INTRODUCTION

Urinary stone disease remains a significant global and national health concern. This underscores the need for measures to improve disease outcomes. The development and implementation of clinical practice guidelines for urolithiasis was deemed essential due to variations in practice, the evolving urologic field with its emerging interventions, which may have significant cost implications.

METHODS

The CPG was developed following the GRADE Adolopment method, the CORE GRADE Approach and the GRADE Evidence to Decision framework, and utilized the Technical Manual for Clinical Practice Guideline Development of the Department of Health (2nd edition). The guideline development group was organized after review and management of the members' conflict of interest declarations. Clinical questions were prioritized and a systematic search and synthesis of the relevant literature to answer the questions was done. Considering the balance of benefits and harms, certainty of the evidence, cost and cost effectiveness, accessibility, acceptability and feasibility of the interventions, the guideline panel developed recommendations by consensus.

RESULTS

The CPG addresses eleven priority clinical questions involving diagnosis and treatment of acute flank pain due to suspected urolithiasis among adults, minimally invasive treatment of nephrolithiasis measuring 1-2 cm and the use of alpha blockers after ESWL through twelve recommendations and one good practice statement.

CONCLUSION

The Philippine CPG on the management of urolithiasis in adults provides actionable recommendations to address important clinical questions on the diagnosis and management of urinary stone disease. The full text of the clinical practice guideline may be viewed and downloaded from https://doh.gov.ph/dpcb/doh-approved-cpg/

Human ; Adult ; Urolithiasis

BACKGROUND: Septic shock causes life threatening organ dysfunction needing vasopressor despite adequate fluid resuscitation. Numerous studies and meta-analysis have proven norepinephrine as the initial vasopressor of choice in septic shock with vasopressin as add-on. Although guidelines have established the goal monitoring response in septic shock, optimal approach in discontinuation of the vasopressors in the recovery phase of septic shock remains limited. METHODS: A systematic review and meta-analysis was performed on randomized controlled trials (RCTs) and nonrandomized studies comparing incidence of hypotension within 24 hours of discontinuing norepinephrine first versus vasopressin. Three reviewers independently selected studies, assessed their quality, and extracted the following data: the number and characteristics of patients enrolled, inclusion and exclusion criteria for each study, the description of interventions (discontinuing norepinephrine first versus discontinuing vasopressin first) and outcomes (incidence of hypotension within 24 hours). RESULTS: Seven retrospective cohort studies and one prospective randomized control trial were included. Compared with norepinephrine, risk of hypotension is higher when vasopressin is discontinued first among patients in the recovery phase of septic shock (RR 2.06; 95% CI [1.11,3.82]; I 2 91%). Results were consistent in the subgroup analysis after excluding abstract-only and poor-quality studies (RR 1.73; 95% CI [0.74, 4.03]; I 2 93%). There is no difference in ICU (RR 0.97; 95% CI [0.71, 1.32]; I 2 38%) and in-hospital mortality (RR 0.88; 95% CI [0.66, 1.16]; I 2 41%) between the two vasopressor weaning strategies. Finally ICU length of stay was reported on 5 studies with no significant difference between the two strategies. CONCLUSION: Based on the results, there is increased risk of hypotension when vasopressin is discontinued first versus norepinephrine.
Norepinephrine ; Shock, Septic ; AVP protein, human ; Vasopressins ; Vasoconstrictor Agents ; Neurophysins