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Composition of iv fluids common c y alloid iv fluid sal con en (%) sodium (meq/l) normal saline 0.9 154 d5 ½ (half) normal 0.45 75 hartmann or ringer lactate 131 a hypovolemic patient, aggressive uid resuscitation is required with several liters o uid within the rst ew hours. Similarly, patients who are kept npo or more than 8 hours may require maintenance uids at a rate o 83 ml/h (table 3-3). Central venous catheters and central line-associated bloodstream infections approximately 80,000 central line-associated bloodstream in ections occur in icus each year. A patient population is exposed to 15 million central venous catheter (cvc) days each year.23,24 t e 4 microbes most commonly causing clabsi are coagulase-negative staphylococci, s. Aureus, candida species, and gram-negative bacilli. When a clabsi is suspected, blood cultures should be drawn a er the cvc is removed, and antibiotics should be started empirically. Cvcs should be placed in upper extremity sites only.

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No special care beyond gentle handling to buy cialis cebu avoid pain in the first neonatal days is required for clavicle fractures, which generally heal uneventfully and without sequelae. Indeed, many fractured clavicles in the newborn period undoubtedly occur unnoticed. 2. The thorax should be inspected for shape and symmetry. One or more accessory nipples in the mammary line may be noted occasionally. Tiny periareolar 96 i assessment of the newborn skin tags that generally dry up and fall off in the first days of life may also be noted. Breast buds due to the influence of maternal hormones can normally be palpated in term newborns. Parents will sometimes need reassurance that the tip of the xiphoid process, which can be quite prominent in the newborn, is also a normal finding. E. Abdomen. The abdominal examination of a newborn differs from that of older infants in that observation can again be used to greater advantage. I. The anterior abdominal organs (e.G., liver, spleen, bowel) can often be seen through the abdominal wall especially in thin or premature infants. The edge of the liver is occasionally seen, and the intestinal pattern is sometimes visible. Diastasis rectus abdominis is frequently seen in neonates, most evident during crying.

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I + i i atelectasis + buy cialis cebu v/q mismatch in utero gasping + + meconium aspiration peripheral airway obstruction ~ i post partum aspiration i complete fetal compromise (hypoxia cord compression, etc.) -+ meconium passage + i continued compromise i i proximal airway obstruction i i !. Inflammatory and chemical pneumonitis partial + ball-valve effect + i air-trapping i+i i air ~ks i ,. I ~ acidosis hypoxemia hypercapnia t t .... "' ___, remodeling of pulmonary vasculature i persistent pulmonary hypertension figure 35.1. Pathophysiology of meconium aspiration. V/q ventilation-perfusion ratio. (from wiswell t, bent rc. Meconium staining and the meconium aspiration syndrome. Unresolved issues. Pediatr clin northam 1993;40:955. Used with permission.) ovale resulting in worsened ventilation-perfusion (v/q) mismatch and severe arterial hypoxemia. Approximatdy one-third of infants with mas devdop persistent pulmonary hypertension of the newborn (pphn), which contributes to the mortality associated with this syndrome {see chap. 36). Aspirated meconium also inhibits surfactant function. D. Classification of respiratory disease. Mild mas is a disease requiring <40% oxygen for <48 hours. Moderate mas is a disease requiring >40% oxygen for >48 hours without air leak. Severe mas is a disease requiring assisted ventilation for >48 hours, often associated with pphn. E. Sequdae. In utero passage of meconium in term infants has been associated with an increased risk of perinatal and neonatal mortality, severe acidemia, need for caesarean section delivery, need for intensive care and oxygen administration, and adverse neurologic outcome. Preterm infants who pass meconium before ddivery have similar adverse effects, as well as an increased incidence of severe intraventricular hemorrhage, cystic periventricular leukomalacia, and cerebral palsy. Ill. Prevention of mas a. Prevention of passage of meconium in utero. Mothers at risk for uteroplacental insufficiency and, thus, msaf include those with preeclampsia or increased blood pressure, chronic respiratory or cardiovascular disease, poor intrauterine respiratory disorders i 431 fetal growth, postterm pregnancy, and heavy smokers.

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The ng route is buy cialis cebu used most commonly for short-term enteral access. The major advantage of this route is that the tube can be placed quickly and inexpensively by the nurse at the bedside. Gastrostomy tubes, in which an incision is made directly through the abdominal wall, are indicated for patients who can tolerate gastric feedings but in whom long-term feedings are anticipated. The most commonly placed gastrostomy tubes are either placed by interventional radiology or are peg tubes placed endoscopically. Gastrostomy tubes also can be placed laparoscopically or during an open procedure by a surgeon. Placement of a gastrostomy tube either endoscopically or surgically is more expensive than bedside og or ng placement but can result in placement of a larger bore tube. An advantage of feeding into the stomach is that feedings can be delivered either intermittently or continuously. When feeding directly into the small bowel continuous feedings must be used. Intermittent feedings into the small bowel result in gi intolerance in most patients.