Monitoring general recommendations

General recommendations for instmmentation include monitoring gas concentration, temperature, time, and the moisture content of the chamber. Hospital sterilizers are not usually equipped with instmmentation providing direct display of gas concentration and moisture content. These rely instead on a specific sequence of steps performed automatically and the recording of pressure which when 100% ethylene oxide is used is a perfect measure for the concentration of this gas. 

The frequency of TSH monitoring during levothyroxine dose titration is generally recommended at 6- to 8-week intervals until normalization. For patients who have recently initiated levothyroxine therapy and whose serum TSH has normalized or in patients who have had their dosage or brand of levothyroxine changed, measure the serum TSH concentration after 8 to 12 weeks. 

Volatile anesthetic agents - Close perioperative monitoring is recommended in patients undergoing general anesthesia who are on amiodarone therapy as they may be more sensitive to the myocardial depressant and conduction effects of halogenated inhalational anesthetics. 

Recommended testing should include a white blood cell count and differential to permit assessment of neutropenic side effects. The total lymphocyte count as a measure of ART treatment response is unreliable and not generally recommended. Serum alanine or aspartate aminotransferase (ALT, AST) level determinations are recommended to monitor for hepatotoxicity. Creatinine and phosphate should be measured 4 weeks after initiation of tenofovir. 

The physician may want to do repeat monitoring, however, if the patient requires doses above the generally recommended limit. Once the proper dose is established, most or all of the medication can generally be given once daily, usually 1 hour before bedtime. Exceptions to single daily dosing would be not to exceed 150 to 200 mg of a TCA at one time and to use divided, lower total daily doses in the elderly, in the very young, or in medically ill individuals, particularly those with cardiac disease. 

Therefore, extra precaution should be exercised in patients with preexisting thyroid disease or those taking other drugs that may interfere with thyroid function (e.g., CBZ, phenytoin, ketoconazole). During maintenance therapy, physiological monitoring at baseline and on at least a yearly basis is generally recommended (e.g.,... 

Clonidine. This drug is now well established on the withdrawal of opiate addiction. However, due to its ability to produce postural hypotension and sedation, its use is often limited to in-patients. It is being used for out-patients in some centres but it is necessary to ensure daily contact with the patients so any side effects, particularly low blood pressure, can be monitored and this may be possible for example through the Community Psychiatric Nurse (CPN) of a Community Drugs Team. Further work is needed in its use for outpatients before it can be generally recommended. 

Based on the experience of Iranian physicians who treated sarin toxicity during the Iran-Iraq war (Newmark, 2004), PAM was not available on the front lines and atropine alone was used for treatment. The doses of atropine used were considerably higher than those used in the Tokyo subway sarin attack, or that are generally recommended in the USA (Medical Letter, 2002). The Iranian protocol called for initial administration of 4 mg intravenously. If no atropine effects (improvement in dyspnea or decrease in airway secretions) were seen after 1 to 2 min, 5 mg was then administered intravenously over 5 min while heart rate was monitored. A rise in heart rate of 20 to 30 beats per min was regarded as an atropine effect. In severe cases, 20 mg to 200 mg was given. Regardless of dose, the key to saving lives, in their opinion, was how soon the atropine was administered. 

Lithium and Diuretics. Sodium depletion is known to increase lithium toxicity, and it is generally recommended that lithium not be used in patients on diuretic therapy or on a sodium-restricted diet. Even protracted sweating or diarrhea can cause sufficient depletion of sodium to result in decreased lithium tolerance. The sodium depletion caused by diuretics reduces the renal clearance and increases the activity of lithium. However, if preferable therapeutic alternatives are not available, concurrent therapy need not be contraindicated as long as the interaction is recognized and appropriate steps are taken to monitor therapy and adjust the dosage. 

The interactions of the protease inhibitors and atorvastatin or simvastatin appear to be established by the pharmacokinetic studies cited here, and supported by a few ease reports. It is generally recommended that simvastatin and lovastatin, which is similarly metalxrlised, should be avoided in patients taking protease inhibitors, and several manufacturers of simvastatin contraindicate concurrent use. Atorvastatin should be used in low doses (i.e.lO mg) with care. See also muscle toxicity , (p.l086), for further guidance on monitoring, and risk factors for muscle toxicity. 

Employees should be made aware of the risks. Local exhaust ventilation around the lips of vapour degreasing tanks is necessary, and in confined spaces good general ventilation is essential. In work areas, atmospheric monitoring is recommended to ensure that exposure is kept to a minimum and certainly below the Maximum Exposure Limit (MEL) of 350 ppm for 8 hours. 

Consequently, this review focuses on installed equipment performance and depends on monitoring its performance in the operating environment. A minimum of 1 year of operating experience and an installed base sufficient to yield a minimum of 100,000 hours of operation in multiple installations is generally recommended. A minimum operating time allows sufficient time for early failures, such as those related to specification, handling, installation and commissioning, to be identified, adequately understood, and accounted for in the equipment manual. 

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