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M. Diego, M.A., Ph.D.

Program Director, Idaho College of Osteopathic Medicine

This has included focusing attention on removing sharps hazards through the development and use of engineering controls. Exposure of mucous membranes of the eyes, nose and mouth to blood and body fluids has been associated with the transmission of bloodborne viruses and other infectious agents to healthcare personnel66, 752, 754, 779. These include keeping gloved and ungloved hands that are contaminated from touching the mouth, nose, eyes, or face; and positioning patients to direct sprays and splatter away from the face of the caregiver. The performance of procedures that can generate small particle aerosols (aerosol-generating procedures), such as bronchoscopy, endotracheal intubation, and open suctioning of the respiratory tract, have been associated with transmission of infectious agents to healthcare Last update: July 2019 Page 57 of 206 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) personnel, including M. Protection of the eyes, nose and mouth, in addition to gown and gloves, is recommended during performance of these procedures in accordance with Standard Precautions. Use of a particulate respirator is recommended during aerosol-generating procedures when the aerosol is likely to contain M. Options for patient placement include single patient rooms, two patient rooms, and multi-bed wards. Of these, single patient rooms are prefered when there is a concern about transmission of an infectious agent. However, most hospitals and long-term care facilities have multi-bed rooms and must consider many competing priorities when determining the appropriate room placement for patients. In the absence of obvious infectious diseases that require specified airborne infection isolation rooms. When there are only a limited number of single-patient rooms, it is prudent to prioritize them for those patients who have conditions that facilitate transmission of infectious material to other patients. Single-patient rooms are always indicated for patients placed on Airborne Precautions and in a Protective Environment and are preferred for patients who require Contact or Droplet Precautions23, 24, 410, 435, 796, 797. During a suspected or proven outbreak caused by a pathogen whose reservoir is the gastrointestinal tract, use of single patient rooms with private bathrooms limits opportunities for transmission, especially when the colonized or infected patient has poor personal hygiene habits, fecal incontinence, or cannot be expected to assist in maintaining procedures that prevent transmission of microorganisms. In the absence of continued transmission, it is not necessary to provide a private bathroom for patients colonized or infected with enteric pathogens as long as personal hygiene practices and Standard Precautions, especially hand hygiene and appropriate environmental cleaning, are maintained. Assignment of a dedicated Last update: July 2019 Page 58 of 206 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) commode to a patient,and cleaning and disinfecting fixtures and equipment that may have fecal contamination. Results of several studies to determine the benefit of a single-patient room to prevent transmission of Clostridium difficile are inconclusive 167, 800-802. Some studies have shown that being in the same room with a colonized or infected patient is not necessarily a risk factor for transmission791, 803-805. However, for children, the risk of healthcare-associated diarrhea is increased with the increased number of patients per room806. Thus, patient factors are important determinants of infection transmission risks, and the need for a single-patient room and/or private bathroom for any patient is best determined on a case-by-case basis. Cohorting is the practice of grouping together patients who are colonized or infected with the same organism to confine their care to one area and prevent contact with other patients. Cohorts are created based on clinical diagnosis, microbiologic confirmation when available, epidemiology, and mode of transmission of the infectious agent. It is generally preferred not to place severely immunosuppressed patients in rooms with other patients. Modeling studies provide additional support for cohorting patients to control outbreaks Talon817-819. However, cohorting often is implemented only after routine infection control measures have failed to control an outbreak. Assigning or cohorting healthcare personnel to care only for patients infected or colonized with a single target pathogen limits further transmission of the target pathogen to uninfected patients740, 819 but is difficult to achieve in the face of current staffing shortages in hospitals583 and residential healthcare sites820-822. However, when continued transmission is occurring after implementing routine infection control measures and creating patient cohorts, cohorting of healthcare personnel may be beneficial. However, when available, single patient rooms are always preferred since a common clinical presentation. Furthermore, the inability of infants and children to contain body fluids, and the Last update: July 2019 Page 59 of 206 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) close physical contact that occurs during their care, increases infection transmission risks for patients and personnel in this setting24, 795. Patients actively infected with or incubating transmissible infectious diseases are seen frequently in ambulatory settings. Signs can be posted at the entrance to facilities or at the reception or registration desk requesting that the patient or individuals accompanying the patient promptly inform the receptionist if there are symptoms of a respiratory infection.

Characterized by lymphocytic and plasma cell infiltration of affected exocrine glands throughout the body. Keratoconjunctivitis sicca: Burning, itching eyes; diminished lacrimation; thickened/sticky tears; photophobia. Interstitial lung disease, lymphocytic interstitial pneumonitis, tracheobronchitis sicca. Other: Ancillary testing can demonstrate tear production, low salivary flow, and sicca. Ankylosing Spondylitis the four seronegative spondyloarthropathies are grouped because: Shows a predominance of males over females; characterized by an early age of onset (generally < 35 years). Inflammatory low back pain that worsens in the morning and with inactivity but improves with exercise. Imaging: Look for radiographic evidence of sacroiliitis and/or spinal involvement (see Figure 17. Aortitis and aortic regurgitation (more rarely, cardiac conduction system involvement). Pseudoarthroses can occur when a fused spine is severed in a traumatic accident, which can cause spinal cord compromise. Pseudorheumatoid Oligoarticular Arthritis mutilans Spondylitis Symmetric, smaller-joint polyarthritis. Reactive Arthritis Males (particularly young men) are affected more often than females. Conjunctivitis, urethritis, and mucocutaneous ulcerations are seen, as is keratoderma blennorrhagicum (pustular eruptions on the soles of the feet). Hyperuricemia Hyperuricemia the risk of gout, but most patients with hyperuricemia will not get gout. Gout Usually associated with abnormal uric acid metabolism and hyperuricemia; can be associated with uric acid stones and urate nephropathy (renal toxicity). Additional features are as follows: Tophi: Deposits of uric acid crystals in joints, bone, tendon, cartilage, and subcutaneous tissues. Classically exhibits a monoarticular presentation, but can be oligoarticular or polyarticular in long-standing disease. Look for the presence of tophi on the external ears, elbows, hands, and feet (see Figure 17. Radiographs of chronic tophi show "rat-bite" erosions adjacent to affected joints (see Figure 17. Hypersensitivity syndrome may also be seen (in renal disease and elevated serum metabolite levels). Precipitates urate nephropathy and nephrolithiasis if used in tophaceous gout or in patients with a history of urate calculi. Many patients will experience few if any future attacks and choose no further uric acid therapy. Usual dose is 300 mg/day; lower initial starting dose if patient has creatinine clearance. Acute pseudogout is marked by inflammation in one or more joints that lasts for several days to two weeks. Differentiation from gout or infection may be difficult and requires arthrocentesis. Synovial fluid aspiration reveals the following: An inflammatory fluid profile in acute attacks. Chondrocalcinosis An accelerated degenerative joint disease characterized by osteoarthritis of unusual joints. Aggressive disease or unusual age at presentation should prompt evaluation and treatment of an underlying metabolic disorder. Polymyositis A systemic inflammatory disorder that specifically targets the proximal musculature.

Remove your finger and count how many seconds it takes before the capillaries refill and the blanching resolves. Fever contributes to dehydration through increased insensible loss through the skin, sweating, and increases respiratory rates leading to additional fluid loss. In general, no labs are needed unless the patient is assessed to be moderately-to-severely dehydrated. How does your approach to rehydration of a patient with hypernatremia, Na >150 meq/L differ from your approach to the patient with normal sodium The higher sugar concentrations in these fluids may exacerbate diarrhea by presenting a large osmotic load to the intestine. Strong evidence suggests that both the volume and duration of diarrhea are reduced when children are fed immediately following rehydration. In the moderate to severely dehydrated child, a metabolic acidosis is frequently seen. In general, there is no need to alter fluid management in the presence of a metabolic acidosis secondary to dehydration. Diagnosis and Treatment Treatment options depend upon degree of dehydration and presence of any underlying conditions that may exacerbate the illness. Oral rehydration therapy First choice for the conscious child who has mild or moderate dehydration Fluid absorption can be promoted by enteral administration of properly designed fluids, even in the face of ongoing losses. Parenteral Therapy for Dehydration: For patients who have severe dehydration (shock) fluids are administered intravenously or intraosseously when access difficult. Take note that parenteral solutions used for bolusing patients generally do not contain dextrose unless glucose testing has demonstrated that the patient is hypoglycemic. Enteral fluid therapy may begin immediately if the patient is conscious airway protective reflexes are intact fluids are given either by mouth or nasogastric tube. P a g e 146 Fluids and Electrolyte Management, Case #4 Written by Lavjay Butani, M. Definitions for Specific Terms: Total Body Fluid Requirements- the sum of maintenance + deficit + ongoing fluid losses. Maintenance Intravenous Fluids- the quantities of water and electrolytes that must be consumed to replace the amount of water and electrolytes lost each day that occur as a result of normal daily metabolic activities, without requiring any renal compensation. Ongoing Fluid Losses- Sensible and insensible fluid losses Sensible Fluid Losses- Measurable forms of fluid loss such as urinary losses and stool losses in the absence of diarrhea Insensible Fluid Losses- Less readily measurable forms of fluid loss such as losses from the skin and the respiratory tract Replacement Fluid Losses- Term used to denote deficit fluids and/or ongoing losses if they are significant or excessive. The degree of dehydration can be estimated if a recent previous weight of the child when well is known. Children with moderate to severe dehydration are at risk of evolving into hypovolemic shock and so their vital signs and sensorium need to be evaluated. P a g e 147 What have the parents been giving the child at home for rehydration Infants are especially vulnerable to develop severe electrolyte abnormalities such as hypo or hypernatremia if improper oral rehydration solutions are used (such as water or inappropriately mixed homemade oral rehydration solutions) Clinical Reasoning 1. What might be some of the common causes of moderate to severe dehydration in a child of this age Acute blood loss from any source, including head injury (accidental or non-accidental trauma) g. Excess loss of fluid in sweat (as in children with cystic fibrosis during the summer months) 2. Children with mild to moderate dehydration can be safely and effectively managed with oral rehydration if their vital signs remain stable, they tolerate oral fluids and their sensorium is normal. Alternatively other routes of rehydration, including nasogastric and intravenous, can be employed, either exclusively or in combination with oral rehydration. For infants with moderate to severe dehydration, it is important to obtain a blood glucose (finger stick) and electrolytes to evaluate their renal function and for detection of electrolyte abnormalities such as acidosis and dysnatremias. Initial fluid management: Replete effective circulating volume with isotonic saline since a sodium containing solution will stay in the Intravascular extracellular compartment in the most effective manner (since sodium is the predominant cation in the extracellular compartment).