CN213759878U - Neonate's coloclysis device - Google Patents
Neonate's coloclysis device Download PDFInfo
- Publication number
- CN213759878U CN213759878U CN202022361863.5U CN202022361863U CN213759878U CN 213759878 U CN213759878 U CN 213759878U CN 202022361863 U CN202022361863 U CN 202022361863U CN 213759878 U CN213759878 U CN 213759878U
- Authority
- CN
- China
- Prior art keywords
- lavage
- paper diaper
- fixing ring
- ring
- anal tube
- Prior art date
- Legal status (The legal status is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the status listed.)
- Expired - Fee Related
Links
- 239000007788 liquid Substances 0.000 claims abstract description 55
- 210000002255 anal canal Anatomy 0.000 claims abstract description 23
- 230000002262 irrigation Effects 0.000 claims abstract description 16
- 238000003973 irrigation Methods 0.000 claims abstract description 16
- 210000000436 anus Anatomy 0.000 claims abstract description 14
- 210000001072 colon Anatomy 0.000 claims abstract description 7
- 238000003780 insertion Methods 0.000 claims abstract description 7
- 230000037431 insertion Effects 0.000 claims abstract description 7
- 239000002985 plastic film Substances 0.000 claims description 18
- 229920006255 plastic film Polymers 0.000 claims description 18
- 230000000112 colonic effect Effects 0.000 claims description 11
- 238000005303 weighing Methods 0.000 claims description 8
- 238000004321 preservation Methods 0.000 claims description 5
- 210000001015 abdomen Anatomy 0.000 abstract description 7
- 238000005259 measurement Methods 0.000 abstract description 4
- 230000000968 intestinal effect Effects 0.000 description 8
- 230000003187 abdominal effect Effects 0.000 description 5
- 230000010412 perfusion Effects 0.000 description 5
- 239000013010 irrigating solution Substances 0.000 description 4
- 238000001802 infusion Methods 0.000 description 3
- 230000000474 nursing effect Effects 0.000 description 3
- 206010051986 Pneumatosis Diseases 0.000 description 2
- FAPWRFPIFSIZLT-UHFFFAOYSA-M Sodium chloride Chemical compound [Na+].[Cl-] FAPWRFPIFSIZLT-UHFFFAOYSA-M 0.000 description 2
- 239000005030 aluminium foil Substances 0.000 description 2
- 210000001217 buttock Anatomy 0.000 description 2
- 238000010586 diagram Methods 0.000 description 2
- 230000002550 fecal effect Effects 0.000 description 2
- 239000012530 fluid Substances 0.000 description 2
- 238000010438 heat treatment Methods 0.000 description 2
- 230000001050 lubricating effect Effects 0.000 description 2
- 239000007787 solid Substances 0.000 description 2
- 230000008719 thickening Effects 0.000 description 2
- 238000012546 transfer Methods 0.000 description 2
- 229940099259 vaseline Drugs 0.000 description 2
- 239000002699 waste material Substances 0.000 description 2
- 241000792859 Enema Species 0.000 description 1
- XAGFODPZIPBFFR-UHFFFAOYSA-N aluminium Chemical compound [Al] XAGFODPZIPBFFR-UHFFFAOYSA-N 0.000 description 1
- 229910052782 aluminium Inorganic materials 0.000 description 1
- 230000017531 blood circulation Effects 0.000 description 1
- 230000036760 body temperature Effects 0.000 description 1
- 230000008859 change Effects 0.000 description 1
- 238000004891 communication Methods 0.000 description 1
- 230000013872 defecation Effects 0.000 description 1
- 230000007547 defect Effects 0.000 description 1
- 230000029087 digestion Effects 0.000 description 1
- 230000000694 effects Effects 0.000 description 1
- 239000007920 enema Substances 0.000 description 1
- 229940095399 enema Drugs 0.000 description 1
- 208000010227 enterocolitis Diseases 0.000 description 1
- 210000003608 fece Anatomy 0.000 description 1
- 239000011888 foil Substances 0.000 description 1
- 230000002496 gastric effect Effects 0.000 description 1
- 230000030136 gastric emptying Effects 0.000 description 1
- 210000001035 gastrointestinal tract Anatomy 0.000 description 1
- 238000001727 in vivo Methods 0.000 description 1
- 239000012774 insulation material Substances 0.000 description 1
- 230000007794 irritation Effects 0.000 description 1
- 238000002504 lithotomy Methods 0.000 description 1
- 239000000463 material Substances 0.000 description 1
- 238000000034 method Methods 0.000 description 1
- 238000012986 modification Methods 0.000 description 1
- 230000004048 modification Effects 0.000 description 1
- 235000015816 nutrient absorption Nutrition 0.000 description 1
- 238000011017 operating method Methods 0.000 description 1
- 210000002640 perineum Anatomy 0.000 description 1
- 230000008855 peristalsis Effects 0.000 description 1
- 239000002504 physiological saline solution Substances 0.000 description 1
- 230000008569 process Effects 0.000 description 1
- 230000001737 promoting effect Effects 0.000 description 1
- 230000005855 radiation Effects 0.000 description 1
- 230000001105 regulatory effect Effects 0.000 description 1
- 239000013049 sediment Substances 0.000 description 1
- 238000004904 shortening Methods 0.000 description 1
- 239000011780 sodium chloride Substances 0.000 description 1
- 238000003756 stirring Methods 0.000 description 1
- 230000000007 visual effect Effects 0.000 description 1
- XLYOFNOQVPJJNP-UHFFFAOYSA-N water Substances O XLYOFNOQVPJJNP-UHFFFAOYSA-N 0.000 description 1
- 230000004584 weight gain Effects 0.000 description 1
- 235000019786 weight gain Nutrition 0.000 description 1
Images
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- External Artificial Organs (AREA)
Abstract
The utility model provides a coloclysis device for neonates. The colon lavage device comprises a paper diaper, an anal tube, a drainage bag and a lavage device, wherein a rotary fixing hole is formed in the position, corresponding to the insertion position of the anal tube, of the paper diaper, the inserted anus end of the anal tube penetrates through the rotary fixing hole and is arranged in the paper diaper, and the other end of the anal tube is respectively connected with the drainage bag and the lavage device through a first three-way joint; the lavage device comprises a lavage device and a lavage liquid container, wherein the first three-way joint is communicated with the lavage device and the lavage liquid container through the second three-way joint respectively. The utility model discloses can better collect the irrigation liquid and accurate measurement, prevent because the infant abdomen presses too big to cause the anal canal to deviate from and the irrigation liquid from anus splash everywhere, keep the bed unit clean to but one-man operation reduces the manpower, simplifies the operation tool.
Description
Technical Field
The utility model relates to a neonate nurses the field, specifically indicates a device that is used for neonate's coloclysis.
Background
Colon lavage is a clinical invasive nursing operation in which a lavage fluid is infused into the colon through the anal canal by using a lavage device, and then the liquid containing the fecal residues is passively sucked out until the lavage fluid is clear and free of fecal residues. Compared with the common enema, the insertion position of the anal tube is deeper during the colonic lavage, and the accumulated excrement and the accumulated qi in the deep part of the colon can be better discharged. The combination of abdominal massage during lavage can stimulate defecation, reflexively cause gastrointestinal peristalsis, promote gastric emptying and intestinal digestion, thereby promoting nutrient absorption and weight gain, and shortening hospitalization time. Through colonic lavage, the intestinal wall blood circulation and the intestinal micro-ecological environment are improved, the occurrence of enterocolitis is reduced, and the intestinal operation rate is reduced.
The existing neonatal intestinal lavage mainly comprises the steps of lifting a bed head, padding a nursing pad under the hip, helping a patient to take an lithotomy position by an assistant, extracting 39-41 ℃ physiological saline (lavage liquid) by using a 20ml lavage device to connect an anal canal, and slowly and gently inserting the anal canal along the direction of the intestinal canal into the position with the depth of 20-25cm after the front end of a Vaseline lubricating catheter. The normal saline is slowly injected from the anal canal with low pressure, 15-20 ml each time. Massaging the abdomen clockwise with palm after injecting saline water, irrigating until the discharged liquid is clear and has no feces, the discharged liquid should be larger than or substantially equal to the injected irrigating liquid, and gently pulling out the anal canal after irrigating.
When carrying out the colon lavage operation to the neonate clinically, because do not have suitable irrigation liquid collection device at present, take the irrigation liquid of excrement sediment sample to collect in panty-shape diapers or take out with the laveur and squeeze into the garbage bin in, sometimes because the too big irrigation liquid of sick child abdominal pressure can directly splash from the anus everywhere, cause the pollution of bed or even warm incasement wall, also can influence the accurate measurement of irrigation liquid. And two people are needed to cooperate during operation, one person massages the abdomen, the other person needs to fix and adjust the position of the anal canal in the lavage process, and the anal canal is prevented from being sprayed out due to overlarge abdominal pressure. Moreover, the neonate needs to operate in a warm box or a far infrared radiation table of the neonate to maintain normal body temperature, and the range of operation available after the lavage liquid and other articles are placed is limited.
Disclosure of Invention
The utility model provides a device for coloclysis of newborn aiming at the defects of the prior art, which can better collect and accurately measure the perfusion liquid, prevent the anal canal from dropping out and the perfusion liquid from splashing around the anus due to the overlarge abdominal pressure of the sick child, and keep the bed unit clean; and can be operated by one person, reduce manpower, simplify the operation tool.
In order to achieve the above technical object, the present invention provides a coloclysis device for neonates. The colon lavage device comprises a paper diaper, an anal tube, a drainage bag and a lavage device, wherein a rotary fixing hole is formed in the position, corresponding to the insertion position of the anal tube, of the paper diaper, the inserted anus end of the anal tube penetrates through the rotary fixing hole and is arranged in the paper diaper, and the other end of the anal tube is respectively connected with the drainage bag and the lavage device through a first three-way joint; the lavage device comprises a lavage device and a lavage liquid container, wherein the first three-way joint is communicated with the lavage device and the lavage liquid container through the second three-way joint respectively.
The utility model discloses further technical scheme: the rotary fixing hole comprises an outer ring fixing ring, an inner ring fixing ring and a cylindrical plastic film, two ports of the cylindrical plastic film are respectively provided with an elastic fixing band, the outer ring fixing ring is fixed on the paper diaper, and the inner diameter of the outer ring fixing ring is matched with the outer diameter of the inner ring fixing ring; one port of the cylindrical plastic film is fixed on the inner ring fixing ring, the cylindrical plastic film is twisted into a rope in a rotating mode, the other end of the rope is turned outwards and then fixed on the outer ring fixing ring, the inner ring fixing ring and the outer ring fixing ring which are connected with the two ports of the cylindrical plastic film are mutually nested, and a hole of which the size is controlled by rotating the inner ring fixing ring is formed in the center position of the mutually nested inner ring fixing ring and outer ring fixing ring; the anal canal is inserted from the hole.
The utility model discloses better technical scheme: a waterproof transparent observation window is arranged around the position of the paper diaper with the rotary fixing hole.
The utility model discloses better technical scheme: the lavage liquid container is a heat-insulating container, and a speed regulator is arranged on a communicating pipeline of the second three-way joint and the lavage liquid container.
The utility model discloses better technical scheme: the paper diaper is provided with one or two weighing rings, and the two weighing rings are symmetrically arranged on the front side and the rear side of the paper diaper.
The utility model discloses better technical scheme: the anal tube is an anal tube with scales.
The utility model discloses better technical scheme: the inner ring fixing ring is provided with a rotating handle.
The utility model discloses better technical scheme: the rotary fixing hole and the waterproof transparent observation window are both arranged on the middle rear side of the paper diaper.
The rotary fixing hole of the utility model can control the size by rotating the inner wheel, thereby fixing the anal canal; adopt two three way connection, can with anal canal, drainage bag connecting pipe, lavage ware and transfer line connection on the tee bend, make lavage ware suction lavage liquid pour into the infant into again through the tee bend knob, make lavage liquid flow into in the drainage bag through massage belly, but scale direct display lavage liquid volume on the drainage bag after the lavage, panty-shape diapers are through the measurement title measurement liquid volume, both add promptly the total amount. Its lavage liquid container adopts heat preservation container, and heat preservation material chooses thickening aluminium foil insulation material for use, can pack the lavage liquid that the heating is good into heat preservation container, plays the heat preservation effect.
The utility model has the advantages that:
(1) the utility model collects the perfusion liquid better through the drainage bag, the scale on the drainage bag can directly display the volume of the perfusion liquid, and the color and the stool character of the perfusion liquid can be observed conveniently; the irrigating solution flowing out of the anus can be directly collected in the paper diaper for direct weighing, and the total amount of the irrigating solution is obtained by adding the two amounts, so that the metering is convenient; and the bed unit and the inner wall of the warm box are not polluted due to the splashing of the irrigation liquid.
(2) The utility model discloses a two tee bend passageways connect each pipeline, stir the tee bend knob through control during the operation and realize the operating procedure of drawing liquid-pouring into-discharge-collection.
(3) The paper diaper fixes the position of the anal canal through the rotating small hole, so that the anal canal can not be separated due to the increase of abdominal pressure of the massage abdomen, if the sick child has more accumulated intestinal gas, the lower end of the anal canal can be separated to be connected with the tee joint of the drainage bag, and the continuous anal canal exhaust can be carried out; and a transparent observation window is arranged around the part of the paper diaper inserted into the anal canal, so that the inserting depth of the anal canal and the liquid discharge condition through the anus can be checked at any time.
(4) The lavage liquid is placed in a thickened aluminum foil heat-insulating container after being heated, and cannot be cooled due to long operation time, so that the intestinal irritation of the children patients is avoided.
Drawings
Fig. 1 is a schematic structural diagram of the present invention;
FIG. 2 is a schematic front view of a diaper;
FIG. 3 is a schematic side view of a rotary fastening hole;
FIG. 4 is a schematic view of the inner and outer race fixing rings of the rotary fixing hole in a disassembled state;
FIG. 5 is a schematic front view of a rotary mounting hole;
FIG. 6 is a schematic view of a rotary fixed hole for rotationally adjusting the size of the hole;
FIG. 7 is a schematic view of a cylindrical plastic film;
FIG. 8 is a schematic diagram of the cord eversion of a cylindrical plastic film;
in the figure: 1-panty-shape diapers, 2-anal canal, 3-drainage bag, 4-lavement ware, 5-lavage liquid container, 6-rotation type fixed orifices, 600-outer lane solid fixed ring, 601-inner circle solid fixed ring, 602-hole, 603-cylindric plastic film, 604-elastic fixation area, 605-rotation handle, 7-first three way connection, 8-second three way connection, 9-waterproof transparent observation window, 10-speed regulator, 11-ring of weighing, 12-transfer line.
Detailed Description
The present invention will be further explained with reference to the drawings and examples. Fig. 1 to 5 are drawings of the embodiment, which are drawn in a simplified manner and are only used for clearly and concisely illustrating the purpose of the embodiment of the present invention. The following detailed description of the embodiments of the present invention is presented in the drawings and is not intended to limit the scope of the invention as claimed. Based on the embodiments in the present invention, all other embodiments obtained by a person skilled in the art without creative efforts belong to the protection scope of the present invention.
In the description of the present invention, it is to be understood that the terms "upper", "lower", "inner", "outer", "left", "right", and the like indicate orientations or positional relationships based on the orientations or positional relationships shown in the drawings, or orientations or positional relationships that are conventionally placed when the products of the present invention are used, or orientations or positional relationships that are conventionally understood by those skilled in the art, and are merely for convenience of description of the present invention and simplifying the description, but do not indicate or imply that the device or element that is referred to must have a specific orientation, be constructed and operated in a specific orientation, and thus, should not be construed as limiting the present invention. Furthermore, the terms "first," "second," and the like are used merely to distinguish one description from another, and are not to be construed as indicating or implying relative importance.
An embodiment provides a device for colonic irrigation for a newborn, as shown in fig. 1, which comprises a paper diaper 1, an anal tube 2 with scales, a drainage bag 3 and an irrigation device, wherein the structure of the paper diaper 1 is as shown in fig. 1 and fig. 2, the structure is similar to that of a common paper diaper, only a weighing ring 11 is added on the paper diaper for facilitating weighing, a rotary fixing hole 6 is arranged at a position, corresponding to the insertion of the anal tube 2, of the paper diaper 1, a waterproof transparent observation window 9 is arranged around the position of the rotary fixing hole 6, the waterproof transparent observation window 9 is about 8cm in length and about 6cm in width, the inserted part of the anal tube 2 can be covered, and the insertion depth of the anal tube 2 and the liquid discharge condition through the anus can be conveniently observed. The inserting anus end of the anal tube 2 penetrates through a rotary fixing hole 6 to be inserted into the anus of the sick child, the other end of the anal tube is respectively connected with a drainage bag 3 and an irrigating device through a first three-way joint 7, the irrigating device comprises an irrigator 4 and an irrigating solution container 5, and the first three-way joint 7 is respectively communicated with the irrigator 4 and the irrigating solution container 5 through a second three-way joint 8; realize the lavage and discharge waste liquid work through two tees, the tee bend knob makes 4 suction lavage liquid of lavipeditum ware reinject into the infant in vivo, makes the lavage liquid flow in drainage bag 3 through massage belly. Lavage liquid container 5 is the insulated container, specifically adopts thickening aluminium foil insulated bag. A speed regulator 10 is arranged on a communication pipeline of the second three-way joint 8 and the lavage liquid container 5, and the flow rate of the lavage liquid can be regulated.
The rotary fixing hole in the embodiment, as shown in fig. 3 to 8, comprises an outer ring fixing ring 600, an inner ring fixing ring 601 and a cylindrical plastic film 603, wherein the diameter of the outer ring fixing ring 600 is 3cm, the diameter of the inner ring fixing ring 601 is 2.5cm, and the outer ring fixing ring is rotatably sleeved on an outer wheel; two ports of the cylindrical plastic film 603 are respectively provided with an elastic fixing band 604 (elastic band), the outer ring fixing ring 600 is fixed on the paper diaper 1, and the inner diameter of the outer ring fixing ring is matched with the outer diameter of the inner ring fixing ring 601; one port of the cylindrical plastic film 603 is fixed on the inner ring fixing ring 601, as shown in fig. 4 and 8, the cylindrical plastic film 603 is twisted into a rope, the other end of the rope is turned outwards and then fixed on the outer ring fixing ring 600, then as shown in fig. 3, 5 and 6, the inner ring fixing ring 601 and the outer ring fixing ring 600 which are connected with the two ports of the cylindrical plastic film 603 are mutually nested, and a hole 602 of which the size is controlled by rotating the inner ring fixing ring 601 is formed in the central positions of the mutually nested inner and outer ring fixing rings; the anal canal 2 is inserted through the hole 602.
When the utility model is used for carrying out the coloclysis of the newborn, the bed head is raised by 30 degrees, the nursing pad is arranged under the buttocks, the improved paper diaper 1 is worn by the patient, the perineum and the anus are exposed in the transparent visual window, and the rotary fixing hole 6 is kept at the anus; heating the lavage liquid to 39-41 ℃, placing the lavage liquid in a heat-insulating lavage liquid container 5, hanging the lavage liquid container on an infusion support, connecting the infusion tube, and connecting 2 tee joint devices; a third port of a second three-way joint 8 connected with the transfusion tube is connected with the laveur 4, the upper end of a first three-way joint 7 is connected with the anal tube 2, and the lower end is connected with the drainage bag 3. Then lubricating the front end of the anal tube 2 by Vaseline, slowly and softly inserting the anal tube 2 into the anus of the patient from a rotary fixing hole 6 of the paper diaper 1, and screwing the fixing hole after the insertion depth is 20-25 cm; and closing a three-way port connected with the drainage bag 3, closing a three-way port knob of the infusion tube 12 after sucking 15-20 ml of lavage liquid by using the lavage device 4, and slowly injecting the lavage liquid into the anal tube 2 at low pressure. After the lavage liquid is injected, the palm is used for massaging the abdomen clockwise, meanwhile, a three-way port knob communicated with the drainage bag 3 is opened, so that the waste liquid after lavage flows into the drainage bag 3, the operation is repeated until the lavage liquid is clear and has no excrement, and the anal canal 2 is pulled out gently. If more pneumatosis in the intestinal tract of the infant, separate anal canal 2 and tee bend after the lavage and exhaust, pull out anal canal 2 again after the pneumatosis is discharged, wipe the buttock clean, change clean panty-shape diapers, take up drainage bag 3 perpendicularly, read out the degree of graduation of lavage liquid in drainage bag 3 to weigh the weight of panty-shape diapers and calculate the lavage liquid in panty-shape diapers 1, add up and obtain the total amount.
The above description is only one embodiment of the present invention, and the description is specific and detailed, but not construed as limiting the scope of the present invention. It should be noted that several variations and modifications are possible and are within the scope of the invention. Therefore, the protection scope of the present invention should be subject to the appended claims.
Claims (8)
1. A device for colonic lavage of a newborn, comprising: the colon lavage device comprises a paper diaper (1), an anal tube (2), a drainage bag (3) and a lavage device, wherein a rotary fixing hole (6) is formed in the position, corresponding to the insertion position of the anal tube (2), of the paper diaper (1), the inserted anus end of the anal tube (2) penetrates through the rotary fixing hole (6) and is arranged in the paper diaper (1), and the other end of the anal tube is respectively connected with the drainage bag (3) and the lavage device through a first three-way joint (7); lavage device includes lavage ware (4) and lavage liquid container (5), first three way connection (7) are through second three way connection (8) respectively with lavage ware (4) and lavage liquid container (5) intercommunication.
2. A device for colonic irrigation for newborns according to claim 1, wherein: the rotary fixing hole (6) comprises an outer ring fixing ring (600), an inner ring fixing ring (601) and a cylindrical plastic film (603), two end openings of the cylindrical plastic film (603) are respectively provided with an elastic fixing band (604), the outer ring fixing ring (600) is fixed on the paper diaper (1), and the inner diameter of the outer ring fixing ring is matched with the outer diameter of the inner ring fixing ring (601); one port of the cylindrical plastic film (603) is fixed on the inner ring fixing ring (601), the cylindrical plastic film (603) is twisted into a rope in a rotating mode, the other end of the rope is turned outwards and then fixed on the outer ring fixing ring (600), the inner ring fixing ring (601) and the outer ring fixing ring (600) which are connected with the two ports of the cylindrical plastic film (603) are mutually nested, and a hole (602) of which the size is controlled by rotating the inner ring fixing ring (601) is formed in the center positions of the mutually nested inner ring fixing ring and outer ring fixing ring; the anal canal (2) is inserted from the hole (602).
3. A device for colonic irrigation for newborns according to claim 1 or 2, wherein: a waterproof transparent observation window (9) is arranged around the position of the paper diaper (1) provided with the rotary fixing hole (6).
4. A device for colonic irrigation for newborns according to claim 1 or 2, wherein: the lavage liquid container (5) is a heat preservation container, and a speed regulator (10) is arranged on a transfusion tube (12) connected with the second three-way joint (8) and the lavage liquid container (5).
5. A device for colonic irrigation for newborns according to claim 1 or 2, wherein: the paper diaper (1) is provided with one or two weighing rings (11), and the two weighing rings (11) are symmetrically arranged at the front side and the rear side of the paper diaper.
6. A device for colonic irrigation for newborns according to claim 1 or 2, wherein: the anal tube (2) is an anal tube with scales.
7. A device for colonic irrigation for newborns according to claim 1 or 2, wherein: a rotating handle (605) is arranged on the inner ring fixing ring (601).
8. A device for colonic irrigation for newborns according to claim 3, wherein: the rotary fixing hole (6) and the waterproof transparent observation window (9) are arranged at the middle rear side of the paper diaper (1).
Priority Applications (1)
Application Number | Priority Date | Filing Date | Title |
---|---|---|---|
CN202022361863.5U CN213759878U (en) | 2020-10-21 | 2020-10-21 | Neonate's coloclysis device |
Applications Claiming Priority (1)
Application Number | Priority Date | Filing Date | Title |
---|---|---|---|
CN202022361863.5U CN213759878U (en) | 2020-10-21 | 2020-10-21 | Neonate's coloclysis device |
Publications (1)
Publication Number | Publication Date |
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CN213759878U true CN213759878U (en) | 2021-07-23 |
Family
ID=76910294
Family Applications (1)
Application Number | Title | Priority Date | Filing Date |
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CN202022361863.5U Expired - Fee Related CN213759878U (en) | 2020-10-21 | 2020-10-21 | Neonate's coloclysis device |
Country Status (1)
Country | Link |
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CN (1) | CN213759878U (en) |
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2020
- 2020-10-21 CN CN202022361863.5U patent/CN213759878U/en not_active Expired - Fee Related
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CF01 | Termination of patent right due to non-payment of annual fee |
Granted publication date: 20210723 |
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CF01 | Termination of patent right due to non-payment of annual fee |