Medical Instructor, University of Washington School of Medicine
These data suggest that it may be beneficial to withhold enteral nutrition for the first 24 to 48 hours in patients with severe sepsis symptoms tracker purchase detrol 1 mg without prescription. Randomized controlled trials proving that starvation is detrimental to critically ill and injured patients have until recently not been performed medications 377 generic 2 mg detrol mastercard. This is likely because of the lack of equipoise by researchers and the notion that such an experiment would be unethical medicine joint pain buy discount detrol on-line. In this study, patients with acute severe pancreatitis were randomly assigned to nasoenteric tube feeding within 24 hours after randomization or to an oral diet initiated 72 hours after presentation with tube feeding provided the oral diet was not tolerated. The alimentary tract and metabolic pathways of humans appear designed for intermittent ingestion of nutrients a few times a day. Humans have evolved as intermittent meal eaters and are not adapted to a continuous inflow of nutrients; normal physiology appears to be altered when this approach is adopted. Continuous as opposed to intermittent enteral feeding likely limits protein synthesis, and this may be an important factor in promoting critical illness–acquired muscle weakness [230]. In addition to adversely affecting protein synthesis, continuous enteral feeding can have other adverse consequences including uncontrolled hyperglycemia, hepatic steatosis, functional changes of the small intestine, and diminished gall bladder contraction [230]. These data suggest that anorexia with limited nutrient intake is an evolutionary preserved response that may be beneficial during the first 24 to 48 hours of acute illness. In those patients who are unable to resume an oral diet after this time period, enteral nutrition via orogastric tube is recommended. Continuous tube feeding targeting normocaloric goals has not been proven to improve outcome; such a mode of feeding may be unphysiologic. Each patient is unique, with a unique set of genes and comorbidities, and responds to illness and its treatment in a unique and often unpredictable manner. This dictates that patients with sepsis be treated with an appropriate physiologic approach that promotes healing and limits the potential for intragenic harm. Whippy A, Skeath M, Crawford B, et al: Kaiser Permanente’s performance improvement system, part 3: multisite improvements in care for patients with sepsis. Ait-Oufella H, Maury E, Lehoux S et al: the endothelium: physiological functions and role in microcirculatory failure during severe sepsis. Trzeciak S, Rivers E: Clinical manifestations of disordered microcirculatory perfusion in severe sepsis. Sanfilippo F, Corredor C, Fletcher N, et al: Diastolic dysfunction and mortality in septic patients: a systematic review and meta-analysis. Landesberg G, Gilon D, Meroz Y, et al: Diastolic dysfunction and mortality in severe sepsis and septic shock. Gomez H, Ince C, De Backer D, et al: A unified theory of sepsis- induced acute kidney injury: inflammation, microcirculatory dysfunction, bioenergetics, and the tubular cell adaption to injury. Legrand M, Dupuis C, Simon C, et al: Association between systemic hemodynamics and septic kidney injury in critically ill patietns: a retrospective observational study. Rivers E, Nguyen B, Havstad S, et al: Early goal-directed therapy in the treatment of severe sepsis and septic shock. Dark P, Blackwood B, Gates S, et al: Accuracy of LightCycler SeptiFast for the detection and identification of pathogens in the blood of patients with suspected sepsis: a systematic review and meta-analysis. Clinical and Laboratory Standars Institute: Principles and Procedures for Blood Cultures: Approved Guideleine. Lamy B, Roy P, Carret G, et al: What is the relevance of obtaining multiple blood samples for culture? Brodska H, Malickova K, Adamkova V, et al: Significantly higher procalcitonin levles could differentiate Gram-negative sepsis from Gram-positive and fungal sepsis.
Management of the Difficult Airway A difficult airway may be recognized (anticipated) or unrecognized at the time of the initial preintubation airway evaluation medicine zolpidem discount detrol 2 mg amex. Difficulty managing the airway may be the result of abnormalities such as congenital hypoplasia symptoms uti buy detrol 2mg cheap, hyperplasia of the mandible or maxilla symptoms bronchitis safe detrol 4 mg, or prominent incisors; injuries to the face or neck; acromegaly; tumors; and previous head and neck surgery. Difficulties ventilating the patient with a mask can be anticipated if two of the following factors are present: older than 2 55 years of age, body mass index greater than 26 kg per m, beard, lack of teeth, and a history of snoring [38]. When a difficult airway is recognized before the patient is anesthetized, an awake tracheal intubation is usually the best option. It may be particularly useful when the upper airway anatomy has been distorted by tumors, trauma, endocrinopathies, or congenital anomalies. This technique is sometimes valuable in accident victims in whom a question of cervical spine injury exists and the patient’s neck cannot be manipulated. An analogous situation exists in patients with severe degenerative disk disease of the neck or rheumatoid arthritis with markedly impaired neck mobility. After adequate topical anesthesia is obtained (discussed in “Anesthesia before Intubation” section), the bronchoscope can be used to intubate the trachea via either the nasal or oral route. If mask ventilation cannot be maintained, a cannot ventilate–cannot intubate situation exists and immediate lifesaving rescue maneuvers are required. When properly inserted, it fits over the laryngeal inlet and allows positive-pressure ventilation of the lungs. When air is aspirated, the needle is in the airway, and the catheter is passed over the needle into the trachea. Management of the Airway in Patients with Suspected Cervical Spine Injury Any patient with multiple trauma who requires intubation should be treated as if cervical spine injury was present. In the absence of severe maxillofacial trauma or cerebrospinal rhinorrhea, nasal intubation can be considered. If oral intubation is required, an assistant should maintain the neck in the neutral position by ensuring axial stabilization of the head and neck because the patient is intubated. In a patient with maxillofacial trauma and suspected cervical spine injury, retrograde intubation can be performed by puncturing the cricothyroid membrane with an 18-gauge catheter and threading a 125-cm Teflon- coated (0. A bite block can be positioned in patients who are orally intubated to prevent them from biting down on the tube and occluding it. Once the tube has been secured and its proper position verified, it should be plainly marked on the portion protruding from the patient’s mouth or nose so that advancement can be noted. Cuff Management Although low-pressure cuffs have markedly reduced the incidence of complications related to tracheal ischemia, monitoring cuff pressures remains important. Maintenance of intracuff pressures between 17 and 23 mm Hg should allow an adequate seal to permit mechanical ventilation under most circumstances while not compromising blood flow to the tracheal mucosa. The intracuff pressure should be checked periodically by attaching a pressure gauge and syringe to the cuff port via a three-way stopcock. The need to add air continually to the cuff to maintain its seal with the tracheal wall indicates that (a) the cuff or pilot tube has a hole in it, (b) the pilot tube valve is broken or cracked, or (c) the tube is positioned incorrectly, and the cuff is between the vocal cords. If the valve housing is cracked, cutting the pilot tube and inserting a blunt needle with a stopcock into the lumen of the pilot tube can maintain a competent system. Suctioning can produce a variety of complications, including hypoxemia, elevations in intracranial pressure, and serious ventricular arrhythmias.
Over time medicine versed generic 4 mg detrol with visa, bacteria are capable of migrating up the ureters and reaching the kidney symptoms stomach flu buy cheap detrol. Once bacteria enter the renal parenchyma symptoms liver cancer cheap detrol 4 mg amex, they are able to enter the bloodstream and cause septic shock. In young, sexually active women, Staphylococcus saprophyticus accounts for 5–15% of cases of cystitis. In patients who experience recurrent infections, have been instrumented, or have anatomic defects or renal stones, Enterobacter, Pseudomonas, and enterococci are more commonly cultured. Candida species are frequently encountered in hospitalized patients who are receiving broad-spectrum antibiotics and have a bladder catheter. Patients with structural abnormalities are more likely to have polymicrobial infections. Escherichia coli is the most frequent pathogen, followed by Klebsiella and Proteus. Staphylococcus saprophyticus causes 5–15% of cystitis cases in young, sexually active women. Nosocomial infections usually involve Enterobacter, Pseudomonas, enterococci, Candida, S. One week before admission (4 weeks after her honeymoon), she noted mild burning on urination. Two days before admission, she experienced fever associated with rigors and increasingly severe flank pain. The physical examination showed a blood pressure of 80/50 mmHg, a pulse of 125 per minute, and a temperature of 37. The remainder of her physical examination was normal, except for mild left costovertebral angle tenderness. Clinical Manifestations Patients with cystitis usually experience acute-onset dysuria (pain, tingling, or burning in the perineal area during or just after urination). In addition, patients need to urinate frequently, because inflammation of the bladder results in increasing suprapubic discomfort when the bladder is distended and may cause bladder spasms that interfere with bladder distension. Some patients note blood in the urine caused by inflammatory damage to the bladder wall. However, in addition to symptoms of cystitis, patients with pyelonephritis are more likely to experience fever and chills, costovertebral angle pain, nausea and vomiting, and hypotension. Patients with diabetes mellitus often experience subacute pyelonephritis that clinically mimics cystitis. Elderly patients have a higher probability of having upper-tract disease and a higher risk for developing bacteremia. Patients who have had symptoms for more than 7 days are also at increased risk for pyelonephritis. When antibiotic treatment for cystitis is delayed for this period, bacteria have time to migrate up the ureters and infect the kidneys. Cystitis symptoms include dysuria, urinary frequency, hematuria, suprapubic discomfort. Pyelonephritis symptoms include fever and chills, nausea and vomiting, tachycardia, hypotension, and costovertebral angle pain and tenderness, the disease is more likely to occur in a) diabetic patients (who often have only symptoms of cystitis), b) elderly patients (who may present with confusion or somnolence), or c) patients who have had cystitis symptoms for more than 7 days. Asymptomatic bacteriuria is defined as a positive culture with no symptoms, and usually without pyuria. Urethritis can be mistaken for cystitis; usual indicators are fewer than 5 10 bacteria on culture and a lack of suprapubic tenderness. Vaginitis can mimic cystitis; pelvic examination is a must if symptoms are associated with vaginal discharge.
In one series medicine 2 times a day generic detrol 2 mg, 95% of nasotracheally intubated patients developed radiographic evidence of pansinusitis [6] medicine etodolac purchase detrol master card, as did 25% of patients who were orotracheally intubated symptoms 8 days after ovulation 4 mg detrol otc. Pathogenesis Critically ill patients are predisposed to develop nosocomial sinusitis for several reasons. The diameter of the ostia, normally as small as 1 or 2 mm, has been shown to decrease with recumbency as much as 23% because of venous hydrostatic pressures [7]. Larger intranasal tubes (tracheal) induce radiographic sinus changes more quickly than smaller tubes (gastric) [4]. Using multiple logistic regression analysis, risk factors for nosocomial sinusitis, of strongest association, are sedative use; nasogastric feeding tubes; Glasgow coma scale less than 8; and nasal colonization with enteric gram-negative bacteria [8]. Etiology the microbiology of nosocomial sinusitis is quite distinct from that of community-acquired sinusitis, and is similar to that of other nosocomial respiratory infections. Nosocomial sinusitis is polymicrobial in 54% of cases, with gram-negative aerobic organisms being the most common causative agents (49%), followed by gram-positive aerobic organisms (37%), fungi (7. The organisms isolated in nosocomial sinusitis are the ones frequently identical to those cultured from the lower respiratory tract [3,9]. Such findings support the concept of general colonization of the airway mucosa of critically ill patients. Aspergillus and species of Zygomycetes such as Mucor are identified in the majority of cases, with Mucor spp. The most common presenting symptoms are fever, purulent nasal drainage, facial pain, facial swelling, nasal crusting, and visual symptoms [10]. Radiographically, sinus opacity and bony erosion are seen in all cases, and these findings are usually unilateral [11]. Cryptococcus neoformans can cause sinusitis with a high relapse rate and significant mortality in immunocompetent and immunocompromised patients [12]. Orbital complications include edema, predominantly of the eyelids, orbital cellulitis, orbital abscess, subperiosteal abscess, and cavernous sinus thrombosis [15,16]. Intracranial complications have an overall mortality of 40% and include osteomyelitis, meningitis, epidural abscess, subdural empyema, and brain abscesses [17–19]. For these cases, sinus drainage is imperative and antibiotics are started early and redirected by culture results. Several investigators have examined the relationship between nosocomial sinusitis and ventilator-associated pneumonia. In addition, clinically evident sinusitis increases the risk of bloodstream infections, and in patients with sinusitis and bloodstream infections, the same organism is identified among 20% of cases [5]. A prospective, randomized study of a strategy to systematically detect and treat nosocomial sinusitis, both radiographic evidence and bacteriologic evidence of sinusitis were reported for 55% of febrile, mechanically ventilated patients [20]. In 198 patients, the cause of the fever remained unknown despite initial investigations that included chest radiographs. Although bone often presents obstacles to ultrasound imaging, the anterior walls of the maxillary sinuses are flat bones composed of compact tissue, allowing adequate ultrasound penetration. Vargas and coworkers used B-mode ultrasound in the semi-recumbent position in 120 patients with suspected sinusitis [24]. On transnasal puncture, fluid could be aspirated from all such patients, and the cultures were positive for 67% of patients [24]. In patients where only the posterior wall of the maxillary sinus is hyperechogenic, 80% of transnasal punctures yield fluid, and cultures are positive in half of those where fluid is obtained. Rhinoscopy and Antral Aspiration As reviewed earlier, opacification of the paranasal sinuses among the critically ill patient does not necessarily indicate infectious sinusitis; in some series, half or more of such patients have sterile cultures. In patients with both purulent secretions in the middle meatus by rhinoscopy and radiographic evidence of sinusitis, 92% have positive cultures by antral lavage. Although cultures obtained from the maxillary sinus by antral puncture had previously been considered the gold standard for diagnosis of nosocomial sinusitis, endoscopically guided middle meatal cultures accurately reflect cultures obtained from direct maxillary sinus aspiration in 85% to 100% of patients [26].
Although a detailed anatomic description is beyond the scope of this book medicine vending machine order detrol 4mg without prescription, an understanding of some features and relationships is essential to performing intubation treatment quadriceps strain order genuine detrol on line. The anatomic proximity of the roof to intracranial structures dictates that special caution be exercised during nasotracheal intubations symptoms night sweats purchase detrol cheap. The mucosa of the nose is provided with a rich blood supply from branches of the ophthalmic and maxillary arteries, which allow air to be warmed and humidified. Because the conchae provide an irregular, highly vascularized surface, they are particularly susceptible to trauma and subsequent hemorrhage. The hard and soft palates compose the superior surface, and the oropharynx forms the posterior surface. Nasopharynx the base of the skull forms the roof of the nasopharynx, and the soft palate forms the floor. The roof and the posterior walls of the nasopharynx contain lymphoid tissue (adenoids), which may become enlarged and compromise nasal airflow or become injured during nasal intubation, particularly in children. The Eustachian tubes enter the nasopharynx on the lateral walls and may become blocked secondary to swelling during prolonged nasotracheal intubation. Oropharynx the soft palate defines the beginning of the oropharynx, which extends inferiorly to the epiglottis. The palatine tonsils protrude from the lateral walls and, in children, occasionally become so enlarged that exposure of the larynx for intubation becomes difficult. Contraction of the genioglossus muscle normally moves the tongue forward to open the oropharyngeal passage during inspiration. Hypopharynx the epiglottis defines the superior border of the hypopharynx, and the beginning of the esophagus forms the inferior boundary (approximately 1 cm below the cricoid ring). The thyroid, cricoid, epiglottic, cuneiform, corniculate, and arytenoid cartilages compose the laryngeal skeleton. The cricoid cartilage articulates with the thyroid cartilage and is joined to it by the cricothyroid ligament. When the patient’s head is extended, the cricothyroid ligament can be pierced with a scalpel or large needle to provide an emergency airway (see Chapter 9). The anterior wall of the larynx is formed by the epiglottic cartilage, to which the arytenoid cartilages are attached. Because normal phonation relies on the precise apposition of the true vocal cords, even a small lesion can cause hoarseness. The superior and recurrent laryngeal nerve branches of the vagus nerve innervate the structures of the larynx. The superior laryngeal nerve supplies sensory innervation from the inferior surface of the epiglottis to the superior surface of the vocal cords. A large internal branch pierces the thyrohyoid membrane just inferior to the greater cornu of the hyoid. It also supplies all the muscles of the larynx except the cricothyroid, which is innervated by the external branch of the superior laryngeal nerve. It is bounded posteriorly by the esophagus and anteriorly for the first few cartilage rings by the thyroid gland. The trachea is lined with ciliated cells and has mucus glands; through the beating action of the cilia, foreign substances are propelled toward the larynx. Too frequently, inexperienced personnel believe that this requires immediate intubation; however, attempts at intubation may delay establishment of an adequate airway. Such efforts are time consuming, can produce hypoxemia and arrhythmias, and may induce bleeding and regurgitation, making subsequent attempts to intubate significantly more difficult and contributing to significant patient morbidity and even mortality [2,3]. Some simple techniques and principles of emergency airway management can play an important role until the arrival of an individual who is skilled at intubation.
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