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Synovial fluid analysis on patients with a mono or polyarticular arthropathy of unclear etiology may be helpful in determining the etiology medications recalled by the fda buy liv 52 120 ml low price. Which studies should generally be performed on synovial fluid after arthrocentesis A measurement of the distance in millimeters that red blood cells travel in a Westergen or Wintrobe tube over 1 hour that is an indirect measurement of acute-phase reactants in systemic inflammation medications safe in pregnancy 120 ml liv 52 fast delivery. The titer has little prognostic value in an individual patient symptoms shingles order liv 52 australia, and remeasurements provide little added information treatment atrial fibrillation 100 ml liv 52 visa. With the development of immunofluorescence microscopy techniques, different staining patterns were discovered, and it became clear that many different nuclear antigens can elicit an antibody response. Next, fluorescent anti-Ig is added, which binds to antibodies (if present) in the test serum. Different patterns of staining occur, and although they may provide some information, they do not identify the specific antibody present, nor are they specific for a disease entity or clinically relevant. For example, the rim or peripheral pattern (usually associated with antibodies directed against nuclear membrane proteins) may be obscured if another autoantibody (staining a homogeneous pattern) is present. Inflammatory arthritis tends to involve small joints, has a morning stiffness component, and improves with activity. To increase the diagnostic likelihood of a specific rheumatic diagnosis and provide prognosis. Calcific tendinitis Ehlers-Danlos Parathyroid disease Chondrocalcinosis syndrome Renal osteodystrophy Dermatomyositis Neoplasia Sarcoidosis Diabetes Neuropathic Scleroderma arthropathy Trauma 36. Describe typical radiographic features of inflammatory arthritis in early and progressive disease. Soft tissue swelling and juxta-articular osteoporosis in early disease and more diffuse osteoporosis with uniform loss of cartilage in chronic disease. Further inflammation will lead to synovial hypertrophy and erosions with marginal areas of the synovium. Peak incidence is in the fourth and fifth decades of life, but almost any age can be affected. Estrogen has been shown to inhibit T suppressor cell function and enhance T helper function, leading to stimulatory effects on the immune system. A 25 pack-year or more history of tobacco use is associated with more severe disease with greater seropositivity, nodules, and radiographic changes. A 1 to 2-cell-thick lining of the joint made up of two types of synoviocytes: type A (macrophage-like cells probably derived from bone marrow) and type B (fibroblast-like cells that are probably of mesenchymal origin. Increased numbers of type A and type B synoviocytes are added to the synovial lining. A term to describe the area of proliferating synovium that can erode the adjacent cartilage and bone. Pannus tissue adheres to articular cartilage, and the cells within the pannus produce proteinases thatcandestroycartilage. Synovial tissue analysis also reveals inflammatory mediators including cytokines, enzymes, adhesion molecules, and transcription factors. Larger joints of the upper and lower extremities, such as the elbows, shoulders, ankles, and knees, are also commonly affected, although symptoms may appear later. Less common are cervical spine, temporomandibular, and sternoclavicular joint involvement. Significant laxity at the atlantoaxial joint with subluxation makes patients prone to slowly progressive, spastic quadriparesis. If this laxity is present, the hyperextension of the neck that occurs during intubation for general anesthesia can produce quadriplegia. Therefore, patients with neck pain or longstanding disease should undergo cervical spine evaluation before any surgical procedure. Firm, usually movable nodules ranging in size from a few millimeters to 2 cm found over pressure areas. The classic rheumatoid nodule has a central area of necrosis surrounded by a rim of palisading fibroblasts surrounded by a collagenous capsule with perivascular collections of chronic inflammatory cells. Patients are more susceptible to bacterial infections and have a higher risk of development of non-Hodgkin’s lymphoma. Multiple perihilar lung nodules with pathology similar to rheumatoid nodules are also found. These patients can develop massive fibrosis and are at increased risk of tuberculosis. Because functional status may be one of the best predictors of premature mortality. Because the joints can be significantly structurally damaged early in the disease if not treated. The structural damage produces mechanical derangements in the joint leading to deformity and profoundly impaired joint function. Postpartum flares of disease occur in approximately 90% of women who experience improvement during pregnancy. Disease-modifying medications including the biologic agents have improved clinical outcomes in rheumatoid arthritis. Although glucocorticoid treatments are common in managing several rheumatic diseases, there are many untoward side effects including osteoporosis, increased cardiovascular disease, elevated glucose, and increased risk of infection. Gold compounds were used more frequently in the past, but much less frequently now because of high levels of toxicity. Cyclosporine, tacrolimus, and azathioprine have been shown to have efficacy as well. An autoimmune inflammatory disease that can affect many organ systems with protean manifestations. The pathogenesis of lupus is largely unknown, but immunologic abnormalities can give rise to excessive autoantibody production that can cause tissue damage. Pleuritis: convincing history of pleuritic pain or rub heard by pericarditis physician or evidence of pleural effusion or b. Pericarditis: documented by electrocardiogram or rub or evidence of pericardial effusion Renal disorder a. Cellular casts: may be red cell, hemoglobin, granular, tubular, or mixed Seizures or a. Seizures: in the absence of offending drugs or known metabolic psychosis derangement (e. Although these criteria may be helpful in aiding the diagnosis of lupus, patients who do not fulfill the classification criteria may still have the disease. Discrete erythematous plaques covered by scales that extend into hair follicles, causing follicular plugging. Raynaud’s Bullae Livedo reticularis phenomenon Livedo reticularis Alopecia Periungual Petechiae telangiectasia Vasculitis 81. List the differential diagnoses of a lupus patient who presents with musculoskeletal complaints. Synovitis Myopathy Septic arthritis Fibromyalgia Osteonecrosis Adrenal insufficiency Myositis Fractures Some of these disorders are related to the disease itself, whereas others may be related to medication side effects or existing comorbid conditions. Although there are reports of subsequent disease exacerbations, disease activity usually does not recur in transplanted kidneys. Oral ulcerations (most commonly painless buccal erosions) were identified in 40% of one group of patients. Esophageal involvement such as esophagitis, esophageal ulceration, or esophageal dysmotility seems to correlate with the presence of Raynaud’s phenomenon. Intestinal involvement results in abdominal pain, diarrhea, and occasionally, hemorrhage. Intestinal ischemia may be present and may progress to infarction and perforation. Vasculitis is suggested by such commonly used designations as “lupus cerebritis” and occurs in < 15% of patients. Neuropsychiatric manifestations of lupus may occur in approximately 70% of patients.
The intravenous antibiotics with subsequent conversion analysis did not find significant differences for treat to oral antibiotics symptoms 3dpo cheap 100 ml liv 52 free shipping. The mean length of stay of those patients There is inadequate evidence to recommend a was 0 treatment for sciatica discount 120 ml liv 52 overnight delivery. World Journal of Emergency Surgery (2016) 11:34 Page 10 of 25 Timing of appendectomy and in-hospital delay to the second model medicine look up drugs order generic liv 52 line, only a few perforations can be pre vented by a speedy operation after the patients have ar Does in-hospital delay increase the rate of complica rived at the hospital medicine stone music festival buy liv 52 60 ml cheap. Kelly) Similarly, others have found that the trends for non perforating and perforating appendicitis radically differ the management of most intra-abdominal acute surgical and it is unlikely that perforated appendicitis is simply conditions has evolved significantly over time and many the progression of appendicitis resulting from delayed are now managed without emergency operation. They studied 4529 patients who were inflammation and infection, and delay to operation allows admitted with appendicitis over 8 years and 4108 increasing tension in the wall with ischemia, necrosis and (91 %) patients underwent appendectomy with perfor perforation. There were three inde with all cases of appendicitis, as discussed below, and pendent predictors of perforation: age > 55 years, emergency operation is not always needed. Whatever the cause for oping advanced pathology increased with time and it delay, the real issue is if it will lead to more complica was associated with longer length of hospital stay and tions: there are numerous studies looking at the question antibiotic treatment as well as postoperative compli of in-hospital delay and indirect evidence can be cations [77]. No clinically signifi current diversity in practice appears to be caused by cant difference was found in outcome measures, including lack of high-level evidence although this is beginning overall morbidity and serious morbidity or mortality. It should be noted that the danger of per authors concluded that the results did not change when foration is possibly overstated and that negative ex disease severity was excluded from the model suggesting ploration is not benign [36]. The perforation rate, of more than 12 h, age over 65 years, time of admission therefore, should not be used as a quality measure of the during regular hours, and the presence of co-morbidity management of patients with suspected appendicitis [36]. Perforation He also notes that the increasing proportion of perfora was associated with a higher re-intervention rate and tions over time is explained by an increase in the number increased hospital length of stay. They concluded that in of perforations according to the traditional model and elderly patients with co-morbidity and suspected appendi mainly by selection due to resolution of non-perforated citis, a delay of surgery of more than 12 h should be appendicitis according to the alternative model. World Journal of Emergency Surgery (2016) 11:34 Page 11 of 25 As can be seen, the evidence is conflicting but recently – Primary or secondary closure of the wound They found that the most recent meta-analysis reported that the laparo timing of operation was not related to risk of complex scopic approach of appendicitis is often associated with appendicitis. Seven studies on children question of whether in-hospital delay is safe and not were included, but the results do not seem to be much associated with more perforations cannot be answered different when compared to adults. However, delays authors conclude the in those clinical settings where should be minimised wherever possible to relieve pain, surgical expertise and equipment are available and to enable quicker recovery and decrease costs. One review – Mesoappendix dissection: endoclip, endoloop, showed no difference in mortality [86]. Ligation or diagnostic tool in fertile women, in can be used also invagination of the stump In conclusion, there is no strong current choice over open appendectomy in pregnant pa evidence as to the preferred modality of appendectomy, tients. However, low grade evidence No major benefits have also been observed in lap shows that laparoscopic appendectomy during pregnancy aroscopic appendectomy in children, but it reduces might be associated with higher rates of foetal loss [98]. World Journal of Emergency Surgery (2016) 11:34 Page 13 of 25 open appendectomy [107], did not show any advantages Statement 5. In Peritoneal irrigation does not have any advantages perforated appendicitis the issue of using endoloops or over suction alone in complicated appendicitis. Whilst earlier securing the blood supply, or a small number of endo studies initially reported advantages with routine use clips, appearing to be really useful in case of mobile of endostaplers in terms of complication and opera cecum avoiding the need of an additional port. In tive times [116], more recent studies have repeatedly addition, potential hazards of diathermy are avoided, demonstrated no differences in intra or post the appendicular artery can be ligated under direct operative complications incidence between either vision, and smoke is not created [110]. Al nabsorbable foreign body is left in the peritoneal cavity though operative times maybe longer (but it is prob and may slip or become detached. Moreover, it requires ably biased by the learning curve) [120], the more experience especially in case of inflamed appendix operative costs were invariably and significantly lower with the risk of bleeding [111–113]. Endoloops were at differences are present in surgical time and conversion least as safe and effective as endostapler also in to open rate [111]. All three methods gave acceptable complication stapler over endoloops for stump closure for both rates. However, the need of evacuate of the smoke could when appropriate skills/learning curve are available. In addition, there is no inversion over simple ligation, either in open or lap evidence for any short-term or long-term advantage in aroscopic surgery. Scoring systems for intra-operative grading of appendicitis the practice of leaving intra-abdominal drains is also and their clinical usefulness widely used when complicated/perforated appendicitis is found. Mostly from paediatric experiences, it seems that What are the histopathological criteria for the use of drainage and irrigation is associated with appendicitis of clinical importance Gomes) Previous studies in children with perforated appendicitis have already reported a significantly lower incidence of the systematic review by Swank et al. Most drainage group (n = 228) and the no drainage group patients with malignant neoplasms, parasite infection (n = 225) after emergency open appendectomies and and granulomatosis underwent additional investigation found no significant differences between the two or treatment [133]. The author assesses three im Drains are not recommended in complicated ap portant disease aspects: appendix gross appearance, pendicitis in paediatric patients. Drains did not prove any refers to inflammation outside the appendix and its efficacy in preventing intra-abdominal abscess and most common causes are gynaecological disorders like seem to be associated with delayed hospital discharge. Similar result were achieved also in at laparoscopy in the absence of any other obvious Di Saverio et al. World Journal of Emergency Surgery (2016) 11:34 Page 15 of 25 pathology appeared to be an effective treatment for re the prospective study by Gomes et al. The appendix was citis is performed, even if another diagnosis cannot be graded by the surgeon upon its visual appearance: found at laparoscopy [136]. On the other hand, in the grade 0 (normal looking), 1 (redness and oedema), 2 retrospective study by Phillips et al. This was then compared with a the removal of a normal looking appendix in the ab biochemical-histologic assessment of the removed ap sence of other explanatory pathology [137]. The authors conclude that negative appendec the biochemical-histological diagnosis changed for 48 tomy should not be undertaken routinely during lapar (25. H ow ever,the intra-operative diagnosis alone is insufficient for score still needs to be validated within a multicentre identifying unexpected disease. Interestingly, the surgeon’s termining optimal grade disease management and experience did not affect the disagreement rate. Nonetheless, the clinical significance of these Role of percutaneous drainage and Interval early and/or mild forms of microscopic appendicitis is Appendectomy or immediate surgery. World Journal of Emergency Surgery (2016) 11:34 Page 16 of 25 the study with highest level of evidence about the 2 months [145], up to 38 % after 12 months [70]. In order conservative treatment of complicated appendicitis to avoid this quite high chance of recurrence, some with abscess or phlegmon is the meta-analysis by authors recommend routine elective interval append Simillis et al. The system (847 treated with conservative treatment and 725 with atic review by Hall et al. Data revealed that conservative treat studies for a total of 127 cases of non-surgical treat ment was associated with significantly less overall ment of appendix mass in children: after successful complications (wound infections, abdominal/pelvic ab non-operative treatment, the risk of recurrent appen scesses, ileus/bowel obstructions, and re-operations) if dicitis was found to be 20. However, this means difference was found in the duration of the first that 80 % of children may not need interval append hospitalization, the overall hospital stay and the dur ectomy. Overall, the complications reported included from 60 patients with appendicular abscess treated ei wound infection, prolonged postoperative ileus, ther with immediate laparoscopic surgery (30 pa hematoma formation, and small bowel obstruction, tients) or with conservative treatment (30 patients. In the laparos Because of its consistent morbidity, after successful copy group there were significantly fewer unplanned conservative management, the routine indication to readmissions (3 % versus 27 %, P = 0. Some authors recom group, instead, required more additional interventions mend routine interval appendectomy, not to avoid the (surgery or percutaneous drainage) (30 % versus 7 %, risk of recurrence, but to rule out possible P = 0. In the retrospective study by patients in the laparoscopy group and in four (13 %) Carpenter et al. The rate of un out of 24 patients with complicated appendicitis eventful recovery was 90 % in the laparoscopy group (7. The these data brought to the conclusion that several fac incidence of neoplasms was significantly higher in the tors support the use of immediate surgery in patients patients underwent interval appendectomy than in the with appendicular abscess [145]. However, it should immediate appendectomy group (five patients, 28 % be highlighted that laparoscopic appendectomy as vs. Average hos Preoperative and postoperative antibiotics pital stay was also not statistically different between the two groups. The study demonstrated that an antimicrobial Should Preoperative antibiotics prophylaxis be given When should postoperative patients with complicated appendicitis did not increase antibiotics be given In the last years use of antibiotics in patients undergo Recently, a prospective randomized trial on 518 ing appendectomy has been debated [150, 151]. Although discontinuation of antimicrobial treatment Antibiotics were superior to placebo for preventing wound should be based on clinical and laboratory criteria, a period infection and intra-abdominal abscess, with no apparent of 3–5 days for adult patients is generally sufficient to treat difference in the nature of the removed appendix [152].
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The clinical signicance is that increased retroversion places the patient at increased risk for posterior instability symptoms 3 weeks pregnant buy liv 52 200 ml without a prescription. Is there a relationship between glenoid inclination and rotator cuff tears/ instability Preliminary studies have demonstrated that increasing superior inclination of the glenoid signicantly reduces the amount of force required for superior humeral head migration hair treatment cheap liv 52 100 ml otc. This suggests that more upward-facing glenoids may increase the risk for superior humeral translation symptoms ulcer stomach buy cheapest liv 52 and liv 52, which has been shown to contribute to the development of rotator cuff disease medicine grace potter lyrics order 100 ml liv 52 free shipping. Increased glenoid retroversion has been shown to increase the risk for posterior instability. In Post M et al, editors: the shoulder: operative technique, Baltimore, Md, 1998, pp 1-42, Williams & Wilkins. Pieper H et al: Anatomic variation of the coracoacromial ligament: a macroscopic and microscopic cadaveric study, J Shoulder Elbow Surg 6:291-296, 1997. Patients with a rotator cuff tear who are asymptomatic have a 51% chance of becoming symptomatic in the future. Pieper H et al: Anatomic variation of the coracoacromial ligament: a macroscopic and microscopic cadaveric study, J Shoulder Elbow Surg 6:291-296, 1997. Patients with a rotator cuff tear who are asymptomatic have a 51% chance of becoming symptomatic in the future. Os acromiale, or unfused acromial epiphysis, is the failure of the distal end of the acromion to ossify. Os acromiale is often bilateral and may be seen in up to 8% of the normal population. The four presentations of os acromiale (pre, meso, meta, and basi) involve the acromion to greater or lesser degrees. An os acromiale may project into the rotator cuff outlet, decreasing its total area, and is thought to be associated with rotator cuff pathology. It has been proposed that acromial hooks lie within the coracoacromial ligament and are actually traction spurs. Whenever the humeral head is pressed upward against the coracoacromial arch, it places a traction load on the distal lateral acromion, and a traction spur forms in response to the loading. It is similar to traction spurs that form on the calcaneus at the attachment of the plantar fascia. Patients usually are less than 25 years old and have pain with activity that usually resolves with rest. The condition is reversible, and treatment is conservative (relative rest and medication. Patients typically are between 25 and 40 years old and experience recurrent pain with activity that does not always abate with rest. According to Neer, subacromial decompression should be considered if conservative treatment fails. Patients typically are older than 40 years and have a history of progressive disability that has led to a tear of the rotator cuff. Patients typically are older than 60 years and have a history of progressive disability with a torn rotator cuff. Clinical management consists of rotator cuff repair, hemi-arthroplasty, or total shoulder replacement. The coracoacromial arch consists of the coracoacromial ligament, which spans the distance between the coracoid and acromion of the scapula. The ligament provides a protective covering over the subacromial bursa and rotator cuff tendons and restricts excessive superior humeral head migration. Clinically the coracoacromial ligament has been associated with rotator cuff pathology (especially in overhead athletes. During humeral elevation and internal rotation, the greater tuberosity and the attached rotator cuff tendons can be compressed against the arch. Repetitive compression may traumatize the rotator cuff tendons and lead to pathology. What is a partial-thickness rotator cuff tear (tensile failure of the rotator cuff) The rotator cuff degenerates naturally with increasing age, especially after the third decade of life. Degeneration or tensile failure of the rotator cuff begins deep within the tissue near the under surface attachment of the tuberosity. Partial-thickness tears of the rotator cuff also may occur on the bursal side of the cuff, most commonly near the insertion. Partial-thickness tears attempt to heal, but in most instances they progress to full-thickness tears. Matsen describes why partial-thickness rotator cuff tears eventually progress to full-thickness tears: • Ruptured bers can no longer sustain a load; thus increased loads are placed on neighboring bers, making them more susceptible to rupture. This process produces a “zipper effect” and extends or unzips the tendon from the tuberosity. Undersurface rotator cuff tears are caused by rupture of the deep tissues of the rotator cuff that attach to the tuberosity. Undersurface tears, in fact, are partial-thickness tears of the rotator cuff on the articular surface. They can result from the natural degenerative process that affects the shoulder but often are noted in younger overhead athletes. Undersurface tearing in overhead athletes is thought to result from repetitive eccentric tensile loading. With massive tearing of the rotator cuff, cuff tendons slide off the humeral head. These tendons, which once served as humeral head depressors, now act as humeral head elevators and promote superior translation of the humeral head. The result is excessive wear and degeneration on both the humeral head and the undersurface of the acromion. If allowed to progress, the degeneration of the glenohumeral joint can become so signicant and painful that a hemi-arthroplasty or total shoulder replacement is indicated. In severe cases of rotator cuff arthropathy, radiographs can aid in the diagnosis before surgery. Radiographs reveal sclerosis of the undersurface of the acromion (“eyebrow sign”) secondary to prolonged bone-on-bone contact (humeral head in contact with undersurface of acromion) and cystic changes of the greater tuberosity. The typical patient requiring acromioplasty and decompression is between 25 and 40 years of age, experiences recurrent pain with activity that does not always abate with rest, and has failed conservative treatment (physical therapy, medications. Some surgeons believe that a more complete decompression is accomplished with the open technique. In addition, if a large rotator cuff tear is encountered during the open procedure, it can be repaired with relative ease, whereas arthroscopic repair of a large rotator cuff tear is difcult and technically demanding. Should the coracoacromial ligament be released during subacromial decom pression The coracoacromial ligament is a static stabilizer that limits superior humeral head translation. Release of the ligament contributes to increased superior humeral head migration and degenerative processes in shoulders with a massive rotator cuff tear. Thus some surgeons believe in retaining the coracoacromial ligament and preserving the arch to limit more severe superior humeral head migration, which may lead or contribute to rotator cuff arthropathy. Mumford originally intended the surgery to provide pain relief for patients suffering from acromioclavicular dislocation. Distal clavicle excision often is performed during acromioplasty and subacromial decompression to allow even greater rotator cuff decompression. The acromioclavicular joint no longer exists, however; distal stability of the scapula is maintained through the intact costoclavicular ligaments (conoid and trapezoid. Another form of this exercise is prone scaption, in which the patient lies prone and performs scaption from 90 degrees of elevation to approximately 120 to 150 degrees. Infraspinatus—External rotation can be performed in many different positions, such as standing or side-lying. The teres minor is also an external rotator but seems to have greater electromyographic activity when external rotation is combined with glenohumeral extension. The patient lies prone, with the arm hanging off the table, and then extends the shoulder level with the horizon while maintaining the shoulder in external rotation.
From day 2 tube feeds are gradually introduced and intravenous fuid is gradually stopped over a number of days symptoms zinc overdose order liv 52 no prescription. If milk feeds are tolerated well symptoms vertigo liv 52 120 ml sale, without vomiting treatment definition 60 ml liv 52 otc, abdominal distension or apnoea medicine of the people generic liv 52 200 ml without prescription, then the volume per feed can be increased. Infants weighing 1500g or more at birth They can be started on milk feeds from birth and usually do not need an intravenous infusion. Tube feeds of breast milk or formula are started at 60 ml/kg on day 1 and can be gradually increased to 150 ml/kg/day by day 5. Sick infants are usually fed as you would feed an infant weighing less than 1500 g, i. If milk feeds are given to sick infants, the infant’s stomach should be aspirated before each feed. Note that not all preterm infants and low birth weight infants need intravenous maintenance fuid. Small volume feeds can usually be started when the clinical condition of the infant improves. If milk feeds cannot be given for more than 72 hours, then total parenteral nutrition must be considered. To avoid these complications, sick infants are ofen kept nil per mouth for a few days. If sick infants are fed by tube, the stomach should be aspirated before each feed. When tube feeds are given to sick infants, the infant’s stomach should be aspirated before each feed. As both these groups of infants are at high risk of hypoglycaemia, milk feeds or an intravenous infusion of maintenance fuid must be started within an hour of delivery. If possible milk feeds should be given, as they contain more energy than maintenance fuid. The volume of milk per feed can usually be increased much faster than in preterm or sick infants. Both the multivitamin and iron drops can be added to the formula or breast milk if nasogastric or cup feeds are used. Tere is usually no need to introduce solids until the preterm infant is 4–6 months old. Many normal infants occasionally vomit because the volume of the feed is too big, due to swallowing too much air with the feed or due to excessive handling afer the feed. Vomiting is abnormal if any of the following features are present: • The infant vomits frequently, or vomits most of the feed, and as a result fails to gain weight or loses weight. An intravenous infusion must be started and the infant must be urgently referred to a level 2 or 3 hospital for investigation of a possible bowel obstruction. This is common in preterm infants, where the muscle sphincter in the lower oesophagus is immature and allows milk to pass up the oesophagus from the stomach. Congenital abnormalities such as oesophageal atresia, duodenal atresia or obstruction of the small or large intestine. Replace the nasogastric or orogastric tube to ensure that it is in the correct position. If the above fails to stop the vomiting, then the infant must be transferred to a level 2 or 3 hospital for further management. Cup feeds can be thickened with 5 ml Nestagel/100 ml milk when other more serious causes of vomiting have been excluded. Unlike Nestagel, Gaviscon only thickens the feed when the feed reaches the stomach. Only infants below 1800 g, infants with apnoea or respiratory distress and infants who vomit frequently are nursed on their abdomens. Other infants should be nursed on their back as this decreases the risk of cot death. Case study 1 A 1900 g, healthy preterm infant is born by normal vertex delivery afer a 34 week gestation. Case study 2 A preterm, underweight for gestational age infant is delivered by caesarean section at 32 weeks and weighs 1100 g at birth. Small tube feeds of expressed breast milk (or preterm formula if breast milk is not available) can be started on day 2. Afer day 2 the volume of milk is gradually increased as the volume of intravenous fuid is gradually decreased to give a steady increase in total volume until day 5 when 150 ml/kg milk feeds should be given. Terefore breast (or cup) feeds can be started when this infant is about 36 weeks, i. Some infants will start to suck earlier, especially if they receive skin to-skin (kangaroo mother) care. Case study 3 A 2100 g infant with hyaline membrane disease is given headbox oxygen and nursed under an overhead radiant warmer. As the infant has severe respiratory distress and an ileus, it is decided that the infant is too sick to be given milk feeds. However, an additional 25 ml/kg must be given as the infant will have increased fuid losses due to the overhead heater. If the infant remains very distressed, has a distended abdomen or poor bowel sounds, then the introduction of milk feeds will have to be delayed further and the maintenance fuid replaced with parenteral nutrition. A hypotonic solution as the concentration of electrolytes is less than that of blood. Because they are isotonic fuids, having the same concentration of electrolytes as blood. Case study 4 A 1600 g, preterm infant of 33 weeks is 1 week old and is cared for in a level 1 hospital. The infant appears well but vomits afer most feeds and has not started to gain weight yet. What other common or important causes of vomiting should you always think of when any infant has repeated vomits Nurse the infant prone (on the abdomen) and slightly raise the head of the matress. If the infant continues to vomit and fails to gain weight, refer to a level 2 hospital. Nestagel can be added to cup feeds if other causes of vomiting have been excluded. Passing a nasogastric tube A nasogastric tube, which passes through a nostril to reach the stomach, is used in infants who are too preterm or too ill to suck and yet need milk feeds. In very small infants and infants with respiratory distress, an orogastric tube, which is passed through the mouth instead of the nose, may be used instead of a nasogastric tube. A size F 5 tube is used for infants weighing less than 1500 g and a size F 6 tube is used for infants weighing between 1500 g and 2500 g. The length of the tube from the nostril to the stomach can be determined by measuring the distance from the suprasternal notch to the xiphisternum (the length of the infant’s sternum), doubling this distance and then adding 2. The correct length can be marked on the tube with a felt tipped or ball point pen or a narrow strip of coloured plastic tape. Flex the infant’s neck slightly and gently pass the required length of tube through one nostril. If the tube does not slide easily into the nostril, try inserting the tube into the other nostril. If the litmus paper turns pink then the fuid is acidic and confrms that the end of the tube is in the stomach. If the litmus paper remains blue then either the tube has not been pushed far enough down the oesophagus or is not in the oesophagus at all but is in the trachea or curled up in the pharynx. If the end of the tube is in the oesophagus instead of the stomach, the infant may vomit or develop apnoea when a feed is given, due to the refux of milk. If acid fuid is not obtained afer pushing the tube in a litle further, remove the tube completely and try inserting it again. If an orogastric tube is needed, the length of the tube is measured as for a nasogastric tube. If the milk does not fow out of the funnel, place a sterile rubber teat into the open end of the funnel and push your thumb into the teat.