Methods for Prevention of Post-ERCP Pancreatitis

Methods for Prevention of Post-ERCP Pancreatitis Prevention of post endoscopic retrograde cholangiopancreatography pancreatitis Abstract: Pancreatitis is the most common and important complication of ERCP. Several risk factors exist that help to formation and progress pancreatitis. These risk factors may be factors that are related to patient, and factors that related to Procedure, or factors related to operator. All of the risk factors should be considered and as far as possible may be lowered with attention to pathogenesis of the development of post-ERCP pancreatitis. These pathogenesis are include: sphincter spasm, infection, contrast toxicity and pancreatic secretion that induce activation of proteolytic enzymes and inflammatory process. Some of methods and pharmacologic agent assessed for prevention pathogenesis pathway to decrease post-ERCP pancreatitis. Introduction: In about 75 percent of patients after endoscopic retrogradecholangiopancreato-graphy (ERCP) may have elevation in serum amylase ; but acute clinical pancreatitis (defined as a clinical syndrome of abdominal pain and hyperamylasemia) is less common. However, acute pancreatitis is the important complication of ERCP and need to pay attention it to prevent from its morbidity and mortality [1]. Mechanism for post ERCP pancreatitis: The exact mechanism for PEP is unknown. It needs to be a trigger event that turn on the inflammatory process, that can be the fallowing: thermal injury from sphincterotomy, mechanical obstruction to outflow of the pancreatic secretions , papillary edema from attempted multiple cannulations, sphincterotomy etc., injury from guide wire, chemical injury of the contrast, microbiological injury due to introduction of duodenal flora into the pancreas etc [2]. Risk Factors for Post-ERCP Pancreatitis: It is important to identify cases in which there are high risks for pancreatitis that we can prevent the complications of the prophylactic method such as pancreatic stenting or pharmacological prophylaxis. Assessment of both patient- and procedure-related factors is necessary to detect the high-risk cases (Table 1) [3]. Table 1: Risk Factors for Post-ERCP Pancreatitis [3]. Definition of post ERCP pancreatitis: To diagnose PEP need to be at least two of the following criteria: Epigastric pain with radiation to the back, Elevation of amylase and / or lipase at least 3 times higher than normal. Radiological imaging that suggests pancreatitis. Amylase and lipase may have an elevation despite the patients does not has any symptom. Radiological imaging is helpful when the diagnosis is difficult [4]. Methods and pharmacologic prevention of post-ERCP pancreatitis A. the Following techniques should be adhered to in order to decrease the risk of post-ERCP pancreatitis: 1. Endoscopic techniques 2. Cannulation 3. Electrocautery 4. Pancreatic stenting B. Pharnacologic prophylams: Nonsteroidal anti-inflammatory drugs Steroidal anti-inflammatory agents Other anti-inflammatory agents   Allopurinol semapimod- interleukin 10- pentoxifylline- Platelet-activating factor-Epinephrine Inhibitors of pancreatic secretion: Somatostatin- Somatostatin combined with diclofenac- octerotide- calcitonin Agents that stimulate pancreatic secretion and reduce sphincter tone: Secretin Agents that reduce of sphincter tone: Nifedipine-Nitrates-Glyceryl trinitrate botulinum toxin-topical lidocaine Inhibitors of protease activation: Gabexate mesilate- Nafamostat- Ulinastatin- C1-inhibitor- Heparin Antioxidants: N-acetylcysteine- Sodium selenite- Beta- Carotene Antimicrobial agents Antimetabolites : 5-FU (5 Fluoro Uracil)[5]. Some of the drugs that tested in different trials are described below: Pharmacological Prevention for Post-ERCP Pancreatitis: Since the introduction of ERCP, numerous pharmacologic drugs have been assessed to prevent post-ERCP pancreatitis based on their pharmacologic mechanism and their effect on one or more of the factors associated with pancreatic damage (Figure 1) [6]. 1- NSAIDs: NSAIDs (diclofenac or indomethacin) are the most drugs that are using for prevention of post-ERCP pancreatitis [7]. The European Society of Gastrointestinal Endoscopy recommends routine rectal administration of 100 mg diclofenac or indomethacin for prevention of post-ERCP pancreatitis [8]. 2- Glyceryl trinitrate: Glyceryl trinitrate reduces sphincter of Oddi pressure and may uses to prevent post-ERCP pancreatitis. ManuelMoretà ³ in his study assessed that could transdermal glyceryl trinitrate be effective in the prevention of post-ERCP pancreatitis? The results of his study show that transdermal glyceryl trinitrate patch significantly reduces post-ERCP pancreatitis [7]. 3- Nifedipine: Calcium channel inhibitors can prevent the development of experimental pancreatitis. Nifedipine is from the calcium channel blocker drugs and its effect is reducing sphincter spasm. Part done randomized, placebo-controlled trial to determine whether the calcium channel blocker nifedipine prevents post-ERCP pancreatitis. Nifedipine or placebo was administered before and within 6 hours after ERCP. This study failed to show significant effect of nifedipine in the prevention of post-ERCP pancreatitis [8]. 4-Antibiotics: Infections that occur when ERCP is done can activation proteolytic enzymes and lead to pancreatitis. Now there is this question that antibiotics can use in the prevention of post-ERCP pancreatitis. One prospective randomized controlled trial showed that the ceftazidime administration before ERCP significantly decreased the incidence of post-ERCP pancreatitis in the control group that did not receive antibiotic [9]. The quality of the study is questionable because the control group did not received no antibiotic [10]. 5- Risperidone: Ulinastatin inhibited systemic inflammatory responses and may benefit for prevention post-ERCP pancreatitis. Tsujino assessed the effect of risperidone (a selective serotonin 2A antagonist) combined with ulinastatin for the prevention of PEP in high-risk patients. In a multicenter, randomized, controlled trial, patients were randomly compared to administration ulinastatin with or without risperidone. The incidence of PEP was not significantly different between two groups, but pancreatic enzymes level were significantly lower in the risperidone+ulinastatin group as compared with ulinastatin alone [11]. 6- Indomethacin Indometacin is from nonstroidal antiinflamatory drugs that are used for prevention of post-ERCP pancreatitis. Joseph Elmunzer in a multicenter, randomized, placebo-controlled, double-blind clinical trial assigned patients that were high risk for post-ERCP pancreatitis to receive a single dose of indomethacin or placebo immediately after ERCP. Among patients at high risk for post-ERCP pancreatitis, rectal indomethacin significantly reduced the incidence of the post-ERCP pancreatitis [12]. Yaghoobi also assigned one meta-analysis to assessed rectal indomethacin for the prevention of post-ERCP pancreatitis. This meta-analysis showed that the rate of pancreatitis was significantly lower when using indomethacin as compared with placebo. [13]. 7- Corticosteroid: Corticosteroids are anti-inflammatory drugs and may be able to decrease the risk of post-ERCP pancreatitis. In a prospective randomized controlled multicentre study, administration of prednisone did not reduce the incidence of pancreatitis rather than placebo [14]. 8- N-acetyl Cysteine: N-acetyl Cysteine can reduce inflammation and may be useful in post-ERCP pancreatitis. Pezhman Alavi Nejad wants to evaluate efficacy of N-acetyl Cysteine for the Prevention of Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis. He assigned a prospective double blind randomized study. There were significant reduce in the prevalence of acute pancreatitis between the groups. This study shows that NAC could be used for the prevention of post-ERCP pancreatitis [15]. 9- Aprepitant Aprepitant is one drug from the classification of neurokinin-1 receptor antagonists. Upendra Shah wants to assess the efficacy of aprepitant at preventing post-ERCP pancreatitis in high risk patients. A randomized, double-blind, placebo controlled trial assigned. Patients received either placebo or oral aprepitant. Aprepitant could not decrease the incidence of post-ERCP pancreatitis against placebo [16]. pancreatic stents: Abhishek Choudhary assessed a meta-analysis and to determined effect of pancreatic stents for prevention of post-ERCP pancreatitis. This meta-analysis of the RCTs showed that pancreatic stent placement reduces the incidence pancreatitis and hyperamylasemia [17]. Conclusion: Considering the fact that pancreatitis is the most important of the ERCP complications we should pay attention the methods for prevention of post-ERCP pancreatitis. Pancreatic stents are useful for this aim. From the pharmacologic agents, Glyceryl trinitrate, Indometacin and N-acetyl Cysteine could significantly decrease the incidence of post-ERCP pancreatitis. Other drug that assessed in this review article such as Nifedipine, Risperidone, Corticosteroids, and Aprepitant did not show significant effect for prevention of post-ERCP pancreatitis.

Mental Health Act Essay

The main purpose of this act is to allow action to be taken, where necessary, to make sure that people with mental health difficulties or learning difficulties get the care and treatment they need for their own health and safety or for the protection of other people. The Mental Health Act 1983 is the law in most of the united kingdom that allows people with a ‘mental disorder’ to be admitted to hospital, detained and treated without their consent if it is truly needed, and if for their own health and safety or for the protection of other people. The court can also admit people who they believe that could be a danger to themselves and others around them. However the hospital can only keep the person detained for a maximum of six months, but they can decide to discharge the patient but still have on going supervised community treatment. A doctor who is ‘approved’ under section 12 of the Act is approved on behalf of the Secretary of State because they have special expertise knowledge in the diagnosis and treatment of ‘mental disorders’. Doctors who are approved clinicians are automatically also approved under section 12. Section 12 approved doctors have a role in deciding whether someone should be detained in hospital under section 2 and section 3 of the Mental Health Act. An approved clinician is a doctor, a psychologist, a mental health nurse, an occupational therapist or a social worker who has been trained and approved for over at least five years to carry out certain duties under Act. Only approved clinicians can take overall responsibility for the case of someone who has been detained in hospital or put on supervised community treatment – be their ‘responsible clinician’ the legislation states that the nearest relative is someone’s husband, wife or unmarried partner and only of they have been living together for over six months. The person is unmarried or does not have a partner if next of kin will then be there children if they are over 18, however if the child is not over eighteen or there is no child present the next of kin will then be one of their parents. However, a nearest relative should be informed or consulted if mental health professionals are proposing to detain someone for treatment under the Mental Health Act unless it is not practicable to do so, or unless consultation would result in ‘unreasonable delay.’ Medication You may be required to take medication prescribed for you by your doctor if you are on a community treatment order (CTO) under the Mental Health Act. There are rules in place, called consent to treatment, that cover whether you should take it. These rules also ensure that you understand why you need to take the treatment, how it will be given to you and possible side-effects. When you are first given medication for your mental illness, your doctor should: explain what the medication is for. tell you about any side-effects. ask for your consent. What happens next? After one month, if you still give consent to continue taking your medication, your doctor will fill in a certificate to confirm this. However, if you are too unwell to give consent, your doctor must have the agreement of a Second Opinion Appointed Doctor (SOAD) for your treatment to continue. If the SOAD agrees that you should continue with all of your medication, or just some of it, they will fill in a certificate confirming this. Can I change my mind? You can change your mind at any time – even after you have agreed to continue taking your medication. You should talk to your doctor before you make any decisions. What if I do not give my consent? If you refuse your medication while on a community treatment order, your doctor cannot force you to take it. However, if your doctor believes that you may become unwell without taking the treatment, they can recall you back to hospital. Additionally, consent to treatment rules may not apply to you if: Your life is at risk. Your health will deteriorate without the treatment. You are a danger to yourself or others.

Home Hemodialysis - 1457 Words

Qualitative and Quantitative Articles on Home Hemodialysis Elizabeth Hetherington Northeastern University Receiving hemodialysis in the in-patient or outpatient setting is uncomfortable and non-pleasurable. Thankfully, â€Å"the movement of medical care out of institutional settings into patients’ homes has increased in most industrialized countries as part of the general emergence of self- care options in the†¦show more content†¦29). This training helped patients overcome anxiety over needles, use and learn from other patients on NHHD, understand the importance of the patient-clinician relationship, overcoming the mental and physical challenges of learning while ill, and adapting to the individuals techniques. The five themes observed gave light to physicians that technology-related issues involving the machine was a barrier in training, however â€Å"the primary topics volunteered by the participants in the present study were psychosocial in nature† (Halifax, 2009, p. 31). At the end of Visaya’s research she discovered that, â€Å"in terms of the rel ationship between hemodialysis patients’ perceptions, HHD and self-care, 26 out of the 49 participants had positive perceptions regarding HHD† (Visaya, 2010, p. 26). Reflecting on the Patient Perception Survey, â€Å"49 patients found that 46.9% of the patients identified negative perceptions of HHD and 53.1% of the 49 patients identified positive perceptions of HHD† (Visaya, 2010, p. 26). The JPAT identified only 8 of the 49 participants suitable for HHD. Visaya also determined that, â€Å"when a patient scored high on the Patient Perception Survey, meaning he or she has negative perceptions regarding HHD, the patient as well had low levels of social support and communication† (Visaya, 2010, p. 26). â€Å"The associations between a hemodialysis patient’s perception regarding HHD and all other subscalesShow MoreRelatedMs. Conlon Applies The Nursing Process System Or Processes At The Unit / Team / Work Group Level846 Words   |  4 PagesMs. Co nlon applies the nursing process to systems or processes at the unit/team/work group level to improve care. Deirdre has been the primary nurse for 6 hemodialysis patients. She has involved patients and families in monthly interdisciplinary meetings to promote self-efficacy and quality of life. With the help of the interdisciplinary team Deirdre has worked collaboratively to address and reinforce nutritional needs, social/family issues, barriers to care, and safety concerns. 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A Case Study on Clinical Pastoral Education Essay

CLINICAL PASTORAL EDUCATION A CASE STUDY OF â€Å"AMBER BILL† A PATIENT AT ST. PAUL’S HOSPITAL IN SASKATOON BY PATRICK AMPANI CASE STUDY ROAD MAP A. INTRODUCTION AND THEOLOGY OF MINISTRY B. PATIENT’S BACKGROUND INFORMATION C. FIRST ENCOUNTER (VERBATIM) D. PRELIMINARY REFLECTION a. my initial reaction b. main issues c. my plan of action d. psychological theory at work e. spiritual assessment f. theological reflection E. SECOND ENCOUNTER (followed by preliminary reflection including session a-f) F. THIRD ENCOUNTER (followed by preliminary reflection including session a-f) G. CONCLUSION A. INTRODUCTION AND THEOLOGY OF MINISTRY: St. Paul’s Hospital is an acute health care facility†¦show more content†¦Jim was never there for the mother due to the long existing tensions between him and the family. This was a thing of concern for the patient in her dying bed. The patient was anxious about the tensions in the family, on how to deal with it and resolve it, as well, she was anxious about dying. 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