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Tinned food/juices buy terazosin 5mg blood pressure medication that starts with c, colddrinks buy generic terazosin canada pulse pressure for dengue, packaged drinks and packaged wafers buy terazosin visa blood pressure 4020, health drinks buy 5 mg terazosin otc hypertension 140 80, nutrition supplements promoted for “picky eaters”, bakery products, drinks with low nutrient value such as tea, coffee and sugary drinks should be avoided. Before the parents start using such a product, they should be given the following information: • An infant grows rapidly in the early months of life. In the second year, the growth will be slower, the appetite may decrease and vary from day to day. Between 15 months to 3 years, the child often passes through a phase of negativism and does the opposite of what the parents want. If the child is unwell, the appetite may suffer even more though the mother’s milk is often not refused. Allow children to eat with their hands, even if it turns out to be a messy affair. The parents may fill the spoon off and on or may offer the child some food with a separate spoon, while gradually encouraging the child to eat independently. Children have their Feeding during and after Illness moods; for some days, they may eat less of certain foods, the appetite during an illness may go down. However, but if left to themselves, they may start eating the same even sick babies continue to breastfeed quite often. They should be encouraged to take enough liquids and • Children, who are small at birth, may not weigh as small quantities of nutrient rich food that they like to eat. The parents should be told that After the illness, the nutrient intake can be increased by so long the child follows the growth curve, they should adding one or two extra meals in the daily diet for about be happy. In fact, if these children are given food or a month by offering nutritious snacks between meals, products too high in calories and become obese, they by giving extra amount at each meal and by continuing become potential candidates for developing diabetes breastfeeding. Junk and Commercial Nutrition • Convey to the parents that the product promoted for supplements “picky eaters” is expensive, not wholesome and comes in Commercial readymade cereals, though convenient to the way of the child developing healthy food habits. Besides high one may get a false sense of security while the underlying cost, the smooth consistency of such products may make causes for fussy eating mentioned above are missed. Health workers and the baby food industry: World Health Organization acts to end conflict of interest and • Initiate breastfeeding as early as possible after birth, promote breastfeeding. Feeding exclusive breastfeeding from birth to 6 months of age Fundamentals: A Handbook on Infant and Young Child and introduce complementary foods at 6 months (180 Nutrition. Increase the quantity and frequency as the child Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2002. Hyderabad, • Gradually, increase food consistency and ensure that National Institute of Nutrition; 2000. Complementary Feeding: Nutrition, Culture and • Practice responsive feeding, applying the principles of Politics, 1st edition. The Womanly Art of • Practice good hygiene by handwashing with soap and Breastfeeding, 8th edition. New York: Ballantine Book; water before preparing food, before feeding the child 2010. Complementary Feeding of • Increase fluid intake during illness, including more Young Children in Developing Countries: A Review of Current frequent breastfeeding, and encourage the child to Scientific Knowledge. Infant and Young Child Feeding: child to eat more often Model Chapter for Textbooks for Medical Students and Allied • Ensure adequate nutrition including control of Health Professionals. Geneva: World Health Organization; anemia in infants, young children, adolescent girls 2009. Though poverty is the main contributing cause, it is greatly aggravated by lack of proper dietary knowledge. Annually, undernutrition kills or disables severely underweight) and 20% for wasting in underfive millions of children. Prevalence of malnutrition varies state wise with in the survivors and prevents millions more from reaching highest in Madhya Pradesh (55%), and lowest in Kerala their full intellectual and productive potential. The damage caused by malnutrition in the intrauterine life or in the first 2 years of Magnitude of the Problem life may be irreversible due to impairment in developing brain. Moderate malnutrition is defined when the weight for Protein energy malnutrition is a generalized syndrome complex, and it is very difficult to classify it using a Table 4. A large number of classifications using anthropometric, clinical and biochemical parameters have Indicator Measure Cut off been proposed. A slowing in the rate of growth indicated by poor gain in • chest/head circumference ratio: Chest circumference height would take at least 6 months to manifest itself, while becomes equal to head circumference at 1 year, and a slowing of weight gain or loss can be demonstrated within after 2 years, it becomes more than head circumference. Sites for Age Dependent Criteria measurements are usually the triceps and subscapular region. The idea of monitoring the growth of the individual nutritional emergencies but is less useful in longterm which would be useful in provision of child health care, gave growth monitoring programs. Since then various growth charts have been used comparing the child’s weight with the expected weight (s 4. Combinations of these measurements have been suggested sometimes to distinguish types of malnutrition. For example, ecology and etiology of Malnutrition Waterlow proposed that weight/height allows one Protein energy malnutrition is the result of a complex to distinguish between children who have suffered interplay of interacting and related factors in the individual, malnutrition in the past from those who are currently family and community. In acute malnutrition, however, her/his increase susceptibility to and severity of infections. The height for age is appropriate, but she/he is wasted (low causes in individual are anorexia, increased losses from weight for height and age). Thus, weight and height intestine, malabsorption and micronutrient deficiency measurements together are useful to understand the disease, infectious diseases, inadequate intake of breast dynamics of malnutrition, distinguishing between milk, early weaning from breast, late introduction of current malnutrition and longterm or chronic malnut complementary feeding and inadequate access to food. His nutritional status is easily cultural practices and beliefs, marginalizing of girls and read as 50%, 60%, 70% or 80% of the standard. The community and national causes finally manifesting as malnutrition and death (Flow causes have direct impact on the family and individual child. While the basic causes in families who use unusual and inadequate foods to feed remain the same in either group, the lack or deficiency of infants, whom the parents believe to be at risk for milk 137 allergies, and also in families who believe in fad diets. The latest theory postulated by Golden To meet the energy requirement, initially fat stores are suggests deficiency of type I (functional nutrients), like a 138 ure 4. Nutritional marasmus results from predo malnourished children due to decrease in appetite. In clinical practice, such extremes account only for a small proportion of the clinical manifestations of malnutrition depend on the cases of malnutrition. A majority has mildtomoderate severity and duration of nutritional deprivation, the age deficiency with varied clinical manifestations, and of the undernourished subject, relative lack of different this range is known as protein energy malnutrition. Those hidden in the community do not present with any clinical signs, and are diagnosed by constitute a vast majority of children suffering from mild anthropometry. They are not brought for any medical attention, and are at a highrisk of deterioration Marasmus and progress to severe forms if uncared for prolonged Marasmus can develop in the first few months of life, period. It is diagnosed by gross loss of subcutaneous fat, and weight and later length, and (2) sedentary children, who the infant seems to have only skin and bones, ribs become maintain their growth initially by limiting their activities but visible and costochondral junctions look prominent. The age incidence is later than that of marasmus and this condition is uncommon under the age of 1 year.
The nasal passage and posterior pharynx may also reveal a purulent discharge suggestive of sinusitis buy 1 mg terazosin overnight delivery how is pulse pressure used as a diagnostic tool, an infection that less commonly leads to meningitis buy terazosin 5 mg low cost prehypertension and alcohol. Auscultation of the heart may reveal a diastolic murmur suggesting aortic insufficiency buy 1mg terazosin mastercard hypertension 5 weeks pregnant, which would strongly suggest bacterial endocarditis as the primary infection leading to meningitis order generic terazosin on-line hypertension young adults. Most cases of endocarditis complicated by meningitis are the result of infection with S. Lung examination may reveal findings of pneumonia (asymmetrical lung expansion, bronchovesicular breath sounds, rales, egophony, and dullness to percussion), making S. A thorough examination of the skin needs to be performed looking for purpuric lesions. Petechiae and purpura are most commonly encountered in patients with meningococcemia, but they also may be found in S. The exact level of neurologic function should be documented by determining a Glasgow score (Table 6. The level of consciousness on admission is an important criterion for the use of corticosteroids and is also a useful prognostic indicator. The patient who is unresponsive to deep pain (Glasgow score 3) has a much higher mortality than the patient who responds to voice (Glasgow score 10- 15). Lateralgaze palsy as a result of sixth nerve dysfunction can result from increased intracranial pressure. Focal findings such as hemiparesis, asymmetric pupillary response to light, or other unilateral cranial nerve deficits are uncommon in bacterial meningitis, and they raise the possibility of a space-occupying lesion such as a brain abscess or tumor. The finding of papilledema on fundoscopic examination is rare in meningitis and usually indicates the presence of a space-occupying lesion. Upper respiratory or ear infection interrupted by the abrupt onset of meningeal symptoms: a) Generalized, severe headache b) Neck stiffness c) Vomiting d) Depression of mental status 2. Physical findings: a) Brudzinski (neck flexion) and Kernig (straight leg raise) signs are insensitive; “head jolt” maneuver may have higher sensitivity. It is important to keep in mind that meningitis in very young and very old individuals does not present with these classic symptoms and signs. Meningeal signs are less commonly reported, and many elderly patients have neck stiffness as a consequence of osteoarthritis, an old cerebrovascular accident, or Parkinson disease. The physician must have a high index of suspicion and must aggressively exclude the possibility of bacterial meningitis in an elderly patient with fever and confusion. In very young patients, neonatal and infant meningitis presents simply as fever and irritability. No history is obtainable, and as a consequence, lumbar puncture should be included in the fever workup of the very young patient. Diagnosis the critical test for making a diagnosis of meningitis is the lumbar puncture. If the clinician has included meningitis as part of the differential diagnosis, a lumbar puncture needs to be performed. If no focal neurologic symptoms or deficits are apparent, and if papilledema is not seen on fundoscopic examination, a lumbar puncture can be safely performed (ure 6. Because this organism usually remains intracellular, Gram stain is positive in only 25% of cases. However, it must be emphasized that the sensitivity of these tests is somewhat variable, and a negative latex agglutination test does not exclude the possibility of bacterial meningitis. In addition, a positive culture allows for antibiotic sensitivity testing, which is particularly important for guiding treatment of S. Treatment Evaluation and institution of antibiotic therapy should occur within 30 minutes if bacterial meningitis is being strongly considered. Blood samples for culture should be drawn before antibiotics are started; they often yield the cause of the illness. Empiric therapy depends on the age and immune status of the patient and on whether infection is nosocomial or community-acquired (Table 6. For community-acquired meningitis in patients aged 3 months to 60 years, maximal doses of a third-generation cephalosporin (ceftriaxone or cefotaxime) is recommended (for doses, see Table 6. If the patient is severely ill, vancomycin should be added to this regimen to cover for the possibility of penicillin-resistant S. In the patient with an immediate hypersensitivity reaction to penicillin or a history of allergy to cephalosporins, vancomycin is recommended. In patients over the age of 60 years, maximal doses of ampicillin are added to the third-generation cephalosporin to cover for L. This organism is not sensitive to cephalosporins, and penicillin or ampicillin is the treatment of choice. For the immunocompromised host, a third-generation cephalosporin, ampicillin, and vancomycin are recommended for empiric therapy. Antibiotic Treatment of Bacterial Meningitis Once a specific bacterium is identified, the antibiotic regimen can be focused. For this reason, high-dose ceftriaxone or cefotaxime is recommended for intermediately penicillin- resistant S. Rifampin combined with vancomycin may also be effective for the treatment of highly resistant S. The antibiotic response should be monitored in patients infected with highly penicillin- resistant pneumococci. In these patients, the lumbar puncture should be repeated 24–36 hours after the initiation of therapy. Aminoglycosides, erythromycin, clindamycin, tetracyclines, and first- generation cephalosporins should not be used to treat meningitis, because these drugs do not cross the blood-brain barrier. Neurologic damage is primarily a consequence of an excessive inflammatory response. In adults with pneumococcal meningitis and Glasgow coma scores of 8–11, dexamethasone administration (10 mg q6h × 4 days) was also found to reduce morbidity and mortality. Subsequent studies of adults in developing countries have failed to demonstrate a benefit. Experts now recommend that in industrialized countries where patients with possible bacterial meningitis are seen quickly, dexamethasone is likely to be of benefit and is not associated significant harm. Dexamethasone should be given just before or simultaneously with antibiotics, because inflammatory mediators are released in response to the lysis of bacteria induced by antibiotic treatment. Additional therapeutic measures are primarily directed at reducing cerebral edema and controlling seizures. Oral glycerol may also reduce cerebral edema, and its efficacy has been proven in children, but this treatment has not been shown to be of benefit in adults. Seizures develop in 20-30% of patients with meningitis, but anti-seizure medications (Dilantin and diazepam are most commonly used) are not recommended for prophylaxis.
Semipermanent Tunneled Catheters (Long-Term Central Venous Catheters) Cuffed double-lumen subclavian catheters tunneled subcutaneously are used primarily for infusing parenteral nutrition solutions and cancer chemotherapy order 1 mg terazosin overnight delivery blood pressure medication best time to take. Pulmonary Artery Catheters Use of pulmonary artery catheters has decreased markedly in the last decade because of the introduction of new hemodynamic monitoring technologies discount terazosin 1 mg arrhythmia originating in the upper chambers of the heart. The approach to placement and maintenance of these catheters in patients who have an appropriate indication should generally follow established guidelines for central line placement  order discount terazosin on line arrhythmia interpretation. Peripheral Arterial Catheters Although peripheral arterial catheters were initially believed to have lower risk of catheter-related infection buy 1mg terazosin amex blood pressure medication used for adhd, indwelling arterial catheters appear to have rates of complications similar to those for venous catheters [3,26]. Signs and symptoms of infection for arterial catheters are similar to those for venous catheters; however, the absence of local signs of inflammation does not preclude infection. Distal embolic lesions and hemorrhage are highly predictive of arterial catheter-associated bloodstream infection. Midline Catheters Midline catheters are 3 to 8 inches in length, are inserted into the antecubital fossa or upper arm veins, and extend no further than the distal portion of the subclavian vein. These catheters are ideal if infusions are required for 6 to 14 days for non–critically ill patients . They can remain in place for 4 weeks, are convenient to insert, are associated with fewer infections than central venous catheters, and cause less phlebitis than peripheral catheters . However, infusions that irritate the vascular endothelium, such as vancomycin, nafcillin, and amphotericin B, cannot be given through this type of catheter. Catheter Insertion Choice of Insertion Site Regardless of the type of catheter inserted, the major risk factor for the development of catheter-associated infection is the breach of a major host defense against infection—the skin. Catheter-associated infections are usually because of organisms colonizing the skin, particularly gram- positive cocci, such as coagulase-negative staphylococci and Staphylococcus aureus. Patients who have a productive cough or a tracheostomy can easily contaminate their skin with organisms from their respiratory tract . Central venous catheters inserted in the internal jugular and femoral veins are associated with bloodstream infection significantly more often than those inserted into the subclavian vein . Increased risk of thrombosis, contamination, and difficulties in dressing the site may play a role [4,31]. Insertion site colonization risk is particularly increased among obese patients with femoral catheters and for patients with tracheostomies with jugular catheters [3,30,32]. Risk of pneumothorax is more common among patients who have subclavian catheters; insertion using ultrasound guidance may help limit this complication [4,33]. Decisions regarding insertion site must be based on the risks of mechanical complications versus infectious and thrombotic risks. For long-term catheters, for which the risks of infection and thrombosis increase with duration of catheterization, use of the subclavian site is preferred [4,31]. All catheters should be removed as promptly as possible especially if they are inserted emergently under less than sterile conditions or if the catheter is no longer needed [3,4]. Insertion Techniques It is essential that health care personnel perform hand hygiene with an alcohol-based waterless product or washing with antiseptic soap and water prior to insertion of a catheter [3,4,34]. Catheter-associated phlebitis and infection are more likely to occur when catheters are inserted by inexperienced personnel rather than personnel who are trained in these techniques. The importance of sterile techniques using maximal barrier precautions for short-term central catheters cannot be overemphasized and should become a part of house staff training [3,4]. Use of a standardized catheter cart or kit that contains all of the equipment necessary to insert a central venous catheter and use of a hospital-specific bundle or catheter insertion checklist filled out by a trained observer to ensure and document adherence to infection prevention practices at the time of insertion are recommended [3,4,16]. Health care personnel should be empowered to stop the catheter insertion if any breach in aseptic technique is observed. Ultrasound guidance for the insertion of central vascular catheters, especially internal jugular catheters, has been shown to reduce the risk of infection [3,4,33]. Cutaneous Antisepsis Chlorhexidine and iodine-based solutions, alone or in combination with alcohol, have been used to reduce microbial contamination at the insertion site of the catheter [3,4]. Antimicrobial ointments have been shown to increase the risk of infection with Candida and antibiotic-resistant bacteria and may affect the integrity of some catheters. With the exception of povidone–iodine ointment for some hemodialysis catheters, routine use of ointments at the catheter insertion site is discouraged [3,4]. However, several guidelines do not recommend routine use of this patch, but rather suggest that it can be considered for use when the rates of catheter-associated infection remain high despite consistent use of evidence-based prevention bundles [3,4]. Use of these patches could be considered for patients who have limited access and a history of recurrent catheter-associated infections and for those who have a heightened risk of severe sequelae if infection should occur . The use of systemic antibiotics as prophylaxis before the placement of central venous devices is strongly discouraged because selection for antibiotic-resistant microorganisms is highly likely [3,4]. Care of the Catheter and Insertion Site Insertion Site Dressings Either gauze and tape bandages or transparent semi-permeable dressings can be used for peripheral and central catheters. Transparent dressings are changed every 5 to 7 days and gauze dressings every 2 days or more frequently if the dressing is soiled, loose, or damp . Catheter Hub Disinfection Local disinfection of the hubs of central venous catheters must be performed using either a chlorhexidine-based preparation or 70% alcohol before attempting access [3,4]. With either preparation, it is very important to allow the antiseptic to dry to ensure antimicrobial activity before accessing the catheter. Maintenance of the catheter hub should be performed with strict standards, similar to those for insertion of catheters, to decrease the risk of contamination and infection . A randomized controlled trial found that reducing the frequency of changing unsoiled adherent dressings from 3 to 7 days, and thus decreasing manipulation of the site, did not increase the risk of infection . Catheter Replacement Peripheral Catheters Phlebitis of a peripheral vein is a well-recognized harbinger of infection and may be quite uncomfortable for the patient. Complications of peripheral venous catheter insertion, including phlebitis and catheter-associated infection, increase after 72 hours of insertion. Recommendations to remove and change these catheters to another site every 72 hours are aimed at decreasing the risk for infection and the discomfort associated with phlebitis . Central Catheters the risk of infection increases during the time that a central catheter is in place, but several studies have shown that routine replacement of these catheters does not reduce rates of catheter-associated bloodstream infections [3,4]. Routine rotation of a central catheter to a different site is associated with increased risk for pneumothorax, laceration of a vessel with hemothorax, and arrhythmias and thus, is not recommended . However, a meta- analysis of studies employing this technique failed to show an effect on decreasing infections, and routine catheter changes over a guidewire are not recommended [4,37]. An exception is made for the patient who has poor access and is dependent on a surgically implanted semipermanent central catheter. In-Line Devices and Filters In-line devices can be a significant source of catheter-associated infections. Pressure transducers have been implicated during outbreaks of catheter-associated bloodstream infection, particularly those due to water-associated gram-negative bacilli, including Pseudomonas, Serratia, Enterobacter, Citrobacter, and Acinetobacter spp. Stopcocks are easily contaminated through manipulation by personnel or by injection with contaminated syringes and may be an important source of infection; use of a closed system rather than stopcocks has been shown to lead to less contamination of the line. Some studies suggest that needleless mechanical valve devices may pose a greater risk of infection than split septum devices [40,41]. Disposable transducer domes, stopcocks, needleless components, and other in-line devices should be changed with the rest of the infusion set.
Arteriovenous fistula and pseudoaneurysm are rare chronic complications of arterial puncture; the former is more likely to occur when both femoral vessels on the same side are cannulated concurrently  order generic terazosin from india heart attack zip. As such buy generic terazosin 2 mg on line blood pressure chart pdf uk, the Centers for Disease Control and Prevention guidelines recommend avoidance of the femoral site unless absolutely necessary  generic terazosin 5mg without prescription pulse pressure equivalent. In addition buy generic terazosin 5 mg line pulse pressure below 40, lower extremity deep vein thromboses have a higher rate of symptomatic embolization compared to those in the upper extremity . Subclavian Vein Approach This route has been used for central venous access for many years and is associated with the most controversy, largely because of the relatively high incidence of pneumothorax and occasional-associated mortality. The advantages of this route include consistent identifiable landmarks, easier long-term catheter maintenance with a comparably lower rate of infection, and relatively high patient comfort. Anterior to the vein throughout its course lie the subclavius muscle, clavicle, costoclavicular ligament, pectoralis muscles, and epidermis. We usually initially produce an axial view of the vein by placing the probe in the cranial–caudal direction. The probe is then rotated 90 degrees to produce a longitudinal view of the vein, which is maintained during venipuncture and guidewire insertion. Although this method is often successful, it may be very difficult in patients with obesity, and tends to be more time consuming. The differences in success rate, catheter tip malposition, and complications between the two approaches are negligible, although catheter tip malposition and pneumothorax may be less likely with supraclavicular cannulation . Skin puncture is 2 to 3 cm caudal to the clavicle at the deltopectoral groove, corresponding to the area where the clavicle turns from the shoulder to the manubrium. Skin puncture should be distant enough from the clavicle to avoid a downward angle of the needle in clearing the inferior surface of the clavicle, which also obviates any need to bend the needle. After skin infiltration and liberal injection of the clavicular periosteum with 1% lidocaine and a time-out, the 18-gauge thin-wall needle is mounted on a 10-mL syringe. Skin puncture is accomplished with the needle bevel up, and the needle is advanced in the plane until the tip abuts the clavicle. To avoid pneumothorax, it is imperative the needle stay parallel to the floor and not angle down toward the chest. This is accomplished by using the operator’s left thumb to provide downward displacement in the vertical plane after each attempt, until the needle advances under the clavicle. As the needle is advanced further, the inferior surface of the clavicle should be felt hugging the needle. The needle is advanced toward the suprasternal notch during breath holding or expiration, and venipuncture occurs when the needle tip lies beneath the medial end of the clavicle. If venipuncture is not accomplished on the initial attempt, the next attempt should be directed slightly more cephalad. If venipuncture does not occur by the third or fourth attempt, another site should be chosen or another operator should try, because additional attempts are unlikely to be successful and may result in complications. To increase the success rate of proper placement of the catheter, the J-wire tip should point inferiorly . Triple-lumen catheters should be sutured at 15 to 16 cm on the right and 17 to 18 cm on the left to avoid intracardiac tip placement [27,58]. The needle should enter the jugulosubclavian venous bulb after 1 to 4 cm, and the operator may then proceed with catheterization. The ultrasound machine is positioned so that the operator can visualize the screen with minimal head movement, and the line of sight along the needle insertion trajectory is as close as possible to that required to see the screen. If using the subclavicular approach, the transducer is held in longitudinal orientation and placed on the clavicle using a sagittal scanning plane directed through the medial third of the clavicle. With further lateral movement of the probe, the target vessel and its paired artery are visualized in the subpectoral area away from the clavicle. If using the supraclavicular approach, the transducer is used to examine the supraclavicular area while angling medially. The use of spectral Doppler flow measurements is not recommended unless the operator has expert-level knowledge of Doppler ultrasonography. Following the application of maximum barrier precautions, the vessel is visualized in its longitudinal axis, and the needle inserted with direct visualization of the entire needle throughout its insertion trajectory. The operator holds the probe with their nondominant hand, whereas the needle and syringe are guided by the dominant hand. Some operators prefer to perform needle insertion using ultrasonography guidance with the vessel visualized in its transverse axis (longitudinal scanning plane). In obese or edematous patients, the probe needs to be pressed into the chest tissue, with further difficulty in selecting the initial needle entry site. Even minimal deviation from the narrow tomographic plane of the probe may result in the operator losing control of the needle tip and mistaking the body of the needle for the tip, resulting in injury to the adjacent pleura or artery. Another challenge is maintaining a constant view of the target vessel in longitudinal axis while simultaneously keeping the entire needle in view while it is moved toward the target vessel. For the inexperienced operator, we recommend repeated deliberate practice on a vascular access model before the first closely supervised attempt on a patient. Subclavian venous access with landmark technique uses the clavicle as a definitive guide to successful cannulation, whereas ultrasonography does not. This requires the operator to rely totally on the ultrasonography image for guidance, and to discount the clavicle as a relevant landmark. Unsuccessful catheterizations are a result of venipuncture failure or inability to advance the guidewire or catheter. Catheter tip malposition occurs in 5% to 20% of cases and tends to be more frequent with the infraclavicular approach. The overall incidence of noninfectious complications varies depending on the operator experience and the circumstances under which the catheter is inserted. Factors resulting in a higher complication rate are operator inexperience, multiple attempts at venipuncture, emergency conditions, variance from standardized technique, and body mass index. There are many case reports of isolated major complications involving neck structures or the brachial plexus; the reader is referred elsewhere for a complete listing of reported complications . Pneumothorax accounts for one-fourth to one-half of reported complications, with an incidence of about 1. Fifty catheterizations are cited frequently as a cutoff number, but it is reasonable to expect an operator to be satisfactorily experienced after having performed fewer. Most pneumothoraces are a result of lung puncture at the time of the procedure, but late-appearing pneumothoraces have been reported. Many will require thoracostomy tube drainage with a small chest tube and a Heimlich valve, but some can be managed conservatively with 100% oxygen and serial radiographs or needle aspiration only . As with other routes, arterial puncture may result in arteriovenous fistula or pseudoaneurysm [12,60]. The importance of the discrepancy between clinical symptoms and radiologic findings is unknown, but upper extremity thrombosis, even if asymptomatic, is not a totally benign condition .
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