Bedside Drainage Bags - Urine Collectors, Bedpans

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Bedside Drainage

Limiting aspiration to the maxillary sinuses might miss the source of infection if located in the other sinuses. The potential importance of this observation is supported by the lack of improvement of 12% of patients who underwent maxillary sinus drainage with no other source of infection other than opacification of the accompanying ethmoid and sphenoid sinuses on computer tomography scan (4).

The choice of antibiotics must consider the local hospital flora and the antibiogram of drug-resistant pathogens such as methicillin-resistant Staphylococcus aureus, extended spectrum [beta]-lactamase-positive enterobacteriaceae, and quinolone-resistant Pseudomonas aeruginosa. Anaerobic coverage should be entertained as anaerobic bacteria have been cultured in up to 60% of the cases (23). Antibiotics should be adjusted according to the susceptibility of antral cultures. In retrospective study of 42 critically ill patients, Ramadan and colleagues showed that 83% of these patients had a resolution of fever when their antibiotic were changed to match the antibiogram of pathogens recovered from antral lavage (18). The optimal duration of therapy is not well defined, although a minimum of 7 days of systemic antibiotics is recommended (24). Failure to respond should prompt the insertion of a drainage catheter. Nasal decongestants are often prescribed, but their efficacy remains unclear in the absence of randomized controlled studies.

AIRWAY DISORDERS

Upper Airway Obstruction

Supraglottitis was predominantly a disease of children, but the widespread use of the Haemophilus influenzae type B vaccination in children in the late 1980s has reduced its incidence to 0.6 per 100,000 according to the most recent survey (25). By comparison, the mean annual incidence of supraglottitis in adults has risen from 0.8 to 3.1 per 100,000 in the years spanning 1986-2000 (26). The case fatality rate remained constant, however, with reports ranging from 0-7.1% (27, 28).

Throat culture is positive in 45-61% of the cases (29), whereas bacteremia occurs in 12-26%, with H. influenzae type B accounting for the majority of isolates (30). Other agents occasionally implicated are pneumococci, staphylococci, streptococci, and Candida albicans. Although herpes simplex has been reported in a number of cases (31), the role of viruses in acute epiglottitis has not been well established. Noninfectious etiologies have included both chemical and thermal injuries sustained during the ingestion of caustic material (32) and the inhalation of hot objects while smoking illicit drugs (33). Bedside Drainage Bag, Bedside Drainage, Bard, CURITY MONO FLO Anti Reflux Device Drain Bag, Urinary Night Drainage Set

Over 90% of those afflicted with the disease present with severe sore throat and odynophagia (31). Stridor, drooling, and sitting erect have been reported in less than 50% of the cases. Physical examination may reveal tenderness of anterior neck and cervical adenopathy. The diagnosis could be easily mistaken for a case of pharyngitis unless a high index of suspicion is maintained. Once suspected, it is recommended that oral examination be conducted in the presence of an anesthesiologist or an otolaryngologist because of the risk of sudden airway occlusion. A radiograph of the lateral neck may show thickening of the epiglottis, prevertebral soft tissue swelling, and an emphysematous epiglottitis. However, there are reports of a normal-appearing epiglottis on radiographic examination (34). To account for the wide variability in size of the soft tissue structures in the supraglottic region, Nemzek and coworkers proposed that the ratio of the width of the epiglottis to the anteroposterior width of the C-4 vertebral body should not be greater than 0.33 (35). When tested on 27 adult patients with epiglottitis, the sensitivity and specificity were determined at 96% and 100%, respectively. In cases of normal-appearing epiglottis on lateral neck radiography, careful nasopharyngeal fiberoptic examination may be attempted. Typically, there is diffuse swelling of the aryepiglottic structures unlike the classic cherry red epiglottis in the pediatric age group.

The traditional approach to control posterior bleeding relies on anterior-posterior nasal packing using commercial balloons, a Foley catheter, or specialized nasal packs (55, 56). However, these measures can be extremely uncomfortable and have been associated with serious complications such as septicemia, cerebral ischemia, myocardial infarction, and even death (57). Moreover, the failure rate for this approach can range from 0-52% (58, 59). A new paradigm advocating surgical intervention as a primary treatment for posterior epistaxis has been favored by shorter hospital stay (3.2 days), higher success rate (90%), and a cost savings of $1,846 per patient for those undergoing arterial ligation over traditional packing (60). Alternatively, arterial embolization is advocated for bleeding sites that are difficult to reach surgically, for those with systemic bleeding disorders, and for patients who are compromised hemodynamically to undergo a surgical intervention. In experienced hands, the embolization success rate surpasses 90% with long-term morbidity rate of less than 1% (61).

Among the other causes of upper airway hemorrhage, tracheoinnominate fistula after tracheostomy placement represents an uncommon but a life-threatening complication, with a peak incidence between the first and second week (62). Approximately 50% of patients present with a massive hemorrhage, whereas the other half may report a small "herald" bleed (63). Although the most frequent site of fistula formation is at the level of the endotracheal cuff, approximately one-third results from pressure necrosis from the elbow or the tip of the cannula. Other predisposing factors include the presence of an anomalous innominate artery, infection, and the use of steroids.

Overinflation of the tracheostomy is the first maneuver that should be attempted in the face of a bedside massive hemorrhage. This technique can be successful in 85% of the cases (63). Otherwise, a cuffed endotracheal tube should be inserted under direct laryngoscopy into the glottis and beyond the tracheoinnominate fistula. Finger pressure is then applied on the innominate artery through the stomal opening after removal of the tracheostomy tube (64).

Bedside Drainage Bag, Bedside Drainage, Bard, CURITY MONO FLO Anti Reflux Device Drain Bag, Urinary Night Drainage Set. For those patients presenting with sentinel bleed, preparation should be made for transfer to the operating room and emergency chest exploration. A diagnostic flexible bronchoscopy might be attempted first, but a rigid bronchoscopy is recommended for a better visualization and superior ability to suction blood clots. The rigid bronchoscope allows the operator also to stop the bleeding by applying the tube firmly against the innominate artery. The postoperative death is relatively high, as only 25% of those who survive the surgery are discharged alive (65).

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