降低气管切开鼻饲误吸发生率的护理干预

目的探讨护理干预对行气管切开鼻饲误吸发率的影响。方法选择2012年1月至2013年3月本院重型外伤气管切开鼻饲的患者57例,随机分为干预组和对照组,对照组26例,干预组31例。对照组按护理技术操作规程置入胃管及进行常规的鼻饲护理,干预组患者除上述护理外实行护理干预,包括增加胃管插入的长度,改变鼻饲时体位,减少鼻饲量,减慢速度和增加鼻饲次数,加强胃管的检查和固定。比较两组患者鼻饲过程返流,误吸,窒息,吸人性肺炎的发生率。结果干预组的返流,误吸,窒息,吸人性肺炎的发生率低于对照组（均P〈0．05）。结论对重型颅脑外伤气管切开鼻饲的患者鼻饲过程实施有效的护理干预,能有效预防反流和误吸的发生,减少窒息及肺部感染等并发症的发生,促进患者早日康复。     

The role of clinical pharmacist to improve medication administration through enteral feeding tubes by nurses

Background As a common practice, medications are given in addition to nutrients through enteral catheters especially in critically ill patients. Nurses are primarily responsible to administer medications in this manner. The correct drug delivery via enteral tubes requires special skills. Objective This study was designed to evaluate effectiveness of clinical pharmacist-led educational program in progressing nurses' knowledge and practice regarding medications delivery via enteral catheters. Setting This study has been performed in two teaching hospital affiliated to Tehran University of Medical Sciences. Methods This is a case-control, interventional study. At first, a knowledge and practice questionnaire regarding drug administration trough enteral feeding tube by intensivist nurses was prepared. This questionnaire was filled by each nurse at pre-intervention phase of the study. Then, the clinical pharmacists provided educational programs including preparing evidence-based booklet and classes for case group nurses. Nurses in case and control groups were evaluated again after 3?months. At pre- and post-intervention phases nurses were observed regarding their practice to administer drugs via enteral tubes as well. Main outcomes Mean scores of knowledge and practice questions as well as percent of nurses with correct answers were compared between pre- and post-intervention phases in case and control groups. Results The mean scores of knowledge and practice questions significantly increased in the case group but decreased or remained unchanged in the control group. In contrast to control group, the percent of nurses with correct answers to each domain of knowledge and practice questions increased significantly in the case group. Conclusion This study showed that nurses did not have sufficient baseline knowledge about rules of drug administration via enteral feeding tubes; however, integrated educational program by clinical pharmacists that focus on promoting correct administration of drugs via enteral feeding catheters significantly improved knowledge and practice of nurses. A theory-practice gap was found in this study that may be related to the authority of physicians not nurses in ordering rules for medication administration through enteral catheters.     

Palatability and relative bioavailability of an extemporaneous carbamazepine oral suspension

The palatability of five flavored and unflavored extemporaneous carbamazepine 20-mg/mL oral suspensions was tested, and the bioavailability of the unflavored suspension relative to that of the tablet used in its manufacture was determined in a randomized, crossover study of 12 healthy volunteers. Carbamazepine 400 mg was administered with a glass of water as either 20 mL of unflavored oral suspension (20 mg/mL) or two 200-mg tablets. Subjects were randomly assigned to receive first either the tablets or the suspension in crossover fashion on two days separated by at least two weeks. Blood samples were taken just before and at various times up to 72 hours after the carbamazepine dose. Serum samples were assayed for carbamazepine content by high-performance liquid chromatography. Of five flavored and unflavored carbamazepine suspensions tested in eight volunteers, the cherry-mint formulation was the least palatable. There was no trend in preference among the remaining suspensions (banana, tutti-frutti, grape, and unflavored). Mean values of maximum serum concentration and absorption rate constant were significantly greater for the unflavored suspension (5.7 mg/L [24 mumol/L] and 0.832 hr-1, respectively) than for the tablet (4.9 mg/L [20.8 mumol/L] and 0.266 hr-1, respectively). The mean time to maximum concentration was significantly shorter after suspension administration (3.87 hours) than after tablet administration (11.8 hours). There was no significant difference in the extent of absorption of the tablet and suspension formulation as reflected by the corrected values of the area under the serum concentration-versus-time curves. The mean (+/- S.D.) bioavailability of the suspension relative to the tablet was 94.46% +/- 20.42 (range 76.35-132.72%).(ABSTRACT TRUNCATED AT 250 WORDS)     

Delivery of esomeprazole magnesium through nasogastric and gastrostomy tubes using an oral liquid vehicle as a suspending agent in vitro.

PURPOSE: The optimal delivery medium for esomeprazole magnesium enteric-coated pellets dispersed in various concentrations of Ora-Plus suspension through commonly used nasogastric and gastrostomy tubes using a previously used standardized in vitro protocol was studied. METHODS: The study was conducted in two phases. In phase A, 60 size 14 French nasogastric tubes were used to compare esomeprazole pellet delivery via tap water or 30, 50, or 70% Ora-Plus concentrations (15 tubes for each). In phase B, tap water and the concentration that yielded the best pellet delivery from phase A were used with the narrower size 8 and shorter size 20 French tubes. In both phases, the appropriate volume of water was added. All capsules were assumed to have 1,240 pellets. At the end of each administration, pellet retention counts were performed. RESULTS: The results showed excellent delivery of esomeprazole pellets using water as a medium for tube delivery. When compared with tap water as a delivery medium, no differences in pellet retention were observed when 30% and 50% Ora-Plus were used; thus, these Ora-Plus concentrations are feasible alternatives to tap water for nasogastric tube delivery of esomeprazole pellets. CONCLUSION: Administration of esomeprazole magnesium enteric-coated pellets dispersed in tap water or Ora-Plus through size 14 French nasogastric tubes in vitro delivered over 99% of capsule contents, regardless of the Ora-Plus concentration used. For immediate bedside administration, Ora-Plus at 50% concentration is a feasible alternative to water when delivering the pellets through size 14 French tubes, while 30% Ora-Plus is an alternative to water for all tubes studied.     

Stability of carbamazepine suspension after repackaging into four types of single-dose containers

The stability of carbamazepine in commercially available suspension that had been repackaged in various single-dose containers was studied. Carbamazepine suspension was repackaged in 2-mL and 8-mL aliquots in amber glass vials, polypropylene vials, and amber polypropylene syringes and in 2-mL aliquots in amber glass oral syringes. Containers were stored at room temperature and continuously exposed to fluorescent light for up to 12 weeks. Samples from each container type and volume were assayed for carbamazepine content by high-performance liquid chromatography at various intervals during storage. Carbamazepine concentrations in the samples were compared with the carbamazepine concentration in the original manufacturer's container. The pH of the samples was also determined, and the suspensions were inspected for color, odor, and large particles. There was no significant decrease in carbamazepine concentration of more than 10% in samples stored for up to eight weeks. After 12 weeks, significant decreases in concentration were observed in all but one container type. No changes in color, odor, or consistency were observed during the 12 weeks, and there were no significant changes in pH. In commercially available suspension repackaged in volumes corresponding to common pediatric doses, carbamazepine (20 mg/mL) is stable for at least eight weeks when stored at room temperature in the containers tested.     

母乳鼻饲对缺血缺氧性脑病新生儿的营养支持作用

目的：探讨母乳鼻饲对轻、中度缺血缺氧性脑病（HIE）新生儿的营养支持作用。方法选择本院2012年6月~2013年12月收治的轻、中度HIE新生儿84例,全部患儿随机分为研究组和对照组,两组患儿均给予常规治疗,研究组在上述治疗基础上进行母乳鼻饲,对照组患儿进行配方奶经口喂养,喂养1周后采静脉血检测患者血总蛋白、白蛋白、血尿素氮、血胆红素水平,记录患儿住院时间,并统计住院期间患儿并发症发生情况。结果研究组的血总蛋白、白蛋白水平明显高于对照组,血尿素氮、胆红素水平明显低于对照组,差异有统计学意义（P〈0.05）;研究组的住院时间明显短于对照组（P〈0.05）;研究组的肺炎及败血症发生率明显低于对照组（P〈0.05）,两组均未见应激性溃疡或出血性小肠炎发生。结论母乳鼻饲对HIE新生儿的营养支持作用较好,能满足机体营养需求,并且耐受性较好,值得推广应用。     

The bioavailability of bromazepam, omeprazole and paracetamol given by nasogastric feeding tube

Aims

To characterize and compare the pharmacokinetic profiles of bromazepam, omeprazole and paracetamol when administered by the oral and nasogastric routes to the same healthy cohort of volunteers.

Methods

In a prospective, monocentric, randomized crossover study, eight healthy volunteers received the three drugs by the oral (OR) and nasogastric routes (NT). Sequential plasma samples were analyzed by high-performance liquid chromatography–UV, pharmacokinetic parameters (C_max, ${\text{AUC}}_{0 - \infty } Aims  To characterize and compare the pharmacokinetic profiles of bromazepam, omeprazole and paracetamol when administered by the oral and nasogastric routes to the same healthy cohort of volunteers. Methods  In a prospective, monocentric, randomized crossover study, eight healthy volunteers received the three drugs by the oral (OR) and nasogastric routes (NT). Sequential plasma samples were analyzed by high-performance liquid chromatography–UV, pharmacokinetic parameters (C_max, , t_?, k_e, t_max) were compared statistically, and C_max, and t_max were analyzed for bioequivalence. Results  A statistically significant difference was seen in the of bromazepam, with nasogastric administration decreasing availability by about 25%: AUC_OR = 2501 ng mL⁻¹ h; AUC_NT = 1855 ng mL⁻¹ h (p < 0.05); ratio (geometric mean) = 0.74 [90% confidence interval (CI) 0.64–0.87]. However, this does not appear to be clinically relevant given the usual dosage range and the drug’s half-life (approx. 30 h). A large interindividual variability in omeprazole parameters prevented any statistical conclusion from being drawn in terms of both modes of administration despite their similar average profile: AUC_OR = 579 ng mL⁻¹ h; AUC_NT = 587 ng mL⁻¹ h (p > 0.05); ratio (geometric mean) = 1.01 (90% CI 0.64–1.61). An extended study with a larger number of subjects may possibly provide clearer answers. The narrow 90% confidence limits of paracetamol indicate bioequivalence: AUC_OR = 37 μg mL⁻¹ h; AUC_NT = 41 μg mL⁻¹ h(p > 0.05); ratio (geometric mean) = 1.12 (90% CI 0.98–1.28). Conclusion  The results of this study show that the nasogastric route of administration does not appear to cause marked, clinically unsuitable alterations in the bioavailability of the tested drugs.     

Effect of serum separator tubes on free and total phenytoin and carbamazepine serum concentrations

The effect of serum separator tubes (SSTs) on free and total serum phenytoin and carbamazepine concentrations was determined by comparing standard no-additive tubes with SSTs (Becton Dickinson SST and Terumo Autosep). The influence of time prior to centrifugation, sample volume, and initial drug concentration on the effects were also studied. Results were analyzed using repeated measures two-way analysis of variance with tube type and either time, sample volume, or concentration as main effects. The most significant reductions noted were with Becton Dickinson SSTs in free and total serum phenytoin and total carbamazepine concentrations, where all reductions were less than 10%. The only factor to significantly influence extent of reduction was the effect of time on total serum phenytoin concentration in Becton Dickinson SSTs. Terumo Autosep tubes caused no major reductions in free or total phenytoin or carbamazepine serum concentrations. Autosep tubes should provide accurate measurements of total and free serum phenytoin and carbamazepine concentrations. With Becton Dickinson SSTs, the reductions noted in free and total phenytoin and total carbamazepine concentrations were not large enough to preclude their clinical use. Becton Dickinson SSTs should not be used for determining free or total phenytoin or total carbamazepine concentrations for purposes of research.     

The influence of various excipients on the conversion kinetics of carbamazepine polymorphs in aqueous suspension

The influence of various excipients on the conversion of carbamazepine polymorphs to the dihydrate in aqueous suspension has been investigated. Ten excipients having functional groups which were potentially able to form hydrogen bonds with carbamazepine (group 1: methylcellulose, hypromellose (hydroxypropyl methylcellulose), hydroxypropylcellulose (HPC), 2-hydroxyethylcellulose (HEC), carmellose sodium (sodium carboxymethylcellulose), cellobiose; group 2: povidone (polyvinylpyrrolidone), povidone-vinyl acetate copolymer (povidone/VA) and N-methyl-2-pyrrolidone; group 3: macrogol (polyethylene glycol) and polyethylene oxide-polypropylene oxide copolymer (PEO/PPO)) were selected. Carbamazepine polymorphic forms III and I were dispersed separately into each aqueous excipient solution (0.1%, w/v) for 30 min at room temperature. The inhibition effect of each excipient was quantified using Raman spectroscopy combined with multivariate analyses. The solubility parameter of each excipient was calculated and used for categorizing excipients. Excipients in groups 1 and 2, which had both low solubility parameters (< 27.0 MPa(1/2)) and strong hydrogen bonding groups, inhibited the conversion completely. With increasing solubility parameter, the inhibition effect decreased for group 1 excipients, especially for carbamazepine form I, which had a higher specific surface area. Also, the excipients of group 3, lacking strong hydrogen bonding groups, showed poor inhibition although they had low solubility parameters (< 21.0 MPa(1/2)). This study indicated the importance of both hydrogen bonding interaction and a suitable hydrophobicity (expressed by the solubility parameter) in the inhibition of the conversion of carbamazepine to the dihydrate.     

管饲给药的临床评估与操作建议

临床上当患者采用管饲营养时,药物也常从此途径输入胃肠道。管饲给药与经口服药存在显著的不同,给药不当会导致管路堵塞、药效降低、不良反应增加等。管饲给药前需要考虑管饲通道的材质、内径、开口位置,同时评估药物剂型的适用性。一般首选液体制剂,其次选择易崩解或可研碎的固体制剂,不推荐选择肠溶包衣及缓控释制剂。给药时需对药物剂型进行妥当处理,选择适当的给药剂量和时间,给药前后注意冲管。密切监测患者临床反应,必要时调整给药剂量。操作者应按照规范的流程进行给药操作,以最大程度保证管饲给药疗效、减少药物治疗相关并发症。     

Esomeprazole administered through a nasogastric tube provides bioavailability similar to oral dosing

AIM: To determine if nasogastric tube administration of the enteric-coated pellets from an opened esomeprazole capsule provides bioavailability similar to oral dosing with the intact capsule. METHODS: A randomized, single-centre, open-label, two-period crossover pharmacokinetic study consisting of two 5-day dosing periods separated by a 7- to 14-day washout period was conducted. Healthy subjects between the ages of 18 and 50 years received esomeprazole 40 mg once daily either orally as an intact capsule, or as a suspension of the enteric-coated pellets from an opened capsule in water through a nasogastric tube. RESULTS: In 47 evaluable subjects, the 90% confidence intervals were 0.87-1.08 and 0.93-1.25 for the geometric mean of the ratio of nasogastric tube administration relative to administration of the intact capsule for the area under the plasma concentration-time curve and for maximum plasma concentration, respectively, on day 1, demonstrating bioequivalence. Oral and nasogastric administration also demonstrated similar bioavailabilities on day 5. Esomeprazole was well tolerated regardless of the mode of administration. CONCLUSIONS: Nasogastric tube administration of the enteric-coated pellets from an opened esomeprazole 40 mg capsule provides bioavailability similar to oral dosing. Administration of the contents of an opened esomeprazole 40 mg capsule in water through a nasogastric tube is a practical alternative for patients with feeding tubes who require effective gastric acid suppression, but cannot swallow an oral preparation.     

螺旋型鼻肠管双导丝置管方法在ICU临床应用研究

目的探索ICU病房内对危重患者应用双导丝法和主动置管法行床边盲插鼻肠喂养管的成功率和安全性。方法同一初学操作者随机将163例危重住院患者分别采用双导丝法(n=87)和主动置管法(n=76)行床边盲插鼻肠喂养管,观察2种置管方法的成功率、重要生命体征的变化及呼吸道内置管或消化道穿孔等并发症发生情况。结果双导丝法和主动置管法的置管成功率分别为94.25%和71.05%,差异有非常显著性(P<0.01);2种置管方法患者重要生命体征无明显变化,均无呼吸道内置管或消化道穿孔等并发症。结论对于初学床边盲插鼻肠喂养管操作者,双导丝法与主动置管法相比,是技术上更易掌握、成功率更高且有着同样安全性的置管法。     

Characterizing the conversion kinetics of carbamazepine polymorphs to the dihydrate in aqueous suspension using Raman spectroscopy

In an aqueous environment, polymorphic forms I-III of carbamazepine all convert to the dihydrate. This study investigated the conversion of each polymorphic form individually and of a mixture of forms III and I to the dihydrate. Two batches of form I with different crystal morphology were used. Samples were dispersed independently in water at 23+/-1 degrees C and recovered at various timepoints varying from 10 to 210 min. Scanning electron microscopy, X-ray powder diffraction and Raman spectroscopy were used to characterize the initial polymorphic forms and the recovered samples after 210 min. Raman spectroscopy combined with partial least squares analysis was used to generate quantitative models of binary and ternary mixtures of the different polymorphic forms with the dihydrate. On the basis of these models the conversion kinetics of the polymorphic forms I-III were characterized. First-order kinetics with an unconverted portion were used to model the data (R2> or =0.95). The unconverted portions ranged from 16 to 51% after dispersion for 210 min. The conversion kinetics were similar between polymorphic forms with comparable crystal morphology, but differed significantly between batches of the same polymorph (form I) with different crystal morphology. Furthermore, the conversion of forms III and I in the aqueous suspension was not influenced by the presence of the other polymorph when dispersed together.     

空肠造口与留置鼻空肠营养管在全胃切除术中应用效果比较

目的 比较全胃切除术中空肠造口与留置鼻空肠营养管的应用效果.方法 采用回顾性分析方法,按肠内营养支持方法不同将23例行全胃切除患者分为留置鼻空肠营养管组（A组）17例和空肠造口组（B组）6例.比较两组患者术后睡眠情况、排痰不利、肛门恢复排气时间、咽喉疼痛、恶心、肺部感染、吻合口漏等术后并发症发生率.结果 与A组比较,B组患者睡眠不佳、排痰不利、咽喉疼痛、恶心、呕吐明显减少;肛门恢复排气时间显著提前.吻合口漏、十二指肠残端瘘、腹腔和肺部感染等并发症两组间无明显差异.结论 在全胃切除术中应用空肠造口,相比留置鼻空肠营养管,患者痛苦更小,心理负担更轻,更易于护理,康复更快,是一种有效、安全、合理的策略.