Conscious sedation clinical guideline. Conscious Sedation Working Group, Medical Association of South Africa.

OBJECTIVE: The objective of this guideline is to promote safe conscious sedation technique. OUTCOME: (I) The use of safe conscious sedation techniques with endpoints of patient comfort and anxiolysis without loss of protective reflexes; (II) the use of drugs with a wide margin of safety that will protect against unintended oversedation. EVIDENCE: Based on existing consensus statements and some research reports. VALIDATION: Relevant organisations involved in conscious sedation were asked to select a representative to participate in the MASA Conscious Sedation Working Group. All participants represented organisations. The working group met in January 1996 to consider a draft guideline. The document was amended and circulated to working group members, representative organisations and 35 interested persons for endorsement and comment using a modified Delphi technique. All respondents endorsed the guideline (with or without minor corrections.) The national organisations endorsing the guidelines are listed. RECOMMENDATIONS: The use of drugs, equipment and personnel as directed in such a way that enhances the safety of the patient. Pre-sedation screening for at-risk patients. Intra-sedation monitoring, especially the use of a pulse oximeter. Post-sedation care and discharge instructions for the patient.

Ambulatory nursing. The handmaiden/specialist dichotomy.

Will ambulatory nursing roles change sufficiently to cope with the healthcare demands of the next century or should they be taken over by administrative personnel? The authors analyze traditional and clinical nurse specialist ambulatory nursing activities and highlight the dichotomy between menial handmaiden and professional nursing activities that must be bridged if ambulatory nursing is to survive.

Hypertension guideline 2003 update.

OUTCOMES: Extensive data from many randomised controlled trials have shown the benefit of treating hypertension. The target blood pressure (BP) for antihypertensive management should be systolic BP < 140 mmHg, diastolic < 90 mmHg, with minimal or no drug side-effects. However, a lesser reduction will elicit benefit although this is not optimal. The reduction of BP in the elderly and in those with severe hypertension should be achieved gradually over 6 months. Stricter BP control is required for patients with end organ damage, co-existing risk factors and co-morbidity, e.g. diabetes mellitus. Co-existent risk factors should also be controlled. BENEFITS: Reduction in risk of stroke, cardiac failure, renal insufficiency and probably coronary artery disease. The major precautions and contraindications to each antihypertensive drug recommended are listed. RECOMMENDATIONS: Correct BP measurement procedure is described. Evaluation of cardiovascular risk factors and recommendations for antihypertensive therapy are stipulated. The total cardiovascular disease risk profile should be determined for all patients and this should inform management strategies. Lifestyle modification and patient education plays an essential role in the management strategy. Drug therapy: First line--low dose thiazide-like diuretics; second line--add one of the following: reserpine, or beta-blockers or ACE inhibitors or calcium channel blockers; third line--add another second line drug or hydralazine or alpha-blocker. The guideline includes management of specific situations, i.e. hypertensive emergency and urgency, severe hypertension with target organ damage and refractory hypertension (BP > 160/95 mmHg on triple therapy), hypertension in diabetes mellitus, etc. VALIDITY: Developed by the Working Groups established by the Executive Committee of the Southern African Hypertension Society with broader consensus meeting endorsement. The 2001 version was endorsed by the South African Medical Association Guideline Committee. The 2003 revisions were endorsed by the Executive Committee and a wider Working Group.

The role of the advanced clinical nurse in a hypertension clinic.

The use of advanced clinical nurses (ACNs) has enabled expansion of the Hypertension Clinic at the Johannesburg Hospital. The ACNs care for elderly patients whose hypertension is stable and who require a minimum of drugs. Blood pressure control in this group of patients is satisfactory and the default rate is low. The ACN therefore appears acceptable, at least to the patient. However, problems of continuing education, evaluation and official recognition remain. The case for allowing the ACN to prescribe from a limited pharmacopoeia is presented.