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When the calibre of the catheter is large (> 8 French) 400mg motrin free shipping back pain treatment upper, accurate placement can be made by using a guiding needle previously inserted into the abscess motrin 600 mg sale pain medication for dogs with kidney disease. Tereafer buy discount motrin on-line new treatment for shingles pain, a small skin incision is made alongside the needle, and the trocar is advanced parallel to the guiding needle. When the catheter is in position, the inner stylet of the trocar is retracted, some millilitres of pus aspirated, and the trocar then removed. Seldinger technique An 18 to 20-gauge needle is inserted into the collection site and a guide wire passed through the needle. Afer needle insertion and aspiration of a few millilitres of fuid, a guide wire is inserted and the needle is withdrawn. It may be necessary to use dilators of increasing calibre to obtain an adequate track for introduction of the catheter. An advantage of the trocar technique is its relative simplicity, whereas the Seldinger technique allows more accurate location of the catheter. Management of the catheter A primary mechanism for internal catheter retention is the catheter confguration. Catheter output, the characteristics of the drained material and any changes in these characteristics should be carefully recorded. Output reduction while the abscess is incompletely drained may indicate the presence of a clog in the tube, in which case the catheter should be changed. Suspicion of a fstula with adjacent organs or other structures should be confrmed by injecting contrast fuid into the abscess through the catheter. Indications Liver Pyogenic abscess The pus is characteristically creamy and unpleasant smelling. Needle aspiration (even with a fne needle) is recommended as the frst diagnostic procedure, as it allows assessment of the thickness of the purulent material and, thus, facilitates the choice of catheter. It is lef in situ for a few days afer drainage has stopped (with the catheter open). Catheter drainage of a large pyogenic abscess of the liver Amoebic abscess The pus is yellow or dark-brown (‘anchovy sauce’) and, typically, odourless. The results of percutaneous drainage are very satisfactory for both kinds of abscess. Preliminary aspiration of cystic fuid (10–20 ml) for parasitological and biological examination is performed. Catheter insertion is only sometimes useful but is mandatory for large cysts and thick material. Afer fuid aspiration, 95% ethanol or 30% hypertonic 57 saline solution is introduced in a quantity equivalent to about one third of the aspirated fuid to ensure an efective concentration of the scolicide in the cyst. A variation involves repeating the ethanol injection (about 100 ml) every 3 days without reaspiration. The procedure is efective and safe: prolonged follow-up has not shown leakage of hydatid fuid or passage of ethanol or saline solution into the bile system. The operator must, however, bear in mind the risk of chemical cholangitis; therefore, a rapid test for bilirubin should be performed on the fuid from the cyst, before scolicide injection. Pus from a pyogenic abscess is yellow (a), whereas that from amoebic abscess is typically brown (b) a b Fig. Reaspiration of scolicide progressively empties the cyst 58 Pancreas Pancreatic pseudocyst Tese are collections of pancreatic juice encapsulated by a connective wall of varying thickness, without an epithelial lining. They originate from the pancreas and, in many instances, communicate with pancreatic ducts. They are usually found within or adjacent to the pancreas in the lesser peritoneal sac. Occasionally, pseudocysts dissect the mesentery and can be found anywhere in the abdomen. In the frst, there is an episode of acute pancreatitis with gland infammation, exudates and eventual disruption of the ductular system. When the presumed duration of collection of pancreatic juice is less than 6 weeks, treatment should be avoided to allow maturation of the pseudocyst wall. Percutaneous drainage of pseudocysts requires the use of large-bore catheters, as the collection fuid is rich in fbrin plugs and gross necrotic debris. The time needed to cure pseudocysts by percutaneous drainage is generally very long and sometimes takes months. The catheter is visible within the collection (black and white arrows), which is progressively emptied a b c d 59 Fig. The number of patients suitable for liver resection is sharply limited by many factors: multicentre tumours, non-resectable location, advanced liver cirrhosis and comorbidity. Methods for local tumour ablation have thus been proposed, and some ultrasound-guided procedures have gained ground. It is generally accepted that single tumours of less than 5 cm in diameter or multiple tumours (diameter < 3 cm) can be treated. It is performed, without anaesthesia, by inserting, under ultrasound guidance, a fne needle (22 gauge) into diferent tumour sites. Access is intercostal or subcostal, and 2–5 ml of 95% ethanol is injected at each session. The total amount of injected ethanol can be calculated from Shiina’s formula, in which a correction factor is introduced into the sphere volume calculation: 4/3 π (r + 0. A mild sedative is administered, before the skin is pricked with a small lancet under local anaesthesia. The radiofrequency generator is activated, and a temperature of about 100 °C is reached around the electrode tip and maintained for 10–20 min. Recent approaches to wider thermal necrosis have centred on modifying the needle electrodes: expandable electrodes enlarge the surface of the active electrode by means of extensible hooks (expandable system); and internal cooling of the needle electrode prevents adjacent tissue desiccation and hence allows higher power input (cooled system). In a substantial proportion of cases, the tumour is found to be completely 60 necrotized at the end of treatment. Recurrences afer these procedures are high (65–90% at 5 years), with a disease-free survival rate of about 25% at 3 years. Another advantage of this procedure is that tumour ablation can be achieved in only one or two sessions, while a large number of sessions are required for percutaneous ethanol injection over many weeks. Percutaneous ethanol injection is inefective for treating liver metastases, and this indication for the procedure has been abandoned. Studies carried out in a single institution are rare because few centres carry out enough procedures to be able to make such analyses. However, multicentre studies tend to underreport data, and data on therapeutic procedures are, in some settings, difcult to analyse. As some of these procedures (particularly drainage of abdominal abscesses and pancreatic collections) are carried out on severely ill patients, it is difcult or impossible to distinguish between procedure-related complications and the disease outcome. For local treatment of liver tumours (by percutaneous ethanol injection or radiofrequency ablation), the patient’s condition is relatively good and patients are closely followed afer treatment. Diagnostic procedures The risks associated with these diagnostic procedures are low: the mortality rate in the multicentre surveys lies in the range 0. In a recent survey of 16 648 ultrasound-guided liver procedures in one centre, no deaths were observed.
Syndromes
Following this purchase 600 mg motrin amex arthritis pain treatment guidelines, apply either ethanol (700 ml/l) buy motrin 400 mg visa pain medication for dogs after shots, • Coma may last for hours to months order generic motrin pills groin pain treatment video, but in tincture or aqueous solution of iodine or povidone untreated patients, respiratory arrest usually occurs iodine. Even if intensive care facilities are available, the infiltration of human rabies specific complications occur during the coma phase, which immunoglobulin around the wound may be result in death: hypoxia, anaemia, renal failure, indicated in high risk cases, for example, bites cardiac arrythmias, congestive cardiac failure, and sustained in a country where there is a high risk of cerebral oedema. Human rabies Those who work with animals in endemic areas, specific immunoglobulin provides immediate and anyone exposed to an animal bite or lick on passive protection. Rabies immunoglobulin is difficult to access in many areas Diagnosis and rabies vaccine can be expensive (see further No tests are currently available to diagnose rabies notes) so may not be easily available. In the clinical course of the disease, the virus can Now carry out Learning Activity 6. A corneal impression smear and skin biopsies may Nursing care show a positive result; although this will confirm Intensive care facilities can prolong life, but since a diagnosis, a negative result does not exclude death is inevitable, the most humane care for such infection. Postmortem diagnosis can be confirmed patients involves the relief of agony and suffering by examination of brain tissue. Methods of treatment Supportive care for the presenting symptoms There is no specific treatment once the disease is includes: established. Since elimination of the rabies virus at the site of infection by chemical or physical means is the most Infection control effective mechanism of protection, immediate Rabies virus may be present in saliva, tears, urine, Page 116 Module 4 or other body fluids. Therefore, in order to prevent any possible transmission basic precautions, Universal Precautions and transmission based precautions should be taken (see Module 1). While human-to-human transmission has not been recorded, pre-exposure vaccination is recommended for those caring for, or likely to care for, a patient with rabies. Post-exposure vaccine can be given to staff found to be caring for infected patients. Prevention of spread This is dependent upon: • reduction of rabies virus in animal hosts through vaccination campaigns; and • post-exposure treatment following a potentially infected bite. Pre exposure vaccination does not rule out the need for further vaccine if exposed to the virus. Epidemiological summary • Clinical examination at this stage may also show Tetanus occurs throughout the world and is a rigidity of spinal muscles and board like firmness leading cause of death in many developing of the abdominal muscles. Countries in Europe reporting sporadic cases in • the death rate is estimated at 3 per 100 with recent years include Albania, Azerbaijan, Croatia, good hospital care. Clostridium tetani is Mode of transmission recovered from the wound in only 30% of patients. The bacterium Clostridium tetani is found in the intestinal tracts of man and animals, where it Methods of treatment remains harmless and causes no disease. However, Guidelines for treating wounds spores are produced which are passed in the faeces, Thorough and careful wound cleaning is essential and contaminate the environment. Protection against can persist for years in soil and dust and are resistant tetanus with vaccine and human tetanus to heat, drying, chemicals and sunlight. Tetanus cannot be spread directly by person • Six hour interval between wound or burn and to-person contact. These spasms are often that shows substantial devitalised tissue, a puncture triggered by sensory stimuli, so a calm, quiet wound,contamination with soil or manure, and the environment should be provided. These may be different in other Tetanus can never be eradicated because the spores are European countries. However, prevention of Specific anti-tetanus prophylaxis Immunization Status Clean Wound – Treatment Tetanus Prone Wound – Required Treatment Required Last of 3 dose course or Nil Nil (a dose of human tetanus reinforcing booster immunoglobulin may be given if within last 10 years infection is considered high e. Patients with mild muscular spasms may be treated Immunization should therefore be given to anyone with infusions of diazepam. Post-exposure prophylaxis with specific human immunoglobulin can be initiated following a Modes of transmission potentially infectious tick bite, but there is no the virus responsible for this disease is transmitted specific treatment for this disease once established. Skin should be inspected Epidemiological summary for ticks every few hours and any ticks found should the disease is endemic in parts of Europe and be removed immediately. Scandinavia, and in forested areas (especially where • Those living in endemic areas should be aware there is heavy undergrowth). Immunization Manifestations A pre-exposure vaccine is available for those likely • the incubation period is 1–2 weeks. The vaccine is will develop after 10 days, characterised by severe widely used to protect special groups of workers headache and fever. Prompt treatment with post exposure prophylaxis Risk factors (specific human immunoglobulin) is available and Tickborne encephalitis is primarily an occupational provides immediate passive protection if given disease affecting soldiers, agricultural workers, and within four days of the tick bite. Urgent diagnosis is required • Faecal-oral spread through eating poorly cooked because sight may be severely and permanently meats, especially pork and mutton. Reactivation of latent illness • Faecal-oral spread through contact with cat’s the most common presentation is as faeces. The diagnosis Vertically: a congenitally acquired infection can of endophthalmitis is by culture of vitreous occur when a pregnant woman acquires an acute humour. Treatment Treatment is usually with oral pyremethamine and Epidemiological summary sulphonamide. Hospital referral is essential for Toxoplasmosis is one of the most common of infants with endophthalmitis. It is more common in countries where important for women during pregnancy and the meat is eaten raw or rare. Advice should include: • wash hands after handling raw meat and poultry; Manifestations • do not touch eyes or mouth whilst handling raw Uncomplicated infection meat and poultry; • Generally asymptomatic • cook meat completely (heat to at least 65° C); • 10–20% of cases will experience a flu-like illness • do not clean cat litter boxes; if unavoidable, wear • the clinical course is benign and self-limiting gloves while doing so; and and any symptoms will resolve within a few • wear gloves when gardening. As an additional precaution for children, keep Page 121 Infection in an immunocompromised patient children’s play areas free of cat excrement. Module 4 Page 121 West Nile fever Definition Manifestations West Nile fever is caused by the West Nile • A flu-like illness characterised by an abrupt onset flavivirus. Wild birds are the principal hosts • Occasionally (< 15% of cases) encephalitis, of this virus, although it has been isolated from meningitis, hepatitis, and myocarditis occurs. The virus is principally maintained within the bird Diagnosis population, but human outbreaks of the disease Peak viraemia occurs 4–8 days post infection, but occur when the culex mosquitoes feed on both can be identified from a blood sample for up to 10 infected birds and humans. Epidemiological summary Treatment In Europe, the virus was first isolated in 1963 from There is no specific treatment for this illness, but patients in the Rhone Delta and Volga Delta. Over the use of analgesics and anti-inflammatories will the past 40 years cases have been identified in provide relief of general symptoms. Intensive care southern France, southern Russia, Spain, Romania, (Appendix 1) may be required if more severe Belarus, Ukraine and Czechoslovakia. In 1996–1997, an outbreak of West Nile fever in Prevention and near Bucharest, Romania, resulted in more than Prevention is dependant upon: 500 clinical cases and a case fatality rate approaching • Control of the mosquito population (See 10%. Global warming may also tickborne encephalitis, toxoplasmosis, and West Nile fever? Oxford, Oxford animals and insects varies due to its dependence University Press, 1997 (Oxford General Practice upon numerous factors including variations in Series). Oxford, Oxford University Press, • Transmission of infection may be direct from the 1993.
