Anita Vashi, MD

• Department of Emergency Medicine
• Mount Sinai School of Medicine
• New York, New York

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Note the left primary coronary artery rapidly divides into the left anterior descending and the left circumflex arteries. A: (1) Left anterior descending artery with septal branches; (2) ramus medianus; (3) diagonal artery; (4) first septal branch; (5) left circumflex artery; (6) left atrial circumflex artery; (7) obtuse marginal artery. B: (1) Conus artery; (2) sinoatrial node artery; (3) acute marginal artery; (4) posterior descending artery with septal branches; (5) atrioventricular node artery; (6) posterior left ventricular artery. Green, right coronary artery; blue, left anterior descending artery; pink, left circumflex artery. Induction of Anesthesia Cardiac operations often require common anesthesia, endotracheal intubation, and controlled air flow. These strategies have by no means been popular in North America because of considerations about the risk of spinal hematomas following heparinization, the associated medical�legal penalties, and the restricted proof of an consequence profit. Some facilities use a single intrathecal opioid injection to present postoperative analgesia. Patient tolerance of inhaled anesthetics generally declines with declining ventricular function. Blood strain and coronary heart rate are repeatedly evaluated following unconsciousness, insertion of an oral airway, urinary catheterization, and tracheal intubation. A sudden improve in heart price or blood pressure could point out mild anesthesia and the need for extra anesthetic previous to the following challenge, whereas a lower or no change means that the patient is prepared for the subsequent stimulus. Reductions in blood pressure higher than 20% generally call for administration of a vasopressor (as described later). A series of challenges could additionally be used to choose when anesthetic depth will allow intubation without a marked hypertensive response, whereas also avoiding hypotension from excessive anesthetic dosing. The interval following intubation is commonly characterised by a gradual lower in blood strain resulting from the anesthetized state (often related to vasodilation and decreased sympathetic tone) and an absence of surgical stimulation. Small doses of phenylephrine (25�100 mcg), vasopressin (1�3 units), or ephedrine (5�10 mg) may be useful to keep away from excessive hypotension. Following intubation and establishment of controlled ventilation; arterial blood gases, hematocrit, serum potassium, and glucose concentrations are measured. Choice of Anesthetic Agents Anesthetic methods for cardiac surgical procedure have evolved over time. Successful strategies vary from primarily inhalation anesthesia to high-dose opioid totally intravenous methods. In latest years, total intravenous anesthesia with short-acting brokers and mixtures of intravenous and risky agents have turn into most popular. But pure high-dose opioid anesthesia (eg, fentanyl, 50�100 mcg/kg, or sufentanil, 15�25 mcg/kg) produces prolonged postoperative respiratory depression (12�24 h), is associated with an unacceptably excessive incidence of patient awareness (recall) during surgery, and often fails to control the hypertensive response to stimulation in many sufferers with preserved left ventricular operate. Other undesirable results include skeletal muscle rigidity throughout induction and extended postoperative ileus. Moreover, simultaneous administration of benzodiazepines with large doses of opioids can produce hypotension and myocardial depression. When remifentanil (rather than an extended persisting agent) is used throughout cardiac anesthesia one should anticipate the necessity for postoperative analgesia after its discontinuation. Mixed Intravenous/Inhalation Anesthesia Selection of anesthetic brokers is oriented to hemodynamic stability in addition to early extubation (1�6 h). Renewed interest in unstable brokers took place following research demonstrating the protecting effects of unstable agents on ischemic myocardium and the utility of those agents for fast-track recovery of cardiac sufferers. The major benefit of risky agents or infusions of remifentanil or propofol is the flexibility to change the anesthetic concentration and depth quickly. Isoflurane, sevoflurane, and desflurane are essentially the most commonly used volatile anesthetics. Early laboratory stories of isoflurane inducing intracoronary steal have been overshadowed by later reports of myocardial safety. Nitrous is particularly disadvantageous in the course of the time interval between cannulation and decannulation, because of its tendency to broaden any intravascular air bubbles that may kind. Other Techniques the combination of ketamine with midazolam (or propofol) for induction and upkeep of anesthesia is a useful method, significantly in frail sufferers with hemodynamic compromise. It is related to steady hemodynamics, reliable amnesia and analgesia, minimal postoperative respiratory depression, and rare (if any) psychotomimetic unwanted effects. Hypertension following intubation or surgical stimulation could be handled with propofol, opioids, -blockers, or a volatile agent. Muscle Relaxants Muscle leisure is helpful for intubation, to facilitate sternal retraction, and to prevent patient motion and shivering.

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Communication in this scenario is critical between the team members resuscitating the affected person with blood merchandise and those making an attempt to management the hemorrhage (see Chapter 39). Urticarial Reactions Urticarial reactions are usually characterised by erythema, hives, and itching with out fever. They are relatively common (1% of transfusions) and are thought to be because of sensitization of the patient to transfused plasma proteins. Urticarial reactions can be treated with antihistaminic drugs (H1 and perhaps H2 blockers) and steroids. Anaphylactic Reactions Anaphylactic reactions are rare (approximately 1:150,000 transfusions). These severe reactions might happen after just a few milliliters of blood has been given, typically in IgA-deficient patients with antiIgA antibodies who receive IgA-containing blood transfusions. The prevalence of IgA deficiency is estimated to be 1:600 to 1:800 in the general population. Such reactions require remedy with epinephrine, fluids, corticosteroids, and H1 and H2 blockers. Patients with IgA deficiency ought to obtain completely washed packed red cells, deglycerolized frozen red cells, or IgA-free blood items. Graft-Versus-Host Disease this kind of reaction may be seen in immunocompromised sufferers. Cellular blood merchandise include lymphocytes capable of mounting an immune response in opposition to the compromised recipient. The platelet depend usually drops precipitously 5 to 10 days following transfusion. Transfusion-Related Immunomodulation 5 Allogeneic transfusion of blood merchandise might diminish immunoresponsiveness and promote inflammation. Post-transfusion immunosuppression is clearly evident in kidney transplant recipients, in whom preoperative blood transfusion improves graft survival. Recent research suggest that perioperative transfusion might increase the risk of postoperative bacterial infection, cancer recurrence, and mortality, all of which emphasize the want to keep away from unnecessary blood product administration. Hepatitis the incidence of post-transfusion viral hepatitis varies tremendously, from approximately 1:200,000 transfusions (for hepatitis B) to roughly 1:1,900,000 (for hepatitis C). Hepatitis C is the more critical infection; most cases progress to continual hepatitis, with cirrhosis growing in 20% of continual carriers and hepatocellular carcinoma growing in up to 5% of chronic carriers. Some individuals contaminated with these viruses turn out to be asymptomatic infectious carriers; the white cells in blood models from such donors are capable of trans6 mitting either virus. Parvovirus transmission has been reported following transfusion of coagulation issue concentrates and can lead to transient aplastic crises in immunocompromised hosts. West Nile virus an infection could result in encephalitis with a fatality rate of up to 10%, and transmission of this virus by transfusion has been reported. Parasitic Infections Parasitic ailments that could be transmitted by transfusion embody malaria, toxoplasmosis, and Chagas illness. Bacterial Infections Bacterial contamination of blood merchandise is the second leading cause of transfusion-associated mortality. To keep away from the potential for important bacterial contamination, blood products should be administered over a interval shorter than four h. Specific bacterial ailments hardly ever transmitted by blood transfusions from donors embody syphilis, brucellosis, salmonellosis, yersiniosis, and various rickettsioses. For most grownup sufferers, the total estimated blood quantity is the equivalent of 10 to 20 units. Because citrate metabolism is primarily hepatic, sufferers with hepatic illness or dysfunction (and presumably hypothermic patients) might demonstrate hypocalcemia and require calcium infusion during massive transfusion, as may small children and others with comparatively impaired parathyroid�vitamin D perform. Hypothermia Massive blood transfusion is an absolute indication for warming all blood merchandise and intravenous fluids to normal body temperature. Ventricular arrhythmias progressing to fibrillation typically happen at temperatures close to 30�C, and hypothermia will hamper cardiac resuscitation.

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When confronted with hemodynamic instability during life-threatening hemorrhage, the surgeons intervene to stop the hemorrhage till the hemodynamic status can be stabilized, and in a case of abdominal trauma, to limit gastrointestinal contamination of the belly compartment. In this case, they pack off the stomach until enough blood-based resuscitation restores systolic blood pressures to eighty to ninety mm Hg, which ought to enable the surgery to proceed. Emphasizing warmed blood product transfusion throughout hemorrhage reduces hypothermia and acidosis while attenuating trauma-induced coagulopathy (providing intravenous crystalloid administration is stored to a minimum). Blood merchandise in this situation, aside from platelets, must be infused by way of a fluid hotter able to delivering massive volumes of infusate for prolonged intervals of time. An increased endtidal carbon dioxide tracing is now observed, and the surgeon notes the aorta is now extra agency. What technology is available for extra intently tailoring blood element administration on this scenario These technologies assess the useful status of clot formation, with results available inside 5 min of sampling. Patterns of clot formation can information the administration of platelets, fibrinogen, and plasma. Thrombolysis can also be detected with this technology, providing proof of the need for antithrombolytic therapies. The surgeon now indicates that the sources for bleeding-a ruptured spleen and lacerated kidney-are managed. The anesthesiologist notifies the team that blood products will no longer must be quickly infused unless hemodynamic instability recurs. The question of when to provoke vasopressors during trauma resuscitation has not been outlined. So-called permissive hypotension throughout lively surgical hemostasis and injury control resuscitation is perfect to prevent disruption of clot formation. Systolic blood pressures within the eighty to 90 mm Hg range scale back blood loss and transfusion wants. However, as soon as the supply of blood loss is surgically managed, no tips exist as to when vasopressors must be initiated, rather than continued transfusion of blood merchandise. Summary this typical trauma scenario broadly addresses the widespread resuscitation and management selections required for main trauma resuscitation. Unlike trauma, where the affected person is often hypotensive for an extended time frame (frequently more than an hour), intraoperative hemorrhage is usually recognized promptly and addressed quickly. Unlike trauma coagulopathy, intraoperative coagulopathy in the setting of surgical hemorrhage is more likely dilutional, somewhat than endothelium-derived (thrombolytic), as in the trauma setting. These concepts are accepted and defendable interventions in nontrauma resuscitation, the place analysis is ongoing to clarify best practices. Damage management resuscitation in sufferers with severe traumatic hemorrhage: A follow management guideline from the Eastern Association for the Surgery of Trauma. Risk elements and medical outcomes related to perioperative transfusionassociated circulatory overload. Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury issues. Pregnant sufferers display enhanced sensitivity to local anesthetics during regional anesthesia and analgesia, and neural blockade occurs at decreased concentrations of native anesthetics; dose requirements could additionally be reduced as a lot as 30%. Obstruction of the inferior vena cava by the enlarging uterus distends the epidural venous plexus and and increases epidural blood volume. Approximately 5% of ladies at term develop the supine hypotension syndrome, which is characterised by hypotension associated with pallor, sweating, or nausea and vomiting. The discount in gastric motility and gastroesophageal sphincter tone place the parturient at excessive threat for regurgitation and pulmonary aspiration. Ephedrine, which has appreciable -adrenergic exercise, has historically been considered the vasopressor of alternative for 7 2 hypotension during being pregnant. However, scientific research suggest that the -adrenergic agonist phenylephrine is more effective in treating hypotension in pregnant patients and is associated with much less fetal acidosis than ephedrine. Volatile inhalational anesthetics lower blood pressure and, probably, uteroplacental blood move. Current methods using dilute combos of a local anesthetic (eg, bupivacaine, zero. It concludes with an outline of the physiological transition from fetal to neonatal life. Progesterone, which is sedating when given in pharmacological doses, increases as a lot as 20 occasions normal at term and is a minimal of partly answerable for this phenomenon.

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Pulmonary resection is often indicated for enormous hemoptysis when conservative measures have failed and the disease is localized. Patients with diffuse bronchiectasis have a continual obstructive ventilatory defect. Intraoperative Management Preparation As with anesthesia for cardiac surgical procedure, optimal preparation may help to stop potentially catastrophic problems. Moderate risk: Morbidity and mortality charges may differ based on the values of split lung functions, exercise tolerance, and extent of resection. Risks and benefits of the operation must be thoroughly mentioned with the patient. High risk: the chance of mortality after commonplace major anatomic resections may be larger than 10%. Considerable danger of severe cardiopulmonary morbidity and residual functional loss is anticipated. Patients must be recommended about different surgical (minor resections or minimally invasive surgery) or nonsurgical options. Physiologic evaluation of the affected person with lung cancer being thought of for resectional surgery: Diagnosis and management of lung most cancers, 3rd ed: American College of Chest Physicians evidence-based medical apply tips. However, patients are increasingly being treated with numerous antiplatelet and anticoagulant drugs, which may preclude epidural catheter placement. Opioid-sparing, multimodal analgesia regimens, including paravertebral blocks, local injection of liposomal bupivacaine, and wound infusion catheters, are increasingly part of enhanced recovery applications for thoracic surgery sufferers. In sufferers with significant coronary artery disease or pulmonary hypertension, intraoperative diagnosis of hypovolemia or decreased right or left ventricular performance may be simply accomplished with transesophageal echocardiography. An sufficient depth of anesthesia will assist forestall reflex bronchospasm and exaggerated cardiovascular pressor responses to laryngoscopy. This may be completed by incremental doses of the induction agent, an opioid, or deepening the anesthesia with a volatile inhalation agent (the latter is especially useful in patients with reactive airways). Moreover, risky anesthetic brokers may protect the lung from harm during one-lung ventilation. Controlled positive-pressure air flow helps prevent atelectasis, paradoxical respiratory, and mediastinal shift; it additionally permits management of the operative subject to facilitate the surgical procedure. Venous Access At least one large-bore (14- or 16-gauge) intravenous line is obligatory for all open thoracic surgical procedures. A blood warmer and a rapid infusion device are also desirable if extensive blood loss is anticipated. Most lung resections are performed with the affected person within the lateral decubitus position. Pillows are positioned between the arms and legs, and an axillary (chest) roll is often positioned just beneath the dependent axilla to scale back stress on the inferior shoulder (it is assumed, but not proven, that the axillary roll helps protect the brachial plexus); care is taken to keep away from pressure on the eyes and the dependent ear. Maintenance of Anesthesia All present anesthetic strategies have been efficiently used for thoracic surgical procedure, however the best strategies should present the power to administer high concentrations of inspired oxygen and all should allow fast adjustments in anesthetic depth. Potent halogenated agents (isoflurane, sevoflurane, or desflurane) are sometimes utilized in North American follow. Advantages of the halogenated brokers versus total intravenous strategies include potent, dose-related bronchodilation and consistent despair of airway reflexes. Advantages of opioids include (1) usually minimal hemodynamic effects; (2) depression of airway reflexes; and (3) residual three postoperative analgesia. If epidural or intrathecal opioids are to be used for postoperative analgesia, intravenous opioids must be minimized throughout surgery to forestall excessive postoperative respiratory depression. Excessive fluid administration in thoracic surgical patients has been associated with acute lung harm within the postoperative period. Excessive fluid administration in the lateral decubitus position might promote a "decrease lung syndrome" (ie, gravity-dependent transudation of fluid into the dependent lung). The latter will increase intrapulmonary shunting and promotes hypoxemia, significantly during one-lung air flow. While we handle lung resections with a relative fluid restriction, we acknowledge that definitive studies on a super goal-directed fluid management technique are lacking. The collapsed lung could additionally be vulnerable to acute lung harm because of surgical retraction through the procedure and possible ischemia�reperfusion damage. During lung resections, the bronchus (or remaining lung tissue) is normally divided with an automated stapling system. The bronchial stump is then examined for an air leak under water by transiently sustaining 30 cm of optimistic strain to the airway.

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Treatment is directed to reversal of cardiac manifestations and skeletal muscle weakness, and to restoration of regular plasma [K+]. Therapeutic modalities employed depend on the reason for hyperkalemia and the severity of manifestations. Hyperkalemia associated with hypoaldosteronism may be treated with mineralocorticoid replacement. Drugs contributing to hyperkalemia must be discontinued and sources of elevated potassium consumption decreased or stopped. Calcium (5�10 mL of 10% calcium gluconate or 3�5 mL of 10% calcium chloride) partially antagonizes the cardiac results of hyperkalemia and is helpful in symptomatic patients with marked hyperkalemia. Care should be exercised in administering calcium to patients taking digoxin, as calcium potentiates digoxin toxicity. An intravenous infusion of glucose and insulin (30�50 g of glucose with 10 units of insulin) can be efficient in selling mobile uptake of potassium and reducing plasma [K+], however might take up to 1 h for peak effect. The ultimate objective of pressing or emergent remedy of hyperkalemia is discount of total body potassium. Forced diuresis with a loop diuretic is an effective therapy of acute hyperkalemia in sufferers with adequate kidney function, and dialysis is the definitive urgent or emergent therapeutic modality for patients with impaired kidney operate. Disorders of Calcium Balance Although 98% of complete body calcium is in bone, maintenance of a standard extracellular calcium focus is critical to homeostasis. Calcium ions are involved in nearly all essential biological features, including muscle contraction, the release of neurotransmitters and hormones, blood coagulation, and bone metabolism, and abnormalities in calcium steadiness can outcome in profound physiological derangements. Calcium is also secreted into the intestinal tract, a phenomenon that seems to be constant and impartial of absorption. Renal calcium excretion averages a hundred mg/d but may range from as little as 50 mg/d to greater than 300 mg/d. Calcium reabsorption parallels that of sodium in the proximal renal tubules and the ascending loop of Henle. Anesthetic administration of hyperkalemic perioperative sufferers is directed at each lowering the plasma potassium focus and stopping any additional increases, with therapy approach dependent upon situational acuity. Succinylcholine is contraindicated, as is using potassium-containing intravenous solutions. The avoidance of metabolic or respiratory acidosis is important to forestall further increases in plasma [K+]. Ventilation must be controlled under basic anesthesia, and delicate hyperventilation could also be Plasma Calcium Concentration the normal plasma calcium focus is eight. Approximately 50% is within the free, ionized type, 40% is protein sure (mainly to albumin), and 10% is complexed with anions such as citrate and amino acids. The free, ionized calcium focus ([Ca2+]) is physiologically most essential. Changes in plasma pH directly have an effect on the diploma of protein binding and thus ionized calcium concentration. In distinction, calcium normally leaves the extracellular compartment by (1) deposition into bone, (2) urinary excretion, (3) secretion into the intestinal tract, and (4) sweat formation. Patients with cancer can present with hypercalcemia whether or not or not bone metastases are present. Hypercalcemia because of increased turnover of calcium from bone can additionally be encountered in sufferers with benign conditions similar to Paget disease and persistent immobilization. Increased gastrointestinal absorption of calcium can lead to hypercalcemia in sufferers with the milk-alkali syndrome (marked increase in calcium intake), extreme vitamin D consumption, or granulomatous ailments (enhanced sensitivity to vitamin D). Clinical Manifestations of Hypercalcemia Hypercalcemia usually produces anorexia, nausea, vomiting, weakness, and polyuria. Hyperparathyroidism Malignancy Excessive vitamin D intake Paget illness of bone Granulomatous problems (sarcoidosis, tuberculosis) Chronic immobilization Milk-alkali syndrome Adrenal insufficiency Drug-induced Thiazide diuretics Lithium Treatment of Hypercalcemia 9 Symptomatic hypercalcemia requires rapid remedy. The handiest preliminary therapy is rehydration followed by a brisk diuresis (urinary output 200�300 mL/h) utilizing intravenous saline infusion and a loop diuretic to speed up calcium excretion. Premature diuretic therapy previous to rehydration could worsen the hypercalcemia by exacerbating quantity depletion. Although hydration and diuresis might remove the potential threat of cardiovascular and neurological issues of hypercalcemia, the serum calcium degree usually stays elevated above regular. Additional therapy with a bisphosphonate or calcitonin could also be required to additional lower the serum calcium stage.

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Diagnosis and remedy should be prompt, if everlasting neurological sequelae secondary to neuronal ischemia are to be prevented. Symptoms include sharp again and leg pain with a motor weakness or sphincter dysfunction, or each. Neuraxial anesthesia ought to be prevented in patients with coagulopathy, significant thrombocytopenia, platelet dysfunction, or those that have acquired fibrinolytic or thrombolytic remedy. Practice pointers ought to be reviewed when considering neuraxial anesthesia in such patients, and the chance versus benefit of these techniques ought to be weighed and delineated within the informed consent course of. Meningitis and Arachnoiditis Infection of the subarachnoid house can follow neuraxial blocks as the outcome of contamination of the tools or injected options, or on account of organisms tracked in from the skin. If hospital policy permits their presence throughout epidural placement, such individuals ought to be suggested to keep away from contaminating the tray. Family members should also put on a mask to prevent contamination of the epidural tray with oral flora. In one reported series, there was a mean of 5 days from catheter insertion to the event of symptoms, though presentation could be delayed for weeks. Prognosis has persistently been proven to correlate to the diploma of neurological dysfunction on the time the analysis is made. We advocate prompt consultation with specialists in neurosurgical and infectious disease. The affected person has an extended history of spinal problems and has undergone fusion of the cervical spine (C3� C6) and laminectomy with fusion of the decrease lumbar backbone (L3�L5). Selection of the sort of anesthesia, as all the time, should be based on patient desire after informed consent. This affected person presents potential difficulties for each common and regional anesthesia. Induction of common anesthesia would be safest after the airway is secured with an awake fiberoptic intubation. Regional anesthesia also presents an issue in that the affected person has had previous again surgical procedure within the lumbar area, the place neuraxial anesthesia is most commonly carried out. Postoperative distortion of the anatomy makes the block technically challenging and should improve the chance of a failure, inadvertent dural puncture throughout epidural anesthesia, paresthesias, and unpredictable spread of the local anesthetics. If the affected person chooses to have neuraxial anesthesia, would spinal or epidural anesthesia be extra acceptable The associated sympathectomy and subsequent drop in blood strain are extra gradual after epidural anesthesia than that following spinal anesthesia. With either kind of anesthesia, vital hypotension should be treated with vasoconstrictors and fluids, and bradycardia must be treated with anticholinergics. If a catheter have to be withdrawn while the needle stays in situ, both should be carefully withdrawn collectively. If a catheter breaks off within the epidural area, many experts recommend leaving it and observing the patient. If, nonetheless, the breakage happens in superficial tissues, the catheter should be surgically eliminated. Local Anesthetic Systemic Toxicity Absorption of excessive quantities of native anesthetics can produce toxic blood levels (see "Intravascular Injection"). Excessive absorption from epidural or caudal blocks is uncommon when acceptable doses of native anesthetic are used. It is mostly related to hyperbaric lidocaine (incidence as a lot as 12%), however has additionally been reported with tetracaine (2%), bupivacaine (1%), mepivacaine, prilocaine, procaine, and subarachnoid ropivacaine. The incidence of this syndrome is best amongst outpatients, significantly males present process surgical procedure within the lithotomy place, and least amongst inpatients present process surgical procedure in positions other than lithotomy. Placement of an epidural catheter is tried on the L1�L2 interspace, however unintended dural puncture happens. Options include injecting a spinal dose of local anesthetic through the epidural needle to induce spinal anesthesia, passing an epidural catheter into the subarachnoid house to perform a continuous spinal anesthetic, or continuing with an awake fiberoptic intubation prematurely of general anesthesia. If a spinal dose of native anesthetic is to be injected, the syringe and needle should be kept in place for a couple of moments to forestall vital back leakage of anesthetic via the massive dural hole. Threading an epidural catheter via the needle into the subarachnoid area permits subsequent redosing and will scale back the incidence of dural puncture headache. A potential hazard of epidural anesthesia at a degree adjacent to a big dural puncture is the chance that some local anesthetic might pass through the dural puncture into the subarachnoid area.

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These defects are encountered in sufferers taking carbonic anhydrase inhibitors, such as acetazolamide, and in those with renal tubular acidosis. The kidneys are unable to adequately acidify the urine, and urinary pH is inappropriately high relative to the systemic acidemia. Other Causes of Hyperchloremic Acidosis Dilutional hyperchloremic acidosis could happen when extracellular quantity is rapidly expanded with a bicarbonate-free, chloride-rich fluid similar to regular saline. Amino acid infusions (parenteral hyperalimentation) contain organic cations in excess of organic anions and might produce hyperchloremic metabolic acidosis as a end result of chloride is often used as the anion for the cationic amino acids. Lastly, the administration of extreme portions of chloride-containing acids, such as ammonium chloride or arginine hydrochloride (usually given to deal with a metabolic alkalosis), could cause hyperchloremic metabolic acidosis. In either case, serial blood gasoline measurements are mandatory to keep away from issues (eg, overshoot alkalosis and sodium overload) and to information additional remedy. Profound or refractory acidemia may require acute hemodialysis with a bicarbonate dialysate. Specific remedy for diabetic ketoacidosis consists of replacement of the existing fluid deficit resulting from a hyperglycemic osmotic diuresis first, in addition to insulin, potassium, phosphate, and magnesium. The treatment of lactic acidosis must be directed first at restoring sufficient oxygenation and tissue perfusion. Treatment choices for ethanol or ethylene glycol intoxication embrace ethanol infusion or fomepizole administration, which competitively inhibit alcohol dehydrogenase and hemodialysis or hemofiltration. Treatment of Metabolic Acidosis Several common measures could be undertaken to management the severity of acidemia till the underlying processes are corrected. Respiration should be controlled, if needed; a Paco2 in the low 30s may be fascinating to partially return pH to normal. Although this theoretically ought to equal the extracellular fluid house (approximately 25% of physique weight), in actuality, it ranges wherever between 25% and 60% of body weight, depending on the severity and duration of the acidosis. This variation is no less than partly associated to the amount of intracellular and bone buffering that has taken place. In the lungs, respiratory alkalosis increases bronchial smooth muscle tone (bronchoconstriction), however decreases pulmonary vascular resistance. Because most opioids are weak bases, acidosis can enhance the fraction of the drug in the nonionized type and facilitate opioid penetration into the brain, potentiating its sedative impact. The circulatory depressant results of each volatile and intravenous anesthetics may additionally be exaggerated. Moreover, any agent that rapidly decreases sympathetic tone can doubtlessly permit unopposed circulatory depression within the setting of acidosis. Succinylcholine ought to typically be averted in acidotic patients with hyperkalemia to forestall further will increase in plasma [K+]. Movement of H+ out of cells in trade for the movement of extracellular K+ into cells can produce hypokalemia. Chloride-Sensitive Metabolic Alkalosis Depletion of extracellular fluid causes the renal tubules to avidly reabsorb Na+. Because not sufficient Cl� is out there to accompany all of the Na+ ions reabsorbed, increased H+ secretion should take place to preserve electroneutrality. Physiologically, upkeep of extracellular fluid volume is due to this fact given priority over acid�base stability. Because secretion of K+ ion also can maintain electroneutrality, potassium secretion can also be enhanced. Urinary chloride concentrations during a chloride-sensitive metabolic alkalosis are characteristically low (<10 mEq/L). Diuretic therapy is the most common explanation for chloride-sensitive metabolic alkalosis. Diuretics, similar to furosemide, ethacrynic acid, and thiazides, increase Na+, Cl�, and K+ excretion, leading to NaCl depletion, hypokalemia, and normally mild metabolic alkalosis. Loss of gastric fluid can also be a standard cause of chloride-sensitive metabolic alka9 losis. Gastric secretions contain 25 to one hundred mEq/L of H+, forty to one hundred sixty mEq/L of Na+, about 15 mEq/L of K+, and about 200 mEq/L of Cl�. Infants being fed formulation containing Na+ with out chloride readily develop metabolic alkalosis because of the elevated H+ (or K+) secretion that should accompany sodium absorption. Most circumstances of metabolic alkalosis can be divided into (1) these related to NaCl deficiency and extracellular fluid depletion, typically described as chloride-sensitive, and (2) these associated with enhanced mineralocorticoid exercise, commonly referred to as chloride-resistant (Table 50�6). Increased H+ and K+ secretion takes place to steadiness enhanced mineralocorticoidmediated sodium reabsorption, leading to metabolic alkalosis and hypokalemia.

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Fetal station refers to the level of descent (in centimeters) of the presenting part relative to the ischial spines (eg, �1 or +1). Effect of Labor on Maternal Physiology During intense painful contractions, maternal minute air flow could increase up to 300%. Oxygen consumption also will increase by an additional 60% above third-trimester values. Marked hypocapnia could cause intervals of hypoventilation and transient maternal and fetal hypoxemia between contractions. Excessive maternal hyperventilation also reduces uterine blood circulate and promotes fetal acidosis. Primigravida Prolonged labor High parenteral analgesic requirements Use of oxytocin Large baby Small pelvis Fetal malpresentation Effect of Anesthetic Agents on Uterine Activity & Labor A. Inhalational Agents Sevoflurane, desflurane, isoflurane, and halothane depress uterine activity equally at equipotent doses; all trigger dose-dependent uterine rest. Parenteral Agents Opioids minimally lower the development of labor; ketamine, in doses of less than 2 mg/kg, seems to have little impact. Current evidence indi9 cates that dilute combinations of an area anesthetic (eg, bupivacaine, zero. Intense regional analgesia/anesthesia can take away the urge to bear down through the second stage (Ferguson reflex), and motor weak point can impair expulsive efforts, often prolonging the second stage of supply. Use of dilute native anesthetic�opioid mixtures can preserve motor function and permit efficient pushing. Intravenous fluid loading (crystalloid boluses) is commonly used to cut back the severity of hypotension following an epidural or subarachnoid injection, and the prophylactic infusion of phenylephrine started on the time of intrathecal local anesthetic injection is efficient in preventing post�spinal hypotension. Epinephrine-containing native anesthetic options may theoretically extend the primary stage of labor if absorption of epinephrine from the epidural area leads to significant systemic -adrenergic results. Prolongation of labor is usually not clinically observed with very dilute (eg, 1:four hundred,000) epinephrine-containing native anesthetics. Large doses of -adrenergic brokers, similar to phenylephrine, in addition to causing uterine arterial constriction, can produce tetanic uterine contractions. Small doses of phenylephrine (40 mcg) may improve uterine blood circulate in normal parturients by elevating arterial blood pressure. Complications include fetal distress because of hyperstimulation, uterine tetany, and, much less commonly, maternal water retention (antidiuretic effect). Rapid intravenous infusion could cause transient systemic hypotension because of rest of vascular clean muscle; reflex tachycardia may happen. Immediate administration of oxytocin after supply is a normal measure to prevent this complication. Second-line oxytocics are methylergonovine (Methergine) and carboprost tromethamine (Hemabate). Serious unwanted effects embody hypotension, heart block, muscle weak point, and sedation. Magnesium in these doses and concentrations intensifies neuromuscular blockade from nondepolarizing brokers. This association is made attainable by two cardiac shunts- the foramen ovale and the ductus arteriosus: 1. Well-oxygenated blood from the placenta (approximately 80% oxygen saturation) mixes with venous blood returning from the lower physique (25% oxygen saturation) and flows via the inferior vena cava into the right atrium. Right atrial anatomy preferentially directs blood move from the inferior vena cava (67% oxygen saturation) via the foramen ovale into the left atrium. Left atrial blood is then pumped by the left ventricle to the upper physique (mainly the brain and the heart). Poorly oxygenated blood from the upper body returns via the superior vena cava to the right atrium. Right atrial anatomy preferentially directs circulate from the superior vena cava into the proper ventricle.

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Hematoma formation might cause airway compromise from collapse of the trachea, significantly in patients with tracheomalacia. Dissection of the hematoma into the compressible gentle tissues of the neck might distort the airway anatomy and should make intubation troublesome. Immediate therapy includes opening the neck wound and evacuating the clot, then reassessing the necessity for reintubation. Anesthesia employees in the postoperative setting must be ready to open the surgical wound and relieve airway compression if the surgeon is unavailable. Hypoparathyroidism from unintentional removal of all 4 parathyroid glands will cause acute hypocalcemia within 12 to 72 h (see the section on Clinical Manifestations underneath Hypoparathyroidism). Hypothyroidism during neonatal improvement results in cretinism, a condition marked by bodily and psychological retardation. Clinical manifestations of hypothyroidism in the adult are often delicate and embrace infertility, weight achieve, chilly intolerance, muscle fatigue, lethargy, constipation, hypoactive reflexes, boring facial features, and depression. In superior instances heart price, myocardial contractility, stroke quantity, and cardiac output are all decreased, and extremities are cool and mottled due to peripheral vasoconstriction. The remedy of hypothyroidism consists of oral alternative therapy with a thyroid hormone preparation, which takes several days to produce a physiological effect and several weeks to evoke clear-cut medical enchancment. Myxedema coma outcomes from excessive hypothyroidism and is characterised by coma, hypoventilation, hypothermia, hyponatremia (from inappropriate antidiuretic hormone secretion), and congestive coronary heart failure. It is extra common in elderly sufferers and may be precipitated by an infection, surgery, or trauma. Myxedema coma is a life-threatening disease that could be handled with intravenous T3. Steroid replacement (eg, hydrocortisone, 100 mg intravenously each 8 h) is routinely given as a result of frequent coexisting adrenal gland suppression. Intraoperative 5 Clinically hypothyroid patients are extra susceptible to the hypotensive effect of anesthetic agents because of diminished cardiac output, blunted baroreceptor reflexes, and decreased intravascular volume. In this circumstance, ketamine or etomidate can be really helpful for induction of anesthesia. The risk of coexistent major adrenal insufficiency ought to be thought of in instances of refractory hypotension. Other potential coexisting conditions embody hypoglycemia, anemia, hyponatremia, problem during intubation because of a large tongue, and hypothermia from a low basal metabolic price. Postoperative Recovery from general anesthesia may be delayed in hypothyroid sufferers by hypothermia, respiratory melancholy, or slowed drug biotransformation; thus, these patients might require mechanical air flow. Because hypothyroidism will increase vulnerability to respiratory melancholy, a multimodal strategy to postoperative ache management, somewhat than strict reliance on opioids is acceptable. Preoperative Patients with uncorrected extreme hypothyroidism or myxedema coma should not bear elective surgery. Such sufferers should be treated with T3 intravenously prior to urgent or emergency surgical procedure. In addition, they could fail to respond to hypoxia with increased minute air flow. It will increase serum calcium concentrations instantly by selling resorption of bone and teeth, limiting renal excretion of calcium, and not directly by stimulating vitamin D synthesis within the kidney to improve gastrointestinal absorption. Of the calcium within the blood, 40% is certain to proteins and 60% is ionized or complexed to natural ions. The remaining major participant in this system, vitamin D, is a steroid hormone that might be absorbed by way of the gastrointestinal tract from meals or synthesized from ldl cholesterol derivatives. Conversion of 7-dehydrocalciferol to vitamin D3 is facilitated by exposure to ultraviolet gentle. Overall, the most typical explanation for hypercalcemia in hospitalized patients is malignancy. Parathyroid hormone�related peptide could trigger important hypercalcemia when secreted by a tumor (eg, bronchogenic [lung] carcinoma or hepatoma). Bone invasion with osteolytic hypercalcemia may complicate a number of myeloma, lymphoma, or leukemia. Nearly all medical manifestations of hyperparathyroidism are due to hypercalcemia (Table 35�7).

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The left ventricle may be comparatively under-loaded secondary to the insufficient delivery of blood throughout the pulmonary circulation as a consequence of the embolus. Treatment and Prevention one of the best remedy for perioperative pulmonary embolism is prevention. The use of intermittent pneumatic compression of the legs might decrease the incidence of venous thrombosis in the legs, however not in the pelvis or the heart. After a pulmonary embolism, parenteral anticoagulation prevents the formation of latest blood clots or the extension of existing clots. All sufferers should begin warfarin remedy concurrent with starting parenteral remedy, and the 2 should overlap for at least 5 days. The international normalized ratio must also be inside the therapeutic vary (>2. Thrombolytic therapy is indicated in patients with massive pulmonary embolism and hypotension. Recent surgical procedure and energetic bleeding are contraindications to anticoagulation and thrombolytic therapy. In these circumstances, an inferior vena cava filter may be positioned to forestall recurrent pulmonary emboli. Pulmonary embolectomy may be lifesaving for hemodynamically unstable patients with huge embolism in whom thrombolytic remedy is contraindicated or ineffective. Preoperative Management Patients with acute pulmonary embolism could current in the operating room for placement of an inferior vena cava filter, or, rarely, for pulmonary embolectomy. In most instances, the affected person will have a historical past of pulmonary embolism and presents for unrelated surgical procedure; on this group of patients, the chance of interrupting anticoagulant therapy perioperatively is unknown. Moreover, except in the case of persistent recurrent pulmonary emboli, pulmonary operate has normally returned to normal. The emphasis in the perioperative management of those patients should be in preventing new episodes of embolism (see earlier discussion). If air is recognized in the best atrium, or if it is suspected, emergent central vein cannulation and aspiration of the air may be lifesaving. For all different emboli, treatment is supportive, with intravenous fluids and inotropes. Intraoperative Management Vena cava filters are usually placed percutaneously underneath local anesthesia with sedation. They are often already intubated, but tolerate positive-pressure ventilation poorly. Intraoperative Pulmonary Embolism Significant pulmonary embolism is rare throughout anesthesia. Air emboli are widespread but are sometimes ignored until large amounts are entrained. Fat embolism, in addition to embolism of microthrombi and bone debris, can occur during orthopedic procedures; amniotic fluid embolism is a uncommon, unpredictable, and often deadly, complication of late pregnancy and obstetrical supply. Manipulation of tumors with intravascular extension (eg, renal cell carcinoma invading the vena cava) can similarly produce pulmonary embolism. What are the advantages of laparoscopic cholecystectomy in contrast with open cholecystectomy Laparoscopic strategies have quickly increased in reputation because of the a number of advantages related to much smaller incisions than with traditional open strategies. These advantages include decreased postoperative pain, much less postoperative pulmonary impairment, a reduction in postoperative ileus, shorter hospital stays, earlier ambulation, and smaller surgical scars. Thus, laparoscopic surgical procedure can present substantial medical and economic advantages. The resulting increase in intraabdominal strain displaces the diaphragm cephalad, causing a decrease in lung compliance and a rise in peak inspiratory stress. These modifications ought to be exaggerated on this obese patient with a protracted history of tobacco use. A head-down (Trendelenburg) place causes a cephalad shift in belly viscera and the diaphragm. A head-down position additionally tends to shift the trachea upward, in order that a tracheal tube anchored at the mouth may migrate into the proper mainstem bronchus.

Thorald, 26 years: In common, the extra distally the clamp is applied to the aorta, the much less the effect on left ventricular afterload.

Folleck, 51 years: Features of severe preeclampsia include the standard features of preeclampsia in association with any of the following: blood stress higher than 160/110 mm Hg, thrombocytopenia (<100,000/L), proteinuria larger than 5 g/d, impaired liver function, progressive kidney insufficiency (serum creatinine concentration higher than 1.

Curtis, 32 years: The blood is heat, and clotting factors and platelets are at optimum temperature and pH.

Sinikar, 30 years: Intracellular potassium focus is estimated to be 140 mEq/L, whereas normal extracellular potassium concentration is approximately 4 mEq/L.

Yussuf, 42 years: From a practical point of view, efforts aimed at stopping or limiting neuronal tissue damage are often similar whether the ischemia is focal or world.

Kayor, 29 years: As with tricyclic antidepressants, exaggerated responses to vasopressors and sympathetic stimulation ought to be expected.

Akascha, 49 years: Stress echocardiography (exercise or dobutamine) may be helpful in diagnosing coronary artery disease when indicated by suggestive indicators and symptoms.

Masil, 25 years: Patients recovering from anesthesia delivered in these areas must obtain the identical normal of care as surgical patients recovering from anesthesia.

Samuel, 55 years: Traditional "soft" cervical collars provide primarily no helpful cervical spine stabilization.

Kalesch, 40 years: Epidural and subdural hematomas can happen as isolated lesions, in addition to in affiliation with cerebral contusions (more generally with subdural than epidural lesions).

Riordian, 37 years: Other systemic diseases, corresponding to diabetes, hypertension, coronary artery illness, heart failure, and persistent obstructive lung illness, frequently manifest within the patient with cerebrovascular illness.

Ali, 34 years: In the case of opioid dependence, any opioid can be used, whereas for alcohol, a benzodiazepine is usually substituted due to the reluctance of hospital pharmacies to dispense alcohol-containing drinks to patients.

Agenak, 44 years: As little as 1 mL of local anesthetic delivered into the vertebral artery could induce a seizure.

Zakosh, 63 years: The basic incidence of saccular aneurysms in some estimates is reported to be 5%, but solely a minority of these with aneurysms could have issues.

Mortis, 23 years: Nonetheless, massive doses and extended infusions of nitroprusside should be avoided because the immature liver of the fetus could have a restricted ability to metabolize the cyanide breakdown product.

Giores, 50 years: A differential diagnosis of pronounced tachycardia and hypertension might include pheochromocytoma, malignant hyperthermia, or thyroid storm.

References

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• American Thoracic Society. Targeted tuberculin testing and treatment of latent tuberculosis infection. MMWR Recomm Rep. 2000;49(RR-6):1-51.
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