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The timing of gastric aspirates may be critical to the agreement between continuous monitoring and pH paper medications hyperthyroidism buy 250mg trecator sc overnight delivery. Poor correlation was noted for both the median pH values and the percentage of time below pH 3 between 24-h monitoring and once-daily aspirates (40) medicine to help you sleep discount 250 mg trecator sc, whereas better correlation was found with more frequent aspirate measurements (36 treatment notes buy generic trecator sc on-line, 41) medicine 831 order trecator sc 250mg amex. Intragastric pH measurements may actually be more reflective of the microenvironment surrounding mucosal cells but could also be registering only the gastric pH in contact with the electrode and differ in various parts of the stomach or gastric contents (19, 37, 42, 43). This may be important in monitoring intestinal pH when the collection of adequate amounts of aspirate is difficult (19, 44). Given the time involved in collecting an aspirate and the potential for various interferences with paper color changes, continuous pH Evidence-Based Practice for Point-of-Care Testing monitoring was judged to be a simpler, safer, faster, and more reliable measure of gastric pH when compared to measurement of gastric aspirates with pH paper (19, 33, 36). However, continuous pH monitoring is expensive, and litmus paper might offer a more economical alternative for those clinicians wanting to monitor acid therapies at the bedside (45). The electrodes must be calibrated before each use and the calibration drift monitored after each patient. There is no standard method for calibration or consensus about acceptable bias and drift. Additional corrections may be necessary at very low pH or pH values near 7, at which certain types of electrodes may display more bias (26). If the electrode is not far enough into the esophagus, the monitor may fail to detect reflux episodes, and if the electrode is placed too far, the test may monitor gastric or duodenal pH changes (26). Most studies have limited the examination of data from patients for whom the electrode did not drift by more than 0. Monitoring therapy with pH paper, although considered a standard of care in many critical care units, may have a clinical role, but there is a lack of supporting evidence that pH monitoring to guide acid suppression therapies actually lowers patient morbidity and mortality (31). Clinically significant bleeding as opposed to occult bleeding has been suggested as a more appropriate therapeutic endpoint (32). Ar ch iv ed Does the use of pH paper for assisting the placement of nasogastric tubes, compared to clinical judgment (air, pressure), improve the placement of tubes for inpatient, endoscopy, home care, and nursing home patients We recommend the use of pH testing to assist in the placement of nasogastric tubes. Radiography is considered the gold standard means of determining tube placement, but there is fair evidence that pH testing can predict the position of nasogastric tubes while reducing the number of radiographs and exposure of the patient to additional radiation. The choice of measuring pH with an intragastric electrode or testing tube aspirates with a pH meter or pH paper will depend on consideration of the clinical limitations of each method, and there is conflicting evidence about which method is better. Radiography is considered the gold standard means of determining tube placement in clinically ambiguous cases; however, pH testing may provide a faster, safer, and more economical means of screening tube placement before radiography is considered. Because acid inhibitors and antacids increase gastric pH, studies on patients under acid suppression suggest that a higher gastric cutoff of pH 6. More than 81% of gastric samples were found to have a pH between 1 and 4, whereas more than 88% of intestinal aspirates had a pH 6 (38, 50). Radiography studies may be useful in equivocal cases of aspirated fluid with a pH between 4 and 6. However, the effect of these suggestions on patient outcome remains to be examined. Although pH testing is useful in determining tube placement, there is some controversy about which method of monitoring pH is better: use of a continuous intragastric electrode or measurement of the pH of tube aspirates with a pH meter or pH paper. Intragastric monitoring with a pH probe attached to the end of a feeding tube can assist in both tube placement and monitoring of acid suppression therapy for several hours. These probes are technically simpler and faster and may be more accurate than testing gastric aspirates with pH paper (33, 36). Intragastric pH monitoring is capable of continuously monitoring pH changes of the gastric contents, but this pH may not reflect the actual pH at the mucosal cell surface (37). Therapy to raise the pH content of gastric contents based on gastric aspirates may vary significantly from intragastric pH, overestimating the true intragastric acidity, and guide therapy changes that may not be sufficiently protective. This hypothesis is supported by case reports of bleeding and treatment failure while patients receive acid suppression, and significant bleeding as opposed to 123 occult bleeding may be a better endpoint of acid therapy than pH (32). Testing the pH of aspirated gastric contents with paper or a pH meter also may not provide equivalent pH results.

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