Sunday, December 12, 2010

Umbilical vein catheterization technique

Umbilical vein catheterization may be a life-saving procedure in neonates who require vascular access and resuscitation. The umbilical vein remains patent and viable for cannulation until approximately 1 week after birth.
Umbilical vein catheters (UVC), are used for exchange transfusions, monitoring of central venous pressure, and infusion of fluids (when passed through the ductus venosus and near the right atrium); and for emergency vascular access for infusions of fluid, blood products or medications.
Usually in the emergency department peripheral access is preferred for critically ill newborns and if this is impossible, umbilical vein catheterization may be attempted.

Technique :
# The umbilical cord stump and surrounding abdomen should be sterilized with a bactericidal solution. Sterile drapes should be placed.
# A purse-string suture or umbilical tape is tied around the base of the stump to provide hemostasis and to anchor the line after the procedure.
# Using the scalpel, the cord is cut horizontally, approximately 1.5-2 cm from the abdominal wall. Two thick-walled small arteries and one thin-walled larger vein should be identified. The umbilical vein may continue to ooze blood.
# Hemostasis is achieved through tightening the umbilical tape or suture. The arteries do not usually bleed secondary to vasospasm.
# Forceps are then used to clear any thrombi and dilate the vein.
# A 3.5F catheter is used for preterm newborns, and a 5F catheter is used for full-term newborns.
5F umbilical catheter. Note proximal attachment for stopcock

# The catheter should be flushed with pre-heparinized solution and attached to a closed stopcock.
# The catheter is then grasped 1 cm from its distal tip with the iris forceps and gently inserted, aiming the tip toward the right shoulder. Advance the catheter only 1-2 cm beyond the point at which good blood return is obtained. This is approximately 4-5 cm in a full-term neonate. If resistance is initially met, loosen the umbilical tape or suture and manipulate the angle of approach.
Insertion of umbilical vein catheter
# Do not force the advancement.
# Secure the catheter with a suture through the cord, marker tape, and a tape bridge.
# The position of the catheter must be confirmed radiographically. A properly placed umbilical vein catheter appears to travel cephalad until it passes through the ductus venosus.
# Standardized graphs estimate the length of catheter insertion based on shoulder-to-umbilicus length. Alternatively, the shoulder-to-umbilicus length may be multiplied by 0.6 to determine a length that leaves the tip of the catheter above the diaphragm but below the right atrium.
# In an emergency resuscitation, the catheter is best advanced only 1-2 cm beyond the point at which good blood return is obtained.

No anesthesia is typically required for the procedure.

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Bellevue Guide Outpatient Medicine

The Bellevue Guide to Health Care represents a collaboration among primary care and specialist physicians in the Department of Medicine at New York School of Medicine. It is intended for use by teachers, students and practitioners of primary care and in the hospital outpatient department. The Guide presents data about prevalence of disease, accuracy and diagnosis from congestive heart failure to domestic violence. Advice about patient management is interwoven with annotated references in a unique two column format providing the actual data upon which recommendations are based. (For example, recommendations to use statin drugs to treat hypermlipidemia are accompanied by literature based estimates of live-saving potential by statins among various patient groups.)
Readers of The Guide are encouraged to use this data to tailor clinical decisions to meet the needs of their individual patients.


Measuring Blood Pressure Instructions

Appropriate treatment of Rosacea

A 72-year-old man presents to your office complaining of an area of redness associated with the perinasal region. He states that the rash is often worse in the summer, and he has noticed that sunlight exposure makes it worse. Appropriate treatment of this condition consists of
  • A) hydrocortisone cream
  • B) tretinoin gel
  • C) metronidazole cream
  • D) mupirocin ointment
  • E) acyclovir ointment

The answer is: ( C ). (Rosacea)
Rosacea is a common problem encountered by family physicians. The condition is associated with areas of erythema and telangiectasia on the face. It is exacerbated by sunlight, hot or spicy foods, and alcohol. Pronounced rosacea may appear as acneiform papules, pustules, or ruddiness.
Northern Europeans and those of Celtic descent are most commonly affected. Treatment involves oral tetracycline or doxycycline. Topical metronidazole is also effective for milder cases.

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Anatomy on Radiographic Scapula

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Sclerodactyly in Systemic Scleroderma

Systemic scleroderma often affects the hands. The initial stage is swelling (edema), which can last for weeks, months, or years. Often the swelling is intermittent and worse in the morning. It can cause the fingers to look like sausages, with far fewer wrinkles. Skin tightness in the hands can make it impossible to pinch the skin on the fingers.
In some people, the fingers eventually begin to harden from fibrosis, and curl inward. They may then become frozen in this clawed position, which is referred to as "sclerodactyly."

So,When the skin on the fingers become tight, stretched, wax-like, and hardened it is called sclerodactyly. Sclerodactyly is commonly associated with atrophy of the underlying soft tissues.

Not everyone with scleroderma develops this degree of skin hardening. However, it is this symptom that has earned scleroderma the nickname of 'the disease that turns people to stone'.

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Review of heart sounds