FW: Requested DocAlert: Simple Surgical Masks or N95 Respirator Masks to Protect Healthcare Workers From Influenza?

N95 Respirators or Surgical Mask for Protection from Influenza?By current knowledge, a surgical mask is sufficient. Save N95 respirators for TB and other aerosol-transmitted diseases.World Health Organization guidelines for protection of healthcare workers from influenza recommend standard droplet precautions — including surgical masks — except during aerosolizing procedures, when N95 respirators should be used. Researchers performed a literature review to determine whether this recommendation is evidence based and identified 21 studies of respiratory protection in healthcare settings and 25 laboratory studies of the devices' filtering efficiency. Clinical studies evaluated transmission of respiratory syncytial virus, Bordetella pertussis, and severe acute respiratory syndrome (SARS). Reviewers rated only one clinical study as high quality.Three studies that evaluated surgical masks reported protection when masks were used in conjunction with hand hygiene, gloves, and gowns; two reported no protection; and one was equivocal. Three studies that evaluated N95 respirators reported protection, and six studies were inconclusive. Four studies that evaluated N95 respirators and surgical masks showed decreased SARS transmission when either device was used consistently, and one study reported no protective effect. One study of combined use of the two devices was inconclusive.Filtering efficiencies ranged from 0% to 99% for surgical masks, as compared with 95.0% to 99.5% for N95 respirators. Although a recent trial comparing surgical masks and N95 respirators (JW Infect Dis Oct 21 2009) showed equal protection with the two devices, the authors of the literature review suggest that based on findings of the laboratory studies, "aerosol transmission of influenza is plausible," and the currently recommended 1-meter respiratory zone should be enlarged.Comment: Despite the article's title, none of the clinical studies examined influenza transmission, and only three directly compared use of N95 respirators and surgical masks. In addition, many confounders compromised the studies' ability to discriminate between the effects of respiratory protection and other factors. Influenza is considered to spread via droplet rather than aerosol. Absent clear evidence of additional benefit over standard surgical masks, N95 respirators should be reserved for protection from diseases that are clearly aerosol transmitted (e.g., varicella, measles, tuberculosis).— Kristi L. Koenig, MD, FACEPPublished in Journal Watch Emergency Medicine November 6, 2009Citation:Gralton J and McLaws M-L. Protecting healthcare workers from pandemic influenza: N95 or surgical masks? Crit Care Med 2009 Sep 1; [e-pub ahead of print]. (http://tinyurl.com/yztbnke) [Medline® Abstract]

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FW: QOD 12 1 09

Which of the following statements is false with regard to pain management in patients with sickle cell disease?

a. Opioid and non-opioid analgesics may be used.
b. Patients with sickle cell disease may develop opioid tolerance.
c. Opioid tolerance is the same as addiction.
d. Patient-controlled analgesia is an effective way to treat moderate to severe pain.

Vaso-occlusive pain can be acute or chronic. A thorough history and physical examination should be performed to make sure pain is secondary to vaso-occlusion and not another etiology such as appendicitis or infection. Pain management should be initiated promptly, as delays unnecessarily prolong discomfort and may complicate the diagnostic evaluation. Fluids and analgesics, including non-opioids and opioids, should be started. Most patients with sickle cell disease are opioid-tolerant, and this should be taken into consideration when initiating pain management with opioids. In many cases, patients may be able to communicate what their usual effective dose is. In general, oral opioids such as oxycodone or morphine can be given together with an oral non-opioid analgesic, such as ibuprofen, at a dose of 10 mg/kg. If adequate pain control is attained, patients may be discharged on scheduled oral analgesics for 24 to 48 hours, then as needed. If there is inadequate pain control, the pain should be treated as moderate to severe pain with parenteral opioids and parenteral or oral non-opioid analgesics. Table 2 shows the management strategies for mild to moderate pain. Hydration can be started orally prior to the establishment of IV access. If IV fluids are started, a normal saline bolus should be given, followed by IV fluids at a rate of one to one-and-one-half times maintenance. If acute chest syndrome is suspected, IV fluids should be limited to no more than maintenance, as this may cause pulmonary edema and worsen acute chest syndrome. A temperature should be checked to ascertain that there is no fever. Most patients with sickle cell disease have analgesics at home, and pain management may have been attempted prior to presentation to the ED. If the patient has failed management with oral analgesics and is in the ED or being admitted, patient-controlled analgesia (PCA) should be considered. Answer: c