University of Colorado Hospital Policy and Procedure

Neutropenia Management for Oncology and Hematopoietic Stem Cell

Transplant Patients
Related Policies and Procedures:
Standard Precautions
Hand Hygiene-Outside the Surgical Setting
Hospital Infection Control
Isolation/Transmission Based Precautions
Blood/Body Fluid Spills
Aseptic Techniue in In!asi!e and Operati!e Procedures
Clean/Sterile Supply Storage in Clinical Areas
Infectious/"egulated #aste $anagement
%mployee #or& "estrictions for Infectious 'iseases
(i!e Plant and Flo)er "estrictions
'iet "estrictions and "ecommendations for the Hematology and Oncology
Immunocompromised Patient
Central *enous (ines
Animal Assisted Acti!ities/Therapy Program
Approved y: Professional Practice+ Policy and Procedure Committee
%ffecti!e, -././
"e!ie)ed, 0/--
!escription: This policy defines 1eutropenia+ as )ell as fe2rile neutropenia+ and the
necessary assessment parameters+ guidelines+ inter!entions+ and en!ironmental modification that
must 2e implemented 2y 3ni!ersity of Colorado Hospital health care pro!iders in 3CH clinical
settings )hen caring for neutropenic patients4
Accountaility: All 3ni!ersity of Colorado Hospital employees+ physicians+ !olunteers+
students+ temporary and contract employees are responsi2le for complying )ith the
precautions/measures descri2ed in this policy/procedure4 *isitors and other non-hospital-
employee personnel )ill 2e informed of and as&ed to comply )ith the pro!isions of this policy
2y the 3ni!ersity of Colorado Hospital staff4 1on-compliance )ill 2e dealt )ith on an
indi!idual 2asis4
!efinitions:
Neutrophils are the 2ody5s first line of defense against micro2ial in!asion4 They constitute
appro6imately 7.8-9.8 of the total )hite 2lood cell count that usually ranges from 7+...-
-.+.../mm
:
4
Neutropenia is defined as an a2solute neutrophil count ;A1C< less than =../mm
:
4 Could )e add
A1C calculation formula>
-4 The relati!e ris& for infection increases as the A1C decreases4 The A1C is categori?ed into
grades+ )hich reflect the ris& for infection4
c:.-0-- Page - of 0
Neutropenia Management for Oncology and Hematopoietic Stem Cell
Transplant Patients
a4 @rade -, A1C -=..-A.../mm
:
B 1o Significant "is&
24 @rade A, A1C -...--=../mm
:
BSlight Increase in "is&
c4 @rade :, A1C =..--.../mm
:
B$oderate "is&BNeutropenia
d4 @rade 7, A1C less than =../mm
:
BHigh "is&BNeutropenia
Signs and Symptoms of Infection
-4 Localized symptoms of infection, pain at the site of infection that may or may not include
erythema or e6udate4
A4 Generalized symptoms of infection, chills+ myalgias+ arthralgias+ cogniti!e or mental status
changes+ anore6ia+ nausea/!omiting+ fatigue+ tachycardia+ hypotension+ tachypnea+
hypo6emia+ and oliguria+ and4 fe!er
:4 Site-Specific symptomatology, cough+ dyspnea+ a2normal 2reath sounds oral pain+ 2ac&
pain+ rectal discomfort )ith 2o)el elimination+ pain at !ascular access de!ice site+
2urning/urgency )ith urination4
Sources of Infection
-4 The s&in and mucous mem2ranes are !ulnera2le sources of micro2ial in!asion due to
I*/Central line access and mucositis4 For patients undergoing HSCT ;Hematopoietic Stem
Cell Transplant<+ additional ris& factors include @*H' ;@raft !ersus Host 'isease<+ and
to6icities from conditioning regimens that cause prolonged neutropenia ;-.-:. days<4
A4 Primary sites of infection in the neutropenic patient are the digesti!e tract ;mouth+ pharyn6+
esophagus+ large and small 2o)el+ rectum<+ as )ell as the sinuses+ lungs+ and s&in4
:4 Hand hygiene is considered the most important procedure to pre!ent the spread of infections4
Refer UCH Policy and Procedure: Hand Hygiene-Outside The Surgical Setting.
Tale of Contents:
"# Assessment Parameters
""# 1ursing Inter!ention for Treatment of Fe2rile 1eutropenia
"""# 1eutropenic Precautions Sign+ Appendi6 A
"$# %' Approach to Patient )ith Possi2le 1eutropenic Fe!er+ Appendi6 B
Policy%Procedure:
Policy
The freuency and se!erity of infection are in!ersely proportional to the A2solute 1eutrophil
CountC the ris&s of se!ere infection and 2loodstream infection are greatest )hen the neutrophil
count is less than -../mm
:
4 $ost patients )ith solid tumors ha!e neutropenia lasting /--. days
after therapy and are at much lo)er ris& for infection4 For patients undergoing HSCT+
neutropenia can last from -.-:. days after therapy )hich is consistent )ith the therapeutic goal
of destroying malignant cells )ithin the 2one marro)C therefore+ the intent of treatment is grade
7 neutropenia4 After the neutrophil count reco!ers+ humoral and cellular immune dysfunction
may persist+ maintaining suscepti2ility to infection for months4 Appro6imately 7D8 to 9.8 of
neutropenic patients )ho are fe2rile ha!e an esta2lished or occult infection4 Appro6imately -.-
A.8 of patients )ith a neutrophil count less than -../mm
:
)ill de!elop a 2loodstream infection4
Ineffecti!e management of fe2rile neutropenia can result in delayed treatment potentially
resulting in sepsis+ septic shoc&+ and poorer patient outcomes4 Proacti!e management of
neutropenia is critical to decreasing the depth and duration of neutropenia follo)ing HSCT+
c:.-0-- Page A of 0
Neutropenia Management for Oncology and Hematopoietic Stem Cell
Transplant Patients
limiting e6posure to opportunistic and nosocomial pathogens+ and ensuring prompt inter!ention
should fe2rile neutropenia or infection de!elop4
Procedure
"# Assessment Parameters
A# Fe!er ;oral temperature greater than or eual to :D4: degrees Celsius< can often 2e
the only is usually the first sign of a potentially life-threatening infection4 (ocali?ed
symptoms of infection such as redness+ s)elling+ pain+ and e6udate may not 2e
present due to the ina2ility of the patient5s 2ody to create an inflammatory response
resulting from due to the a2sence or decreased num2er of neutrophils4
-4 Although uncommon+ a patient )ith neutropenia and signs or symptoms of
infection ;i4e4 a2dominal pain+ se!ere mucositis+ perirectal pain< )ithout fe!er+
should 2e considered to ha!e an acti!e infection4
&# Assessment @uidelines
-4 'etermine e6pected duration and se!erity of neutropenia
a4 Consider the patient5s current and past treatment regimens including one or
more of the follo)ing, chemotherapy+ radiation therapy+ immunotherapy+
immunosuppressi!e therapy+ HSCT4
24 Consider the patient5s comor2itities+ medications+ history of prior documented
infections+ recent anti2iotic therapy+ e6posure to infections from household
mem2ers+ pets+ tra!el ;including Tu2erculosis e6posure<+ HI* status+ and
recent 2lood product administration4
A4 Assess for common sites of infection in patients )ith fe!er and neutropenia, the
alimentary tract+ groin+ s&in+ lungs+ sinus+ ears+ peri!agina+ perirectum+ and
!ascular access de!ice sites
:4 $onitor !ital signs ;T+P+"+BP< E7h
74 $onitor Inta&e and Output EDh ;E7h for acti!e transplant patients<
=4 $onitor la2oratory/radiology data,
a4 CBC )ith differential+ including #BC count4 If A1C less than -...+ institute
neutropenic precautions4 Refer to Neutropenic Precautions sign (ppendi!
".
24 Comprehensi!e $eta2olic Panel+ ('H+ 3ric Acid+ Creatinine+ B31+ (FTs+
Total Serum Biliru2in4
c4 Blood and other Culture "eports-notify Physician/1urse Practitioner if
positi!e and institute appropriate transmission 2ased precautions if necessary4
Refer to UCH Policy and Procedure: #solation$Trans%ission &ased
Precautions.
d4 Consider chest 6-ray+ 3A+ pulse o64 Chest 6-ray for all patients )ith resp4
symptoms4 ;1CC1 guidelines+ A.-:<4
""# Nursing "ntervention 'or Treatment of 'erile Neutropenia
A# 'erile Neutropenia
-4 HSCT patients
c:.-0-- Page : of 0
Neutropenia Management for Oncology and Hematopoietic Stem Cell
Transplant Patients
a4 Patients admitted for HSCT are treated )ith prophylactic anti2iotics prior to
2ecoming neutropenic and throughout the e6pected neutropenic state during
hospitali?ation4 Once patients recei!e their stem cells+ they 2egin @-CSF
therapy to assist in #BC reco!ery4 Refer to pre-printed orders for details.
24 ()en a patient ecomes ferile *oral temperature greater t)an or e+ual
to ,-#, degrees Celsius., refer to pre-printed orders' )hich indicate o2taining
a chest 6-ray+ urine culture and sensiti!ity+ and t)o sets of 2lood cultures4 At
least one of the t)o sets of cultures is to 2e o2tained from the patient5s
!ascular access de!ice if present4
-4 Colla2orate )ith Physician/1urse Practitioner regarding o2taining one of
the t)o sets of 2lood cultures peripherally4
c4 According to the A.-:A../ 1CC1 guidelines+ if there is entry or e6it site
inflammation around the !ascular access de!ice+ -< o2tain a set of 2lood
cultures is to 2e o2tained from each lumen+ A< s)a2 e6it site drainage ;if
present< for culture+ and :< *ancomycin should 2e started or addded it if site
not responding after 7D hours of empiric therapy4 to the e6isting empiric
therapy4 If the !ascular access de!ice cultures are positi!e for infection+
colla2orate )ith Physician/1urse Practitioner regarding o2taining further
2lood cultures from each lumen+ remo!al of !ascular access de!ice+ and
additional anti2iotic therapy4
d4 If patient symptomatology )arrants+ colla2orate )ith Physician/1urse
Practitioner regarding o2taining site specific cultures including rectal+ stool+
s&in+ mouth+ throat+ sputum+ and nasopharyn64
e4 If patient continues to 2e fe2rile+ 2lood cultures+ urine culture and sensiti!ity+
and chest 6-ray are to 2e done only once e!ery A7 hours4
f4 Refer to pre-printed orders for fe(er day anti)iotic instructions. Once the
patient is fe2rile ;oral temperature greater than or eual to :D4: degrees
Celsius<+ anti2iotics are to 2e gi!en according to Fe!er 'ay - instructions4
Initiate anti2iotic therapy )ithin the hour of the fe!er 2ut not 2efore o2taining
2lood cultures4 For each su2seuent fe!er not )ithin consecuti!e A7 hour
periods+ colla2orate )ith Physican/1urse Practitioner regarding anti2iotics to
start/discontinue4 If a patient continues to 2e fe2rile for consecuti!e A7 hour
periods+ continue to follo) the pre-printed orders indicating )hich anti2iotics
to administer4
g4 S/P Hematopoietic Stem Cell Transplant Patients returning to the hospital for
complications related to their transplant+ including infection+ are to 2e
directly admitted to the Hematopoietic Stem Cell Transplant unit )hen
possi2le4 #hen a 2ed is not a!aila2le+ they are to )ait at home until a 2ed is
ready or if their condition )arrants+ they are to go to the %mergency
'epartment and 2e placed in a pri!ate room if possi2le4
-4 If patient is fe2rile+ %' nurse is to colla2orate )ith 1urse
Practitioner/Physician regarding *+ pproach to Patient ,ith Possi)le
Neutropenic -e(er (ppendi! &"Add B$T 1eutropenic Path)ay
A4 Solid Tumor Fe2rile 1eutopenia patients not undergoing HSCT
a4 1otify Physician to o2tain order to dra) t)o sets of 2lood cultures4 One set
is to 2e dra)n from the !ascular access de!ice if present+ and one set is to 2e
c:.-0-- Page 7 of 0
Neutropenia Management for Oncology and Hematopoietic Stem Cell
Transplant Patients
dra)n peripherally4 O2tain an order for urine culture/sensiti!ity and chest 6-
ray4
24 According to the A../ 1CC1 guidelines+ if there is entry or e6it site
inflammation around the !ascular access de!ice+ a set of cultures is to 2e
o2tained from each lumen and *ancomycin should 2e started or added to the
e6isting empiric therapy4 If the !ascular access de!ice cultures are positi!e
for infection+ colla2orate )ith Physician regarding o2taining further 2lood
cultures from each lumen+ remo!al of the !ascular access de!ice+ and
additional anti2iotic therapy
c4 O2tain order to start anti2iotics4 Initiate anti2iotic therapy )ithin the hour of
the fe!er+ 2ut not 2efore o2taining 2lood cultures# If patient symptomatology
)arrants+ colla2orate )ith Physician regarding o2taining site
specific cultures including rectal+ stool+ s&in+ mouth+ throat+ sputum+ and
nasopharyn64
d4 Colla2orate )ith Physician regarding initiating @-CSF therapy4
e4 Fe2rile 1eutropenic solid tumor oncology patients in the %mergency
'epartment are to 2e triaged according to the *+ pproach to Patient ,ith
Possi)le Neutropenic -e(er (ppendi! &" "efer to cards gi!en to patients in
Outpatient Cancer Center
&# /nvironmental Modification
-4 All neutropenic patients are placed in pri!ate rooms4 Patients admitted for HSCT
are to 2e placed in positi!e pressure rooms )ith H%PA filtration4
A4 1eutropenia precaution sign is to 2e placed 2eside the door to alert staff and
!isitors of infection pre!ention protocol/measures4 Refer to Neutropenic
Precautions sign (ppendi! ".
C# Protective Measures for Neutropenic Patients
-4 Hand)ashing is the single most important inter!ention to pre!ent infection4
a4 All persons entering the room )ill soap and )ash hands at time of entry and
time of e6it )ith either alcohol 2ased gel or )ith soap and )ater for -=
seconds4
A4 Anyone )ith symptoms of illness is to a!oid contact )ith neutropenic patients4
#hen contact is una!oida2le+ staff/!isitors are to )ear mas&s )hen entering the
patient5s room and adhere to proper hand hygiene4
:4 Children under the age of -A are not to enter the Hematopoietic Stem Cell
Transplant unit regardless of the presence of neutropenic patients4
74 Allogeneic Hematopoietic Stem Cell Transplant patients are to 2e fitted for a 1-
0= mas& upon admission4 Once neutropenic+ A1C less than -...+ these patients
are to 2e instructed to )ear this mas& )hene!er they lea!e their room4
=4 HSCT patients )ho are under contact isolation due to their 2eing infected )ith a
highly transmissi2le infectious organism+ such as *"% and $"SA+ are to remain
in their room at all times+ unless reuired to lea!e their room for testing4 In this
case+ the patient is to )ear appropriate PP%+ including yello) go)n+ and glo!es4
If the patient is neutropenic and/or under air2orne/droplet precautions a mas& is to
2e )orn ;1-0= for allogeneic transplant patients at all times+ standard mas& for
c:.-0-- Page = of 0
Neutropenia Management for Oncology and Hematopoietic Stem Cell
Transplant Patients
autologous transplant patients+ unless a 1-0= is reuired for air2orne/droplet
precautions<4
94 A!oid rectal maneu!ers ;rectal temperatures+ enemas+ rectal medications+ rectal
tu2es+ digital e6ams< and urinary catheteri?ations4
/4 A!oid 2rea&do)n of s&in and mucous mem2ranes 2y limiting !enipunctures or
other in!asi!e procedures4 Cleanse and protect )ounds that 2rea& the s&in as
directed 2y Physician/1urse Practitioner4
D4 Place patient on neutropenic diet and ensure that patient recei!es 2ottled )ater4
Patients undergoing HSCT are not to recei!e food prepared outside of the hospital
due to the potential for infection4 Refer to Neutropenic Precautions sign
(ppendi! "
04 Change urinals and hats )hen !isi2ly soiled4 Change nasal canulas+ OA mas&s
)ee&ly and )hen !isi2ly soiled4
-.4 Change peripheral I*s e!ery : days and I* tu2ing e!ery A days4 Refer to UCH
Policy and procedure: .ines' Central /enous for instructions regarding dressing
changes4
--4 %ncourage consistent patient personal hygiene
a4 'aily sho)er or 2ath+ including shampooing head/hair
24 Change linens daily and more freuently if !isi2ly soiled4
c4 "outine oral care4 Refer to UCH Hospital 0uidelines regarding oral care.
-A4 (i!e plant and flo)ers are not allo)ed in the rooms of neutropenic patients )hose
immune compromise is such that infection can 2e acuired from soil/plant
organisms4 Refer to UCH Policy and Procedure: .i(e Plant and -resh -lo,er
Restrictions.
-:4 Animals are restricted from the Oncology/HSCT unit due to the potential
infection ris& for the immunocompromised patient population4 Refer to UCH
Policy and Procedure: ni%al ssisted cti(ities$Therapy Progra%.
References:
-4 Centers for 'isease Control and Pre!ention4 ;A..:<4 0uidelines for *n(iron%ental #nfection
Control in Healthcare -acilities' 1223 F'ata fileG4 A!aila2le from Centers for 'isease
Control and Pre!ention )e2 site+ )))4cdc4go!4 ;(O% I<
A4 $arrs+ H4 ;A..9<4 Care of Patients #ith 1eutropenia4 Clinical 4ournal of Oncology Nursing+
-.;A<+ -97--994 ;(O% I*<
:4 1CC14 ;A../<4 Fe!er and 1eutropenia-!4-4A../4 NCCN Clinical Practice 0uidelines in
Oncology. (C+". Hen&into)n+ PA, 1CC14 ;(O% I<
74 1iren2erg+ A4+ Bush+ A4P4+ 'a!is+ A4+ Friese+ C4"4+ @illespie+ T4#4+ "ice+ "4'4 ;A..9<4
1eutropenia, State of the Ino)ledge Part I/Part II4 Clinical 4ournal of Oncology Nursing'
::;9<+ --0:--A.-+ -A.A--A.D4 ;(O% I<
=4 Shelton+ B4I4 ;A..:<4 %!idence-Based Care for the 1eutropenic Patient )ith (eu&emia4
Se%inars in Oncology Nursing' -0;A<+ -::--7-4 ;(O% I*<
94 #est+ F4+ $itchell+ S4 ;A..7<4 %!idence-Based @uidelines for the $anagement of
1eutropenia Follo)ing Outpatient Hematopoietic Stem Cell Transplantation4 Clinical
4ournal of Oncology Nursing+ D;9<+ 9.--9-:4 ;(O% I*<
c:.-0-- Page 9 of 0
Neutropenia Management for Oncology and Hematopoietic Stem Cell
Transplant Patients
/4 Jitella+ (4+ Friese+ C4+ Hauser+ H4+ Holmes+ B4@4+ #oolery+ $4A4+ O5(eary+ C4+ Andre)s+ F4
;A..9<4 Putting %!idence Into Practice, Pre!entions of Infection4 Clinical 4ournal of
Oncology Nursing' -.;9<+ /:0-/=.4 ;(O% I<
c:.-0--
Appendi0 A
N/UTROP/N"C PR/CAUT"ONS
#ASH HA1'S B%FO"% PATI%1T CO1TACT
*isitors )ith cold symptoms or contagious illness should not !isit patient at this time4
Patient $3ST )ear a mas& )hen lea!ing room4
1O F"%SH F(O#%"S O" P(A1TS4
'I%TA"K "%ST"ICTIO1S I1C(3'%,
Fresh fruit and !egeta2les O1(K if thic& s&inned
o ;oranges+ melon+ 2ananas<+ not o!erly ripe and thoroughly )ashed )ith soap and )ater4
1O soft cheeses+ unpasteuri?ed foods/fluids+ dried fruits+ pepper or loose tea4
1O undercoo&ed or ra) meat+ fish or eggs4
Teas )ill 2e prepared directly 2y staff for patient 2y reuest4
Fresh ice )ill 2e pro!ided 2y staff from clean ice trays4
Ser!e 2ottled )ater O1(K to 2e ordered and pro!ided on trays4
P(%AS% S%% TH% 13"S% IF KO3 HA*% A1K E3%STIO1S "%@A"'I1@ TH%S%
P"%CA3TIO1S
c:.-0-- Page / of 0
Neutropenia Management for Oncology and Hematopoietic Stem Cell
Transplant Patients
Appendi0 &
/! Approac) to Patient 1it) Possile Neutropenic 'ever
%' @OA(,
To administer anti2iotics )ithin - hour of %' presentation for patients )ith A1C ;a2solute
neutrophil count< less than -... mm
:
To recogni?e )hich patients reuire in-patient management and )hich can 2e safely
managed as outpatients

;see "is& Stratification+ p4 -.<
To facilitate outpatient A1' inpatient )or&-up and continuity )ith patient5s oncology team4
T"IA@% P"OC%'3"%,
I' patient at triage
Patient )ith oncology information card
Patient s/p chemotherapy/radiation treatment )ithin -7 days
Patient s/p hematopoietic stem cell transplant
Oncology patient )ith fe!er or other !ague c/o
Pro!ide and instruct neutropenic patient to )ear a mas&
O2tain patient5s )eight
'etermine allergies
'ocument L1eutropenic PatientM in comments on trac&ing 2oard
Assign triage %SI (e!el A and 2ring patient to e6am room immediately ;consider @reen Care
Team I' "ed/Kello) full<
1otify "esource 1urse+ )ho )ill notify attending or senior resident of patient5s arri!al4
Place 1eutropenic pac&et of algorithms on patient5s chart
%' P"OC%'3"%,
#hen patient is placed in e6am room+ immediately dra) CBC )ith manual differential and
t)o sets of 2lood cultures4
'ra) second 2lood culture from another site
1otify physician as soon as A1C results ha!e returned ;la2 )ill call results to primary "1<4
If A1C less than -...+ send all other la2s as ordered on pre-printed order sheet4 Other la2s
may 2e clinically indicated e!en if A1C is greater than -...4
After recei!ing A1C results+ the %' Attending or Senior "esident )ill contact the inpatient
B$T 1urse Practitioner if the patient is s/p hematopoietic stem cell transplantC other)ise the
Oncology Fello) is to 2e notified4
Physician )ill stratify patient to either IP or OP treatment ;according to clinical criteria listed
in pac&et< and )ill order appropriate anti2iotics if A1C less than -...4
If outpatient treatment is appropriate, the physician )ill call the patient5s primary
Oncologist/1urse and )ill coordinate discharge )ith PO anti2iotics4
Anti2iotics must 2e administered immediately upon recei!ing the order from the Senior
"esident or %' Attending4
c:.-0-- Page D of 0
Neutropenia Management for Oncology and Hematopoietic Stem Cell
Transplant Patients
Ris2 Stratification in 'erile Neutropenia
Fe!er is defined as a single oral temperature greater than or eual to N:D4:OC ;-.-OF< or greater than or eual to
:D4.OC ;-..47OF< for greater than or eual to - hour4 1eutropenia is defined as a neutrophil count less than =..
cells/mm
:
+ or a count less than -... cells/mm
:
)ith a predicted decrease to less than =.. cells/mm
:
4 ;I'SA+ A..A<
Group Description
Low
Risk (I)
Must
meet all
criteria
No associated comorbid illnesses*
Alert and oriented times 3 / No mental status changes
Non transplant, solid tumor or hematologic malignancy with no previous fungal infection
Serum creatinine less than 2mg/dl
Liver function tests less than 3 times normal
eceiving oncology care in the !"# system$
#as resources and is able to fill oral antibiotic prescription within %2 hours &able to comply with and
consent to outpatient pathway'
Contact Hematology-Oncology Fellow to initiate outpatient order set and consent form.
High
Risk (II)
(one marrow transplant / hematologic malignancies or uncontrolled cancer
Age greater than )*
Altered mental status or confusion
!nable to ta+e ,- medication &nausea / vomiting or mucositis'. dehydration
No telephone or transportation, no acute medical center within % hour from home
Serum creatinine greater than 2$* mg/dl or renal failure re/uiring intervention
Liver function tests greater than 3 times normal
S(, less than 0* mm#g, # &resting' greater than %** bpm, greater than 2*/min, -2 sat less
than 0*1&room air/baseline -2'
!ncontrolled comorbid conditions*, significant burden of illness or poor performance status
23pected prolonged neutropenia &less than %**/cells/mm
3
for greater than or e/ual to 4 days' or
bleeding re/uiring transfusion
-bvious central line infection , pneumonia or other comple3 infection
Initiate inpatient febrile neutropenia order set for inpatient admission and contact Hematology-
Oncology Fellow.
Critical
(III)
5eets high ris+ criteria and appears very ill &i$e$ hypotension, shoc+'
Initiate inpatient febrile neutropenia order set for inpatient critical car admission and contact Hematology-
Oncology Fellow.
PComor2id conditions can include dia2etes+ COP'+ CHF ;cardiac pro2lems or %I@ changes4< The use of these guidelines is
su2Qect to the clinical Qudgment of the practitioner and the patient5s clinical presentation4
OT".A.:. ;--/.7<
c:.-0-- Page 0 of 0