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A clamped drain should be immediately unclamped and medical advice sought if a patient complains of breathlessness or chest pain generic 200 mg extra super viagra fast delivery erectile dysfunction medicine in bangladesh. Patients with chest drains should be managed on wards by staff trained in chest drain management generic extra super viagra 200mg fast delivery impotence natural home remedies. A drain that cannot be unblocked should be removed and replaced by new catheter if significant pleural fluid remains. Surgical management : Proper planning & ensuring availability of all the trained & experienced personnel ie. Limited thoracotomy with or without rib resection by 5-7cms total incision on either side of chest tube ,if already in situ. To ensure complete lung expansion at the end of the procedure with minimal air leak. Follow- up : Till complete resolution of disease process & near complete lung expansion on x- ray chest. Referral criteria If no satisfactory response to conservative management by 5-7 days. Initial presentation as stage 2 or 3 of an empyema 23 Suspecting underlying immunodeficiency condition or empyema associated with non pneumonic pathologies which also require specialist’s attention. Situation 2 At Super Speciality Facility in Metro location where higher end technology is available Clinical diagnosis* If a child with pneumonia remains pyrexial or unwell 48 hrs. Patients with underlying conditions such as liver abscess, pancreatitis ,trauma , surgical or endoscopic procedure done etc with respiratory signs & symptoms. Ultrasound may be used to confirm the presence of a pleural fluid collection, septations, to guide thoracocentesis or drain placement. It should be done once surgery is contemplated to know pleural peel thickness, loculations & their details such as number,position,size etc. Diagnostic microbiology Blood cultures should be performed in all patients with parapneumonic effusion. Diagnostic analysis of pleural fluid Pleural fluid must be sent for microbiological analysis including Gram stain and bacterial culture. Tuberculosis and malignancy must be excluded in the presence of pleural lymphocytosis. If there is any indication the effusion is not secondary to infection, consider an initial small volume diagnostic tap for cytological analysis, avoiding general anaesthesia/sedation whenever possible. Considered only when bronchoalveolar lavage is necessary or suspected foreign body or assessing bronchial mucosal status for safe closure of br. Give consideration to early active treatment as conservative treatment results in prolonged duration of illness and hospital stay. If a child has significant pleural infection, a drain should be inserted at the outset and repeated taps are not recommended. Antibiotics All cases should be treated with intravenous antibiotics and must include cover for Gram positive cocci eg. Broader spectrum cover is required for hospital acquired infections, as well as those secondary to surgery, trauma, and aspiration. Oral antibiotics should be given at discharge for 1–4 weeks, but longer if there is residual disease. Chest drains Chest drains should be inserted by adequately trained personnel to reduce the risk of complications. Routine measurement of the platelet count and clotting studies are only recommended in patients with known risk factors. Where possible, any coagulopathy or platelet defect should be corrected before chest drain insertion. Ultrasound should be used to guide thoracocentesis or drain placement, when available. If general anaesthesia is not being used, intravenous sedation should only be given by those trained in the use of conscious sedation, airway management and resuscitation of children, using full monitoring equipment. Trocar usage preferably should be avoided & should it be needed ,due to circumstances, great care is mandatory to have a guard or control on it while inserting. All chest tubes should be connected to a unidirectional flow drainage system (such as an underwater seal bottle) which must be kept below the level of the patient’s chest at all times. Appropriately trained nursing staff must supervise the use of chest drain suction.

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Advantages of the method It more reliably reflects the clinical state and is the most sensitive method for serial study of chronic diseases buy 200 mg extra super viagra otc erectile dysfunction treatment by yoga, e purchase extra super viagra 200 mg line erectile dysfunction jogging. Disadvantages of the method 194 Hematology It requires a large amount of blood and involves dilution which may be one source of error. Interpretation of results Reference value Men: 0-15mm/hr; Women: 0-20mm/hr There is a progressive increase with age because of the decline in plasma albumin concentration. Enough blood to fill the Wintrobe tube (approximately 1ml) is drawn into a Pasteur pipette having a long stem. The Wintrobe tube is then filled from the bottom up 195 Hematology (so as to exclude any air bubbles) to the "0" mark. Advantages of the method • The method is simple, requires a small amount of blood and there is no dilution. Red cells possess a net negative charge (zeta potential) and when suspended in normal plasma, rouleaux formation is minimal and sedimentation is slow. Alterations in proportions and concentrations of various hydrophilic protein fractions of the plasma following tissue injury or in response to inflammation reduce the zeta potential and increase the rate of rouleaux formation and the size of the aggregates thus increasing the rate of sedimentation. Albumin which tends to counteract rouleaux formation diminishes in concentration (hypoalbuminemia) further increasing the sedimentation rate. However, plasma viscosity may increase to the extent of masking the rouleaux forming property of the plasma proteins. Effect of red cell factors Efficient rouleaux formation depends on the red cells having normal shape and size. Anisocytosis and poikilocytosis will reduce the ability of the red cells to form large aggregates thus reducing the sedimentation rate. Anemia by altering the ratio of red cells to plasma encourages rouleaux formation and accelerates sedimentation. Thus in iron deficiency anemia a 198 Hematology reduction in the intrinsic ability of the red cells to sediment may compensate for the accelerating effect of an increased proportion of plasma. Perpendicularity of the sedimentation tube-slight deviations from the vertical will increase the rate of sedimentation. Effect of temperature Higher temperatures cause falsely elevated results due to a reduction in plasma viscosity. Nevertheless, variation in the ambient temperature of a laboratory is unlikely to be a significant problem unless the tubes are exposed to direct sunlight. It follows then that there is a limit to the hypotonicity of a solution that normal red cells can stand. Although the osmotic fragility test depends upon osmosis, the actual rapture of the cell results from alteration of its shape and diminished 201 Hematology resistance to osmotic forces rather than a change in the composition of the cell or its osmolarity. Conversely, increased resistance against lysis in hypotonic solution is shown in red cells in thalassemia, sickle cell anemia and hypochromic (iron deficiency) anemia. P a r p a r t a n d C o - w o r k e r s m e t h o d o f determination Principle Test and normal red cells are placed in a series of graded - strength sodium chloride solutions and any resultant hemolysis is compared with a 100% standard. Reagent Stock 10% Sodium Chloride solution Dilutions 202 Hematology These may be prepared in 50-ml amounts and stored at 4oC for up to 6 months or may be prepared just before the test. It is convenient to make a 1% solution from the stock 10% and proceed as follows: Tube No Ml of 1% Ml of dist. If dilutions have already been prepared in bulk, place 5ml of the appropriate salt dilution in 203 Hematology each tube. The patient’s blood and a normal control specimen are taken with minimum of stasis and trauma into heparinized tubes. The test should be performed within 2 hours of sample collection or up to 6 hours if the blood is kept at 4oC. For the reading the supernatant of each tube must be removed carefully so as not to 204 Hematology include any cells. Bone marrow examination is used in 207 Hematology the diagnosis of a number of conditions, including leukemia, multiple myeloma, and anemia. The bone marrow produces the cellular elements of the blood, including platelets, red blood cells and white blood cells. While much information can be gleaned by testing the blood itself (drawn from a vein), it is sometimes necessary to examine the source of the blood cells in the bone marrow to obtain more information on hematopoiesis; this is the role of bone marrow aspiration and biopsy.

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