs as well as drugs that are not highly protein bound are more readily cleared. Internal jugular or femoral vein central access is preferred over the subclavian veins for dialysis catheter placement b. The following statements comparing hemodialysis with hemofiltration are true, except: a. A low-flux membrane is typically used for hemofiltration and a high-flux membrane is typically used for dialysis c. Hemofiltration is more effective than hemodialysis at removing cytokines, and hemodialysis is more effective at removing small molecules d. Hemofiltration depends primarily on convection, while hemodialysis depends on diffusion. Later that day, she develops sudden respiratory distress with mild hypotension and hypoxia. Over the next 24 hours, her oxygen requirement improves, and the norepinephrine infusion is weaned off as her hemodynamics stabilize. Several noninvasive diagnostic techniques have been developed to improve the accuracy of the diagnosis; however, no single noninvasive diagnostic test is sensitive or specific enough for the diagnosis in all patients. The cornerstone of management involves identification of high-risk groups and treatment with adequate prophylactic measures. States such as malignancy and inflammatory bowel disease can lead to the upregulation of tissue factor and other coagulation factors, potentiating clot formation. Osteoporosis also occurs in approximately 30% of patients treated with long-term unfractionated heparin therapy. Vitamin K antagonist therapy, or warfarin, is also associated with complications including bleeding and skin necrosis due to protein C or S deficiency. For patients who are hemodynamically stable and the clinician has a low or intermediate clinical suspicion, it is recommended to start by checking a D-Dimer (usually omitted in hospitalized patients because specificity is reduced in this population). Pulmonary angiography is considered the gold standard but is rarely performed today since it requires expertise to perform and interpret, is invasive, and has associated risks.

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Initial evaluation follows the American College of Surgeons Advanced Trauma Life Support algorithm. Burn injuries can be distracting and it is important to ensure that a full exam is performed. Generally, superficial burns heal with minimal scarring and deep involvement is best treated with excision and skin grafting. Circumferential deep burns of the extremities and trunk result in a burn eschar that can cause compartment syndromes and impaired chest wall excursion. The most commonly used methods include the Rule of Nines and the Lund and Browder chart. Electrical injury is classified by the magnitude of the current causing the injury, with high-voltage injuries resulting from currents greater than 1000 volts. With high-voltage injury, the current passes through the patient and can cause deep tissue destruction that can be severely underestimated by the observed 447 skin involvement. Complications can include rhabdomyolysis, compartment syndrome and pigment nephropathy. Unsurprisingly, the presence of significant co-morbidities is associated with increased mortality. Airway Management and Inhalational Injury the airway should be addressed during the primary survey. This should be anticipated and the airway should be secured early if there is clinical concern. The pharynx is efficient in dissipating heat and frank thermal injury to the lower respiratory tract is rare except in the case of inhalation of superheated gas such as steam. Chemical injury to the more proximal airways occurs through exposure to toxic gaseous compounds. Distal damage is facilitated by toxins binding to carbon particles with distribution throughout the respiratory tract. Resulting effects include sloughing of respiratory epithelium, increased mucous secretion, inflammation, atelectasis and airway obstruction. In addition carboxyhemoglobin shifts the oxyhemoglobin dissociation curve to the left and changes the shape of the curve such that there is impaired unloading of oxygen at the tissue level. Symptoms include headache, dizziness, nausea, and confusion leading to unconsciousness. The half-life of carboxyhemoglobin is significantly reduced by administration of 100% oxygen. Hydrogen cyanide is a combustion byproduct of a variety of materials and elevated cyanide levels have been reported in victims of closed space fires. Treatment includes supportive measures but specific therapy is available with hydroxocobalamine and is often initiated in the field. Classic therapies for cyanide toxicity including amyl nitrite and sodium nitrite rely on the generation of methemoglobin to bind cyanide and are contraindicated in patients with elevated carboxyhemoglobin. Fiberoptic bronchoscopy is used to confirm diagnosis via visualization and quantification of hyperemia, edema and carbonaceous material in the airway. Resuscitation 449 Burn shock results from a complex cascade of physiologic events leading to a mixed hypovolemic and distributive shock. A transient increase in capillary permeability results from the action of a variety of inflammatory mediators. With fluid resuscitation, significant edema occurs in both burned and unburned tissue. It is important to understand that resuscitation formulas serve as a starting point in resuscitation. It is necessary to monitor and adjust the administration rate based on patient response.

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Initial efficacy and tolerability of early enteral nutrition with immediate or gradual introduction in intubated patients. Hypocaloric compared with eucaloric nutritional support and its effect on infection rates in a surgical intensive care unit: a randomized controlled trial. Hyperproteic hypocaloric enteral nutrition in the critically ill patient: a randomized controlled clinical trial. High-protein hypocaloric vs normocaloric enteral nutrition in critically ill patients: a randomized clinical trial. Refeeding Syndrome Trial Investigators Group: restricted versus continued standard caloric intake during the management of refeeding syndrome in critically ill adults: a randomised, parallel-group, multicentre, single-blind controlled trial. Lower versus higher dose of enteral caloric intake in adult critically ill patients: a systematic review and meta-analysis. Calorie delivery and clinical outcomes in the critically ill: a systematic review and meta-analysis. Calorie intake of enteral nutrition and clinical outcomes in acutely critically ill patients: a meta-analysis of randomized controlled trials. Optimal amount of calories for critically ill patients: depends on how you slice the cake. U-shaped relationship between calorie intake and outcome in critically ill patients. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a randomized controlled trial. Are prospective cohort studies an appropriate tool to answer clinical nutrition questions? Optimal protein requirements during the first 2 weeks after the onset of critical illness. Effect of parenteral nutrition on muscle amino acid output and 3-methylhistidine excretion in septic patients. Optimal protein and energy mortality in mechanically ventilated critically ill patients: a prospective observational cohort study. Provision of protein and energy in relation to measured requirements in intensive care patients. Clinical outcomes related to protein delivery in a critically ill population: a multicenter, multinational observation study. Greater protein and energy intake may be associated with improved mortality in higher risk critically ill patients: a patient multicenter, multinational observational study. Whole body protein turnover in critically ill patients with multiple organ failure. The influence of protein provision in the early phase of intensive care on clinical outcomes for critically ill patients on mechanical ventilation. Intravenous amino acid therapy for kidney function in critically ill patients: a randomized controlled trial. High-dose amino acid infusion preserves diuresis and improves nitrogen balance in non-oliguric acute renal failure. Prospective randomized trial to assess caloric and protein needs of critically Ill, anuric, ventilated patients requiring continuous renal replacement therapy. Protein requirements in the critically ill: a randomized controlled trial using parenteral nutrition. Insufficient activation of autophagy allows cellular damage to accumulate in critically ill patients. Early administration of protein in critically ill patients: a large retrospective cohort study. Early exercise in critically ill patients enhances short term functional recovery. Early, goal-directed mobilization in the surgical intensive care unit: a randomized controlled trial. Glutamine and antioxidants in the critically ill patient: a post hoc analysis of a large-scale randomized trial.

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Page 2 of 2 patients with kidney failure should be higher than healthy controls [15]. Description and predictive factors of infection in patients with chronic kidney disease admitted to the critical care unit. Are prognostic scores and biomarkers such as procalcitonin the appropriate prognostic precursors for elderly patients with sepsis in the emergency department? Aging Clin Exp Res 28: 917-924 Pfister R, Kochanek M, Leygeber T, Brun-Buisson C, Cuquemelle E, et al. However, the imperfect accuracy of the test withheld recommendations on the use of the test in isolation. Logistics Test Indications: Useful for diagnosis of bacteremia and septicemia in adults and children (including neonates); Diagnosis of renal involvement in urinary tract infection in children; Diagnosis of bacterial infection in neutropenic patients; Diagnosis, risk stratification, and monitoring of septic shock; Diagnosis of systemic secondary infection post-surgery, and in severe trauma, burns, and multiorgan failure; Differential diagnosis of bacterial versus viral meningitis; Differential diagnosis of community-acquired bacterial versus viral pneumonia; Monitoring of therapeutic response to antibacterial therapy. Do not exceed 8 hours on clot/cells/gel or 24 hours off clot/cells/gel at refrigerated temperatures. Increases may also be seen in: First days after major trauma, major surgery, severe burns, treatment with drugs that stimulate release of pro-inflammatory cytokines. Patients with invasive fungal infections and acute infection with plasmodium falciparum malaria. Prolonged or severe cardiogenic shock, prolonged severe organ perfusion anomalies, small cell lung cancer, and medullary C-cell carcinoma of the thyroid. Procalcitonin levels >10ng/ml are almost exclusively due to severe bacterial sepsis or septic shock. Such low levels may be obtained during the early course of infections, in localized infections and subacute endocarditis. The same sample matrix/tube type should be used for patient testing throughout admission due to variations in measurement (i. Reliability of procalcitonin concentrations for the diagnosis of sepsis in critically ill neonates. Mayo Medical Laboratories April 2018 References: Updates: 3/25/2014: Removal of critical value, previously listed as 2. Clinical Nutrition 38 (2019) 48e79 Contents lists available at ScienceDirect Clinical Nutrition journal homepage. Casaer g, Michael Hiesmayr h, Konstantin Mayer i, Juan Carlos Montejo j, Claude Pichard k, Jean-Charles Preiser l, Arthur R. When to start and how to progress in the administration of adequate provision of nutrients is also described. The best determination of amount and nature of carbohydrates, fat and protein are suggested. Particular conditions frequently observed in intensive care such as patients with dysphagia, frail patients, multiple trauma patients, abdominal surgery, sepsis, and obesity are discussed to guide the practitioner toward the best evidence based therapy. For now, a gap exists between nutritional practices and the previous guidelines [6] and many available studies address only one or at most some of the specific aspects of nutritional therapy. In the current guidelines, the timing, route, dose and composition of nutrition will be discussed and recommendations will be made recognizing that acute metabolic changes as well as calorie and protein deficits play a major role in patient outcome. Since most of the previous guidelines were based on observational or retrospective data, and the fact that large prospective randomized controlled studies have since been performed and recently published, our purpose is to integrate the best and most updated knowledge from the literature analyzed by professional methodologists and critical care nutrition experts as well as by invited critical care professionals, in order to reach the best achievable recommendations. Methodology the guideline is a basic framework of evidence and expert opinions aggregated into a structured consensus process. All members of the working group have declared their individual conflicts of interest according to the rules of the International Committee of Medical Journal Editors. Individuals employed by the nutrition and pharmaceutical industry could not participate. Although studies from an unlimited time span were assessed, only studies published in the year 2000 or later were included in the present meta-analyses.


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