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By R. Bozep. Southeast Missouri State University.

Cortical sparing adrenalectomies are51 becoming more common to preserve adrenal function purchase carafate online now. Continuous intra-arterial blood pressure monitoring is required for managing the patient with pheochromocytoma buy carafate 1000mg cheap. Central venous access can be useful for secure administration of anticipated vasoactive medications proven 1000 mg carafate. The presence of coexisting disease would dictate the need for more intensive monitoring. Although there is no clear advantage to one anesthetic technique over another, drugs that are known to liberate histamine are avoided. Dopamine antagonists such as droperidol and metoclopramide can provoke catecholamine release and should not be used. A potent sedative hypnotic, in combination with an opioid analgesic, is used for induction. It is extremely important to achieve an adequate depth of anesthesia before proceeding with laryngoscopy to minimize the sympathetic nervous system response to this maneuver. The disadvantage of long-acting β-blockers may be persistence of bradycardia and hypotension after the tumor is removed. Even esmolol may be problematic because there are cases of cardiac arrest after clamping of the venous drainage in patients receiving large doses of esmolol. Almost every vasodilator has been tried and recommended as an adjuvant to control hypertension. Magnesium sulfate given as an infusion with intermittent boluses has successfully controlled blood pressure. The reduction in blood pressure that may occur after ligation of the tumor’s venous supply can be dangerously abrupt and should be anticipated through close communication with the surgical team. Restitution of any intravascular fluid deficit is the initial therapy in this situation. After replenishment of the intravascular volume, if the patient remains hypotensive, phenylephrine is administered. Hypoglycemia must be watched for as insulin levels rise from loss of catecholamine-induced β-cell suppression. Some56 observational studies report that hyperglycemia is present in 32% to 38% of patients in community hospitals, 41% of critically ill patients with acute coronary syndromes, and 80% of patients after cardiac surgery. Despite a variety of etiologic factors, its hallmark is a deficiency, either absolute or relative, in the amount of insulin effect to the tissues. However, type 1 diabetes and type 2 diabetes are heterogeneous diseases in which clinical presentation and disease progression may vary considerably. The traditional paradigms of type 2 diabetes presenting only in adults and type 1 diabetes only in children are no longer accurate, as both diseases occur in both cohorts. Hyperglycemia in patients with type 1 diabetes cannot be controlled with diet or oral hypoglycemic agents; rather, it mandates treatment with insulin as there is an absolute deficiency of insulin. They are more likely to become ketotic and sustain progressive end-organ complications of diabetes. It is due to a progressive loss of insulin secretion in the background of insulin resistance. However, type 2 form can occur in young people, and many older adults can acquire a severe and brittle form of type 1 diabetes. Because of the obesity epidemic, many adolescents and teenagers are presenting more frequently with this disorder. In milder forms, this version of diabetes can often be treated with diet, lifestyle modifications, and oral hypoglycemic agents. Because these patients are relatively resistant to ketosis, their disease may not be clinically apparent until exacerbated by the stress of surgery or intercurrent illness. Hence, a patient with a glucagonoma, pheochromocytoma, or acromegaly may develop diabetes. An increased effect of glucocorticoids, from either Cushing disease or steroid or tacrolimus therapy (after organ transplantation), may also oppose the effect of insulin enough to elicit clinical diabetes and would certainly complicate the management of pre-existing diabetes. Thiazide diuretic and atypical antipsychotics (clozapine, olanzapine, risperidone, ziprasidone, quetiapine) increase the risk of diabetes. For our purposes, it is60 easiest to regard the effects of insulin on glucose metabolism as primary and to view its effects on other metabolic functions only as they relate to glucose. Insulin is a small protein produced by the β cells of the islets of Langerhans in the pancreas. The basal rate of insulin secretion is about 1 unit/hr, which can increase by 5- to 10-fold after ingestion of food. However, it may clinically appear to have a longer duration of action, due to delays in binding and release from the cellular receptors. These facts lead us to the important principle that once a high61 level of insulin saturates all the binding sites, insulin will not have a more potent effect, just a more long-lasting effect. In patients with hepatic dysfunction, the loss of gluconeogenesis and a prolongation of insulin effect increase the risk of hypoglycemia. They are more prone to hypoglycemia, and exogenous insulin should be administered judiciously in diabetic patients with renal disease. First is the direct effect of glucose and amino acids to stimulate insulin release. The autonomic nervous system, also through vagal stimulation, increases insulin release, as does β-adrenergic stimulation and α-adrenergic blockade. Nitric oxide stimulates insulin secretion, and potassium depletion decreases insulin secretion. The most fundamental action of insulin is to stimulate cellular uptake of glucose in skeletal muscle cells, adipose tissue, and cardiac cells. This is particularly important in skeletal muscle cells, where muscle activity also increases glucose uptake and is an important variable in the management of the physically active diabetic patient. The brain, liver, and immune cells are exceptions, where insulin does not affect glucose transport. Hence, the patient with diabetes has hyperglycemia because of inadequate cellular uptake of glucose in muscle and adipose tissue. Along with glucose, potassium enters the cells under the influence of insulin, so the diabetic patient is also likely to have an imbalance of potassium concentrations across cell membranes. Other important metabolic functions of insulin include the stimulation of 3357 glycogen formation, as well as the suppression of gluconeogenesis and lipolysis. The patient with insulin deficiency has low glycogen stores and active gluconeogenesis. This implies that in the diabetic patient, because of an absence of glycogen, protein must be broken down to make glucose. Fat metabolism is also abnormal in the diabetic state, with acceleration of lipid catabolism and increased formation of ketone bodies.

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Curr Opin Cardiol with left-ventricular assist device implants and tricus- 27(3):288–295 pid valve regurgitation: propensity score-adjusted 30 discount carafate 1000 mg line. Interact Cardiovasc mechanism of tricuspid regurgitation following Thorac Surg 21(6):741–747 implantation of endocardial leads for pacemaker or 39 purchase carafate overnight. Krabatsch References – 352 © Springer International Publishing Switzerland 2017 A purchase carafate now. Predictors of signifcant valve pathology, and normal function recovery are younger age and short duration of and geometry of both the lef and right side of the the disease. Unfortunately, only few cases of myocardial recovery is likely to be sustained for a myocardial recovery in patients sufering from toxic longer time, in the next step, the strategy for with- cardiomyopathy (mostly afer chemotherapy) have drawal of ventricular support should be discussed. Our limited experience shows recur- Tere are several options: rence of heart failure and dilatation of the lef ventri- 1. First, oversewing of the apex of the lef ventricle echocardiography on pump should be performed. If and of the prosthetic anastomosis to the echocardiography shows normal size of the lef ven- ascending or descending aorta. In the case of tricle with satisfactory contractility, echocardiogra- anastomosis to the ascending aorta median phy at reduced pump speed and then an of-pump sternotomy and in the case of anastomosis to study should be scheduled during outpatient visits. Afer an anticoagulation bolus, the bal- and through a subcostal incision with partial loon is infated for 3–4 min and the pump stopped. Te balloon should be and the driveline can be removed, with the defated afer 3–4 min and the pump started for infow and outfow grafs ligated and the 10–20 s, and then the procedure may be repeated 3–5 infow cannula lef in situ. Ligation of the outfow graf is also possible inserted individually designed titanium plug through a small subcostal incision to stop (Fittkau GmbH, Berlin, Germany) is sintered backfow, with transection of the driveline with titanium spheres and becomes overgrown below the skin, while the outfow graf, pump, with tissue , therefore requiring anticoagula- and driveline remain in situ. It is unclear whether In all cases except ligation or interventional reevaluation of the myocardial recovery some closure of the outfow graf, we recommend com- months later would be helpful. Interventional clo- plete removal of the driveline because of the sure of the outfow graf or ligation of the outfow potential risk of infection. Ligation of the outfow Minimally invasive Driveline remains in the Patients with high risk for graft approach, no need for body. Percutaneous No risk of damage or Driveline remains in the Patients with high risk for 34 interventional closure bleeding body. J Heart Lung Transplant 29(11):1316–1317 Krabatsch T, Potapov E et al (2011) Heart failure rever- 5. Morales Chapter 38 Ventricular Assist Device Support for Hypoplastic Left Heart Syndrome, Fontan Failure, and End-Stage Systemic Right Ventricular Dysfunction – 381 Fabrizio De Rita, Antonio Amodeo, and Asif Hasan Chapter 39 Continuous-Flow Pumps in Infants, Jarvik Infant System, and Destination Therapy in Pediatrics – 391 Antonio Amodeo, Sergio Filippelli, Arianna Di Molfetta, Gianluigi Perri, and R. Jarvik 355 35 Mechanical Circulatory Support in Pediatric Population: Clinical Considerations, Indications, Strategies, and Postoperative Management O. Te main etiologies leading to end-stage heart of mechanical ventilation, escalation of inotropic failure requiring mechanical support in children support, inability to tolerate enteral feeds, rise of are dilated cardiomyopathy, myocarditis, and liver function tests, increase in creatinine levels, congenital heart disease. Since end-stage heart altered mental status, low central venous satura- failure is rather uncommon in the pediatric popu- tion (<60%), or elevated lactate. Defnition of the underlying pathology and of the medical therapy, the question arises if exclusion of any residual defect or coronary mechanical support can/should be applied to injury in children with congenital heart save the patient’s life. Since heart transplantation may 35 However, during the child’s treatment, the clini- become necessary, contraindications for cian may be confronted with the question if the transplantation must be considered. Obtaining consent is time consuming but extremely important in establishing a trustful 35. Generally accepted indications are whether the intra-atrial septum is intact or critical cardiogenic shock and progressive decline the aortic and pulmonary valves are despite inotropic support. An intracardial thrombus must clinical presentation is a child who is hemody- be ruled out. Although the vast majority of patients cannulation may become necessary if the needing a long-term device are candidates for cardiac chamber is small, e. Children with a body surface transplantation), recovery of myocardial area larger than 1–1. Depending on body 8 size and patient’s needs, pump chambers of difer­ 7 ent sizes can be chosen 6 5 4 60 ml 50 ml 3 2 30 ml 25 ml 1 15 ml 10 ml 10 20 30 40 50 60 Body Weight [kg] 358 O. Considerations in children with congenital medical support of right ventricular function in heart disease. For children with congenital the intensive care unit is crucial to avoid second- heart diseases, an individualized approach is ary heart failure. Support for children with a A standard protocol for antithrombotic ther- univentricular heart is possible at every stage apy has been proposed [10]. Anticoagulation is of palliation (aortopulmonary shunt, withheld during the frst 24 h until bleeding has superior caval vein anastomosis, and Fontan completely stopped. However, the prognosis is initiated with unfractionated heparin and switched worse in patients with a univentricular to low molecular heparin in infants or warfarin in physiology as compared to patients with children older than 1 year of age. Examples 35 of strategies to lower the adverse event rate include Postoperative management starts in the operat- earlier initiation of unfractionated heparin, higher ing room. To support the right ventricle during target ranges for low molecular heparin and war- weaning from cardiopulmonary bypass, inhaled farin, higher dosages of antiplatelet drugs, and nitric oxide, milrinone, and epinephrine are rec- introduction of a third agent. Transesophageal echocardiog- adverse events such as infections or thromboem- raphy is used to rule out infow obstruction of bolic events. Tereby, the unloading of the lef right ventricular function is severely impaired ventricle is mandatory and must be verifed not despite maximal medical therapy and optimal only directly afer cardiopulmonary bypass but lef ventricular pump settings, the implantation also during follow-up examinations. Directly afer bypass dence of incomplete unloading such as mitral the heparin efect should be completely antago- valve insufciency or increased lef ventricular nized. Initial accurate hemostasis is necessary to dimensions must prompt a careful reassessment minimize the need for blood products and avoid to rule out incorrect position of the cannula, sub- volume overload of the right ventricle. Closure optimal pump settings, aortic regurgitation, or of the chest allows for early extubation, and obstruction of the infow cannula. A pump stop 359 35 Mechanical Circulatory Support in Pediatric Population procedure with echocardiographic and/or inva- 5. N Engl J Med which can only be met by an interdisciplinary 367:532–541 team dedicated to the many diferent aspects of 6. J Heart Lung Transplant 27:112–115 thrombotic therapy; growth on assist with ade- 7. Circulation lines for the management of pediatric heart failure: 127:1702–1711 executive summary. Cardiol 54:S67–S77 Heart 82:237–240 361 36 Continuous-Flow Pumps in Pediatric Population Martin Schweiger, Daniel Zimpfer, Gaetano Gargiulo, and Michael Hübler 36. Due to its size, it is applicable for hospitalization, and to improve QoL in young to children in supporting congenital or acquired patients. Although the ventricle logical” continuous fow; are small, fast, and easy has to be large enough to provide sufcient space to implant; and have a better reliability compared for the infow cannula (see. With miniaturization of implantation in patients as young as a 2-year-old pump design and increasing applications of cf- child has been done (by D. Te infow and outfow cannula are shortened and a reduced size of the fow probe on the out- fow tract is used. A very aggressive anti- tion in a 2 years old child coagulation was necessary to prevent pump 364 M. Te authors Ruygrok and coworkers published their experi- reported their experience of 28 pediatric patients ence with the VentrAssist in three patients (10– (11–18 years, 50–132.

Procedural and Anesthetic Technique Considerations in Interventional Neuroradiology For most interventional neuroradiologic procedures cheap carafate online visa, arterial access is gained using a 6 or 7 French gauge sheath via the femoral or purchase carafate 1000 mg line, rarely carafate 1000 mg on-line, the carotid or axillary artery. Anticoagulation is required during and up to 24 hours after interventional radiologic procedures to prevent thromboembolism. At the end of the procedure or in case of hemorrhage heparin may43 be reversed with protamine. General anesthesia and conscious sedation are both suitable techniques for interventional neuroradiology depending on the complexity of the procedure, the need for blood pressure manipulation, and the need for intraprocedural assessment of neurologic function. The anesthesiologist may facilitate the procedure by manipulating systemic blood pressure and controlling end-tidal carbon dioxide tension. The Wada test (injection of a small dose of a barbiturate or other anesthetic drug directly into one) is used to determine the dominant side for cognitive functions such as speech and memory. This procedure may be used prior to surgery for non–life-threatening conditions such as epilepsy. The50 worldwide unavailability of amobarbital has led to the use of other agents in these tests including propofol50,51 and etomidate. There is an absolute requirement for the patient to remain motionless while the study is being performed and children or adults with psychologic or neurologic disorders preventing immobility may require sedation or anesthesia (Table 33-1). Patients with acute thoracic, abdominal, and cerebral trauma often require urgent imaging to facilitate diagnosis. A high-frequency alternating current is used to generate a localized heat source directly into the tumor causing coagulative necrosis and tumor cell death while avoiding injury to the surrounding tissues. If an anesthesiologist does become involved in the care of these patients, careful evaluation is required; patients may be in the later stages of their disease, have often failed surgical treatment, and may have undergone extensive radiation therapy and/or chemotherapy. Beneficial effects include reduction in bleeding from varices and control of refractory cirrhotic ascites. The procedure causes minimal stimulation, lasts between 2 and 3 hours, and may be performed under sedation or general anesthesia. The considerations are outlined in Table 33-8 (see also Chapter 46 The Liver: Surgery and Anesthesia). If they are then intermittently exposed to a radiofrequency wave, the nuclei change their alignment. As the radiofrequency pulses are discontinued, the protons return to their original alignment (“relax”) within the magnetic field and, as they do, they release energy. Magnetic field strengths are expressed in Gauss (G) and Tesla (T) (1 T = 10,000 G). Ferromagnetic56 implantable medical devices may move in the magnetic field with disastrous consequences. This issue is a particular concern in patients with cardiac pacemakers, which may also malfunction, and cerebral aneurysm clips. The magnetic field takes several days to establish and is constantly present, decreasing in strength with distance from the center of the magnet. Patients58 and staff should wear ear protection and staff should minimize time spent in the scanner. Cables and wires wound in loops may cause induction-heating effects and thermal injury may also occur in skin with large tattoos, especially those with ferromagnetic inks. Patient monitors, ventilator equipment, and electrical infusion pumps may all malfunction when they come too close to the magnetic field. The electrocardiogram is sensitive to the changing magnetic signals, and it is nearly impossible to eliminate all artifacts. The electrodes should be placed close together and toward the center of the magnetic field and the leads insulated from the patient’s skin to avoid causing thermal injury. It may become very warm within the coil of the magnet, often reaching 80°F, adding to patient discomfort and is of particular concern in children whose temperatures should be monitored. Resuscitation attempts should take place outside the scanner because equipment such as laryngoscopes, oxygen cylinders, and cardiac defibrillators cannot be taken close to the magnet. Disadvantages include a higher failure rate than general anesthesia, airway complications arising from oversedation, unpredictable onset of enteral sedatives causing schedule delays, and inadequate analgesia during painful procedures. The choice of sedation or general anesthesia for a particular child is multifactorial and has been obfuscated in the past by the use of imprecise terms to describe the different clinical states. These techniques, however, are being superseded by the use of short-acting agents including propofol, remifentanil, and dexmedetomidine4 which provide more reliable pharmacologic profiles and have preferable track 2204 records for adverse events. Proton beam therapy is a newer modality of this therapy, which has less potential for collateral injury to adjacent or beam- traversed tissues, a factor of utmost importance in pediatric patients at risk of long-term complications of radiation exposure. Many children receive concurrent cytotoxic or immunosuppressive chemotherapy and are at increased risk of sepsis, thrombocytopenia, and anemia. The challenges of anesthesia for children undergoing radiation therapy have recently been reviewed. Radiation doses in the range of 180 to 250 centiGray (cGy) are employed, so interfaced systems of closed-circuit television and telemetric microphones are used with standard monitoring to prevent staff being exposed to high levels of radiation. In the event of a problem, shutdown of the radiation beam and immediate access to the patient (within 20 to 30 seconds) is crucial. Children older than 6 or 7 years can sometimes tolerate repeated treatment sessions without sedation or anesthesia using behavioral techniques, although most require general anesthesia or deep sedation70 techniques with propofol. Most children will have indwelling central venous access, avoiding the need for repeated intravenous puncture or inhalational induction. Radiation treatments are also used in adults who have a greater capacity than children to remain still without sedation or general anesthesia. The American Gastroenterological Association73 reports that 98% of patients for upper and lower endoscopies receive sedation. Of these, over one-third are performed in ambulatory surgery74 centers and only 29% of these procedures involve anesthesia care providers. Patients may have a number of comorbidities, or a risk of gastroesophageal reflux, hepatic dysfunction, coagulopathy, and ascites. Sedation techniques or general anesthesia may be used after careful patient assessment and discussion with the endoscopist. Local anesthetic is sprayed into the oropharynx to81 facilitate passage of the endoscope, which can abolish the gag reflex, increasing the risk of aspiration. A bite block is inserted to prevent the patient from biting down on the endoscope and damaging both the teeth and the endoscope. Procedures are performed in the prone or semiprone position with the patient’s head rotated to the side, making the airway less accessible. Care and attention should also be paid to pressure areas, particularly the eyes, lips, and teeth, and extreme rotation of the neck should be avoided. During the procedure, the biliary and pancreatic duct systems are identified, instrumented, and therapeutic maneuvers such as the passage of stents or removal of stones carried out.

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A bifurcated needle is dipped into the reconstituted vaccine and then 10 to 15 points of entry are made into the dermis of the upper deltoid carafate 1000mg on-line. Because of the side effects of smallpox vaccinations purchase 1000mg carafate, people with immunologic disorders generic carafate 1000 mg on line, eczema (active or with a history of severe eczema), and pregnant or nursing women should not receive the vaccine. Many obstacles have been overcome to develop second- and third- generation smallpox vaccines. Before 2001, the vaccine that was used, Dryvax (similar to what Jenner used in the 18th century), contained live attenuated virus and was the reason that immunocompromised individuals developed adverse events when vaccinated. Anthrax Bacillus anthracis (anthrax) was probably used as a biologic weapon in the Middle Ages, when troops laying siege to a town would catapult infected animal carcasses over the ramparts into the inhabited areas. For reasons discussed later, this method was not a particularly effective method of infecting the native population. During the twentieth century, several countries, including the United States, Great Britain, Russia, and Iraq, studied ways to “weaponize” anthrax. Inhalation anthrax, which was relatively uncommon32 in the past, has an 80% fatality rate. One of the letters that was mailed in the anthrax attacks of 2001 contained 2 g of weapons-grade anthrax. In a terrorist attack, for maximum effect, anthrax could be aerosolized and sprayed from airplanes or delivered through a dispersion device mounted on top of a missile. The attacks on North America in 2001 and the accidental release of spores at a biologic facility in the city of Sverdlovsk in the former Soviet Union in 1979 are illustrative of the potential of anthrax as a weapon. In the United States, 5 of 11 cases resulted in death (45% mortality rate); in the former Soviet Union, 66 of 77 died (86% mortality rate). Fortunately, they used a nonpathogenic strain of anthrax and so there were no casualties. As demonstrated in 200132 in the United States, terrorists are sophisticated enough that they might be successful in obtaining and releasing weapons-grade anthrax. Such attacks, even if detected early, would create mass hysteria and greatly affect the34 entire country and world. The disease is all but gone from North America, but is still prevalent in many developing countries, and herbivores, especially cattle, usually die within 24 to 48 hours of contracting the disease. The carcass has such a large number of organisms, that humans, who are relatively resistant to infection, can be exposed and contract the disease. From a public health perspective, inhalation anthrax is most concerning, as it usually affects 2,000 to 20,000 people worldwide per annum. People can be exposed through contact with animals in an agricultural or industrial setting (i. It manifests as an influenza-like disease with fever, myalgias, malaise, and a nonproductive cough with or without chest pain. The most notable finding on physical examination and laboratory testing is a widened mediastinum. Usually when a patient develops profound dyspnea, death ensues within 1 to 2 days. In the past, penicillin G was the treatment of choice, but since weaponized anthrax has been engineered to be resistant to penicillin G, ciprofloxacin or doxycycline is more commonly used. A more recent study concluded that this drug regimen is the best strategy for managing a small-scale attack, as 4250 occurred in 2001. The first documented use of plague as a biologic weapon was in40 1346 when the Tartars in their siege of the fortress at Kaffa catapulted infected corpses into the city. The plague was used by Unit 731 to infect27 large areas of China, and as many as 200,000 Chinese may have died. Surprisingly, the organism is only viable for approximately 60 minutes after being distributed; if dispersed by an airplane, its viability would limit its infectivity for only 10 km from the dispersion site. Rodents and fleas are its natural hosts, and they re-infect each other by fleas biting infected rodents. Soil can be contaminated and therefore rodents can acquire the disease simply by digging in an infected area. Humans are an accidental host and they usually acquire the disease from a fleabite, though rarely there can be direct inoculation of infected material into a person. With bubonic plague, after a fleabite, there is a 2- to 6-day incubation period, at which time there is the sudden onset of fever, chills, weakness, and headache. Intense painful swelling occurs in the lymph nodes, usually in the groin, axilla, or neck. These swellings or buboes are typically oval in nature, 1 to 10 cm in diameter, and extremely tender. Up to 25% of patients will have pustules, papules, or skin lesions near these buboes. Without treatment, patients become septic, develop septic shock with cyanosis and gangrene in peripheral tissues, leading to the “black death” descriptor that was used during the pandemics in Europe. As mentioned, material from these buboes is infective only if inoculated into human tissue. However, patients who have bubonic plague can seed their lungs, in which case they develop pneumonic plague. Diagnosis is made with a Gram stain or culture of organisms from blood, sputum, or buboes. The treatment of choice is streptomycin, but chloramphenicol and tetracycline are 4251 acceptable alternatives. Patients with pneumonic plague should be managed as one would manage a patient with drug resistance to tuberculosis, because the respiratory secretions are highly infectious. Tularemia Francisella tularensis (tularemia) has some similarities to anthrax and plague, but is not nearly as dangerous. It was studied as a biologic weapon in the twentieth century because it is highly infectious, requiring an inoculum of perhaps as small as only ten organisms. The fact that both armies were infected underscores one of the dangers of using infectious agents as biologic weapons. Often these are dispersed with aerosols, and despite the best predictions of air currents, they are notoriously unpredictable; with the shifting air currents, one’s own troops could become infected. There are several animal hosts, with the cotton-tailed rabbit being one of the most susceptible. Normally, humans acquire tularensis through direct contact of an infected animal or from the bite of an infected tick or deerfly. Occasionally, the41 ingestion of infected food or inhalation of a small amount of aerosol will initiate the disease. Normally, a patient will develop a cutaneous ulcer at the site of entry after contact with an animal. As few as 10 or 50 organisms can invade the body through either hair follicles or mini abrasions. The incubation period is 2 to 6 days, at which time there is swelling and ulceration at the site of entry. As the swelling continues, the skin eventually breaks, creating an ulcer, which develops a necrotic base that becomes black as it scars. The treatment of choice for tularemia is streptomycin, though gentamicin, tetracycline, and chloramphenicol have been used.

Low birth weight 1000 mg carafate with amex, defined as a birth weight of less than 2 buy cheap carafate 1000mg,500 g purchase carafate australia, can be due to prematurity, poor intrauterine growth, or both. Prematurity and intrauterine growth retardation are associated with increased neonatal morbidity and mortality, and it is difficult to completely separate factors associated with prematurity from those associated with intrauterine growth retardation. These newborns have a lower incidence of major physiologic abnormalities typical of the more preterm newborn. Although they usually do not have significant pulmonary abnormalities, they may have some feeding problems or hyperbilirubinemia. This degree of prematurity does not usually have a significant impact on anesthetic management. However, infants born between 30 and 34 weeks’ gestation are much more likely to show some abnormalities related to prematurity that can complicate anesthetic management. This group does have more problems with inadequate feeding, persistent patency of the ductus arteriosus, apnea in response to stress, and temperature instability. However, infants born more prematurely than 30 to 34 weeks’ gestation begin to demonstrate significant physiologic abnormalities related to prematurity. In addition, symptomatic intraventricular hemorrhage is found in about 25% of infants weighing 501 to 750 g, in 12% between 751 and 1,000 g, in 8% between 1,001 and 1,250 g, and in 3% between 1,251 and 1,500 g. Table 42-3 lists some of the most common abnormalities found in the preterm population that have implications for anesthetic evaluation, preparation, and management. Preanesthetic Evaluation—Physical Examination Physical examination of the newborn is focused by the condition requiring surgical intervention. Hydration is often an important issue because of both fasting and losses related to the surgical lesion. Clinical signs of dehydration include a sunken fontanel, poor skin turgor, dry mucous membranes, sunken eyes, poor skin perfusion, delayed capillary refill, hypothermia, tachycardia, or absent urine output. If there are clinical signs of dehydration, efforts should be made to correct the deficits before surgery, except in extreme, life- threatening situations. Physical examination also focuses on the respiratory 2962 and cardiovascular systems. The presence of any cardiovascular abnormalities should be noted, including poor perfusion or pulses, abnormal rhythm or rate, a murmur or gallop, hepatomegaly, or other signs of either heart failure or poor perfusion. The presence of a murmur is of concern in the neonatal period and warrants further evaluation, which is best done by a pediatric cardiologist. An electrocardiogram and echocardiogram will help define whether there is significant cardiovascular disease present that will affect the anesthetic management. Although this evaluation may take some effort and time, it is worthwhile to ensure that the anesthesiologist can plan the child’s care with full knowledge of the limitations cardiovascular disease can impose. Table 42-3 Abnormalities Associated with the Preterm Infant: Common Anesthetic Concerns The respiratory system also must be examined in some detail. The presence of stridor or other evidence of airway obstruction, such as sternal or chest wall retractions, should be identified and investigated. Although upper airway obstruction is relatively rare in the newborn, laryngeal webs, cysts of 2963 the tongue or supraglottic region, vocal cord paralysis after a traumatic delivery, and hemangiomas of the airway can cause obstruction and need to be identified. In addition, newborns that have been previously intubated may have some degree of subglottic edema related to previous intubation. More likely are signs of lower airway disease such as tachypnea, grunting, rhonchi, retractions, and cyanosis. The cause of any respiratory distress needs to be evaluated expeditiously prior to anesthesia to identify treatable causes and begin therapy. Preanesthetic Evaluation—Laboratory Most laboratory investigations are related to the underlying surgical condition such as radiography, computed tomography, magnetic resonance imaging, and echocardiography. However, most newborns will have, at a minimum, a blood count and glucose level drawn. The hemoglobin in a newborn is primarily fetal hemoglobin, which has a higher affinity for oxygen than adult hemoglobin. Because of this higher affinity, the hemoglobin dissociation curve is shifted to the left, releasing less oxygen to the tissues than adult hemoglobin. Newborns have a higher hemoglobin than the infant or child, often in the 15 to 18 g/dL range. Rarely, a newborn will have significant94 polycythemia, with hemoglobin levels above 20 g/dL. If symptomatic, these patients may benefit from therapeutic phlebotomy and volume replacement. The stressed newborn, especially the stressed preterm or small-for- gestational age newborn, are at particular risk for hypoglycemia. A glucose95 level between 60 and 80 mg/dL is expected in a full-term newborn, with a preterm often 10 mg/dL below that. Although there is some controversy about what actually constitutes hypoglycemia in these populations, most agree that levels less than 45 mg/dL warrant therapy with additional dextrose. Other laboratory studies, such as electrolyte determinations and coagulation profiles, are indicated in specific patients. Hypocalcemia, in particular, can be troubling because signs of hypocalcemia are nonspecific. Hypocalcemia is a problem with preterm newborns, but can also be seen in full-term newborns who have a delay in starting enteral feedings. Hyponatremia is not uncommon in newborns who have been receiving 2964 solutions with little or no salt in the first days of life, although hypernatremia may occur if there is inadequate resuscitation of the dehydrated patient when water loss is greater than salt loss. The longer a newborn has received parenteral fluids, the greater the chance of electrolyte abnormalities because of the difficulty in matching ongoing losses with replacement in the presence of an immature kidney. Unexplained thrombocytopenia can be an early sign of sepsis, and a falling count should be an impetus to look for other signs of sepsis. The prothrombin time and partial thromboplastin time levels are about 10% longer in the newborn, but prothrombin time values approach adult levels in the first week of life and partial thromboplastin time levels within the first month of life. Major factors that should be considered in planning the anesthetic include (1) anticipated blood loss and necessity for blood products to be available before beginning the case, (2) monitoring requirements, including invasive monitoring techniques, (3) additional equipment needs for airway and vascular access, (4) transport requirements, (5) postoperative recovery location risk of postoperative ventilation requirements, and (6) plan for postoperative pain relief. Both the medical status of the patient and the planned surgical procedure will impact this planning. The anesthesiologist has the responsibility of clarifying any medical issues with the neonatologist before finalizing the plan, as well as clarifying any issues related to the planned procedure with the surgeon. Occasionally, as planning progresses, it becomes obvious that the patient needs further medical resuscitation or evaluation before it is prudent to proceed with the procedure. Once the anesthetic plan is clear, it should be discussed with the available parent or caregiver who has legal custody of the child. Informed consent is a process by which the anesthesiologist explains his/her understanding of the patient’s status, the planned procedure, the plan for anesthetic management, alternatives to the plan, and some discussion of risks and benefits. Although 2965 there may be rare circumstances in which the legal guardian is not available to provide consent, efforts should be made in all except the most emergent of situations to have this discussion. The goal of informed consent is to help the parent understand what care is being proposed, the risks and benefits involved, and reasonable alternatives. It is the discussion, in terms understandable to the parent, that is the basis of true informed consent.

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J Laryngol Otol 1994;108: pituitary macroadenomas: a consecutive retrospective study with 19–22 13 patients] buy cheap carafate 1000 mg on-line. J Neurooncol croscopic approach for pituitary adenomas and other parasellar tu- 2001;54:187–195 mors: a 10-year experience order carafate 1000mg with amex. Endoscopic endonasal 256 purchase 1000 mg carafate, discussion 256 transsphenoidal approach: outcome analysis of 100 consecutive pro- 52. Minim Invasive Neurosurg 2002;45:193–200 surgery: principles of endonasal oncological surgery. Comparison of endonasal endoscopic surgery and 2008;97:658–664 sublabial microsurgery for prolactinomas. Brief history 375, discussion 375–376 of endoscopic transsphenoidal surgery—from Philipp Bozzini to the 36. Laryngoscope 1992;102: 1999;109:1838–1840 198–202 Extended Endonasal, Endoscopic 24 Transsphenoidal Approach versus Craniotomy for Giant Pituitary Macroadenomas Christoph P. Schwartz With the exception of medically treatable prolactinomas, sur­ classifed tumors as follows: type A, tumor that is bulging gery is the frst-line treatment for symptomatic giant pituitary into the chiasmatic cisterns; type B, tumor that reaches the adenomas. The surgical treatment for giant pituitary mac­ foor of the third ventricle; type C, large suprasellar tumor roadenomas has evolved considerably over the past 100 years growth into the third ventricle up to the foramen of Monro; including the development of the transsphenoidal approach, and type D, tumors that extend into the anterior or middle extended transsphenoidal approach, endoscopic endonasal cranial fossa. The suprasellar extensions techniques can be employed for the treatment of giant pitu­ of macroadenomas were graded, and the giant tumors were itary macroadenomas; sometimes both approaches have been considered to be grades C and D. Maximiz­ with >3 cm suprasellar extension above the foramen of ing the extent of resection in the setting of a low morbidity Monro or a grade C tumor with asymmetrical or multiple and mortality rate is also a goal of surgery. Not all giant pi­ cal experience with transcranial surgery for pituitary tumors tuitary adenomas extend into the third ventricle, and other in general led to development of extracranial approaches to studies have limited them to tumors over 3 or 4 cm in diam­ the sella. He then used a sub­ The use of the microsurgical technique in combination frontal and middle fossa approach with a mortality rate of with traditional transfrontal or transtemporal approaches 20% in 10 patients between 1904 and 1906. At the same to giant pituitary adenomas led to a substantial reduction time Krause27,28 removed a pituitary tumor using a mostly in operative mortality. McArthur29 incor­ with giant pituitary adenomas measuring >4 cm in diam­ porated removal of the supraorbital ridge and orbital roof eter, there was only one postoperative mortality second­ to expose a pituitary tumor in 1908. These techniques were later modifed had evidence of hypopituitarism before surgery. Postop­ by Cushing,32 Dandy,3 and Heuer,33 and a large experience eratively, seven patients had improvement in their endocri­ with transcranial surgery for pituitary tumors was devel­ nologic and ophthalmologic symptoms, and the rest were oped. However, a radical excision was not achieved to open the sylvian fssure and refnement of the pterional in any of the 21 patients52 (Table 24. In contrast, in a se­ approach with sphenoid wing removal, Yasargil et al37 ries of 319 patients with pituitary adenomas, there were described an unobstructed direct view to the parasellar 21 patients with giant adenomas (the authors defne giant structures. The shift from macrosurgical approaches to micro­ adenomas vaguely as adenomas with massive suprasellar surgical approaches in the 1970s dramatically reduced the extension) who underwent transcranial tumor resection morbidity and mortality of transcranial surgery for giant with a subfrontal pterional approach. Postoperative worsening of visual function occurred in ventricle, and to minimize brain retraction (orbitozygo­ two (9. Following transcranial surgery there was one peri­ The operative mortality after transcranial surgery for operative mortality secondary to a pulmonary embolism 2 giant pituitary adenomas was unacceptably high in the months after surgery. These complications were greater in the transcranial 250 Endoscopic Pituitary Surgery Table 24. In one series of 40 patients with giant pituitary rate, 57%, seen in the group who underwent radical surgical 24 Extended Endonasal, Endoscopic Transsphenoidal Approach versus Craniotomy for Giant Pituitary Macroadenomas 251 removal. This decreased to 26% in the partial­removal I Transsphenoidal Surgery for Giant group. Worsening postoperative vision was noted in 10% Macroadenomas after transcranial surgery, and the authors did not spe­ cifcally report on endocrinologic outcomes7 (Table 24. The transsphenoidal approach for the resection of a pituitary The high mortality rate led them to shift to an initial trans­ tumor was frst described by Herman Schlofer54 at the Uni­ sphenoidal removal of the intrasellar component of the versity Clinic in Innsbruck, Austria. He performed a superior tumor and decompression of the suprasellar component if nasal transsphenoidal approach on a 30­year­old man with it descends during the operation. At that who was found to have an enlarged sella on a lateral skull time, suprasellar components descended into the vacant x­ray. Although the surgery proceeded without serious com­ sella space and a second transsphenoidal or transcranial plications, the patient died postoperatively from obstructive operation was performed. During the following years the transsphe­ tients no operative mortality or major complications were noidal approach was modifed, and Harvey Cushing was the reported; however, specifc endocrine outcomes were not frst to present a large clinical series of 231 transsphenoidal reported. However, the cause of death presented with visual loss had postoperative resolution, and was diferent depending on the approach. Clinical follow-up use of skull base techniques substantially decreased the data were available for almost all patients. Ten years after operative morbidity and mortality of giant pituitary ad­ the operation half of the patients were still alive. In a series of 210 patients with large or giant pitu­ tive impaired vision improved in approximately two thirds itary adenomas with suprasellar and parasellar extension, of patients. Two major disadvantages of the transsphenoidal a classic frontotemporal transcranial approach was used approach prompted Cushing to abandon the transsphenoidal for the frst 120 patients and an extradural transcavernous approach. First, given the lack of preoperative imaging, pos­ skull base approach was used for the next 90 patients. Consequently, tumor was left tradural exposure of the cavernous sinus, and it combined behind and caused half of the perioperative mortality associ­ intradural and extradural transcavernous tumor resection. Second, high­power Although the author’s exact defnition of giant adenoma illumination or magnifcation was not available, which se­ was unclear, these tumors required transcranial surgery verely limited access and visibility. Hence, in the late 1920s for removal of their various suprasellar and parasellar ex­ Cushing preferentially used the transfrontal approach, as it tensions. With the classic approach in patients undergoing allowed for intraoperative visualization of suprasellar tumor their frst operation, complete resection was achieved in extension and better decompression of the optic chiasm. Two technologic milestones paved In contrast, with the extradural skull base approach, com­ the way for the revival of the transsphenoidal technique. None of the intraoperative use of the operating microscope improved the patients who underwent the skull base approach had intraoperative illumination and visualization. Specifc anterior or posterior pi­ a high incidence of complete tumor removal and low compli­ tuitary endocrine defcits were not reported. No periop­ cation rate was reported for the transsphenoidal resection of erative mortalities were described with either approach pituitary microadenomas. Of these lesions, 44% had suprasellar extension The other main advantage of the endonasal approach is the and 15% were intrasellar macroadenomas. In this series development of expanded approaches, in which large areas there was no perioperative death. Importantly, Black and of bone of the anterior skull base are removed to increase vi­ colleagues correlated complications with tumor size.

These patients usually are smokers who have hypertension or the metabolic syndrome generic carafate 1000mg otc. These conditions purchase cheapest carafate, like diabetes buy carafate once a day, result in elevation of advanced glycation end products in the blood, which affects glomerular matrix pro- duction and turnover. It is not illustrated here because it is indistinguishable from nodular diabetic glomerulopathy; it is a diagnosis of exclusion. This case of immunotac- toid glomerulopathy contains deposits composed entirely of uniform compact masses of microtubules. In established diabetic glomeru- lopathy, there is diffuse mesangial matrix expansion and acellular mesangial nodule formation known as Kimmelstiel-Wilson nodules. The severity of mesangial expan- sion and nodule formation is remarkably variable both between glom- eruli and within a glomerulus. This image shows a large nodule and smaller nodules with several mesangial regions showing no nodule for- mation, only mild mesangial sclerosis. In this example of mild diabetic glomerulopathy, note that in addition to mesangial matrix expansion there is mild seg- mental mesangial hypercellularity, a common feature Fig. A finding highly correlated with but not specific for diabetes is the combination of afferent and efferent arteriolar hyalinosis. Despite the severity of the arteriolar lesions, the glom- erulus does not show severe mesangial sclerosis 248 6 Glomerular Diseases 6. The mutations result in marked elevation of the plasma concentrations of unesterified cholesterol, triglycerides, and phosphatidylcholine, with resultant lipid deposition in multiple organs. Patients present as a neonate or in child- hood with proteinuria; renal insufficiency develops several decades later. The first ultrastructural abnor- mality that develops in diabetic glomerulopathy is capillary loop base- ment membrane thickening. The pallor is caused by the accumulation of foamy lipid within the mesangium and capillary loops. The subtle vacuolization is strates the abundant lipid deposits that have expanded the mesangium more apparent at higher magnification, especially within the mesan- and involve the capillary loops. There is capillary loop thickening, but its cause may be uncertain ing processing, leaving the mesangium and capillary loops riddled with because the presence of abundant lipid deposition is difficult to lucent defects (arrows). The subendothelial appreciate lipid deposits in this case have induced capillary loop basement mem- brane duplication. The vacuolated nature of the lus, lipid deposits have occluded the capillary loop and permeate expanded mesangium is readily demonstrated on silver stain. Although much of the lipid material lary loop basement membranes also may have a vacuolated appearance has been extracted during processing, there are black lamellar and cur- or show a double contour. However, the most striking finding is in the glomerular capillaries, which are distended by pale, wispy-appearing lipoprotein “thrombi” Fig. The lipid is extracted during tissue processing for paraffin section, although its protein component remains. However, an oil red O stain on frozen tissue typically is impressive, demonstrating abundant lipid in the capillary loop lipopro- tein thrombi Fig. Males are severely affected; they present with proteinuria, and progressive renal failure develops over several decades unless treated. Females have variable enzyme levels and therefore exhibit a wide range of severity. This image shows numerous lipid vacuoles (arrow) with a proteinaceous matrix filling a distended capil- lary loop. The glomeruli in Fabry’s disease show cytoplasmic vacuolization, most prominent in podocytes, as shown here. Admixed with the lipid is granular electron-dense proteinaceous material of unknown composi- tion. In this glomerulus from a female carrier of glomerulus show striking enlargement and vacuolization. The mesan- Fabry’s disease, who presented with proteinuria and normal serum cre- gium shows no abnormality. Masson trichrome stain atinine, silver stain reveals two vacuolated podocytes, one of which is markedly enlarged. This glomerulus is from a female carrier of embedded tissue for electron microscopy allows appreciation of the Fabry’s disease presenting with proteinuria and normal serum creati- true extent of lipid deposition. This electron micrograph shows numerous osmophilic (black) lamellated lipid inclusions within the podocytes. In nephrosialidosis, the oligosaccharide storage products accumulate within glomerular podocytes and endothe- lial, interstitial, and occasionally proximal tubular cells. This electron microscopic image shows the distinctive lamellated nature of the intracellular inclusions, which are known as myelinosomes or myeloid bodies 254 6 Glomerular Diseases Fig. Hale’s colloidal iron stain graphically demonstrates the magnitude of the oligosaccharide storage (Courtesy of Fig. Remaining are largely empty intracellular vacuoles containing a small quantity of residual electron-dense membranous material. They have coarse facial features, psychomotor retardation, joint contractures, deformed long bones, valvu- lar abnormalities, respiratory symptoms, and renal disease. Proximal tubular dysfunction occurs with hypercalciuria, hyperphosphaturia, and aminoaciduria. There is more abundant lamellar electron- dense material in the podocytes than in the above case. The disease findings bear strong resem- blance to those observed in nephrosialidosis, but interstitial cells and endothelial cells are not affected. The vacuoles have modest amounts of lamel- lar material, which might raise the possibility of Fabry’s disease. Renal enlargement, proteinuria, and distal tubular aci- dosis develop, followed by nephrocalcinosis and renal failure. Histologically, glomerulomegaly is present and tubules are vacuolated as a result of extraction of the retained glycogen. The vacuolated or cleared-out apical cytoplasm (arrow) is more apparent at higher magnification. The mutations result in lysosomal accumulation of cystine lead- ing to multiorgan damage. Patients present with Fanconi syndrome, which if untreated is followed by renal failure and death by age 10 years (see Figs. Juvenile cystinosis causes mild mesan- gial matrix expansion and affects the podocyte in a distinctive fashion, causing multinucleation. There were scattered multinucleated podo- cytes in this case, although not every glomerulus showed this finding. The transsphenoidal approach is the result of an evolution- ary process rather than a revolutionary one. Many neurosurgical (and nonneurosur- gical) pioneers have contributed to their development.

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