Michel Billiard, MD

• Honorary Professor of Neurology, Department of
• Neurology, Gui de Chauliac Hospital, Montpellier,
• France

The posterior tibial and peroneal veins also communicate with the soleal sinusoids prehypertension early pregnancy 100 mg tenormin order free shipping. In the thigh hypertension in african americans purchase tenormin 50 mg otc, the deep venous system includes the femoral and deep femoral veins that join approximately 4 cm below the inguinal ligament hypertension over the counter medication buy tenormin 100 mg otc. Perforating veins connect the superficial and deep systems through both direct and indirect mechanisms arteria inflamada del corazon buy tenormin with a mastercard. Venous return from the lower extremities depends largely on compression of the deep veins by the muscles of the calf (gastrocnemius blood pressure zestoretic buy tenormin 100 mg, soleus) during walking. Flow is unidirectional due to a series of one-way valves, which prevent reflux during this cycle of compression. Failure of these valves to close leads to pooling, stasis, and congestion of veins in the lower extremities, and subsequent dilation of the superficial veins. Reflux disease from venous valvular incompetence accounts for most (>80%) chronic venous disease. Valve malfunction can be inherited or acquired through sclerosis or elongation of valve cusps or dilation of the valve annulus despite normal valve cusps. Varicose veins may represent superficial venous insufficiency in the presence of competent deep and perforator systems, or they may be a manifestation of perforator or deep venous disease. Valvular disease below the knee appears to be more critical in the pathophysiology of severe venous disease than disease above the knee. The perforator veins are frequently implicated when venous ulcers exist, but any component of the venous system, either alone or in combination, may be incompetent. Obstructive physiology is a less common cause of venous pathology, with reflux often being present simultaneously. Ulcers with discrete edges and pale bases; more painful than venous ulcers, generally at the tips of the toes 2. Developed by the American Venous Forum in 2000, and revised in 2010; expands the existing system. Ten clinical descriptors: Pain, varicose veins, venous edema, skin pigmentation, inflammation, induration, number of active ulcers, duration of active ulceration, size of ulcer, and compressive therapy use. Leg pain is described as a dull ache, worsening at the end of the day, and often relieved with exercise or elevation. In rare instances, individuals can experience acute, bursting pain with ambulation (venous claudication). With the leg in a dependant position, cuffs are placed on the thigh, calf, and foot and inflated; then the cuffs are rapidly deflated in an attempt to create retrograde venous blood flow in segments of valvular incompetence. Detailed mapping of valve competence of each segment of the venous system is possible, including the common femoral, greater saphenous, lesser saphenous, popliteal, posterior tibial, and perforator veins. Helpful for screening reflux at the saphenofemoral and saphenopopliteal junctions. Limited clinical use due to inability to quantitate reflux and to provide precise anatomic information. An elastic tourniquet is applied at the saphenofemoral junction, and the patient then stands. Rapid filling (<30 seconds) of the saphenous system from the deep system indicates perforator valve incompetence. When tourniquet is released, additional filling of the saphenous system occurs if the saphenofemoral valve is also incompetent. Descending phlebography has a positive predictive value of 44%, and is limited by its inability to study valves distal to a competent proximal valve. Staphylococcus aureus, Streptococcus pyogenes, and Pseudomonas species are responsible for most infections. Usually treated with local wound care, wet-to-dry dressings, and oral antibiotics. Leg elevation can temporarily decrease edema and should be instituted when swelling occurs. Fitted to provide a compression gradient from 30 to 40 mm Hg, with the greatest compression at the ankle. Study of 113 patients treated with initial bed rest, local wound care, and elastic compression stockings demonstrated a 93% ulcer healing rate in a mean of 5. Stockings do not correct the abnormal venous hemodynamics and must be worn after the ulcer has healed to prevent recurrence. Recurrence for compliant patients in the same study was 16% at a mean followup of 30 months. Employed when there is actual skin ulceration, they combine compression therapy with a zinc oxide paste that assists in wound healing. Topical therapy is directed at absorbing wound drainage and avoiding desiccation of the wound. Hydrogen peroxide, povidone-iodine, acetic acid, and sodium hypochlorite are toxic to cultured fibroblasts and should be used for the shortest duration necessary to control ulcer infection. Surgical therapy is indicated for severe disease refractory to medical treatment and for patients who cannot comply with the lifelong regimen of compression therapy. Effective in treating telangiectasias, reticular varicosities, and small varicose veins. Contraindications include arterial occlusive disease, immobility, acute thrombophlebitis, and hypersensitivity to sclerosing agent. A 30-gauge needle is used for sclerosing reticular veins and telangiectasias in supine patients. Compression stockings are applied at the end of the procedure and are worn for several days to 6 weeks. Complications include cutaneous necrosis, hyperpigmentation, telangiectatic matting (new, fine, red telangiectasias), thrombophlebitis, anaphylaxis, allergic reaction, visual disturbances, venous thromboembolism P. Saphenous vein stripping, once considered the gold standard for superficial venous surgery, has since been replaced by the use of minimally invasive techniques. This was shown to effectively treat saphenous reflux and associated varicose veins with less morbidity than saphenectomy (J Vasc Surg. The probe emits either laser or radiofrequency energy, which coagulates and coapts the vein walls, causing complete obliteration of the lumen. Reported outcomes achieved with endovenous radiofrequency and laser obliteration are comparable to those resulting from saphenectomy (Ann Vasc Surg. Incomplete obliteration and recanalization occur in a small percentage of patients. This is associated with decreased morbidity as compared to vein stripping and has gained recognition as an alternative treatment option. Performed by making small port incisions in unaffected skin in the calf and fascia of the posterior superficial compartment. Various types of endoscopes (laparoscopic, arthroplastic, or bronchoscopic) can be used for visualization. The vein is elevated from the incision with a small vein hook, divided, and avulsed from the subcutaneous tissue. This technique is often used in conjunction with other modalities to provide optimal results. The thrombogenic nature of the nidus activates the clotting cascade, leading to platelet and fibrin accumulation. The fibrinolytic system is subsequently activated, with thrombus propagation if thrombogenesis predominates over thrombolysis. Thrombi localized to the calf have less tendency to embolize than thrombi that extend to the thigh veins (Am Rev Respir Dis. Primary hypercoagulable states are inherited conditions that can lead to abnormal endothelial cell thromboregulation. Secondary hypercoagulable states are states in which endothelial activation by cytokines leads to an inflammatory, thrombogenic vessel wall. Phlegmasia alba dolens occurs with extension of thrombus into the collateral venous system, resulting in limb pain and swelling, accompanied by cyanosis, a sign of arterial ischemia. Duplex ultrasonography of the femoral, popliteal, and calf trifurcation veins is highly sensitive (>90%) in detecting thrombosis of the proximal veins (femoral and popliteal) but less sensitive (50%) in detecting calf vein thrombosis. It represents the preferred diagnostic modality because it is less invasive than the reference standard of venography and is more sensitive than impedance plethysmography. Approximately 2% of patients with initial normal ultrasound results have positive results on repeat tests performed 7 days later. Delayed detection rate is attributed to extension of calf vein thrombi or small, nonocclusive proximal vein thrombi. Pulmonary angiography, the reference test, is reserved for patients in whom diagnosis is still uncertain. For anticoagulation treatments following specific procedures, please see the recent guidelines published by the American College of Chest Physicians (Chest. Administered subcutaneously at 5,000 units 1 to 2 hours preoperatively, and every 8 or 12 hours postoperatively (N Engl J Med. Because of the potential for minor bleeding, it should not be used for patients undergoing cerebral, ocular, or spinal surgery. In surgery patients, the use of graduated compression stockings appears to augment the protective benefit of low-dose heparin by nearly 75%. Graduated compression stockings are relatively inexpensive and should be considered for all high-risk patients, even when other forms of prophylaxis are used. For patients with significant bleeding risk with anticoagulation, pneumatic compression is an effective alternative. Absolute and relative indications for caval interruption are listed in Table 29-2 (Chest. The specific types of retrievable and permanent filters are beyond the scope of this chapter, but the use of retrievable filters can reduce P. High-risk trauma patients (head and spinal cord injury, pelvic or lower-extremity fractures) with a contraindication for anticoagulation. The goals are to restore venous flow, preserve venous valve function, and eliminate the possibility of thromboembolism. Technical success and early clinical benefit have been reported, but long-term data are unavailable. Primary lymphedema is the result of congenital aplasia, hypoplasia, or hyperplasia of lymphatic vessels and nodes that causes the accumulation of a protein-rich fluid in the interstitial space. Congenital primary lymphedema (present at birth) represents 10% to 15% of all cases, which can be hereditary (Milroy disease) or nonhereditary. Tarda (late in life) primary lymphedema, representing 10% to 15% of cases, is seen equally in men and women and presents after the third or fourth decade of life. Secondary lymphedema results from impaired lymphatic drainage secondary to a known cause and is the most common cause of lymphedema in the United States. Surgical or traumatic interruption of lymphatic vessels (often from an axillary or groin lymph node dissection), carcinoma, infection, venous thrombosis, and radiation are causes of secondary lymphedema. Secondary lymphedema in the context of filariasis, caused by the parasite Wuchereria bancrofti, represents the most common worldwide etiology of the disease. Early lymphedema is characterized by unilateral or bilateral arm or pedal swelling that resolves overnight. With disease progression, the swelling increases and extends up the extremity, producing discomfort and thickened skin. Patients with secondary lymphedema commonly present with repeated episodes of cellulitis secondary to high interstitial protein content. Lymphedema is seen as an abnormal accumulation of tracer or as slow tracer clearance along with the presence of lymphatic collaterals. The study has a sensitivity and specificity of 92% and 100%, respectively in the diagnosis of lymphedema (J Vasc Surg. Systemic diseases, such as right ventricular failure, myxedema, nephrosis, nephritis, and protein deficiency. Medical management is limited by the physiologic and anatomic nature of the disease. The use of diuretics to remove fluid is not effective because of the high interstitial protein concentration. Development of fibrosis and irreversible changes in the subcutaneous tissue further limit options. The objectives of conservative treatment are to control edema, maintain healthy skin, and avoid cellulitis and lymphangitis. Benzopyrones (such as warfarin) have been effective in reducing lymphedema due to filariasis. Their action is believed to derive from enhanced macrophage activity and extralymphatic absorption of interstitial proteins. Cellulitis and lymphangitis should be suspected when sudden onset of pain, swelling, or erythema of the leg occurs. Intravenous antibiotics should be initiated to cover staphylococci and -hemolytic streptococci. Limb elevation and immobilization should be initiated, and warm compresses can be used for symptomatic relief. Surgical intervention is an alternative approach for patients whose lymphedema has been refractory to nonoperative therapies. Only 10% of patients with lymphedema are surgical candidates, and surgery is directed at reducing limb size. Indications for operation are related to function because cosmetic deformities persist postoperatively. Results are best when surgery is performed for severely impaired movement and recurrent cellulitis. Circumferential excision of the skin and subcutaneous tissue from the tibial tuberosity to the malleoli is performed. The defect is closed with a split- or full-thickness skin graft from the resected specimen or a split-thickness skin graft from an uninvolved site. Lymphatic transposition includes direct (lymphovenous bypass, lymphatic grafting) and indirect (mesenteric bridge, omental flap) procedures.

Of the above prehypertension meaning in urdu cheap 50 mg tenormin mastercard, only an occluded left hypogastric artery does not preclude endograft placement pulse pressure sepsis purchase genuine tenormin line. Type I endoleaks are due to inadequate seal of the proximal or distal components heart attack 3d buy generic tenormin 50 mg on-line, and are usually treated as soon as identified blood pressure yoga proven 50 mg tenormin. Open repair is done via a left thoracotomy hypertension forum buy 100 mg tenormin with amex, often with use of aortofemoral bypass. Rapid surgical repair of Type A dissections has significantly decreased the mortality of this condition. This patient has an uncomplicated, chronic (greater than 14 days duration) Type B dissection. Of the above, age of onset in the middle ages (25 to 55) suggests some other underlying cause. The patients are marked by a low-output cardiac state, and imaging often reveals minimally diseased vessels. The mortality rate is high, and patients benefit from optimization of their hemodynamics rather than surgical intervention. Palpable pulses in the contralateral/unaffected limb with no prior history of claudication confirms absence of significant underlying atherosclerotic disease thus suggesting an embolic etiology. Nonoperative management with risk factor modification and structured exercise is always the initial management for claudication symptoms. Lifestyle limiting claudication despite conservative management is an indication for an operative intervention. The Society of Vascular Surgeons also has practice guidelines for atherosclerotic occlusive disease of the lower extremities. Acute lower extremity compartment syndrome should always be suspected and aggressively managed with adequate 4-compartment fasciotomies when duration of ischemia exceeds 6 hours. Statins are helpful in reducing adverse cardiovascular events in patients with peripheral atherosclerosis in whom coronary atherosclerosis often coexists (Lancet. Small studies have also shown to have a positive effect of statins on pain free walking distance in patients with intermittent claudication (Am J Med. Traumatic joint dislocation can cause mechanical compression or a temporary spasm of an adjacent artery which is completely P. This should always be attempted prior to any operative intervention for an abnormal distal vascular examination. This patient has C5 Es As Pr classification of her lower extremity venous disease. Finally, the pathology as stated in the body of the text is reflux, no mention was made of obstructive pathology. While many view this relatively simple procedure as benign, some of its complications include the very thing it is trying to prevent. If the clot has not propagated within the 2-week period it is unlikely to do so later and no treatment is recommended. Pseudointimal hyperplasia in a graft or neointimal hyperplasia in a native fistula are the most common causes of dysfunction. Evaluation with Duplex ultrasound and fistulogram aid in diagnosis, and intervention with angioplasty or surgery may be required. When the serum creatinine reaches 4mg/dL or the creatinine clearance is less than 30 mL/minute, dialysis access planning is indicated. These guidelines should be considered in light of the rate of worsening renal function as well. Initial empiric antibiotics for catheter-associated peritonitis should cover Grampositive (vancomycin or first-generation cephalosporin) and Gram-negative (third-generation cephalosporin or aminoglycoside) bacteria. Juxta-anastomotic stenosis occurs secondary to shear stress on the vessel walls adjacent to the anastomosis (between 2 and 4 cm) proximal on the arterial inflow side of the anastomosis and 2 to 4 cm distal on the venous outflow side of the anastomosis. Banding of the access decreases the diameter of the anastomosis, thereby reducing the flow and decreasing the severity of steal. Tunneled dialysis catheters have a reduced risk of infection compared to nontunneled dialysis catheters because of fibroblast ingrowth forming a microbial barrier around the catheter within the pocket. ÒHepatic artery thrombosis in the early posttransplantation period may lead to fever, hemodynamic instability, and rapid deterioration, with a marked elevation of the transaminases. An associated bile leak may be noted soon after liver transplantation due to the loss of the bile ductsÕ main vascular supply. Ó the gold standard treatment is to relist this patient for a new liver allograft. Venous hypertension can be caused by the presence or development of outflow vein obstruction. It manifests as swelling, skin discoloration, and hyperpigmentation in the access limb. Management consists of fistulogram and correction of stenosis through either balloon dilatation and/or stent placement. Ninety-five percent of all pancreas transplants are performed in conjunction with a kidney transplant. The peak levels of serum glutamic-oxaloacetic transaminase and serum glutamate-pyruvate transaminase usually are less than 2,000 units/L, and should decrease rapidly over the first 24 to 48 hours postoperatively. The etiology is usually anastomotic leak or ureteral sloughing secondary to ureteral blood supply disruption. Urine leaks present with pain, rising creatinine, and possibly urine draining from the wound. Urine leaks are treated by placing a bladder catheter to reduce intravesical pressure and subsequent surgical exploration. Her initial fluid boluses should also have been in a volume of 10 mL/kg, with up to 20 mL/kg up to two times acceptable. Per the recommendations of the Liver/Spleen Trauma Study Group of the American Pediatric Surgical Association (Stylianos et al. Coiling of the orogastric tube in the upper chest is sufficient for a presumptive diagnosis of esophageal atresia. Plain abdominal film could aid in the determination of whether or not there is an associated tracheoesophageal fistula. The presence of air within the bowel would suggest that there is a communication between the trachea and the distal esophagus. Other additional imaging modalities are not essential in the absence of other examination findings. Proximal esophageal atresia and distal tracheoesophageal fistula are the most common type of tracheoesophageal malformation, accounting for 80% to 90% of cases. Gastroschisis is believed to be the result of an intrauterine vascular insult that creates a defect in the abdominal wall through which bowel herniates. In contrast to omphalocele (described by choices A, C, and D), gastroschisis usually involves a smaller defect, has a much less frequent association with anomalies, and is not covered by a peritoneal sac. Clinical examination and imaging are concerning for a delayed presentation of a congenital diaphragmatic hernia. Emergent thoracotomy is not advisable in this situation as the patient is not stable. Additionally, bedside echocardiogram is insufficient therapy for a hypoxic patient but likely should be done eventually for cyanotic workup and preoperative evaluations. Meissner plexus resides in the submucosal plane, while the Auerbach plexus is between the longitudinal and circular muscular layers. This description is concerning for a mucosal perforation as a result of pyloromyotomy. Although an incomplete or stenotic myotomy is also a postoperative concern, these patients would not demonstrate abdominal distention to the degree that perforated patients would. Mucosal perforation can be managed safely in the stable pediatric patient by bowel rest and decompression. Appendectomy is performed to eliminate any future appendicitis from arising in a nonanatomical position. In a patient with a low cardiac index after open heart surgery, it is important to rule out hemorrhage and tamponade. Transfusion would not be the correct answer since there is no evidence of hemorrhage. An intraaortic balloon pump is reserved for patients who are in cardiogenic shock refractory to inotropes or volume. Patients who have just returned from the operating room may be cold and have inadequate reversal of their heparin. Therefore, warming the patient and giving protamine is the best first step in management of this patient. In the case of aortic insufficiency, a balloon pump is contraindicated because the balloon inflates during diastole, which increases the P. Contraindications include porcelain aorta, no adequate conduits or targets, and unacceptably high perioperative risk. Relative contraindications to transplantation include age older than 65 years, irreversible pulmonary hypertension, active infection or malignancy, recent pulmonary embolus, excessive comorbidity (renal dysfunction, hepatic dysfunction, systemic disease such as amyloidosis, significant peripheral vascular disease, active peptic ulcer disease, uncontrolled diabetes mellitus, morbid obesity), mental illness, active substance abuse, inadequate social support, or psychosocial instability. The patient has no respiratory distress, has a job that is not high risk, is a first time pneumothorax, and is small. This patient is developing a tension pneumothorax, likely from a ruptured bleb in the setting of positive pressure ventilation. The immediate next step is needle decompression, followed by further evaluation and chest tube placement. Navigational bronchoscopy can be challenging to reach and biopsy peripheral lesions. Radiation therapy is contraindicated in patients who have received past chest wall radiation (A) or in patients in the second or third trimester of pregnancy (D). First-line treatment for likely lactation mastitis is antibiotics and increased frequency of breastfeeding. Overall survival per stage is comparable to that observed in women, although men tend to present at later stages. Excisional biopsy is not indicated on cosmetically sensitive areas such as the face (choice B). Shave biopsy is not the preferred method since depth of the lesion is difficult to assess and leads to an inferior cosmetic result (choice E). This patient has a chronic nonhealing wound that is concerning for the development of cancerÑlikely a Marjolin ulcer. There are no signs or symptoms of infection so topical antibiotics are not indicated (choice A). Ankle-brachial indices are likely to be unhelpful in this young patient with palpable pulses (choice D). Axillary lymph node dissection is not indicated at this juncture as he does not have documented adenopathy (choice E). Observation (choice A) is not appropriate as new nevi after 40 years of age must be considered potentially malignant until proven otherwise. This lesion is small and has benign characteristics including mobility, soft texture, and perhaps most importantly, the lesion has not grown over time. Given these characteristics and the fact that the patient is asymptomatic, this can be safely observed. Radiation therapy may be indicated for locoregional control in patients with regional disease. It is not indicated for primary melanoma alone, micrometastatic disease limited to a single sentinel node, or widely metastatic disease (choices A, B, D, E). While biopsy will be needed, the preferred method is core tissue biopsy, hence choices C and E are incorrect. This patient has adenopathy of unknown origin, most consistent with occult or regressed melanoma given normal mammograms. The presentation is not consistent with an infectious etiology (choice D) and a diagnosis is needed before treatment can be considered (choice E). Grade has been found to be the most important prognostic factor in soft-tissue sarcoma. Patients with soft-tissue sarcoma should be staged before undergoing therapy (choices A, B, D, E). En bloc resection of a soft-tissue sarcoma with involved organs greatly enhances survival. This patient has no history of renal failure and has a normal creatinine, so en bloc resection is indicated. Chemotherapy is relatively ineffective and gross positive margins worsen survival, hence answers A, B, C and E are incorrect. Lymphovascular invasion has been shown to portend lower survival than any other prognostic factor in Merkel cell carcinoma. Mohs surgery is costly and time-consuming and reserved for areas where tissue conservation is important (choice C). Since basal cell carcinomas do not metastasize, lymph node biopsies are not indicated (choice D). Radiation therapy can be used if lesions are unresectable or treatment is palliative, however this lesion is amenable to surgical therapy and should be excised. Squamous cell carcinomas and solitary metastases should be resected when possible due to a high chance of cure. Radiation is usually reserved for patients who are not candidates for surgery (choices B and C). Likewise, systemic and topical therapies are not preferred in this scenario (choices D and E. Uncontrolled coagulopathy is an absolute contraindication to laparoscopic surgery. Major intravascular injury, though rare, is a devastating complication of laparoscopic surgery. Robot-assisted laparoscopic surgery is associated with improved ergonomics compared to laparoscopic surgery alone.

Emphysema: defined histologically by dilated alveoli and/or respiratory bronchioles arteriosclerosis vs atherosclerosis buy cheap tenormin 50 mg line, often in upper areas of the lungs prehypertension education cheap tenormin 100 mg with visa. Air trapping and increased airflow resistance result from airway collapse during forceful expiration blood pressure ranges for dogs generic tenormin 100 mg with mastercard. Main considerations: the decision to intubate/ventilate is sometimes difficult arteria 50 mg tenormin order overnight delivery, since weaning from ventilators may be impossible arrhythmia vs atrial fibrillation tenormin 50 mg buy fast delivery. Anaesthetic management: preoperatively: - preoperative assessment for exercise tolerance, bronchospasm, cor pulmonale and history of previous admissions. Pethidine, promethazine and atropine are often used; the latter may help prevent perioperative bronchospasm and reduce secretions, but may increase their tenacity. Adequate postoperative analgesia is vital; regional techniques are particularly useful, as excessive use of systemic opioids must be avoided. Isomerase-binding immunosuppressive drug which interferes with proliferation of activated T lymphocytes. Eliminated via hepatic metabolism, its half-life assuming normal liver function is 19 h. Irreversible nephrotoxicity occurs in a minority of cardiac and renal transplant patients. Has a broad spectrum of activity, but especially against Gramnegative bacteria, including klebsiella, Escherichia, Salmonella, Shigella, Campylobacter, Neisseria, Pseudomonas, Haemophilus and Enterobacter species. System B is more convenient practically, however, since all components are away from the patient. Older systems had a switch that could bypass the soda lime; to prevent this happening accidentally these are not present on newer systems. Advantages: low gas flows may be used, allowing conservation of volatile agent with reduced cost and pollution. System A Patient System B Patient Cigarette smoking, see Smoking Ciliary activity. Continuous beating of the cilia of respiratory epithelial cells results in flow of thick mucus from the nose to the pharynx, and from the bronchi to the larynx. A more watery mucus layer lies between the thick layer and the epithelium, lubricating the cilia. Important in aiding removal of foreign particles and microbes and clearing of the airways. Reduced by smoking, extremes of temperature, volatile inhalational anaesthetic agents, opioid analgesic drugs and prolonged exposure to high O2 levels. Prolonged inhalation of dry gases, anticholinergic drug administration and volatile agents may impair mucus production or flow. H2 receptor antagonist, of faster onset and shorter-acting than ranitidine, lasting about 4 h. The actions of drugs such as warfarin, phenytoin and theophylline may be prolonged, and toxic effects seen. Has been used for epidural anaesthesia (1: 600 solution), infiltration and nerve blocks (1: 1000­2000 with adrenaline), and surface analgesia, up to 2 mg/kg maximum. During spontaneous ventilation, respiratory depression increases as the concentration increases, reducing gas flow through the vaporiser. Trauma scale for use in adult pre-hospital triage when categorising severity of injury. Increases lower oesophageal pressure and increases gastric emptying and intestinal motility. Withdrawn from use in July 2000 because of reports of serious ventricular arrhythmias, often resulting from concomitant use of other drugs such as antifungal and antibacterial drugs. Introduced in 1995, it causes minimal histamine release with cardiovascular stability. Equation characterising the discontinuous phase change between two states of matter. Used practically to predict changes in state in response to alterations in 140 Clark electrode pressure/temperature. Macrolide, antibacterial drug derived from erythromycin and with similar mechanism of action and spectrum of activity, although more active against Streptococcus pneumoniae and Staphylococcus aureus, and with greater penetration of tissues. Side effects: nausea, vomiting, hepatic impairment, phlebitis, Stevens­Johnson syndrome. Compounds comprising a crystal lattice of one type of molecule trapping and containing another. Formation of clathrates consisting of volatile agent and water (gas hydrates) in neuronal cell membranes (thereby disrupting their function) was suggested by Pauling and Miller in 1961 as a basis for the mechanism of action of inhalational anaesthetic agents. Now considered incorrect since: for some fluorocarbons, potency is not related to clathrate formation. Theoretical value representing removal of a substance from plasma or blood by passage through an organ. Defined as the volume of plasma completely cleared of a given substance per unit time. Equals: urine osmolality (mosmol/l) × urine volume (ml/min) plasma osmolality (mosmol/l) If urine is hypotonic, urine volume exceeds osmotic clearance; if hypertonic, osmotic clearance is greater. Although active against aerobic and anaerobic Gram-positive organisms, its use is limited to the treatment of staphylococcal bone and joint infection, peritonitis and endocarditis because of its side effects (especially infection with Clostridium difficile and the development of pseudomembranous colitis). Term denoting a particular aspect of risk management and quality assurance in which responsibility for maintaining standards of care is defined and placed with specified individuals and departments. Requires that evidence-based medicine is in routine use, that good practice and innovations are systematically disseminated and applied, and that high-quality data are collected to monitor clinical care. The concept arose formally from political and medical reactions to well-publicised examples of inadequate care, its introduction achieving particular impetus following the high death rate after paediatric cardiac surgery in Bristol in the 1980s/early 1990s. As a result of disciplinary rulings following this case, all clinicians are now expected to monitor their own performance and undergo regular appraisal and revalidation. Performed to determine whether an intervention is useful, how it compares with others, whether it affects different groups of patients differently and how it is best delivered. Considers whether exposure of patients to the new treatment or denial of the old treatment to controls, or vice versa, is justified, whether adequate information is given to potential participants, and whether proper consent is obtained. Dosage: 1­4 capsules (equivalent to 5­20 ml elixir which contains 50 mg/ml) orally, 3­4-hourly. Side effects include sedation (occasionally excitation), bronchial and salivary hypersecretion, and, rarely, hepatic impairment and blood dyscrasias. Has also been used as an adjuvant drug in spinal anaesthesia and peripheral nerve blockade. Stimulates central presynaptic 2-adrenergic receptors, causing suppression of catecholamine release. Its main effect is on vasomotor centre output, but also has analgesic and sedative actions. May have some 1-agonist action peripherally, causing initial transient hypertension. Metabolised in the liver, with about 65% excreted unchanged in the urine and 20% in the faeces. Side effects: sedation, dry mouth, depression, urinary retention, reduced gastric motility. Thienopyridine antiplatelet drug, used for the treatment of acute coronary syndromes, secondary prevention of ischaemic events or primary prevention in patients with atrial fibrillation for whom warfarin is unsuitable. Recently 141 142 Closing capacity shown to be less effective than newer antiplatelet drugs. Restoration of platelet function requires synthesis (or transfusion) of new platelets. Withdrawal for a week before surgery has been recommended (unless the patient has coronary artery stents in situ ­ see Percutaneous coronary intervention for details). Lung volume at which airway closure occurs, mainly in the dependent parts of the lung. Br J Anaesth; 99: 772­4 Closing volume, see Closing capacity Clostridial infections. Devised inhalers for chloroform and later diethyl ether that delivered accurate concentrations of agent. Clot formation; follows vasospasm and platelet plug formation, which cause temporary haemostasis. Normal sequence of events: vasospasm, thought to be mediated by vasoconstrictor substances released from platelets. The classical explanation of the coagulation pathway involves many circulating factors in a cascade mechanism; each factor, when activated, activates the next in turn. Nomenclature of factors is largely historical, according to the chronological order of discovery. The intrinsic pathway is initiated by exposure of blood to collagen, or in vitro by contact with glass. Normally, the clotting mechanism is balanced by opposing reactions preventing coagulation. The former is more common and may arise from defects in: blood vessels: - infection. Blood transfusion may be associated with dilution of platelets and coagulation factors by fluids and blood components deficient in them. Deficiency (the extent of which is variable) thus results in increased tendency to thrombosis. A particular form of factor V, factor V Leiden, is present in about 2% of Northern European individuals; the risk of thrombosis in homozygotes is estimated at up to 50%. May test different parts of the coagulation pathways: whole blood coagulation: - whole blood clotting time: bedside test of intrinsic and common pathways. Similar to whole blood clotting time, but celite is added to the blood for quicker results. Automated devices are usually used to detect fibrin formation, with a small bar magnet within the test tube. The tube is placed within the device and rotated slowly; when fibrin forms in the tube, the magnet starts to rotate, thereby activating the detector. Values of 3­4 times the pre-heparin value are considered adequate during extracorporeal circulation. If the test is normal, factor deficiency is present; if still prolonged, the sample plasma contains an inhibitor. Unaffected by heparin; thus if normal but the thrombin time is prolonged, presence of heparin is suggested. Coaxial anaesthetic breathing systems - fibrinogen degradation products: normally < 10 mg/l. Addition of thrombin causes clot formation; subsequent lysis depends on the amount of plasminogen activating capacity present. Broad-spectrum antibacterial drug; a mixture of amoxicillin and clavulanic acid in varying proportion. Active against Gram-negative and -positive organisms; uses include respiratory, middle ear and urinary infections. Side effects: as for amoxicillin; also cholestatic jaundice, erythema multiforme and interstitial nephritis. Development of reduced pressure between a fluid jet from a nozzle and an adjacent surface, resulting in adherence of the jet to the surface. If the jet has two surfaces to which it might adhere, it will attach to one only, without splitting. A small signal jet across the nozzle may switch the main jet from one surface to the other; this has formed the basis of control mechanisms in fluidics. Similar behaviour of fluids has been suggested to occur beyond constrictions in blood vessels. J Cardiovasc Med; 8: 251­2 [Henri Coanda (1885­1972), Romanian engineer] Coarctation of aorta. The preductal (proximal to the ductus arteriosus) form is more severe, usually presenting in infancy with cardiac failure. Repaired surgically via left thoracotomy; more recently, balloon angioplasty and stenting of the constricted segment have been performed. Anaesthetic management is similar to that for thoracic aortic aneurysm, in particular: preoperative treatment of hypertension and cardiac failure. Functionally, they are versions of Mapleson A (Lack) and D (Bain) anaesthetic breathing systems, but more convenient to use: Lack. The outer tube is wider than usual to accommodate the inner tube, itself as wide as possible to reduce resistance to expiration. Parallel versions are also available, in which the inner tube is replaced by a second external tube running alongside the main tube. Ideal fresh gas flow rates for spontaneous ventilation are controversial, as high flows cause greater resistance. Penlon Nuffield attached to the reservoir bag fitting (bag removed) by a length of tubing whose volume exceeds tidal volume. Disconnection of the inner tube from the fresh gas source (resulting in the whole length of tubing becoming dead space) must be excluded before use (see Checking of anaesthetic equipment). Ball of coca leaves, mixed with guano and cornstarch, thought to be chewed by South American Incas to release free cocaine base. An alkaloid originally extracted from the leaves and bark of South American coca plants. Used in 1884 for topical analgesia of the eye (by Koller), intercostal nerve block (by Anrep), mandibular nerve block (by Halstead and Hall) and other uses, including local infiltration. Causes vasoconstriction by preventing uptake of noradrenaline by presynaptic nerve endings; also inhibits monoamine oxidase. Cerebral aneurysms, cardiomyopathy and sudden death are associated with chronic abuse.

The white pulp also acts as a site of antigen presentation to lymphocytes that heart attack 5 days collections proven 100 mg tenormin, along with an appropriate cytokine milieu blood pressure monitoring chart template purchase tenormin online now, leads to effective T-cell mediated cytotoxic activity and B-cell antibody responses blood pressure chart uk nhs buy cheap tenormin on line. It is an acquired disease that results from autoantibodies to platelet glycoprotein and results in immune mediated thrombocytopenia heart attack heart rate cheap 50 mg tenormin overnight delivery. Usual location of accessory spleens: (1) Gastrosplenic ligament blood pressure medication new zealand purchase tenormin 50 mg on-line, (2) Splenic hilum, (3) Tail of the pancreas, (4) Splenocolic ligament, (5) Left transverse mesocolon, (6) Greater omentum along the greater curvature of the stomach, (7) Mesentery, (8) Left mesocolon, (9) Left ovary, (10) Douglas pouch, and (11) Left testis. In refractory cases a waiting period of 12 months is recommended, especially in children below 5 years of age where risk of postsplenectomy sepsis is increased (Blood. Splenectomy results in 65% long-term remission (>5 years) and remains the treatment of choice in patients with platelets less the 30,000/mm3 or with a high risk of bleeding. Rituximab has also been shown to have some efficacy in patient failing to respond to splenectomy (Am J Hematology. It is most common in adults and usually idiopathic or drug (cyclosporine, gemcitabine, clopidogrel, quinine) related. Treatment and prognosis of immune (idiopathic) thrombocytopenic purpura in adults. Steroid therapy in addition to plasmapheresis is used in the treatment of relapse. Second-line agents include rituximab, cyclosporin, and increased frequency of plasmapheresis (Br J Haematol. Furthermore, splenectomy has only shown benefit when used in conjunction with plasmapheresis in order to achieve durable remission (Br J Haematol. Anemias (1) Hemolytic anemias constitute a group of diseases for which splenectomy is almost universally curative. This defect results in small, spherical, rigid erythrocytes that fail to deform adequately to transverse the splenic microcirculation. This ultimately leads to the sequestration and destruction of erythrocytes in the spleen. Symptoms include anemia, jaundice (indirect bilirubinemia), and pigmented gallstones. Treatment includes folate supplementation and splenectomy for moderate to severe cases. Most patients are asymptomatic with a mild anemia and do not require additional treatment. Splenectomy is reserved for nonresponders or those requiring high steroid doses and is 60% to 70% effective in achieving remission. Rituximab has also shown efficacy and is suitable second-line treatment for those patients who do not desire to undergo splenectomy (Blood. Most cases respond to protective clothing; however severe episodes may require cyclophosphamide, rituximab, or interferon. Splenectomy does not play a role in the treatment of cold autoimmune hemolytic anemias. Congenital hemoglobinopathies (1) Sickle cell anemia is a result of homozygous inheritance of the S variant of the hemoglobin beta chain. Autosplenectomy usually occurs secondary to repeated vaso-occlusive events and splenectomy is rarely required. However, splenectomy may be reasonable for selected patients with splenic abscess, symptomatic splenomegaly, hypersplenism, or acute splenic sequestration crisis. Splenectomy is reserved for palliation of symptomatic splenomegaly or splenic infarcts. Myeloproliferative and myelodysplastic disorders (1) Chronic myelogenous leukemia is a myelodysplastic disorder characterized by the bcr-abl fusion oncogene, known as the Philadelphia chromosome. Stem cell transplantation is used for cases of treatment failure in eligible patients (Blood. Splenectomy had no effect on survival or disease progression, but it did increase the rate of thrombosis and vascular accidents (Cancer. Splenectomy is indicated only for palliation of symptomatic splenomegaly or hypersplenism that significantly limits therapy. These diseases are treated medically, but splenectomy can be required to treat symptomatic splenomegaly or pain from splenic infarcts. Splenectomy can result in severe thrombocytosis, causing thrombosis or hemorrhage, which requires perioperative antiplatelet, anticoagulation, and myelosuppressive treatment. The condition is characterized by bone marrow fibrosis, leukoerythroblastosis, and extramedullary hematopoiesis, which can result in massive splenomegaly. Indications for splenectomy include symptomatic splenomegaly and transfusiondependent anemias. Although the compressive symptoms are effectively palliated with splenectomy, the cytopenias frequently recur. In addition, these patients are at increased risk for postoperative hemorrhage and thrombotic complications after splenectomy. Primary therapy is medical, with splenectomy reserved for those patients with symptomatic splenomegaly and severe hypersplenism. Splenectomy plays an important role in the diagnosis and staging of patients with isolated splenic lymphoma (known as malignant lymphoma with prominent splenic involvement). In these cases, improved survival has been shown in patients undergoing splenectomy (Cancer. However, due to refinements in imaging techniques and progress in the methods of treatment splenectomy for Hodgkin lymphoma is rare. Splenectomy was previously regarded as the primary therapy for this disease, but improvements in systemic chemotherapy have reduced the role of splenectomy, which is now reserved for patients with massive splenomegaly or refractory disease. Neutropenias (1) Felty syndrome is characterized by rheumatoid arthritis, splenomegaly, and neutropenia. The primary treatment is steroids, but refractory cases may require splenectomy to reverse the neutropenia. Patients with recurrent infections and significant anemia may benefit from splenectomy. In the unstable trauma patient the procedure is traditionally performed via laparotomy. With current imaging modalities grading of splenic injuries (Table 23-2) allows for conservative management in selected patients. Incidental splenectomy occurs when the spleen is iatrogenically injured during an intraabdominal procedure. Injury may result from a retractor placed in the left upper quadrant or during mobilization of the splenic flexure. Small injuries such as capsular tears may be controlled with hemostatic agents or electrocautery, but injuries resulting in significant blood loss may require splenectomy to achieve rapid hemostasis. Vascular (1) Splenic artery aneurysm is the most common visceral artery aneurysm and is typically an incidental finding. It occurs more commonly in females and associated with a high incidence of rupture during pregnancy with significant maternal and fetal mortality. Asymptomatic aneurysms in a patient whom pregnancy is not anticipated may be observed. Management depends on the location of the aneurysm during the course of the splenic artery. Proximal and middle third aneurysms may be excluded by proximal and distal ligation of the artery. Alternatives treatments include endovascular approaches with transcatheter embolization. American Association for the Surgery of Trauma Organ Injury Scale 1: Spleen, liver and kidney. Infectious (1) Parasitic infections account for more than two-thirds of splenic cysts worldwide but are rare in the United States. The primary treatment is splenectomy, with careful attention not to spill the cyst contents. The cyst may be aspirated and injected with hypertonic saline prior to mobilization if concern about rupture exists. Two-thirds arise from seeding of the spleen by a distant site, most commonly endocarditis and urinary tract infections. Staphylococcus and streptococcus account for the most commonly identified organisms, accounting for >50% of cases. Percutaneous drainage may be used in select cases; however, splenectomy and appropriate antibiotic therapy is definitive treatment. Cystic lesions of the spleen may be either true cysts or pseudocysts, but this differentiation is difficult to make preoperatively. Most are typically asymptomatic, but they may present with left upper abdominal or shoulder pain. Those smaller than 5 cm can be followed with ultrasonography and often resolve spontaneously. Percutaneous aspiration is associated with infection and reaccumulation and is not indicated. Laparoscopic management of splenic cysts yields shorter hospital length of stay and fewer complications with no adverse effects (Surg Endosc. Right upper quadrant ultrasound is indicated for preoperative assessment of gallstone disease in patients with hemolytic or sickle cell anemias for planning of concomitant cholecystectomy. Vaccination for encapsulated organisms is an important aspect of managing patients undergoing splenectomy. Pneumococcal vaccine should be administered 2 to 3 weeks prior or 2 weeks after splenectomy (J Traum. Influenza vaccine is recommended annually for asplenic patients as it increases susceptibility to bacterial infections. Patients with hematologic disease, particularly those with autoimmune disorders, often have autoantibodies and are difficult to crossmatch. Thus, blood should be typed and screened at least 24 hours prior to the scheduled operative time. Patients with severe thrombocytopenia (particularly those with counts <10,000/µL) should have platelets available for transfusion, but these should be withheld until the splenic artery is ligated so they will not be quickly consumed by the spleen. Perioperative stressÑdose steroids treatment should be considered for patients receiving steroids preoperatively and should be continued orally postoperatively and tapered gradually once a hematologic response to splenectomy has occurred. Patients who are to undergo a laparoscopic splenectomy should be counseled preoperatively about the possibility of conversion to open splenectomy or a hand-assisted approach and should be prepared identically to those patients for whom an open procedure is planned. When significant splenomegaly is present, a midline incision is usually preferred. A drain is not routinely required unless it is suspected that the pancreatic tail may have been injured during the hilar dissection. Laparoscopic splenectomy has been shown to be safe and effective under most conditions and is the preferred method for elective splenectomy. Splenomegaly increases the complexity of the laparoscopic approach because of the difficulty of manipulating the organ atraumatically and achieving adequate exposure of the ligaments and hilum. Large spleens are also more difficult to place in an entrapment bag using a strictly laparoscopic approach. Although the size limits for attempting laparoscopic or laparoscopicassisted splenectomy are evolving, most moderately enlarged spleens (<1,000 g weight or 15 to 20 cm in length) can be removed in a minimally invasive fashion, often without a hand-port device. For spleens larger than 20 cm in longitudinal length or those that weigh between 1,000 and 3,000 g, the use of a hand port should be considered. In general, massive splenomegaly (spleens greater than 30 cm in craniocaudal length and weighing >3,000 g) should be approached in an open fashion because of the reduced working space and increased difficultly in manipulating the spleen. A search for accessory splenic tissue should always be conducted, particularly if the patient has a hematologic indication for splenectomy. Several large series of laparoscopic splenectomy have been published with excellent results. In a meta-analysis of 51 reports including 2,940 patients, laparoscopic splenectomy was associated with significantly fewer complications overall, primarily as a result of fewer wound and pulmonary complications (Surgery. Hemorrhage is the most common intraoperative complication of splenectomy, which can occur during the hilar dissection or from a capsular tear during retraction. The incidence of this complication is 2% to 3% during open splenectomy but is nearly 5% using the laparoscopic approach. Bleeding during laparoscopic splenectomy may necessitate conversion to a handassisted or open procedure. Pancreatic injury occurs in 0% to 6% of splenectomies, whether done open or laparoscopically. If one suspects that the pancreatic parenchyma has been violated during laparoscopic splenectomy, a closed suction drain should be placed adjacent to the P. Bowel injury (1) Colonic injuries are rare but because of the close proximity of the splenic flexure to the lower pole of the spleen, it is possible to injure the colon during mobilization. Use of energy devices too close to the greater curvature of the stomach can result in a delayed gastric necrosis and perforation. In laparoscopic splenectomies, it may be more difficult to recognize the injury given the pneumoperitoneum, but careful dissection of the splenophrenic ligament can minimize its occurrence. The pleural space should be evacuated under positive-pressure ventilation prior to closure to minimize the pneumothorax. Early (1) Pulmonary complications develop in nearly 10% of patients after open splenectomy, and these range from atelectasis to pneumonia and pleural effusion. Pulmonary complications are significantly less common with the laparoscopic approach (Surgery. Treatment usually consists of percutaneous drainage and the intravenous antibiotics.

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