• Chapter 1: Management
• Chapter 2: Transcutaneous Bilirubin Testing
• Chapter 3: Use of Cardiac Biomarkers for Acute Coronary Syndromes
• Chapter 4: Coagulation
• Chapter 5: Critical care
• Chapter 6: Diagnosis and Management of Diabetes Mellitus
• Chapter 7: Drugs and Ethanol
• Chapter 8: Infectious Disease
• Chapter 9: Occult Blood
• Chapter 10: Intraoperative Parathyroid Hormone
• Chapter 12: Renal Function Testing
• Chapter 13: Reproductive Testing

Does the use of pH paper to diagnose and monitor treatment of chemical exposure in the emergency department and urgent care patient populations improve length of stay and severity of burn compared to empirical treatment (no monitoring)? (Literature Search 76 - Refer to Appendix B - see the "Availability of Companion Documents" field)

Guideline 151. The guideline developers note that pH paper may have utility in monitoring the treatment of chemical exposure in the emergency department and urgent care patient populations, but there is insufficient evidence to make a strong recommendation for or against its routine use. pH testing poses no risk to the patient, and the minimal cost of testing has led to its common availability. However, a systematic examination should be conducted to determine whether pH testing has an incremental benefit during irrigation therapy after chemical exposure that outweighs the time and expense required to maintain test quality training and documentation.
Strength/consensus of recommendation: I
Level of evidence: III (clinical experience, descriptive studies, case reports and opinion)

Does continuous gastric pH monitoring, compared to random gastric pH determinations, improve patient symptoms and severity in the management of achlorhydria and gastric reflux in inpatient and endoscopy patients? (Literature Search 77 - Refer to Appendix B - see the "Availability of Companion Documents" field)

Guideline 152. The guideline developers recommend against the intermittent use of pH paper on gastric aspirates in the diagnosis of gastric reflux disease in favor of continuous monitoring. The role of pH testing to manage acid suppression therapy is controversial. Although the use of pH testing is common on critical care units, there is a lack of evidence that pH monitoring to adjust drug dosage improves either morbidity or mortality in these patients.
Strength/consensus of recommendation: C
Level of evidence: II and III (well-designed case-controlled, or relation trials and opinion)

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? (Literature Search 78 - Refer to Appendix B - see the "Availability of Companion Documents" field)

Guideline 153. The guideline developers 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.
Strength/consensus of recommendation: B
Level of evidence: II and III (prospective comparative trials and expert opinion)

Is one brand of pH paper better than another brand in improving patient symptoms and time to treatment of chemical burns in emergency and urgent care patients, and in improving the accuracy of nasogastric tube placement in inpatient, endoscopy, home care, and nursing home patients? (Literature Search 79 - Refer to Appendix B - see the "Availability of Companion Documents" field)

Guideline 154. There is insufficient evidence to recommend one brand of pH paper over another brand of pH paper for use in the treatment of chemical burns or placement of nasogastric tubes.
Strength/consensus of recommendation: I
Level of evidence: III (case reports and opinion)

Definitions:

Levels of Evidence

1. Evidence includes consistent results from well-designed, well-conducted studies in representative populations.
2. Evidence is sufficient to determine effects, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies; generalizability to routine practice; or indirect nature of the evidence.
3. Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information.

Strength of Recommendations

A - The National Academy of Clinical Biochemistry (NACB) strongly recommends adoption; there is good evidence that it improves important health outcomes and concludes that benefits substantially outweigh harms.

B - The NACB recommends adoption; there is at least fair evidence that it improves important health outcomes and concludes that benefits outweigh harms.

C - The NACB recommends against adoption; there is evidence that it is ineffective or that harms outweigh benefits.

I - The NACB concludes that the evidence is insufficient to make recommendations; evidence that it is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Electronic copies: Available in Portable Document Format (PDF) from the National Academy of Clinical Biochemistry (NACB) Web site.

Print copies: National Academy of Clinical Biochemistry publications are available through American Association for Clinical Chemistry (AACC) Press. To make a purchase or request a catalog, contact AACC Customer Service at 202-857-0717 or custserv@aacc.org.

Electronic copies: Available in Portable Document Format (PDF) from the National Academy of Clinical Biochemistry (NACB) Web site.

Print copies: National Academy of Clinical Biochemistry publications are available through American Association for Clinical Chemistry (AACC) Press. To make a purchase or request a catalog, contact AACC Customer Service at 202-857-0717 or custserv@aacc.org.

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