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Many surgeons blood glucose testing machines order micronase 5 mg amex, however how does diabetes medications work micronase 5 mg with mastercard, will give serious consideration to diabetes mellitus blood test results discount micronase 2.5mg otc open prostatectomy for glands estimated to type 1 diabetes definition wikipedia buy discount micronase 5 mg on line be greater than 75g in size. Treatment with prostate-shrinking 5-alpha reductase inhibitors tends to be confined to the larger prostate. There may be other factors present which incline one towards open prostatectomy and these can usually be established from the history and examination. The presence of bladder stones which are too large for endoscopic cystolitholapaxy, combined with marked enlargement of the prostate is an indication for open prostatectomy. Rarely the patient may have such a long urethra that even a long resectoscope may not allow transurethal access to the entire length of the prostate, and in this situation one has no choice but to remove the prostate by an open technique. However, it is uncommon nowadays not to know in advance that you are likely to have to perform an open prostatectomy. Tests Urine culture the urine should be cultured to determine whether there is infection. Frequency-volume chart Patients with nocturia should be asked to estimate the volume of urine they void at night. Elderly men and women lose the diurnal rhythm of urine production, whereby daytime urine output is greater than that at night. Production of large night-time volumes of urine?nocturnal polyuria?can be confirmed by getting the patient to complete a frequency-volume chart or voiding diary, where urine volume is recorded along with the time of each void (Fig. Serum creatinine Indications and preparations for transurethral resection 53 Serum creatinine should be measured to detect renal failure secondary to high pressure 18,20,21 urinary retention. An elevated creatinine may obviously also be due to primary renal disease, which by impairing renal Figure 4. One should consider other causes for polyuria, such as poorly controlled diabetes, the resulting glycosuria causing an osmotic induced diuresis, with consequent frequency and nocturia. Residual urine volume measurement is useful (along with measurement of serum creatinine) as a safety measure. The Veterans Administration Cooperative Study on Transurethral Resection of the Prostate has shown that in men with moderate urinary symptoms it is safe not to operate where the post-void residual volume is <350 22 ml. At 3 years of follow-up in the watchful waiting group, average residual urine volume had actually decreased by 40 ml from baseline. Bates et al have recently shown that when one observes men with large residual urine volumes over several years (rather than proceeding with Figure 4. In this study, 93 men with residual urine volumes averaging 363 ml and ranging from 250 to 700 ml were observed for an average of 5 years. Over this time period residual urine volume remained stable in 50%, fell in 30% and increased in 20%. In a substantial proportion of patients there is considerable variation in 24,25 residual volumes measured either on the same or on different days. In two-thirds of Indications and preparations for transurethral resection 55 24 men Birch et al found wide variations in residual volumes on at least two measurements on the same day. Bruskewitz et al repeated residual volume measurements between two and five times on the same day by in and out catheterization and found wide variation 25 26 within individual patients between repeat measurements. This represented an average variation within a single individual of 42% between repeated measures. Thus, a patient may have a high residual urine volume on one day and a low one on another. It has been suggested?indeed it seems intuitive?that an elevated residual urine volume predisposes to urinary infection. In fact, what evidence there is relating residual volume to urine infection suggests that an elevated residual urine may not, at least in the neurologically normal 29 adult, predispose to urine infection. These changes occur in the absence of any change in voided volumes between repeated flow tests. Rather as with residual urine volume estimation, which flow rate should you base your decision on treatment on? Uroflowmetry alone cannot distinguish between low flow due to bladder outlet obstruction and that due to a poorly contractile bladder. However, most patients without obstruction have a good outcome and the time and cost of performing pressure-flow studies routinely is perceived by most urologists as not worth the effort. Indications and preparations for transurethral resection 57 Renal ultrasonography Koch has shown that renal ultrasound is only useful if serum creatinine is elevated above the normal range. The percentage of patients having upper tract dilatation on ultrasound according to their serum creatinine level was: creatinine <115 mol/l, 0. As a consequence Koch and colleagues recommended upper tract imaging only if the creatinine level was >130 mol/l, if the residual urine volume was >150 ml with a serum creatinine between 115 and 130 mol/l or in patients presenting with urinary retention. We do not routinely measure urine flow rate or post-void residual urine volume, nor do we routinely perform renal ultrasonography in patients with a serum creatinine below 130 mol/l. Recurrent acute urinary retention A focused history and examination combined with selected tests along the lines of those discussed above for a man presenting with symptoms should be carried out in any patient presenting with urinary retention. This can be managed by a short period with a catheter and is often followed by successful voiding once the patient is more mobile, postoperative pain has settled down and the effects of anaesthetic and other drugs have washed out of his system. Remember to exclude the rare but important causes of retention other than simple prostatic obstruction. Be particularly wary of the man with a history of constipation and of back pain which keeps him awake at night, especially if this has become severe in the weeks before the episode of retention. A trial without catheter is clearly not appropriate in cases where there is back pressure on the kidneys, so-called high pressure retention (see below). About a quarter of 38?40 men with acute retention will void successfully after a trial without catheter. Of those who pass urine successfully after an initial episode of retention, about 50% will go back into retention within a week, 60% within a month and 70% after a year. This means that after 1 year, only about 1 in 10 men originally presenting with urinary retention will not have gone back into retention. Recurrent retention is more likely in those with a flow rate <5 ml/s or average voided volumes of <150 ml. An alpha-blocker started 24 hours before a trial of catheter removal increases the chances of voiding successfully (30% taking 41 placebo voiding successfully, and 50% taking an alpha-blocker). However, whether Transurethral resection 58 continued use of an alpha-blocker after an episode of acute retention reduces the risk of a 42 further episode of retention is not yet known. Comparable studies with prostate-shrinking treatments such as finasteride have not been done in patients who have already had an episode of retention. Hampson reported that in men presenting with acute retention with associated prostate cancer diagnosed on needle biopsy (retention volume <800 ml), 30% voided successfully within 1 month of starting treatment, another 30% voided within 2 months of starting treatment and another 20% voided at 3 months. Conversely, only 40% of those with larger retention volumes voided successfully after treatment with hormone therapy. It is our pratice to recommend a trial of catheter removal in all men presenting with acute retention, as long as there is no evidence of back pressure on the kidneys. High pressure chronic retention 16 Mitchell defined high pressure chronic retention of urine as maintenance of voiding, with a bladder volume of >800 ml and an intravesical pressure above 30 cm H2O, often 44 accompanied by hydronephrosis. When the patient is suddenly unable to pass urine, so-called acute-on-chronic high pressure retention of urine has occurred. A man with high pressure retention who continues to void spontaneously may be unaware that there is anything wrong. He will often have no sensation of incomplete emptying and his bladder seems to be insensitive to the gross distension. This is such an unpleasant and disruptive symptom that it will cause most people to visit their doctor. In such cases inspection of the abdomen will show gross distension of the bladder, which may be confirmed by palpation and percussion of the tense bladder. On catheterization a large volume of urine is drained from the bladder (often in the order of 1?2 L and sometimes much greater). The serum creatinine will be elevated and an ultrasound will show hydronephrosis with a grossly distended bladder if the scan is done before relief of retention. These patients may develop a profound diuresis following drainage of the bladder and a small percentage show a postural drop in blood pressure. It is wise to admit such patients for a short period of observation, until the diuresis has settled.

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Lower doses of buprenorreduce the risk that patients take more phine/naloxone are less likely to diabetes diet espanol micronase 2.5 mg line precipitate medication than prescribed diabetes mellitus jurnal indonesia purchase 5 mg micronase fast delivery. Induction should be Most patients tolerated this dose induction blood glucose 77 cheap micronase 2.5mg with mastercard, and conducted slowly; consider palliating unrelieved the mean daily dose exceeded 8 mg per day withdrawal with nonopioid therapies for the frst by the ffth week ymca diabetes prevention program jobs buy micronase 2.5 mg, when the planned dose was few days of transition to buprenorphine. Dose Stabilization Patients who are currently taking methadone Stabilization occurs when there is evidence of: Some patients who take methadone may wish to. Markedly reduced or eliminated illicit opioid switch to buprenorphine treatment for a variety use. Exercise caution with this approach and thoroughly discuss the risks and benefts with. Patient-reported blunted or blocked euphoria the patients before embarking on the change during illicit opioid use. Document reduced illicit screen and evaluate for mental disorders and drug use via patient self-report and urine drug psychosocial problems that may need to be testing. Support patients engagement in prosocial activities and progress Continue monitoring dose effectiveness toward treatment goals and recovery as they during early stabilization. Buprenorphine treatment should substantially Offer referrals for adjunctive counseling and reduce opioid cravings. It may Management Strategies for detailed information not be possible to eliminate opioid craving on the management of patients taking buprenorcompletely, regardless of the dose. If they take at least 16 mg per day, mu-opioid receptors are approximately 80 to 95 percent occupied. It may not decrease with dose increases if patients spend time with people who use opioids in their presence. Patients who were not interested in adjuncTransmucosal Buprenorphine Dosing tive addiction or mental health counseling Summary during induction may become receptive to it when they are feeling more stable. Induction and stabilization the goal is to reduce or eliminate opioid withBe cautious when increasing doses above 24 drawal and craving without causing sedation: mg/6 mg per day. Induction and stabilization strategies can on daily doses of 4 mg/1 mg to 24 mg/6 mg. It withdrawal if the combination product were to provides useful information and checklists for be injected. The implanter should document be given every 2 hours up to approximately implant and inspection procedures, as with any a 16 mg total daily dose to treat continuing other standard procedure. The initial stabilization dose can often be cosal dose of buprenorphine 12 to 24 hours achieved within the frst several days of before insertion. Maintenance Typical maintenance doses range from 4 mg/1 Implant procedure mg to 24 mg/6 mg per day. An effective mainSubdermal insertion of the four rods takes less tenance dose is the lowest dose that can: than 30 minutes. Treatment should last for as long as patients incision in the inner upper arm between the beneft from treatment. Advise the patient not to drive or engage implants through a central pharmacy for delivery, in heavy physical activity for approximately along with an implant insertion kit that contains 24 hours. Patients should follow the same the patient should return within 1 week of the directions to prepare for implant removal as they implant procedure for a wound care check. The removal procedure may Check for signs of infection, trouble healing, or require stitches. The rods are subdermal, so for removal of stitches and wound assessment they should remain palpable. Stabilization Maintain contact with patients after implant Initiation of Buprenorphine Extendedplacement. Even among highly stable patients, Release Injection return to illicit opioid use can occur. Explain the Healthcare settings and pharmacies need risk of unintentional overdose if patients return special certifcation to order and dispense to illicit opioid or alcohol or benzodiazepine extended-release injectable buprenorphine to use while implants are in place. It is important ensure long-acting preparations are dispensed to monitor the patient between implant directly to healthcare providers for administraplacements. If the patient returns mucosal buprenorphine (8 mg to 24 mg daily) to illicit opioid use, consider whether adequate for at least 7 days. Extended-release buprenorphine is not Consider transmucosal medication supplemenrecommended for patients with severe hepatic tation if a patient with implants destabilizes impairment and may not be appropriate for and reports inadequate opioid blockade. Most pregnancy to recommend initiating this formularequired small doses, such as 2 mg/0. Consider more frequent assessment and higher intensity of treatment for patients who Inform patients that: continue using illicit opioids or other substances. After abdominal injection, a lump may be into other sites or second insertion into a previpresent at the injection site for a few weeks. Patients should not most patients should transition to a transmucosal rub or massage it or let belts or waistbands buprenorphine-containing product for continued rub against it. If the medication is discontinued, that they are being treated with this the patient should continue to be seen and medication. They should have a risk/beneft who stay in treatment often abstain longer from discussion about continuing with this forillicit opioid use and show increasing clinical mulation given the limited safety data on its stability. They should years after buprenorphine treatment entry show be informed that their newborn can have lower illicit opioid use among those with more symptoms of opioid withdrawal at birth. Keep at room temperature for at least 15 minutes before Successful Buprenorphine Treatment injection (discard if left at room temperature for the goal of buprenorphine treatment is full more than 7 days). Maintaining illicit opioid abstinence is ideal, but imperfect abstinence Administration does not preclude treatment benefts. Patients Rotate the abdominal subcutaneous injection should do better in treatment than before site with each injection, following the instructions treatment. Each of the Do not judge treatment progress and success frst two monthly doses (with at least 26 days on the amount of medication a patient needs between doses) should be 300 mg. Some patients gauge treatment progress and success based may beneft from increasing the maintenance on patients achievement of specifc goals that dose to 300 mg monthly if they have tolerated were agreed on in a shared decision-making and the 100 mg dose but continue to use illicit treatment planning process. Examine is critical that you base patients the injection site for reactions, infections, or length of time in treatment on their evidence of attempts to remove the depot individual needs. How have they responded to treatment insulin regularly, the patient worked part time, so far? They may be perfect control and function were not restored, motivated by inconvenience, expense, loss and the patient would not be discharged from of insurance coverage, side effects, feelings care against his or her will. Many of these reasons are Dose Tapering and Buprenorphine not predictive of a successful outcome. What do they expect to be different after Following short-term medically supervised tapering or discontinuing buprenorphine? Taper Document the discussion, patient education, protocols vary in duration and may include use of and decision in the medical record. Providers and patients should understand this before Continue to monitor patients who successfully beginning a taper. Establish ultimately discontinued, patients need additional a post-taper monitoring and support plan (see psychosocial and recovery support during Chapter 3E for more information on medical this time. Continue to assess and months to permit patients to acclimate to the monitor patients progress and how they cope lower dose and to reduce potential discomfort with stress and triggers to use. If you reach this dose, you cannot increase further without calling the offce frst. The offce phone number is [insert phone number]. Day 5 to next visit: In the morning, take the total dose you took on Day 4 = mg. Notes: *If prescribing the buccal flm, ensure the patient understands that the buccal flm is placed on the inner cheek (buccal mucosa) rather than sublingually (under the tongue). The risks and benefts of other treatment for opioid use disorder (including methadone, naltrexone, and nonmedication treatments) have been explained to me. My plan is to store it [describe where and how ].

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The consultation helps ensure there are plans in place for the patient to metabolic disease risk factors buy micronase 5mg free shipping move quickly to diabetes insipidus from head trauma generic micronase 5 mg mastercard transplant diabetes insipidus management guidelines pdf buy micronase 2.5 mg fast delivery, if needed blood sugar is 300 cheap 2.5 mg micronase mastercard, before disease progresses or complications develop. If allogeneic transplant is a possibility, it helps provide adequate time for an unrelated donor or cord blood search. Unrelated donor hematopoietic cell transplantation after non-cytoreductive conditioning for patients with high-risk myeloma. Nonmyeloablative allografting for newly diagnosed multiple myeloma: the experience of the Gruppo Italiano Trapianti di Midollo. New prognostic scoring system for primary myelofibrosis based on study of the International Working Group for Myelofibrosis Research and Treatment. Enzyme replacement therapy and monitoring for children with type 1 Gaucher disease: Consensus recommendations. Strategies for widening the use of cord blood in hematopoietic stem cell transplantation. Rituximab Maintenance Therapy After Autologous Stem Cell Transplantation Prolongs Progression-Free Survival in Patients with Mantle Cell Lymphoma. Fludarabine and Busulfan versus Fludarabine, Cyclophosphamide, and Rituximab as Reduced-Intensity Conditioning for Allogeneic Transplantation in Follicular Lymphoma. Course and management of allogeneic stem cell transplantation in patients with mitochondrial neurogastrointestinal encephalomyopathy. American Society of Blood and Marrow Transplantation, European Society of Blood and Marrow Transplantation, Blood and Marrow Transplant Clinical Trials Network, and International Myeloma Working Group Consensus Conference on Salvage Hematopoietic Cell Transplantation in Patients with Relapsed Multiple Myeloma. The role of cytotoxic therapy with hematopoietic stem cell transplantation in the therapy of multiple myeloma: an evidence-based review. The role of cytotoxic therapy with hematopoietic stem cell transplantation in the therapy of acute lymphoblastic leukemia in children: an evidence-based review. Results and factors influencing outcome after fully haploidentical hematopoietic stem cell transplantation in children with very high-risk acute lymphoblastic leukemia: impact of center size: an analysis on behalf of the Acute Leukemia and Pediatric Disease Working Parties of the European Blood and Marrow Transplant group. Stem cell transplantation after alemtuzumab in T-cell prolymphocytic leukaemia results in longer survival than after alemtuzumab alone: a multicentre retrospective study. Tandem versus single autologous hematopoietic cell transplantation for the treatment of multiple myeloma: a systematic review and meta-analysis. Standardization for terminology of episodes of hematopoietic stem cell patient transplant care. Recommended screening and preventive practices for longterm survivors after hematopoietic cell transplantation. Patient-Tailored Analysis of Minimal Residual Disease in Acute Myeloid Leukemia Using Next Generation Sequencing. Four year follow-up of a case of fucosidosis treated with unrelated donor bone marrow transplantation. Hematopoietic Stem Cell Transplant National Marrow Donor Program /Be the Match and the American Society for Blood and Marrow Transplantation. Effect of body mass index on mortality of patients with lymphoma undergoing autologous hematopoietic cell transplantation. High-dose chemotherapy and autologous stem cell rescue for atypical teratoid/rhabdoid tumor of the central nervous system. The role of cytotoxic therapy with hematopoietic stem cell transplantation in the therapy of acute myeloid leukemia in children: an evidence-based review. The role of cytotoxic therapy with hematopoietic stem cell transplantation in the therapy of acute myelogenous leukemia in adults: an evidencebased review. The role of cytotoxic therapy with hematopoietic stem cell transplantation in the therapy of myelodysplastic syndromes: an evidence-based review. The role of cytotoxic therapy with hematopoietic stem cell transplantation in the treatment of follicular lymphoma: an evidence-based review. The role of cytotoxic therapy with hematopoietic stem cell transplantation in the treatment of diffuse large B cell lymphoma: update of the 2001 evidencebased review. The role of cytotoxic therapy with hematopoietic stem cell transplantation in the treatment of adult lymphoblastic leukemia: update of the 2006 evidence-based review. Hematopoietic cell transplantation for inherited metabolic diseases: An overview of outcomes and practice guidelines. Long-term outcome of patients with multiple myeloma after autologous hematopoietic cell transplantation and nonmyeloablative conditioning. The pathogenesis and treatment of acid sphingomyelinase-deficient NiemannPick disease. High-dose chemotherapy with blood or bone marrow transplants for rhabdomyosarcoma. Systemic sclerosis as an indication for autologous hematopoietic cell transplantation: position statement from the American Society for Blood and Marrow Transplantation. Clinical studies have shown significant response rates with durable remissions in patients who have been heavily pre-treated (Maude, 2014). How do novel molecular genetic markers influence treatment decisions in acute myeloid leukemia? Transplant decisions in patients with myelofibrosis: should mutations be the judge? Appendix Complete Remission and Partial Remission Highlights from Revised Response Criteria for Malignant Lymphoma (Cheson et al. Appendix Hematopoietic Stem Cell Transplant Reference Sheet the following is a list of rare and unusual conditions where allogeneic transplant may be indicated. The list was reviewed and accepted by the 2018 Optum Hematopoietic Stem Cell Transplant Expert Panel. If there is a condition found on this list that is not included in the Indications section above, refer to Medical Director. Appendix *may be considered as marrow failure syndrome rather than immunodeficiency 3. Long term survival and transplantation of hematopoietic stem cells for immunodeficiencies: report of the European experience 1968-99. Shwachman-Diamond syndrome: a review of the clinical presentation, molecular pathogenesis, diagnosis, and treatment. Bone marrow transplantation in children with Hunter syndrome: outcome after 7 to 17 years. Hematopoietic stem cell transplantation for bone marrow failure syndromes in children. Use of intravenous immunoglobulin in human disease: a review of evidence by members of the Primary Immunodeficiency Committee of the American Academy of Allergy, Asthma and Immunology. Concise review: Transplantation of human hematopoietic cells for extracellular matrix protein deficiency in epidermolysis bullosa. Each of these markers has been shown in two or more independent studies to be associated with an approximately 80 % or higher risk of developing myeloma-related organ damage within two years. The use of modern imaging methods at diagnosis and follow-up will enable the diagnosis of myeloma to be made before serious bone damage, such as pathologic fractures, can develop. The diagnosis of smoldering myeloma will now have an upper limit of 60 % for the percentage of clonal plasma cells in the marrow. Patients considered to have smoldering myeloma should not have any myeloma defining events or amyloidosis. A new kind of smoldering multiple myeloma, termed light chain smoldering multiple myeloma, has been recently described in a study conducted at the Mayo Clinic, and the specific monoclonal protein level required for this diagnosis has also been added. International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma. Appendix the following are approved changes incorporated into the revision numbers indicated below. Transplant Review Guidelines separated into two documents: Hematopoietic Stem Cell Transplantation and Solid Organ Transplantation. All other brand or product names are trademarks or registered marks of their respective owner. Because we are continuously improving our products and services, Optum reserves the right to change specifications without prior notice. In adults, haematopoiesis primarily occurs in the bone marrow that is contained within the pelvis, sternum, vertebral column, and skull 20,21 Production of mature blood cells specifcally occurs in the bone marrow microenvironment (Figure 2) 20-22 Figure 2. Advantages and Disadvantages of Haematopoietic Stem Cell Collection Methods1,2,37-40 Collection Advantages Disadvantages Method Bone marrow. Associated with lower rates of morbidity possible complications related to insertion of and mortality central venous catheter.

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The effectiveness of a vaccine is assessed by evidence of protection against the natural disease diabetes type 1 during pregnancy order micronase 5mg line. Vaccines are categorized as live (viral or bacterial diabetes medicine of himalaya micronase 5 mg cheap, which almost always are attenuated) or inactivated (?nonlive?) diabetes in dogs petmd discount micronase 2.5 mg. In the case of conjugate polysaccharide vaccines diabetes mellitus journal buy 5mg micronase with mastercard, the linkage between the polysaccharide and the carrier protein enhances vaccine immunogenicity. Mucosal protection after administration of inactivated vaccines generally is inferior to mucosal immunity induced by live-attenuated vaccines. To overcome these limitations and to facilitate polysaccharide processing by antigen-presenting cells, vaccine antigens are chemically conjugated to a protein carrier with proven immunologic potential (eg, tetanus toxoid, nontoxic variant of diphtheria toxin, meningococcal outer membrane protein complex) to improve the immune response. Allergic reactions may occur if the recipient is sensitive to one or more of these additives. Standardized forms are available to assist clinicians in screening for allergies and other potential contraindications to immunization ( From the Latin word for to help, adjuvants are materials that are added to a vaccine to improve the immune response to the antigen. Aluminum salts, the most commonly used adjuvants, have been used in vaccines for more than 80 years and often are used in vaccines containing inactivated microorganisms or toxoids (eg, hepatitis B vaccine and diphtheria and tetanus toxoids). Despite their well-known clinical effect, their mechanism of action of stimulating an immune response via cytokine release was demonstrated only recently. Preservatives are added to multidose vials to prevent the growth of bacteria or fungi that may be introduced into the vaccine during its use. Thimerosal has been studied extensively and is associated with only rare, mild allergic reactions or other adverse events. Independent safety reviews by the Institute of Medicine regarding thimerosal-containing vaccines as well as vaccines and autism are available ( A recent review of vaccine preservatives by the World Health Organization highlighted that alternative preservatives, such as 2-phenoxyethanol, have variable antimicrobial effectiveness in some formulations. It is very clear that the use of thimerosal in vaccines does not put vaccine recipients at increased risk of neurodevelopmental problems. Multiple re-entries into multidose vials, however, increase the risk of microbial contamination, which is the impetus for thimerosal use in multidose vials in resource-limited settings. The preponderance of available evidence has failed to demonstrate harm associated with thimerosal in vaccines. Stabilizers are added to vaccines to ensure that their potency is not affected by adverse conditions during the manufacturing process (eg, freeze drying) or during transport and storage (eg, mild temperature excursion). Stabilizers commonly added to vaccines for this purpose include sugars (sucrose or lactose), amino acids (eg, glycine), or proteins (eg, gelatin). Immunization providers are responsible for proper storage and handling from the time the vaccine arrives at their facility until the vaccine is given. All staff should be knowledgeable about the importance of proper storage and handling of vaccines. It should detail both routine management of vaccines and emergency measures for vaccine retrieval and storage. Most vaccines are designated for optimal storage between 2?C and 8?C (35?F and 46?F), and such vaccines are referred to as refrigerated vaccines. It is imperative that great care be taken to avoid exposing refrigerated vaccines to freezing temperatures, even for brief periods. Such exposure can compromise the integrity of refrigerated vaccine even without generating ice crystals or other changes in physical appearance of the vaccine. Providers should contact their immunization program, vaccine manufacturer(s), or both for guidance. This can be accomplished by keeping each vial or syringe in its original carton while in recommended storage and until immediate use. Some products may show physical evidence of altered integrity, and others may retain their normal appearance despite a loss of potency. A protocol should be in place for personnel to know under what situations they should contact the immunization program, vaccine manufacturers, or both. Recommendations for handling and storage of selected biologics are summarized in the package insert for each product ( In addition, a physician or manager with understanding of the value and importance of appropriate vaccine storage should be engaged with the responsible vaccine coordinating staff. The details of proper storage conditions should be posted on or near each refrigerator or freezer used for vaccine storage or should be readily available to staff. Receptionists, mail clerks, and other staff members who also may receive shipments should be educated. Use plug guards and warning signs to prevent accidental dislodging of the wall plug. Stand-alone units are recommended; these are self-contained units that only refrigerate or only freeze and are suitable for vaccine storage. For refrigerated vaccine storage, medical-grade units with an electronic thermostat and digital display are preferred. The risk of freeze damage to refrigerated vaccines is increased greatly in combination refrigerator/ freezer units. By design, super cold air from the freezer is circulated in the refrigerator to cool that space. Do not use the top shelf of domestic combination refrigerator-freezer units for vaccine storage. To improve air circulation, place vaccine storage trays used to separate different vaccines away from the walls and rear of the refrigerator. Each vaccine storage compartment should be monitored by a digital thermometer with accuracy of +/ 0. The temperature data should be displayed graphically and should be able to be stored for 3 years. The graphic data should be reviewed and corrective efforts documented if daily maximum and minimum values are found to be outside of acceptable ranges. The National Institute of Standards and Technology maintains a Web site devoted to vaccine storage education ( Temperature accuracy of thermometers can be checked using an ice melting point test ( Review vaccine time and temperature indicators, both chemical and electronic, if included in the vaccine shipment. Find and inspect any temperature excursion devices (electronic or temperaturetape) found in the shipment for evidence of temperature excursions. Measure the temperature of the central part of the storage compartment twice a day, and record this temperature on a temperature log. Predrawing vaccine increases the possibility of medication errors and causes uncertainty of vaccine stability. Vaccine can be used through the last day of the month indicated by the expiration date unless otherwise stated on the package labeling. The expiration date or time for some vaccines changes once the vaccine vial is opened or the vaccine is reconstituted. All reconstituted vaccines should be refrigerated during the interval in which they may be used. Segregate the affected vaccine to avoid use until the vaccine manufacturers can be contacted to determine the disposition of the affected vaccine. Medical refrigerator with electronic thermostat and an external digital display, set to 4?C or 5?C. Displays with current temperature and resettable maximum and minimum temperatures visible on the outside of the unit. Vaccines that have been exposed to temperatures outside the recommended storage range may be ineffective. After a power outage or mechanical failure, do not assume that vaccine exposed to temperature outside the recommended range is unusable; contact the vaccine manufacturer for guidance before discarding vaccine. Each vaccine and diluent vial should be inspected carefully for damage or contamination prior to use. Changing needles between drawing a vaccine into a syringe and injecting the child is not necessary. Information about atraumatic care, positioning, comfort restraint, and comfort care is available (

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