Grading and Staging in Gastroenterology by Guido N. J. Tytgat and Stefaan H.A.J. Tytgat


955b28b77c06f7a-261x361.jpg Author Guido N. J. Tytgat and Stefaan H.A.J. Tytgat
Isbn 9783131426918
File size 8.3MB
Year 2008
Pages 392
Language English
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Category medicine


 

I II III Grading and Staging in Gastroenterology Guido N.J. Tytgat, MD, PhD, FRCP Professor Emeritus in Gastroenterology University of Amsterdam Academic Medical Center Amsterdam The Netherlands Stefaan H.A.J. Tytgat, MD Pediatric Surgeon University of Utrecht University Medical Center Utrecht The Netherlands 220 illustrations Thieme Stuttgart · New York IV Library of Congress Cataloging-in-Publication Data Tytgat, G. N. J. Grading and staging in gastroenterology/Guido N.J. Tytgat, Stefaan H.A.J. Tytgat. p. ; cm. Includes bibliographical references. ISBN 978-3-13-142691-8 (alk. paper) 1. Gastrointestinal system–Diseases–Classification. I. Tytgat, Stefaan H.A.J. II. Title. [DNLM: 1. Gastrointestinal Diseases–pathology. 2. Disease Progression. 3. Neoplasm Staging. 4. Quality of Life. WI 140 T995g 2009] RC802.T98 2009 616.3–dc22 2008035101 © 2009 Georg Thieme Verlag, Rüdigerstrasse 14, 70469 Stuttgart, Germany http://www.thieme.de Thieme New York, 333 Seventh Avenue, New York, NY 10001, USA http://www.thieme.com Cover design: Thieme Publishing Group Typesetting by primustype Hurler GmbH, Notzingen Printed in Germany by APPL aprinta druck, Wemding ISBN 978-3-13-142691-8 1 2 3 4 5 6 Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book. 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V Introduction Staging and grading is indispensable when analyzing disease severity, therapeutic outcomes, or quality of life in a systematic reproducible fashion. Staging systems mainly focus on the development of a given disease over time. Staging usually includes a dimension of severity and should ideally correspond to therapeutic measures required. Grading systems systematize the information often obtained by assigning numerical values to certain conditions. The numbers generated usually correspond to (sub-)categories in a ranking system, whereby the dimensions of the categories and the intervals separating them are often unequal or even poorly defined. A most important purpose of a staging and grading system is to provide a structure for communication among clinicians and investigators. It provides a framework upon which all those interested can begin to communicate observations and interpretations concerning pathophysiology and mechanisms of disease, disease expression, and response to therapeutic interventions. Accurate staging and grading is of vital importance in any discipline for adequate diagnosis, differentiation of disease, patient care, and appropriate therapy. This also applies to gastroenterology-hepatology. Currently there is no synopsis of the most relevant staging and grading systems used in our discipline. The authors of this compendium feel that this absence signifies an important unmet need, especially for fellows in training, for the interested clinician in practice, and for the clinician in academia with interest in teaching and education. This compendium is the first attempt to provide a comprehensive summary of relevant staging and grading systems in gastroenterology. After exhaustive screening of the literature, relevant staging and grading systems were identified and collated into three major domains: generic staging/grading systems, more organ-/ disease-specific systems, and disease-related quality of life instruments. Where appropriate, explanatory comments were added to the grading systems, but our comments are as reserved and objective as possible to enable users to judge for themselves. Illustrations such as sketches, high-quality line drawings, and endoscopy or histology photographs were added to clarify or illustrate certain features. Special care was taken to provide the exact literature references from which the staging/ grading systems were extracted. A uniform, concise way of presentation was attempted throughout the book. It would have been impossible to give in-depth coverage of all possible staging and grading systems ever used within the gastroenterology literature. Therefore some instruments are only mentioned by title or commented upon briefly, but always adequately referenced for reasons of completeness. The interested reader is guided to the full text via the reference list. The authors do realize that omissions are inevitable in a dynamic field such as gastroenterology with new instruments regularly forthcoming. The large amount of material involved and the constant development of new instruments make it impossible to achieve anything like an exhaustive presentation. The book can be used in different ways, but it is primarily a work of references, available at hands reach. The subject index should provide easy access to a given instrument. Occasionally working through individual chapters to obtain an overview, and then comparing the different instruments, may also be a helpful method. The authors hope that this synopsis will fill a vacuum in our discipline. Although primarily aimed at fellows in training and professionals in gastroenterology, including gastrointestinal surgeons, pediatricians, and basic researchers, this atlas should also be available for nursing practitioners, research nurses, and representatives of the dedicated biomedical industry. May this mini encyclopedia ultimately enhance interest in gastroenterology-hepatology and transmit a better understanding of disease severity, further optimizing therapeutic strategies for the benefit of the patients we care for. Guido N.J. Tytgat Stefaan H.A.J. Tytgat VI VII Table of Contents Chapter 1 Instruments for Overall Patient and Disease Assessment Performance Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mental Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nutritional Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hydration Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Grading of Severity of Disease—Organ Failure . . . . . . . . . . Comorbid Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Functional Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vascular/Bleeding Disorders . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 2 Infectious Disorders: Prophylaxis . . . . . . . . . . . . . . . . . . . . . Caustic Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Neoplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chemotoxicity: Drug Toxicity . . . . . . . . . . . . . . . . . . . . . . . . Treatment Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Level of Evidence: Study Quality . . . . . . . . . . . . . . . . . . . . . . Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 54 57 68 73 76 79 83 83 84 85 88 88 98 100 107 108 113 120 120 125 127 130 146 160 160 163 167 170 170 181 186 Vascular Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inflammatory Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . Neoplastic Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomy, Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hepatitis, Cirrhosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hepatic Failure, Liver Transplantation . . . . . . . . . . . . . . . . Hepatic Encephalopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . Neoplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Biliary System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomy, Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gallstone Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ERCP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cholangitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Neoplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomy, Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Neoplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Spleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Splenic Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Peritoneal Cavity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 192 230 240 240 244 246 264 266 269 274 274 275 282 284 287 290 296 296 298 307 311 311 312 317 318 319 319 320 340 340 340 (B) Disease-Specific QoL Instrument . . . . . . . . . . . . . . . . . . 344 QoL in Obesity and Postobesity Surgery . . . . . . . . . . . . . . 354 Other Health-Related Quality of Life Instruments Used in Patients with Chronic Liver Disease by Title . . . . . . . . . 364 Organ-Related Staging and Grading Oropharynx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomical Variants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inflammation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Neoplastic Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomical Variants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vascular Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Infectious Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inflammatory Disorders: GERD . . . . . . . . . . . . . . . . . . . . . . Neoplastic Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stomach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomical Variants, Injury . . . . . . . . . . . . . . . . . . . . . . . . . Vascular Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inflammatory Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . Neoplastic Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Small Intestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomical Variants, Injury . . . . . . . . . . . . . . . . . . . . . . . . . Inflammatory Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . Neoplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Colon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Functional Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomical Variants, Injury . . . . . . . . . . . . . . . . . . . . . . . . . Chapter 3 3 6 10 13 16 35 39 43 Assessment of Quality of Life (QoL) Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aspects of Validity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Aspects of Reliability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (A) Global Generic QoL Assessments . . . . . . . . . . . . . . . . . . Sleep Disorder Assessment . . . . . . . . . . . . . . . . . . . . . . . . . Disability, Assessment of Quality of Life by Title . . . . . . . . Illness in the Aged . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369 VIII 1 Chapter 1 Instruments for Overall Patient and Disease Assessment Performance Status . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Mental Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nutritional Status . . . . . . . . . . . . . . . . . . . . . . . . . . . Hydration Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . Grading of Severity of Disease—Organ Failure . . . . Comorbid Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 10 13 16 35 Functional Disorders . . . . . . . . . . . . . . . . . . . . . . . . . Vascular/Bleeding Disorders . . . . . . . . . . . . . . . . . . 39 43 Infectious Disorders: Prophylaxis . . . . . . . . . . . . . . Caustic Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 54 Neoplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chemotoxicity: Drug Toxicity . . . . . . . . . . . . . . . . . Treatment Evaluation . . . . . . . . . . . . . . . . . . . . . . . . 57 68 73 Level of Evidence: Study Quality . . . . . . . . . . . . . . . Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 79 2 Performance Status Performance Status Performance Status: Karnofsky Scale Aims Performance Status: World Health Organization (WHO) Performance Classification To quantify physical performance status. Aims Karnofsky scale To quantify physical performance. Score Description of performance WHO classification 100 Normal, no complaints Score Description of performance Able to carry on activities; minor signs or symptoms of disease WHO 0 Normal activity WHO 1 Symptomatic, but nearly fully ambulatory (restricted in physical strenuous activity, but ambulatory and able to do light work) 90 80 Normal activity with effort 70 Cares for self. Unable to carry on normal activity or to do active work WHO 2 60 Ambulatory. Requires some assistance in activities of daily living and self-care Some time in bed, but needs to be in bed less than 50 % of normal daytime (capable of self-care, but not work) WHO 3 Requires considerable assistance and frequent medical care Confined to bed more than 50 % of normal daytime (capable of limited self-care) WHO 4 Unable to get out of bed (incapable of any self-care) 40 Disabled; requires special care and assistance WHO 5 Dead 30 Severely disabled; hospitalization indicated though death not imminent 20 Very sick; hospitalization and active supportive treatment 10 Moribund 50 0 Dead Comments Most commonly used scale for grading physical performance in oncology. References Karnofsky DA, Burchenal JH. The clinical evaluation of chemotherapeutic agents in cancer. In: Macleod CM, ed. Evaluation of Chemotherapeutic Agents. New York: Colombia Press; 1949:199–205. 3 4 1 Instruments for Overall Patient and Disease Assessment Eastern Cooperative Cancer Chemotherapie Group (ECOG) Performance Status Performance Status: The ASA Classification of Anesthesia Risk Aims Aims To give an overall assessment of patient status for ECOG studies. To divide patients into anaesthesia risk classes. The ASA system is a measure of the overall sickness of patients receiving surgery and anesthesia. ECOG performance status The American Society of Anesthesia (ASA) classification Grade 0 Fully active, able to carry on all predisease performance without restriction 1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light housework, office work 2 Ambulatory and capable of all self-care, confined to bed or chair more than 50 % of waking hours 3 Capable of only limited self-care, confined to bed or chair more than 50 % of waking hours 4 Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair 5 Dead Healthy patient Class II Mild systemic disease, no functional limitation, no acute problems, e.g. controlled hypertension, mild diabetes, chronic bronchitis, asthma Class III Severe systemic disease, definite functional limitation, e.g. brittle diabetic, frequent angina, myocardial infarction Class VI Severe systemic disease with acute, unstable symptoms, e.g. recent (3 months) myocardial infarction, congestive heart failure, acute renal failure, ketoacidosis, uncontrolled, active asthma Class V Severe systemic disease with imminent risk of death From Keats AS. The ASA classification of physical status—a recapitulation. Anesthesiology. 1978;49:233–236. With permission of Lippincott Williams & Wilkins (LWW). Comments The classification was proposed by the Eastern Cooperative Cancer Chemotherapy Group in a critical examination of the methodology of clinical cancer chemotherapy trials. In essence, this grading is similar to the WHO classification. The grading relates to the Karnofsky scale as follows: ECOG grade Karnofsky 0 100–90 1 80–70 2 60–50 3 40–30 4 20–10 5 Class I Many further explanations and variations have been published regarding the definition of the ASA status. As illustrated in the following table: The American Society of Anesthesiologists classification of physical status Class I The patient has no organic, physiologic, biochemical, or psychiatric disturbance. The pathologic process for which surgery is to be performed is localized and does not entail a systemic disturbance. Examples: a fit patient with an inguinal hernia, a fibroid uterus in an otherwise healthy woman. Class II Mild to moderate systemic disturbance caused either by the condition to be treated surgically or by other pathophysiologic processes. Examples: non- or only slightly limiting organic heart disease, mild diabetes, essential hypertension, or anemia. The extremes of age may be included here, even though no discernible systemic disease is present. Extreme obesity and chronic bronchitis may be included in this category. Class III Severe systemic disturbance or disease from whatever cause, even though it may not be possible to define the degree of disability with finality. Examples: severely limiting organic heart disease, severe diabetes with vascular complications, moderate to severe degrees of pulmonary insufficiency, angina pectoris, or healed myocardial infarction. Class IV Severe systemic disorders that are already life threatening, not always correctable by operation. Examples: patients with organic heart disease showing marked signs of cardiac insufficiency, persistent angina, or active myocarditis, advanced degrees of pulmonary, hepatic, renal, or endocrine insufficiency. Class V The moribund patient who has little chance of survival but is submitted to operation in desperation. Examples: the burst abdominal aneurysm with profound shock, major cerebral trauma with rapidly increasing intra-cranial pressure, massive pulmonary embolus. Most of these patients require operation as a resuscitative measure with little if any anesthesia. 0 From Oken M, Greech RH, Tormey DC et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982;5:649–655. With permission of Lippincott Williams & Wilkins (LWW). References Oken M, Greech RH, Tormey DC et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982;5:649–655. Zubrod CG, Schneiderman M, Frei E et al. Appraisal of methods for the study of chemotherapy of cancer in man: comparative therapeutic trial of nitrogen mustard and triethylene thiophosphoramide. J Chron Dis. 1960;11:7–33. Performance Status ASA physical status classification system Class Description Comments Commonly used classification to assess anesthesia risk. A variation, available on the website http://www.asahq. org/clinical/physicalstatus.htm distinguishes seven classes. P1 A normal healthy patient P2 A patient with mild systemic disease References P3 A patient with severe systemic disease P4 A patient with severe systemic disease that is a constant threat to life P5 A moribund patient who is not expected to survive without the operation P6 A declared brain-dead patient whose organs are being removed for donor purposes Cohen MM, Duncan PG, Tate R. Does anesthesia contribute to operative mortality. JAMA. 1988;41:83. Dripps RD, Lamont A, Eckenhoff JE. The role of anesthesia in surgical mortality. JAMA. 1961;178:261–266. Keats AS. The ASA classification of physical status—a recapitulation. Anesthesiology. 1978;49:233–236. Owens WD, Felts JA, Spitznagel EL Jr. ASA physical status classifications: a study of consistency of ratings. Anesthesiology. 1978;49:239–243. From Dripps RD, Lamont A, Eckenhoff JE. The role of anesthesia in surgical mortality. JAMA. 1961;178:261–266. With permission from Copyright © American Medical Association. All rights reserved. 5 6 1 Instruments for Overall Patient and Disease Assessment Mental Status Mental Status: The Glasgow Coma Scale (GCS)—Level of Consciousness Aims The aim here was to design a scoring system for consciousness which is simple, clearly defined, and reliable. The Glasgow coma scale Score Eyes open (E-score) 4 3 2 1 = = = = Spontaneously To sound To pain Never Best verbal response (V-score) 5 4 3 2 1 = = = = = Oriented Confused conversation Inappropriate words Incomprehensible sounds None Best motor response (M-score) 6 5 4 3 2 1 = = = = = = Obeys commands Localize pain Flexion (withdrawal) Flexion (abnormal) Extension None Subtotal Total: Fig. 1.1 Pain stimulus above the eye. Fig. 1.2 Pain stimulus on the finger. From: Teasdale G, Jeanett B. Assessment of coma and impaired consciousness: a practical scale. Lancet. 1974;2:81–84. With permission of Elsevier. Comments In case the patient is intubated, the best verbal response cannot be scored. Instead of a number it should be scored as “tube,” i. e. Vt. References Teasdale G, Jeanett B. Assessment of coma and impaired consciousness: a practical scale. Lancet. 1974;2:81–84. Teasdale G, Jennett B. Assessment and prognosis of coma after head injury. Acta Neurochir. 1976;34:45–55. Mental Status 1 No reaction Fig. 1.3 2 Extension 3 Flexion (abnormal) 4 Withdrawal 5 Localize pain 6 Obeys commands Motor response, according to M-score. Comments Mental Status: Depth of Sedation References Aims To grade the level of sedation, particularly after i.v. administration of benzodiazepines. Scoring of sedation Score 1 Scoring system, commonly used in endoscopy. Awake 2 Awake, not anxious 3 Eyes open, speech slurred 4 Eyes closed, responds to verbal commands 5 Eyes closed, responds to mild physical stimulation 6 No response to mild physical stimulation From Ng JM, Kong CF, Nyam D. Patient-controlled sedation with propofol for colonoscopy. Gastrointest Endosc. 2001;54:8–13. With permission from the American Society of Gastrointestinal Endoscopy. Ng JM, Kong CF, Nyam D. Patient-controlled sedation with propofol for colonoscopy. Gastrointest Endosc. 2001;54: 8–13. 7 8 1 Instruments for Overall Patient and Disease Assessment Mental Status: Depth of Sedation: Definition of General Anesthesia and Level of SedationAnalgesia by the American Society of Anesthesiologists Aims To define levels of sedation-analgesia. Definition of general anesthesia and level of sedation-analgesia Minimal sedation (anxiolysis) Moderate sedation/analgesia (conscious sedation) Deep sedation/analgesia General anesthesia Responsiveness Normal response to verbal stimulation Purposeful* response to verbal or tactile stimulation Purposeful* response after untreated or painful stimulation Unrousable, even with painful stimulus Airway Unaffected No intervention required Intervention may be required Intervention often required Spontaneous ventilation Unaffected Adequate May be required Frequently inadequate Cardiovascular function Unaffected Usually maintained Usually maintained May be impaired From American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002;96:1004–1017. With permission of Lippincott Williams & Wilkins (LWW). Minimal sedation (anxiolysis). A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected. Moderate sedation/analgesia (conscious sedation). A drug-induced depression of consciousness during which patients respond purposefully* to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Deep sedation/analgesia. A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully* following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. General anesthesia. A drug-induced loss of consciousness during which patients are not rousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in * Reflex withdrawal from a painful stimulus is not considered a purposeful response. maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended. Individuals administering moderate sedation/analgesia (conscious sedation) should be able to rescue patients who enter a state of deep sedation/analgesia, while those administering deep sedation/analgesia should be able to rescue patients who enter a state of general anesthesia. Comments The definitions are given as part of a guideline for sedation and analgesia by nonanesthesiologists. References American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002;96:1004–1017. Mental Status Mental Status: The Level of Cooperation Mental Status: Neurophysiologic Function Analysis Aims To define the level of cooperation. Two scoring systems are shown below. Scoring of patient cooperation Score 1 No cooperation; procedure abandoned 2 Minimal cooperation; continuous movement requiring continuous physical restraint 3 Minimal cooperation; intermittent movement requiring intermittent restraint 4 Good cooperation with occasional movement requiring no restraint 5 Full cooperation From Murdoch JA, Kenny GN. Patient-maintained propofol sedation as premedication in day-case surgery: assessment of a target controlled system. Br J Anaesth. 1999;82:429–431. With permission granted by Oxford University Press/British Journal of Anaesthesia on behalf of © The Board of Management and Trustees of the British Journal of Anasthesia. Comments This represents a useful grading of the level of cooperation in patients with propofol sedation. References Dell RG, Cloote AH. Patient-controlled sedation during transvaginal oocyte retrieval: an assessment of patient acceptance of patient-controlled sedation using a mixture of propofol and alfentanil. Eur J Anaesthesiol. 1998;15:210–215. Murdoch JA, Kenny GN. Patient-maintained propofol sedation as premedication in day-case surgery: assessment of a target controlled system. Br J Anaesth. 1999;82:429–431. Mental Status: Observer Assessment of Alertness/Sedation Scale (OAA/S) Responsiveness Eyes Score Responds readily to name Clear, no ptosis 5 Lethargic response to name Glazed or mild ptosis (쏝 1/2 eye) 4 Responds only when called loudly/repeatedly Marked ptosis (쏜 1/2 eye) 3 Responds after mild prodding/ shaking 2 Unresponsive to mild prodding/shaking 1 From Chernik DA, Gillings D, Laine H et al. Validity and reliability of the Observer’s Assessment of Alertness/Sedation Scale: study with intravenous midazolam. J Clin Psychopharmacol. 1990;10:244–251. With permission of Lippincott Williams & Wilkins (LWW). Comments This score ranges from 5–1; 5 represents awake/alert and 1 represents deeply sedated. References Chernik DA, Gillings D, Laine H et al. Validity and reliability of the Observer’s Assessment of Alertness/Sedation Scale: study with intravenous midazolam. J Clin Psychopharmacol. 1990;10:244–251. Further neuropsychological function tests are described below. The Hopkins Verbal Learning Test-Revised (HVLT-R) assesses verbal learning and memory. In this test, patients listen to a list of 12 words, recalling as much as they can remember after each of three readings. After a 20-minute delay, subjects again recall as much as they can remember, and next perform an auditory recognition task by responding “yes” to words they had been asked to learn, and “no” to distractors (Discrimination score = True-Positive endorsements–False-Positive endorsements). This and similar measures of anterograde memory are particularly sensitive to disruption of the brain’s hippocampus and cholinergic basal forebrain, which benzodiazepines disrupt. The Trail Making Tests (Parts A and B) test visuomotor (psychomotor) scanning speed and mental flexibility. In part A, subjects connect randomly arranged targets on a page in their numerical order as fast as possible. Part B introduces a component of mental flexibility because the circles have both numbers and letters. Subjects must then alternate their connections between numbers and letters. Both parts A and B are sensitive to frontal lobe and subcortical dysfunction. The Digit Symbol task also measures psychomotor speed and is sensitive to generalized cerebral dysfunction. This test requires subjects to quickly transcribe digits to symbols from a key immediately within view. The Digit Span task assesses working memory and attention span by asking subjects to recall digit strings of increasing length immediately after hearing them. The second part of this test requires subjects to recite the digits in the reverse order they were given. The Stroop Color Word Test (Part C) reflects divided attention and inhibition of conditioned reflex by requiring patients to quickly identify the ink color (red, green, and blue) in which color names (red, green, and blue) are printed. However, the names are always printed in a color different in meaning from the word (e.g., red printed in green letters). Rapid and successful performance requires selective attention to the color, and suppression of the automatic reflex to read the word (see references below). From Sipe BW, Rex DK, Latinovich D et al. Propofol versus midazolam/meperidine for outpatient colonoscopy: administration by nurses supervised by endoscopists. Gastrointest Endosc. 2002;55: 815–825. With permission from the American Society for Gastrointestinal Endoscopy. References Golden CJ. Stroop Color and Word Test. Chicago: Stoelting; 1978. Psychological Corporation. WAIS-III WMS-III: technical manual. San Antonio: The Psychological Corporation; 1997. Reitan RM. Trail Making Test. Tucson (AZ): Reitan Neuropsychological Laboratory; 1992. Shapiro AM, Benedict RH, Schretlen D, Brandt J. Construct and concurrent validity of the Hopkins verbal learning testrevised. Clin Neuropsychol. 1999;13:348–358. Sipe BW, Rex DK, Latinovich D et al. Propofol versus midazolam/meperidine for outpatient colonoscopy: administration by nurses supervised by endoscopists. Gastrointest Endosc. 2002;55:815–825. 9 10 1 Instruments for Overall Patient and Disease Assessment Nutritional Status Nutritional Status: The Body Mass Index Aims To use a simple index to classify underweight, overweight, and obesity in adults. The Body Mass Index (BMI) BMI = weight (kg)/height2 (m) Each element scores 1 point if present. A score greater than 3 points predicts a high risk of malnutrition. Comments This score was specially developed for the evaluation of malnourishment in geriatric patients. As no physical examination is included, nonmedical health professionals can use it. References Classification BMI Risk of comorbidities Underweight 쏝 18.50 Low (but risk of other clinical problems increased) Normal range 18.50–24.99 Average Overweight Preobese Obese class I Obese class II Obese class III 욷 25.00 25.00–29.99 30.00–34.99 35.00–39.99 욷 40.00 Increased Moderate Severe Very severe Morley JE. Death by starvation. A modern American problem? J Am Geriatr Soc. 1989;37:184–185. Omran ML, Morley JE. Assessment of protein energy malnutrition in older persons, part I: History, examination body composition and screening tools. Nutrition. 2000;16:50–63. Nutritional Status: Nutritional Index According to Buzby Aims To provide an objective scale of malnutrition. Comments A person of 70 kg weight and a height of 1.75 m has a body mass index of: 70/1.752 = 22.9 Both extremes of the BMI confer increased risk of mortality. Nutritional index References Score Garrow JS. Obesity and Related Diseases. Edinburgh: Churchill Livingstone; 1988. WHO. Obesity: Preventing and Managing the Global Epidemic. WHO Consultation Report. World Health Organization Technical Report Series. 1997;894:1–15. 쏜 100 No malnutrition 97.5–100 Mild malnutrition 83.5–97.5 Moderate malnutrition 쏝 83.5 Severe malnutrition (1.489 × serum albumin (g/I) + 41.7 × (actual/usual weight), where usual weight = stable weight 6 months before admission Comments Nutritional Status: The Malnutrition Risk Scale Aims To develop a malnutrition risk scale that can be used for outpatient screening. The malnutrition risk scale (SCALES) S Sadness C Cholesterol A Albumin 쏝 40 g/L L Loss of weight E Eating problems (cognitive or physical) S Shopping problems or inability to prepare a meal From Morley JE. Death by starvation. A modern American problem? J Am Geriatr Soc. 1989;37:184–185. With permission of Blackwell Publishing. Objective index of nutritional status, useful for selection of enteral/parenteral nutritional activities. References Buzby GP, Williford WO, Peterson OL et al. A randomised clinical trial of total parenteral nutrition in malnourished surgical patients: the rationale and impact of previous clinical trials and pilot study on protocol design. Am J Clin Nutr. 1988;47:357–365. Nutritional Status Nutritional Status: Maastricht Index of Nutritional Status Table 2: Final screening Impaired nutritional status Severity of disease (앒 increase in requirements) Absent Score 0 Normal nutritional status Absent Score 0 Normal nutritional requirements Mild Score 1 Wt. loss 쏜 5 % in 3 months or food intake below 50–75 % of normal requirement in preceding week Mild Score 1 Hip fracture. Chronic patients, in particular with acute complications: cirrhosis, COPD. Chronic hemodialysis, diabetes, oncology Moderate Score 2 Wt. loss 쏜 5 % in 2 months or BMI 18.5–20.5 + impaired general condition or food intake 25–60 % of normal requirement in preceding week Moderate Score 2 Major abdominal surgery. Stroke, severe pneumonia, hematologic malignancy Severe Score 3 Wt. loss 쏜 5 % in 1 month (쏜 15 % in 3 months) or BMI 쏝 18.5 + impaired general condition or food intake 0–25 % of normal requirement in preceding week Severe Score 3 Head injury. Bone marrow transplantation. Intensive care patients (APACHE 쏜 10) Score: + Score: = Total score Age If age 욷 70 years: add 1 to total score above Aims To provide an objective index of malnutrition. Maastricht Index 20.68 – [0.24 × serum albumin (g/L)] – [19.21 × prealbumin (g/L)] – [1.86 × lymphocyte count (106/L)] – (0.04 × ideal body weight) From De Jong PCM, Wesdorp RI, Volovis A et al. The value of objective measurements to select patients who are malnourished. Clinical Nutrition. 1985;4:61–66. With permission of Elsevier. Comments Malnutrition is diagnosed if the score is greater than 0. References De Jong PCM, Wesdorp RI, Volovis A et al. The value of objective measurements to select patients who are malnourished. Clinical Nutrition. 1985;4:61–66. Nutritional Status: the Subjective Global Assessment (SGA) Comments The SGA is one of the most widely used nutritional indices. It consists of a patient history (recent weight loss, changes in eating habits, gastrointestinal symptoms, physical fitness, and stress factor) and a physical examination (body weight, subcutaneous fat mass, muscle atrophy, edema). The subjective global assessment is easy to calculate and useful in a clinical setting. References Detsky AS, McLaughlin JR, Baker JP et al. What is subjective global assessment of nutritional status? J Parenter Enteral Nutr. 1987;11:8–13. = Age-adjusted total score From Kondrup J, Allison SP, Elia M, Vellas B, Plauth M. Educational and Clinical Practice Committee, European Society of Parenteral and Enteral Nutrition (ESPEN). ESPEN guidelines for nutrition screening 2002. Clin Nutr. 2003;22:415–421. With permission of Elsevier. Comments Nutritional Status: The NRS 2002 With a total score 욷 3: the patient is nutritionally at risk and a nutritional care plan is initiated. With a total score 쏝 3: weekly rescreening of the patient. If the patient, for example, is scheduled for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status. Aims References The European Society of Parenteral and Enteral Nutrition have recently developed the NRS. It includes a patient history (weight loss, reduced dietary intake) physical parameters (body mass index) and a disease severity factor. The index can be calculated quickly. Kondrup J, Allison SP, Elia M, Vellas B, Plauth M. Educational and Clinical Practice Committee, European Society of Parenteral and Enteral Nutrition (ESPEN). ESPEN guidelines for nutrition screening 2002. Clin Nutr. 2003;22:415–421. Table 1: Initial screening Yes 1 Is BMI 쏝 20.5? 2 Has the patient lost weight within the last 3 months? 3 Has the patient had a reduced dietary intake in the last week? 4 Is the patient severely ill? (e.g. in intensive therapy) No Yes: If the answer is “yes” to any question, the screening in Table 2 is performed. No: If the answer is “no” to all questions, the patient is re-screened at weekly intervals. If the patient e.g. is scheduled for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status. 11

Author Guido N. J. Tytgat and Stefaan H.A.J. Tytgat Isbn 9783131426918 File size 8.3MB Year 2008 Pages 392 Language English File format PDF Category Medicine Book Description: FacebookTwitterGoogle+TumblrDiggMySpaceShare Staging and grading are indispensable in reaching an adequate diagnosis, to determine disease severity, to choose an appropriate therapy, and to assure the best patient care and quality of life, but up to now no one source in gastroenterology has existed. Gastroenterologists, gastrointestinal surgeons, and fellows-in-training in gastroenterology will therefore immediately recognize the practical value of Grading and Staging in Gastroenterology – a comprehensive and systematic overview of all the current and most relevant information regarding grading and staging in gastroenterology – now selected and compiled for the first time in a single volume.   Organized into three sections – Instruments for Overall Patient and Disease Assessment ; Organ and Disease-related Staging and Grading Systems, and Quality of Life Patient Assessments – readers have the option of using as an overall reference, to refer to a specific organ or disease, or by virtue of the extensive subject index, to research according to specific instrument or other relevant topics.   The following timesaving and didactic features further enhance the usefulness, and whether you are a clinician or surgeon, responsible for training, involved in research including setting up research trials, or require deeper understanding of evidence-based studies you will find making this compendium a part of your gastroenterology library a smart investment.     Uniform presentation — each of the grading and staging systems is anchored in a strict text structure which includes aims, comments, and exact reference Precise and unobtrusive explanatory notes (comments) — especially useful for nurse practitioners Numerous supplementary, high-quality line drawings, and endoscopic, radiologic and histological images — clarify and elucidate where appropriate Complete and accurate reference of all original sources respective to each instrument — saves valuable research time     Grading and Staging in Gastroenterology is for all gastrointestinal professionals looking for an ideal guide into the myriad of staging and grading systems in gastroenterology.     Download (8.3MB) Anaesthesia, Pain, Intensive Care and Emergency Medicine _ A.P.I.C.E. Antimicrobial Stewardship Mohs and Cutaneous Surgery: Maximizing Aesthetic Outcomes Care Of The Critically Ill Surgical Patient, 3rd Edition Spinal Instrumentation: Surgical Techniques Load more posts

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