Monday, November 4, 2013

UTI's in the Elderly

Treatment of asymptomatic bacteriuria is not appropriate for the following populations: women (premenopausal, nonpregnant), diabetics, the elderly, nursing home residents, or patients with spinal cord injury or indwelling urethral catheters.
 
"Bacteriuria in a population sample of women: 24-year follow-up study. Results from the prospective population-based study of women in Gothenburg, Sweden"
Bengtsson C, Bengtsson U, Björkelund C, Lincoln K, Sigurdsson JA
Scand J Urol Nephrol. 1998;32(4):284.
 
So don't screen these women in the first place, and if you find bacteria, don't treat because it doesn't reduce recurrence, perhaps recurrence with a symptomatic strain. It may also lead to antibiotic resistance.

Haldol for delirium

Delirium is an altered mental status that is transient by nature, acute in onset, and can be caused by etiologies in 12 different categories.
drug intoxication , drug withdrawal, metabolic/endocrine disturbance, TBI, seizures, intracranial infection, systemic infection, intracranial neoplasm, systemic neoplasm, cerebrovascular disease, organ insufficiency, other CNS disorders, other systemic diseases.
 
Because I had a patient with delirium, I read two articles about the pharmacological treatment of it.
 
 
"Efficacy and safety of haloperidol versus atypical antipsychotic medications in the treatment of delirium"
Yoon et all
Found that haldol, risperidone, olanzapine, and quetiapine were equally effictive in improving the symptoms of delirium.
Patients over 75 did not respond as well to olanzapine.
Weaknesses of the study include that there was no placebo, no randomization, high dropout rate.
 
 
"Pharmacovigilance in Hospice/Palliative Care: Net Effect of Haloperidol for Delirium"
Crawford et all
119 participants, all on hospice with significant age or poor physical functional status.
Mean dose of 2.1mg/day
1 in 3 patients experienced benefit at 48hrs after starting haldol.
 
 
 
 

Prevention of Contrast-Induced Nephropathy: An Overview by Ellis and Cohan

Be especially careful in patient with GFR less than 60.
AKI
CKD
 
 
1. reduce dose
2. no clear evidence for low osmolality agents yet, maybe soon
Also consider carbon dioxide for vascular studies
3. pre-hydrate with IV fluids
4. weak evidence for N-acetylcysteine 600mg BID for two days before
5. hemodialsis vs hemofiltration, may work, but only in exceptional circumstances