C. Abbas. Marshall University.

The operative plan is approach order plaquenil on line amex, the ninth rib buy 200mg plaquenil with visa, which is the first floating rib purchase plaquenil 200 mg overnight delivery, is har- written down and diagrammed in great detail. In contrast to vested using a retrograde supraperiosteal dissection back to the primary operations where the operative plan is followed bony junction. Next, a large cartilaginous portion of eighth rib with minimal changes, secondary cases demand total flexi- is easily harvested through the same incision. It is typically fused with the caudal border of the seventh rib, which makes for a tedious dissection. The superior aspect of the An aesthetically pleasing dorsum can be achieved in revision rib perichondrium can also be harvested as a possible graft for rhinoplasty cases using a variety of techniques. Technique Alternatively, superficial temporalis fascia is too thin, and ten- sor fascia lata leaves a visible scar. It is then inserted precisely into areas that need as well as less pliable, which can result in postoperative thick- augmentation using a spatula-shaped instrument. Overgrafting should In primary and secondary rhinoplasty cases where the underly- be avoided. In addition, fascia can prevent for structural grafting in major functional or aesthetic recon- “shrink wrappage” of the skin against the underlying osseocar- struction. The graft is guided into the recipient pocket using 4–0 plain catgut sutures placed at the cephalic end of the graft. Next, the caudal end is sutured in Application place near the anterior nasal angle. This technique can be used to correct the deficiency or hypopla- sia of the radix, or as a precise limited dorsal augmentation. Problems Technique There are few problems with either harvesting or using fascia grafts. Donor site problems such as scar formation and hema- A piece of fascia (2×2cm) is folded and guided with sutures toma are minimal. The fascia is then elevated with Aufricht the early phase (3 to 6 weeks postoperative) should be retractor. The patient can compress the dorsum and overnight that has been stripped of periosteum to allow better fusion taping is encouraged. Complications such as used in patients who present requesting a subtle “natural” cor- infection, displacement, or visibility are exceedingly rare. The rection of their dorsum, which is overresected, thereby creating real risk is to use fascia for augmentation when in reality it is the classic “surgical appearance. The cartilage is sharply cut to small pieces less Overcorrection should be avoided in both areas. In addition, when dissecting the radix, one which would lead to unpredictable survival. Experimental stud- should avoid dissecting the pocket too laterally, which can ies comparing the viability of dicing as opposed to crushing of result in a bulge in that region. The graft is constructed on the back table from does not “overgraft” as there is no absorption postoperatively. Long-term histological studies have hide bifidity and on the sides of dorsal rib grafts. The shape was made as identical as possible, but slightly higher (8mm) at the patient’s request. In con- most challenging grafts is the half-length dorsal graft, which trast, full-length dorsal grafts can be made in a variety of fills the radix area and upper dorsum. Due to the flexible nature of these grafts, a variety of shapes The steps of this technique are as follow: (1) Portions of eight and dimensions (thickness and lengths) are created to address and ninth ribs as well as temporalis fascia are harvested. The distal dles is placed on either side at the cephalic end to facilitate per- end of the graft is closed with 4–0 plain catgut and fixed to the cutaneous placement. The graft is guided into place over the dor- envelope can be effectively thickened and normalized typical sum using the percutaneous sutures. Next, the graft is application is the multiply operated nose with a damaged skin inspected for edges and volume. The dermis graft (14×4cm) is then harvested from the suprapubic region, which results in a Problems cesarean section-type scar. The dermis is then should also avoid placing the graft too superiorly, which can advanced over the underlying bone and cartilage framework cause blunting of the radix. It should be noted that absorption has not been experienced in over 300 grafts used in the past 9 years. The open approach revealed that there were no alar carti- tilage vault restoration are accomplished using rib graft. Dorsal augmentation was done using a 6-mm-thick uni- tour on top of the rigid underlying framework. At 6 years postoperatively, the patient has done very well and the 6-mm dorsal augmentation has been maintained. The advantage of this technique is that warping and visible contour irregularity are not a major concern. This is due to Operative Technique the fact that the major structural grafts are placed deep and in a nonvisible location. Open approach revealed total resection of the alar cartilages; success can be achieved. Columellar strut insertion the alar advancement, and then a shield tip graft of rib. Exposure revealed a large rib dorsal graft, multiple contour The patient is shown at 6 years with obvious retention of the grafts over the left lateral wall, and a 3×20-mm columellar dorsal augmentation. Extensive mucosal undermining was done and the nose was lengthened using a 12-mm-wide columellar-septal graft. The left alar and lateral wall was supported on a 20 ×7×1- mm-wide alar batten graft. The base of the pyriform aperture was opened using four A 53-year-old contractor presented with a history of severe limb Z-plasties. She was quite happy with the result for a year, but then had a tip graft of cadaveric cartilage inserted. She had an intravenous line inserted and was kept on Levaquin (Janssen Pharmaceuticals, Inc. Removal of the implant and reinsertion 6 months later was recommended by her original surgeon. She elected to have the implant removed with immediate reconstruction using a rib graft. Although pleased with the aesthetic result, but if possible to increase the dorsal augmentation slightly. Waste not, want not: the use of AlloDerm in secondary rhi- Operative Technique noplasty.

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These ganglionic blocking agents and neuromuscular blocking drugs are positively charged quaternary amines having an agents discount plaquenil 200 mg fast delivery. The nondepolarizing neu- Drugs that block autonomic ganglia were among the frst romuscular blocking agents are administered only by the drugs to be developed for reducing excessive activity of the intravenous route purchase 200mg plaquenil visa. Chapter 7 y Acetylcholine Receptor Antagonists 67 the specifc isomer known as cisatracurium spontaneously respiratory tract so as to enable ventilation and endoscopic decomposes by nonenzymatic chemical (Hoffman) degrada- procedures (e plaquenil 200 mg sale. Hence, cisatracurium is the preferred paralytic agent neuromuscular blocking agents, the degree of neuromuscular for critically ill patients with impaired hepatic and renal blockade can be determined by monitoring the contraction function. In patients with normal renal and hepatic function, of a small limb muscle in response to nerve stimulation. The selection of a nondepolarizing agent of action comparable to that of vecuronium and rocuronium. The curariform drugs act as relative duration of action and the degree of drug-induced competitive antagonists of acetylcholine at nicotinic changes in blood pressure and heart rate. Atracurium, cisa­ receptors in skeletal muscle, and this accounts for their tracurium, rocuronium, and vecuronium provide an inter- muscle-relaxing effects. After a curariform drug is adminis- mediate duration of action (30 to 60 minutes). With the tered, it frst paralyzes the small and rapidly moving muscles exception of atracurium, which can cause histamine release of the eyes and face and then paralyzes the larger muscles at higher doses, the intermediate-acting drugs have minimal of the limbs and trunk. Finally, it paralyzes the intercostal effects on cardiovascular and respiratory function. This rium or pancuronium might be selected when a longer dura- sequence of paralysis is fortunate in that it enables relaxation tion of action is required. Tubocurarine is no longer used of abdominal muscles for surgical procedures without pro- clinically because it is associated with a higher incidence of ducing apnea. Respiratory function should always be closely histamine release and adverse effects. Depolarizing Neuromuscular Blocking Agents Curariform drugs stimulate the release of histamine Succinylcholine, the only depolarizing agent available for from mast cells, and they block autonomic ganglia and clinical use today, is composed of two covalently linked muscarinic receptors (see Table 7-1). Newer tinic receptors in skeletal muscle and causes persistent drugs, such as doxacurium, cisatracurium, rocuronium, and depolarization of the motor end plate. When the drug is vecuronium, tend to cause less histamine release and fewer frst administered, it produces transient muscle contractions autonomic side effects than does pancuronium. Succinylcholine is drugs are potentiated by volatile inhalational anesthetic not hydrolyzed as rapidly by cholinesterase as is acetylcho- agents (e. The effects of paralytic agents are also more pronounced Table 7-1 compares the properties of succinylcholine with in patients who have neuromuscular disorders such as myas- those of the curariform drugs. The sequence of muscle paralysis reversed by administering a cholinesterase inhibitor (e. The effects of succinylcholine, however, at the neuromuscular junction and counteracting the neuro- are not reversed by cholinesterase inhibitors, and no muscular blockade. Neostigmine reversal should not be pharmacologic antidote exists to reverse an overdose of attempted until patients have demonstrated partial recovery succinylcholine. Because of its shorter duration of action, succinyl- for reversing steroidal neuromuscular blocking agents such choline offers the best chance for resumption of spontaneous as rocuronium. Sugammadex forms a tight water-soluble breathing if endotracheal intubation proves diffcult; thus it complex with rocuronium and removes the drug from the is the preferred neuromuscular blocker for adults with emer- neuromuscular junction, producing a fast recovery of neuro- gency airway situations. Before the drug is administered in muscular function and reducing the risk of postoperative a nonemergent situation, patients should be interviewed to respiratory dysfunction. In contrast to cholinesterase inhibi- screen for personal or family history suggestive of atypical tors, sugammadex is effective in subjects demonstrating cholinesterase. Individuals with this inherited disorder complete paralysis when tested with a nerve stimulator. The neuromuscular blockers are primarily in persons with unhealed skeletal muscle injury such as used to induce muscle relaxation during surgery and thereby follows third­degree burns, and it should not be used in facilitate surgical manipulations. Many conditions used as an adjunct to electroconvulsive therapy to prevent involving muscle weakness, such as paralysis caused by spinal injuries that might be caused by involuntary muscle contrac- cord injury, also present an increased risk of hyperkalemia tions. Succi- (A) hallucinations nylcholine can also cause postoperative myalgia, particularly (B) bronchospasm in the muscles of the neck, back, and abdomen. This effect (C) hyperthermia probably results from the muscle fasciculations produced by (D) urinary retention the drug. Finally, succinylcholine has been associated with a (E) blurred vision rare complication known as malignant hyperthermia, 3. Topical ocular administration of tropicamide will cause which is also associated with inhalation anesthetics (see (A) contraction of the ciliary muscle Chapter 21). The therapeutic use of darifenacin is based on its • Muscarinic acetylcholine receptor antagonists relax ability to smooth muscle, increase heart rate and cardiac con- (A) relax bronchial smooth muscle duction, and inhibit exocrine gland secretion. They are also used to reduce Answers And explAnAtions salivary and respiratory secretions and to produce mydriasis and cycloplegia. Succinylcholine is the • Atropine toxicity can cause dryness of the mouth and only depolarizing neuromuscular blocking agent that skin, blurred vision, tachycardia, palpitations, urinary produces persistent depolarization of the motor end plate, retention, delirium, and hallucinations. Cholinesterase inhibitors, acting to increase depolarizing neuromuscular blocking agents known as acetylcholine levels, do not counteract the muscle curariform drugs, such as rocuronium and cisatracu- paralysis produced by succinylcholine and can actually rium. These drugs are used to produce muscle relax- increase the degree of paralysis by prolonging muscle ation during surgery. They do not cause muscle such as atropine and scopolamine cause relaxation of fasciculations, and their effects can be reversed by bronchial smooth muscle and bronchodilation. It produces Scopolamine causes blurred vision by relaxing the muscle fasciculations that are followed by muscle ciliary muscle, thereby producing cycloplegia (paralysis of paralysis. Tropicamide binds to muscarinic receptors and competi- tively blocks acetylcholine released by the parasympa- review Questions thetic oculomotor nerve. This action leads to relaxation of the iris sphincter muscle and dilation of the pupil 1. Which drug produces transient muscle fasciculations (mydriasis), thereby facilitating ophthalmoscopic exami- followed by muscle paralysis that is not reversed by nation of the peripheral retina. It is not (C) cisatracurium used to relax uterine, gastrointestinal, or bronchial smooth (D) succinylcholine muscle. The receptor subtypes have been cloned Catecholamines and their molecular structures determined. The α1-adrenoceptors are pri- • Norepinephrine marily located in smooth muscle at sympathetic neuroeffec- tor junctions, but these receptors are also found in exocrine Noncatecholamines a glands and in the central nervous system. Three main sub- • Albuterol (Proventil, Ventolin) b types of α1-adrenoceptors have been identifed (α1A, α1B, and • Apraclonidine (Iopidone) c α1D), but the functional roles of these receptors have not • Clonidine (Catapres) been clearly established. The α2-adrenoceptors are widely • Midodrine (Proamatine) distributed in presynaptic neurons, various tissues, and blood • Oxymetazoline (Afrin) platelets (see Fig. Indirect-Acting Adrenoceptor Agonists The α1-adrenoceptors mediate contraction of vascular • Amphetamine smooth muscle, the iris dilator muscle, and smooth muscle • Cocaine in the lower urinary tract (bladder, urethra, and prostate) and other tissues. The α2-adrenoceptors located on sympathetic Mixed-Acting Adrenoceptor Agonists postganglionic neurons serve as autoreceptors whose activa- • Ephedrine tion leads to feedback inhibition of norepinephrine release • Pseudoephedrine (Sudafed) from nerve terminals.

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Another simple and effective strategy is to apply a plumping graft of septal cartilage (diced or crushed) to the front of the nasal spine generic 200 mg plaquenil with amex. The placement of this graft at the labiocolumellar angle gives the illusion of rota- tion of the nasal tip and restores one of the most attractive fea- tures of the Mediterranean face generic plaquenil 200mg mastercard. The lateral crural overlay technique proves particularly useful in correcting marked ptosis of the tip buy plaquenil no prescription, above all when combined with overprojection. The cases by abnormal length of the lateral crura, and careful obser- lateral crural overlay technique essentially involves making an vation of the patient’s profile can help to recognize this ana- incision at the beginning of the posterior two-thirds of the tomic situation. Drawing the outline of the lateral crura on pho- lateral crura and laying the anterior segment over the posterior tographs in lateral view also helps to distinguish their excessive while leaving the vestibular skin below intact. One initial procedure to be used in this connection is segments are then sutured with 5–0 nylon. By 549 Ethnic Rhinoplasty restoring the correct physiologic proportion of the lateral crura, this maneuver causes considerable rotation of the tip with a decrease in projection. At the same time, the lateral shifting of the lateral crura leads to enlargement of the domus region and thus makes it necessary in almost every case to make use also of the double-dome unit technique,10 which improves the defi- nition of the nasal tip. This procedure involves a horizontal mattress suture through each dome and then a transdomal mattress suture through both domes to bring them together. Finally, in the case of tip ptosis combined with underprojec- tion, the correction of the latter takes precedence and can be affected by means of sutures of the alar cartilages and/or carti- lage grafts. After satisfactory projection of the tip has been attained, a suitable degree of rotation can of course be obtained by using one or more of the techniques described above depending on the degree of ptosis involved. Cases of underprojection of the tip are also frequently encountered in the surgical approach to the Mediterranean nose. The numerous techniques devised to increase the degree of projection rest essentially either on cartilage sutures or on cartilage grafts. Though in no way ruling out the subsequent or combined use of grafts where necessary, we consider it preferable for treatment to begin with suture techniques such as the lateral crural steal. An alternative adopted for the same purposes is the tongue-in-groove technique,14 which the lateral crura on either side, and the two new domes are then brought closer to the center by means of a transdomal involves suturing the caudal portion of the nasal septum suture. One crucial surgical phase of this technique regards between the two medial crura. Recommended above all when detachment of the vestibular skin beneath the new domes so the aim is also to reduce the length of the nose, this procedure that the cartilages can be freely lifted and sutured without can be used when necessary to enhance the projection and sticking to the surface below. If the projection still proves insuf- rotation of the tip by varying the position of the suture. The cartilage of the cephalic portion of the lateral crura can also be used for grafts of this type in the event of prior cephalic trimming. Optimal projection is ultimately to be sought after on the operating table with careful appraisal of the relationship between tip and supratip, preference being in any case accorded in the case of the Mediterranean nose to maneu- vers that serve to enhance the projection of the tip rather than lower the dorsum. One important cartilage graft that is nearly always employed is the columellar strut,13 cut in a rectangular shape from a straight and sturdy portion of the cartilaginous septum and sutured in place between the two medial crura. This plays a cru- cial part in strengthening the medial crura, ensuring support Fig. It can also serve to correct 550 The Surgical Approach to the Mediterranean Nose 69. The posterior segment of the lateral crura which have constituted the primary focus in the field of nasal must also be detached from front to back for a few millimeters. Cephalic malposition of the lateral crura giving rise to sis deformity with no other defect of the nasal tip, the lateral parenthesis deformity of the nasal tip is frequently found in the crura are moved downward, and the upper “step” is secured Mediterranean nose. Inthecaseofmalpositionedlateralcrura isolation or together with various degrees of impairment as with overprojection and ptosis of the tip, the anterior flap is regards projection and rotation. If malposition of the lateral crura is ution for all the pathologic variants regarding the projection accompanied by marked overprojection of the nasal tip, it is and rotation of the tip with no weakening of anatomic struc- also advisable to make use of the medial crural overlay tech- tures. The fact that the sectioning is step-shaped rather than nique, in which both medial crura are sectioned, overlaid, vertical makes it possible to apply the lateral crural stair-step and secured (▶ Fig. This mod- ification of the lateral crural overlay technique can in fact be used to mobilize the anterior segment of the lateral crura and 69. In the case of a large nasal tip, this is sometimes combined with weakness of the supporting carti- lage structure. Contrary to what may appear obvious at first sight, the reshaping of the cartilage must be particularly sparing in such cases, and the addition of grafts to the existing struc- tures proves advisable rather than any subtraction. In the case of a bulbous, misshapen tip with thick skin, for example, use can be made of a shield graft17 of cartilage taken from the septum and sutured to the front portion of the cau- dal margin of the medial and intermediate crura with 6–0 nylon. In cases involving the correction of not only the definition but also the underprojection of a tip with thick skin, the upper margin of the shield must extend at least 2 to 3 mm past the domes. When this procedure is executed, the optical effect of the visibility of the edges of the graft beneath the skin enhances the definition and harmony of the tip even though there is no decrease in its actual size. In other cases of patients with thick skin, suturing of the lateral crura by means of techniques such as the double-dome or lateral crural steal is recommended, care being taken once again to leave the car- tilage structures in a rather angular and sharply defined state. This makes it possible to obtain greater visibility of the reshaped contour of the cartilage beneath the thick covering of skin. The skin can also be made slightly thinner in particular cases through conservative removal of the subcutaneous fat of the nasal tip. This procedure must be used with great caution due to the risk of complications such as chronic edema, excessive scar tissue, and cutaneous necrosis. The lateral crural stairstep technique: a modification of the Kridel lateral crural overlay technique. An amorphous tip with cephalic mal- The correction of deformities of the Mediterranean nose pre- position of the lateral crura is also frequently encountered. It is in fact important for the surgeon to relate the spe- ian-Mediterranean nasal pyramid: the drooping nose, the cific situation presented by the patient to these classical models strong prominent nose, the heavy nose, and the northern to obtain a wholly natural result in line with what are recog- nose. Arising from the Great importance attaches among the objectives of ethnic accentuation of various typical ethnic traits, the deformities in rhinoplasty to reshaping of the dorsum, as particular care must question are recurrent and generally comprise a long nose, a be taken to ensure a straight a profile for both male and female 552 The Surgical Approach to the Mediterranean Nose patients. This simple and quickly executed procedure other nasal parameters and with the pronounced lineaments of makes the nasolabial angle more open and helps to give the the Mediterranean face. It is interesting to note in this connec- patient’s face a younger and more attractive appearance. Careful tion that a straight nasal profile is requested and recommended examination confirms the presence of this appealing aesthetic today also by patients of the female sex, whereas the “French feature in the most celebrated models of Mediterranean beauty nose” type of profile was preferred a few years ago. The lateral crural stair-step techni- in female taste attests to a stronger and more independent psy- que, which is to be regarded as a recent modification of the lat- chological attitude while coinciding at the same time with the eral crural overlay, can also be used to correct malpositioned canons of the classical models of Mediterranean beauty. This recently identified and described deformity of Depending on the severity of the condition, ptosis of the tip the nasal tip is quite often found in the Mediterranean nose, should be addressed on the basis of common strategies with the either in isolation or combined with defects of rotation and pro- gradual introduction of more complex techniques such as lateral jection. Though cephalic malposition of the lateral crura can crural overlay, which makes it possible to obtain the highest sometimes be masked by a markedly bulbous nasal tip with degree of rotation. Regardless of the degree of ptosis, it very thick skin, careful analysis is sufficient to detect its presence. Palpation can also serve to reveal an greater importance attaches to the eclectic sensibility of a sur- area devoid of cartilage corresponding with the caudal portion geon capable of harmonizing nasal modifications to the ethnic of the nasal wing.

Vasodilators Calcium Channel Blockers Dihydropyridine drugs* Dizziness proven plaquenil 200 mg, edema best plaquenil 200mg, gingival hyperplasia buy plaquenil 200 mg, headache, Serum levels of drug increased by azole antifungal and tachycardia agents, cimetidine, and grapefruit juice. Diltiazem Atrioventricular block, bradycardia, constipation, Increases serum levels of carbamazepine, digoxin, and dizziness, edema, gingival hyperplasia, theophylline. Three primary stimuli to renin secre- coupled with enzymes that increase the formation of inosi- tion exist: (1) a reduction in arterial pressure in renal afferent tol triphosphate and various arachidonic acid metabolites arterioles, (2) a fall in sodium chloride concentration in and decrease the formation of cyclic adenosine monophos- the distal renal tubule, and (3) sympathetic nervous phate. Increased renal pros- taglandin synthesis may also contribute to the hypotensive effects of these drugs. In affected patients, glomerular fltration is maintained by output or blood volume in otherwise healthy persons elevating efferent arteriolar pressure via vasoconstriction produced by (see Table 10-2). Less commonly, bra- In diabetic patients who exhibit early signs of renal dykinin accumulation may contribute to the development of impairment (e. The renin-angiotensin system appears to be involved for the treatment of bipolar disorder. Moreover, telmisartan was phoryl agents include fosinopril; and the carboxyl deriva- shown to be as effective as ramipril in protecting a broad tives include benazepril, enalapril, lisinopril, quinapril, range of patients at increased risk of cardiovascular and other and ramipril. All of these drugs, except captopril and lisin- diseases, and telmisartan had a more powerful blood opril, are enzymatically transformed to active metabolites. Aliskiren is the frst orally effective direct renin inhibitor to be approved for treatment of hypertension. It binds to the Angiotensin Receptor Blockers active site of renin, preventing cleavage of angiotensinogen A more recent approach to angiotensin inhibition has been and formation of angiotensin I. Aliskiren has equal the proximal tubule, and norepinephrine release from sym- or superior blood pressure–lowering ability compared with pathetic nerve terminals. In the treatment of hypertension, these drugs are as hydralazine, minoxidil, and nitroprusside. In the kidney, fenoldopam cardiac tissue and can reduce the heart rate and cardiac dilates both afferent and efferent arterioles, thereby increas- output. The drug is rapidly converted to inac- isradipine, nicardipine, and nifedipine, belong to the dihy- tive conjugates with an elimination half-life of about 5 dropyridine class. Fenoldopam can reduce serum potassium levels, direct effect on cardiac tissue at usual therapeutic levels; which should be monitored at 6-hour intervals during drug however, they can evoke refex tachycardia. In fact, verapamil and lifestyle changes that will improve their general health and diltiazem reduce protein excretion in patients with kidney can substantially lower their blood pressure. Patients should be encouraged to consume a diet hypertensive patients who have asthma or are of African rich in fruits and vegetables and low in saturated and total heritage (see Table 10-6). Selection of Drug Therapy Single-drug therapy is often preferred for the initial treat- Other Vasodilators ment of mild hypertension, and several drugs are available Hydralazine and Minoxidil that can control blood pressure with a low incidence of side Hydralazine and minoxidil are powerful orally effective effects. These drugs have antihypertensive drugs to treat moderate to very severe been shown to effectively control blood pressure and protect hypertension. When used alone, they often evoke refex against cardiovascular and other complications of hyperten- tachycardia and cause fuid retention, and they can precipi- sion. Thiazide diuretics can also be used but are less favored tate angina in susceptible patients. To prevent these prob- today as single-drug therapy, and β-blockers are usually lems, hydralazine or minoxidil is usually given in combination reserved for patients with concurrent heart disease, such as with two other drugs: a diuretic plus either a β-adrenoceptor angina pectoris. Hydralazine has Clinical experience has shown that many patients with been associated with a lupus-like syndrome, whereas min- high blood pressure will require more than one drug to oxidil can cause hypertrichosis (excessive hair growth), par- achieve target blood pressure levels, and combination ticularly in women. In fact, minoxidil has been marketed as therapy is increasingly used for the initial treatment of high a topical formulation for the treatment of several forms of blood pressure. Studies have found that initial therapy with alopecia (baldness) in men and women (as Rogaine). For more than one drug increases the likelihood of achieving a many reasons, hydralazine and minoxidil are reserved for desired blood pressure in a timely manner. A number of combination drug products Sodium nitroprusside is one of several drugs used in the are now available that can be taken once or twice daily. The drug is products can be less expensive and more convenient to use administered by intravenous infusion and has a short half- than two single-drug products, and they enhance patient life. Nitroprusside is rapidly metabolized to cyanide in adherence to the treatment regimen. Her diabetes has been treated with dietary restric- Patients with Specifc Traits or Diseases tions and metformin, although her target glycosylated Table 10-6 summarizes the most preferred and least pre- hemoglobin A1c level (<7%) has not been achieved. Her ferred drugs for hypertensive patients with specifc traits or blood pressure had been controlled with a thiazide diuretic, concurrent diseases. These recommendations are only guide- but over the past 2 years her blood pressure readings have lines, and individual patient characteristics should always increased and now average 138/86 mm Hg. Her latest test results showed microalbuminuria (proteinuria) of 50 m/min been considered when selecting drug therapy. A greater proportion of black hypertensive patients exhibit microalbuminuria (>30 m/min) compared with white Most patients with ischemic heart disease, including patients. The β-blockers protect types of drugs can be combined with metformin to help against sudden death in these patients. Because a thiazide diuretic can decrease insulin sensitiv- level of 130/80 mm Hg or lower (Box 10-1). This is because ity, it was decided to replace this patient’s diuretic with rigorous control of blood pressure is essential for reducing valsartan and amlodipine in order to achieve the target the progression of diabetic nephropathy to end-stage renal blood pressure level and slow the progression of nephropa- thy. Although β-blockers can mask symptoms of hypoglycemia and slow recovery from hypo- The initial goal of treatment of hypertensive emergencies glycemia by blocking glycogenolysis, these problems are is to reduce blood pressure by no more than 25% within usually managed easily and are not absolute contraindica- minutes to 1 hour, and then to 160/100 mm Hg within the tions for β-blocker use in patients with diabetes. If this level of blood pressure is well toler- In patients with asthma, treatment with β-blockers ated, gradual reductions to normal blood pressure can be should be avoided because these agents can cause broncho- implemented in the next 24 to 48 hours. Hypertensive Emergencies and Urgencies A number of drugs can be used to treat hypertensive Hypertensive emergencies are characterized by severe ele- emergencies and urgencies. Parenterally administered drugs vations in blood pressure (>180/120 mm Hg) complicated are usually used, although oral clonidine can be used for by target organ dysfunction (e. The drugs most often used in reduction in blood pressure to limit target organ damage. Hydralazine has been used for hypertension asso- such as with persons who have upper levels of stage 2 hyper- ciated with eclampsia of pregnancy. Nitroglycerin is used tension associated with severe headache, shortness of breath, for hypertensive emergencies in persons with acute coro- or severe anxiety. Esmolol is useful in persons with aortic dissec- (B) metoprolol tion and perioperative hypertension. While away on a business trip, a salesman ingested his These tumors are highly vascularized and contain high con- medication with grapefruit juice and then promptly centrations of norepinephrine and epinephrine, which is fainted on arising from the breakfast table. Which medi- released in a continuous or paroxysmal fashion, the latter cation was he most likely taking? Treatment is by surgical (A) clonidine removal, and patients are pretreated by the administration (B) atenolol of phenoxybenzamine to induce a long-lasting α- (C) enalapril adrenoceptor blockade and β-blockers.

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