Julia A. Drose, BA, RDMS, RDCS, RVT

• Associate Professor
• Department of Radiology
• Chief Sonographer
• Divisions of Diagnostic Ultrasound and Prenatal Diagnosis & Genetics
• University of Colorado Hospital
• Denver, Colorado

If the pain produced with injection is similar to that which the patient experiences on a daily basis symptoms knee sprain purchase 500mg tranexamic visa, it is deemed concordant pain medications without a script tranexamic 500 mg low price. In some circumstances medicine allergies proven 500mg tranexamic, the pressure in the disc following injection is not significantly higher than the opening pressure medicinenetcom best order tranexamic, and this may be due to the presence of a fissure in the disc that tracks to the epidural space treatment 7 cheap tranexamic online visa. Treatment options for discogenic pain include conservative therapy, steroid injections into the disc, heating the posterior annulus of the disc by way of radiofrequency ablation, and surgical fusion with bone graft or hardware placement; each option has shown mixed degrees of success. The evaluation and treatment of discogenic pain is an area of significant controversy and ongoing research. Herniated (Prolapsed) Intervertebral Disc Weakness and degeneration of the annulus fibrosus and posterior longitudinal ligament can cause herniation of the nucleus pulposus posteriorly into 12 the spinal canal. Symptoms usually develop following flexion injuries or heavy lifting and may be associated with bulging, protrusion, or extrusion of the disc. Disc herniations usually occur posterolaterally and often result in compression of adjacent nerve roots, producing pain that radiates along that dermatome (radiculopathy, or radicular pain). Sciatica describes pain along the sciatic nerve due to compression of the lower lumbar nerve roots. When disc material is extruded through the annulus fibrosus and posterior longitudinal ligament, free fragments can become wedged in the spinal canal or the intervertebral foramina. Less commonly a large disc bulges or large fragments extrude posteriorly, compressing the cauda equina in the dural sac; in these instances, patients can experience bilateral pain, urinary retention, or, less commonly, fecal incontinence. Pain associated with disc disease is aggravated by bending, lifting, prolonged sitting, or anything that increases intraabdominal pressure, such as sneezing, coughing, or straining. Bulging of the disc through the posterior longitudinal ligament can also produce low back pain that radiates to the hips or buttocks. Pain while raising the contralateral leg is an even more reliable sign of nerve compression. Imaging studies and other tests should be obtained when severe or progressive neurological deficits are present, or when serious underlying conditions are suspected. Discography may be considered when the pain pattern does not match the clinical findings. A centrally herniated disc will usually cause pain at the lower level, and a laterally protruded disc will cause pain at the same level as the disc. For example, a centrally located disc herniation at L4­L5 may compress the L5 nerve root whereas a laterally located disc herniation at this level may compress the L4 nerve root. The natural course of herniated disc disorders is generally benign and the duration of pain is usually less than 2 months. Over 75% of patients treated nonsurgically, even those with radiculopathy, experience complete or near-complete pain relief. The goals of treatment should therefore be to alleviate the pain and to rehabilitate the patient to return to a maximally functional quality of life. After the acute symptoms subside, the patient can be referred to a physical therapist for instruction on exercises to improve lower back health. Patients who smoke tobacco should be advised to stop smoking, not only for the obvious health benefits but also because nicotine further compromises blood flow to the relatively avascular intervertebral disc. Percutaneous disc decompression involving extraction of a small amount of nucleus pulposus may help to decompress the nerve root. For patients with acute-onset weakness correlating with the level of the disc herniation, surgical management should be considered. When symptoms persist beyond 3 months, the pain may be considered chronic and may require a multidisciplinary approach. Of note, back supports should be discouraged because they may weaken paraspinal muscles. Degeneration of the nucleus pulposus reduces disc height and leads to osteophyte formation (spondylosis) at the endplates of adjoining vertebral bodies. In conjunction with facet joint hypertrophy and with ligamentum flavum hypertrophy and calcification, this process leads to progressive narrowing of the neural foramina and spinal canal. Extensive osteophyte formation may compress multiple nerve roots and cause bilateral 13 pain. It is characteristically worse with exercise and relieved by rest, particularly sitting with the spine flexed (shopping cart sign). The terms pseudoclaudication and neurogenic claudication are used to describe such pain that develops with prolonged standing or ambulation. Electromyography and nerve conduction studies may be useful in evaluating the degree of neurological compromise. Patients with mild to moderate stenosis and radicular symptoms may obtain benefit from epidural steroid injections via a transforaminal, interlaminar, or caudal approach, which may help these individuals tolerate physical therapy. Long-term analgesia may be obtained with radiofrequency ablation of the medial branches innervating the zygapophyseal joints. Facet Syndrome Degenerative changes in the facet (zygapophyseal) joints may also produce back pain. Pain may be near the midline; may radiate to the gluteal region, thigh, and knee; and may be associated with muscle spasm. The diagnosis may be confirmed if pain relief is obtained following intraarticular injection of local anesthetic solution into affected joints or by blockade of the medial branch of the posterior division (ramus) of the spinal nerves that innervate them. Long-term studies suggest that medial branch nerve blocks are more effective than facet joint injections. Medial branch rhizotomy may provide long-term analgesia for patients with facet joint disease. Congenital Abnormalities Congenital abnormalities of the back may be asymptomatic and remain occult for many years. Abnormal spinal mechanics can make the patient prone to back pain, and in some instances, progressive deformities. Relatively common anomalies include sacralization of L5 (the vertebral body is fused to the sacrum), lumbarization of S1 (it functions as a sixth lumbar vertebra), spondylolysis (disruption of the pars interarticularis), spondylolisthesis (displacement anteriorly of one vertebral body on the next due to disruption of the posterior elements, usually the pars interarticularis), and spondyloptosis (subluxation of one vertebral body on another resulting in one body in front of the next). Spinal fusion may be necessary in patients with progressive symptoms and spinal instability. Cervical Pain Although most spine-related pain due to disc disease, spinal stenosis, or degenerative changes in the zygapophyseal joints is felt in the low back and lower extremities, patients may have cervical pain attributed to these processes. A key anatomic difference is that the cervical nerve roots, unlike those in the thoracic and lumbar spine, exit the foramina above the vertebral bodies for which they are named. This occurs until the level of C7, where the extra cervical nerve roots, C8, exit below the pedicles of C7, thus transitioning to the nomenclature of the thoracicand lumbar-level vertebral bodies and nerve root denominations. The clinical examination may help to identify the nerve root that is affected with confirmation by a selective nerve root block. Risks inherent with percutaneous cervical procedures include accidental intravascular injection of local anesthetic or steroid. Particulate steroid injections in the neck have been associated with devastating outcomes and should be avoided. For primarily axial pain in the neck with extension into the head or to the shoulders, cervical 8. When diagnosed by imaging these tumors will be managed by neurosurgeons, radiotherapists, and or medical oncologists, not by pain specialists. Infection Bacterial infections of the spine usually begin as a discitis before progressing to osteomyelitis, and can be due to pyogenic as well as tuberculous organisms. Patients may present with chronic back pain without fever or leukocytosis (eg, spinal tuberculosis). Those with acute discitis, osteomyelitis, or epidural abscess present with acute pain, fever, leukocytosis, elevated sedimentation rate, and elevated C-reactive protein, warranting immediate initiation of antibiotics. Urgent surgical intervention is indicated when the patient also suffers from acute weakness. It typically presents as low back pain associated with early morning stiffness in a young male patient. After a few months to years, the pain gradually intensifies and is associated with progressively restricted movement of the spine. Diagnosis may be difficult early in the disease, but radiographic evidence of sacroiliitis is usually present. As the disease progresses, the spine develops a characteristic "bamboo-like" radiographic appearance. Some patients develop arthritis of the hips and shoulders, as well as extraarticular inflammatory manifestations. Anti­tumor necrosis factor- agents, including infliximab (Remicade), etanercept (Enbrel), adalimumab (Humira), and golimumab (Simponi), decrease the progression of ankylosing spondylitis when administered early in the course of therapy. However, patients treated with these medications may be at increased risk for infection and for the development of lymphoma. Patients with Reiter syndrome, psoriatic arthritis, or inflammatory bowel disease may also present with low back pain, but extraspinal manifestations are usually more prominent. Rheumatoid arthritis usually spares the spine except for the zygapophyseal joints of the cervical spine. Of note, tricyclic antidepressants may have significant anticholinergic side effects that may limit their tolerability. Secondary amines, such as nortriptyline or desipramine, may have fewer or less severe anticholinergic side effects than tertiary amines such as amitriptyline or imipramine. Spinal cord stimulation may be effective for patients who do not tolerate or respond to other treatments. Diabetic Neuropathy of neuropathic pain and is a major cause of morbidity and disability. Its pathophysiology may be related to microangiopathy and to abnormal activation of glycation of proteins as a consequence of chronic hyperglycemia. Diabetic neuropathy may be symmetric (generalized), focal, or multifocal, affecting peripheral (sensory or motor), cranial, or autonomic nerves. The most common diabetic neuropathy syndrome is peripheral polyneuropathy, which results in symmetric numbness ("stocking-and-glove" distribution), paresthesias, dysesthesias, and pain. Loss of proprioception may lead to gait disturbances, and sensory deficits can lead to repetitive traumatic injuries. Isolated mononeuropathies affecting individual nerves may lead to wrist or foot drop or to cranial nerve palsy. Mononeuropathies typically have a sudden onset and are selflimiting, lasting a few weeks. Autonomic neuropathy typically affects the gastrointestinal tract, causing diarrhea, delayed gastric emptying, and esophageal motility disorders. Treatment of diabetic neuropathy is symptomatic and directed at optimal glycemic control to slow progression. It is associated with diabetic neuropathy, causalgia, phantom limbs, postherpetic neuralgia, stroke, spinal cord injury, and multiple sclerosis. Cancer pain and chronic low back pain may also have prominent neuropathic components. Neuropathic pain is often difficult to treat, and multiple therapeutic modalities may be needed. The combination of an antiepileptic drug and a tricyclic antidepressant may be particularly effective. The major difference between the two is the absence or presence, respectively, of documented nerve injury. Previously, this condition was thought to represent sympathetically maintained pain, but there is recent evidence that in some cases the pain may be sympathetically independent. It affects individuals from childhood to late adulthood and may occur more commonly in females. Patients frequently present with burning neuropathic pain accompanied by hyperalgesia and allodynia. The autonomic nervous system may be involved, exemplified by alterations in sweating (sudomotor changes), color, and skin temperature, and by trophic changes in the skin, hair, or nails. Decreases in strength and range of motion in the affected extremity may be present. There may be changes in the cutaneous innervation after a nerve injury, along with changes in central and peripheral sensitization. The pain often has an immediate onset and is associated with allodynia, hyperpathia, and vasomotor and sudomotor dysfunction. It is exacerbated by factors that increase sympathetic tone, such as fear, anxiety, light, noise, or touch. The syndrome has a variable duration that can range from days to months or may be permanent. Causalgia commonly affects the brachial plexus, particularly the median nerve, and the tibial division of the sciatic nerve in the lower extremity. Some patients recover spontaneously, but if left untreated other patients can progress to severe and irreversible functional disability. Sympathetic blocks and intravenous regional sympatholytic blockade are equally effective; these blocks should be continued until either a cure is achieved or the response plateaus. The blocks facilitate physical therapy, which plays a central role and which typically consists of active movement without weights and of desensitization therapy. The likelihood of a cure is high (>90%) if treatment is initiated within 1 month of symptom onset and appears to decrease over time with therapeutic delay. Spinal cord stimulation can be particularly effective in both acute and chronic settings. In the acute phase of treatment, there is increasing interest in placing tunneled epidural catheters for infusion therapy, or percutaneous electrodes for extended trials of spinal cord stimulation, in order to help patients tolerate physical therapy. Many patients benefit from surgical implantation of peripheral nerve stimulators placed directly on larger injured nerves. For sympathetically maintained pain, oral -adrenergic blockers, such as the nonselective phenoxybenzamine or the 1-selective prazosin, may be beneficial.

When the patient is not intubated symptoms panic attack buy cheap tranexamic 500mg, a rapid sequence induction (ketamine or etomidate with succinylcholine) is used medicine evolution 500mg tranexamic. Patients usually swallow a large amount of blood and must be considered to have a full stomach symptoms neck pain buy tranexamic uk. A large doublelumen bronchial tube is ideal for protecting the normal lung from blood and for suctioning each lung separately treatment question tranexamic 500 mg free shipping. If any difficulty is encountered in placing the double-lumen tube symptoms dehydration best tranexamic 500 mg, or its relatively small lumens occlude easily, a large (>8. Lung Abscess Lung abscesses result from primary pulmonary infections, obstructing pulmonary neoplasms (see earlier discussion), or, rarely, hematogenous spread of systemic infections. A rapid-sequence intravenous induction with tracheal intubation with a double-lumen tube is generally recommended, with the affected lung in a dependent position. As soon as the double-lumen tube is placed, both bronchial and tracheal cuffs should be inflated. The bronchial cuff should make a tight seal before the patient is turned into the lateral decubitus position, with the diseased lung in a nondependent position. The diseased lung should be frequently suctioned during the procedure to decrease the likelihood of contaminating the healthy lung. Bronchopleural Fistula Bronchopleural fistulas occur following lung resection (usually pneumonectomy), rupture of a pulmonary abscess into a pleural cavity, pulmonary barotrauma, or spontaneous rupture of bullae. The majority of patients are treated (and cured) conservatively; patients come to surgery when chest tube drainage has failed. Anesthetic management may be complicated by the inability to effectively ventilate the patient with positive pressure because of a large air leak, the potential for a tension pneumothorax, and the risk of contaminating the other lung if an empyema is present. A correctly placed double-lumen tube greatly simplifies anesthetic management by isolating the fistula and allowing one-lung ventilation to the Pulmonary Cyst & Bulla Pulmonary cysts or bullae may be congenital or acquired as a result of emphysema. These air cavities often behave as if they have a one-way valve, predisposing them to progressively enlarge. Lung resection may be undertaken for progressive dyspnea or recurrent pneumothorax. The greatest risk of anesthesia is rupture of the air cavity during positive-pressure ventilation, resulting in tension pneumothorax; the latter may occur on either side prior to thoracotomy or on the nonoperative side during the lung resection. Anesthesia for Tracheal Resection Preoperative Considerations Tracheal resection is most commonly performed for tracheal stenosis, tumors, or, less commonly, congenital abnormalities. Tracheal stenosis can result from penetrating or blunt trauma, as well as tracheal intubation and tracheostomy. The dyspnea may be worse when the patient is lying down, with progressive airway obstruction. Anesthetic Considerations Little premedication is given, as most patients presenting for tracheal resection have moderate to severe airway obstruction. Use of an anticholinergic agent to dry secretions is controversial because of the theoretical risk of inspissation. An inhalation induction (in 100% oxygen) is carried out in patients with severe obstruction. Sevoflurane is preferred because it is the potent anesthetic that is least irritating to the airway. Laryngoscopy is performed only when the patient is judged to be under deep anesthesia. Intravenous lidocaine (1­2 mg/kg) can deepen the anesthesia without depressing respirations. The surgeon may then perform rigid bronchoscopy to evaluate and possibly dilate the lesion. Following bronchoscopy, the patient is intubated with a tracheal tube small enough to be passed distal to the obstruction whenever possible. The surgeon divides the trachea in the neck and advances a sterile armored tube into the distal trachea, passing off a sterile connecting breathing circuit to the anesthesiologist for ventilation during the resection. Return of spontaneous ventilation and early extubation at the end of the procedure are desirable. Surgical management of low tracheal lesions requires a median sternotomy or right posterior thoracotomy. Most procedures are performed through three or more small incisions in the chest, with the patient in the lateral decubitus position. Anesthetic management is similar to that for open procedures, except that one-lung ventilation is required (as opposed to being desirable) for nearly all procedures. These procedures are complicated by the need to share the airway with the surgeon or pulmonologist; fortunately, these procedures are often brief. One of three techniques can then be used during rigid bronchoscopy: (1) apneic oxygenation using a small catheter positioned alongside the bronchoscope to insufflate oxygen (see above); (2) conventional ventilation through the side arm of a ventilating bronchoscope (when the proximal window of this instrument is opened for suctioning or biopsies, ventilation must be interrupted); or (3) jet ventilation through an injector-type bronchoscope. Mediastinoscopy Mediastinoscopy, much more commonly employed in the past than at present, provides access to the mediastinal lymph nodes and is used to establish either the diagnosis or the resectability of intrathoracic malignancies (see above). Mediastinoscopy is performed under general tracheal anesthesia with neuromuscular paralysis. A: the catheter is advanced past the obstruction, and the cuff is deflated when jet ventilation is initiated. Jet ventilation can be continued without interruption during resection and reanastomosis. Because the innominate artery may be compressed during the procedure, blood pressure should be measured in the left arm. Complications associated with mediastinoscopy include (1) vagally mediated reflex bradycardia from compression of the trachea or the great vessels; (2) excessive hemorrhage; (3) cerebral ischemia from compression of the innominate artery (detected with a right radial arterial line or pulse oximeter on the right hand); (4) pneumothorax (usually presents postoperatively); (5) air embolism (because of a 30° head elevation, the risk is greatest during spontaneous ventilation); (6) recurrent laryngeal nerve damage; and (7) phrenic nerve injury. Bronchoalveolar Lavage Bronchoalveolar lavage may be employed for patients with pulmonary alveolar proteinosis. In such patients, bronchoalveolar lavage may be indicated for severe hypoxemia or worsening dyspnea. Unilateral bronchoalveolar lavage is performed under general anesthesia with a double-lumen bronchial tube. The cuffs on the tube should be properly positioned and should make a watertight seal to prevent spillage of fluid into the other side. The procedure is normally done in the supine position; although lavage with the lung in a dependent position helps to minimize contamination of the other lung, this position can cause severe ventilation/perfusion mismatch. Warm normal saline is infused into the lung to be treated and is drained by gravity At the end of the procedure, both lungs are well suctioned, and the double-lumen tracheal tube is replaced with a single-lumen tracheal tube. Preoperative Management Effective coordination between the organ-retrieval team and the transplant team minimizes graft ischemia time and avoids unnecessary prolongation of pretransplant anesthesia time. These procedures are performed on an emergency basis; therefore, patients may have little time to fast for surgery. Administration of a clear antacid, an H2 blocker, or metoclopramide should be considered. Any premedication is usually administered only in the operating room when the patient is directly attended and monitored. Immunosuppressants and antibiotics are also administered after induction and prior to surgical incision. Lung transplantation (as is true for all solid organ transplants) is limited by the availability of suitable organs, not by the availability of recipients. Intraoperative Management Monitoring Strict asepsis should be observed for invasive monitoring procedures. Central venous access might be accomplished only after induction of anesthesia because patients may not be able to lie flat while awake. Patients with a patent foramen ovale are at risk of paradoxical embolism because of potentially high right atrial pressures. Transesophageal echocardiography is used to assess right ventricular function, integrity of the intraatrial septum, and pulmonary vein flow following anastomosis. Cystic fibrosis Bronchiectasis Obstructive Chronic obstructive pulmonary disease 1-Antitrypsin deficiency Pulmonary lymphangiomatosis Restrictive Idiopathic pulmonary fibrosis Primary pulmonary hypertension Induction & Maintenance of Anesthesia Induction with ketamine, etomidate, an opioid, or a combination of these agents is employed, avoiding precipitous drops in blood pressure. Inhalational agents are administered as tolerated for anesthesia and to provide a possible lung-protective effect. Hypercarbia and acidosis may lead to pulmonary vasoconstriction and acute right heart failure, and hemodynamic support with inotropes may be required for these patients. Drugs such as milrinone may be used for inotropic support, and inhaled nitric oxide can be delivered to dilate the pulmonary vasculature. After the recipient lung is removed, the pulmonary artery, left atrial cuff (with the pulmonary veins), and bronchus of the donor lung are anastomosed. Flexible bronchoscopy is used to examine the bronchial suture line after its completion. Pulmonary vasodilators, inhaled nitric oxide, and inotropes (see earlier discussion) may be necessary. Transesophageal echocardiography is helpful in identifying right or left ventricular dysfunction, as well as in evaluating blood flow in the pulmonary vessels after transplantation. Transplantation disrupts the neural innervation, lymphatic drainage, and bronchial circulation of the transplanted lung. The respiratory pattern is unaffected, but the cough reflex is abolished below the carina. Loss of lymphatic drainage increases extravascular lung water and predisposes the transplanted lung to pulmonary edema. Loss of the bronchial circulation predisposes to ischemic breakdown of the bronchial suture line. Postoperative Management Patients are extubated after surgery as soon as is feasible. A thoracic epidural catheter may be employed for postoperative analgesia when coagulation studies are normal. The postoperative course may be complicated by acute rejection, infections, and renal and hepatic dysfunction. Frequent bronchoscopy with transbronchial biopsies and lavage are necessary to differentiate between rejection and infection. Nosocomial gram-negative bacteria, cytomegalovirus, Candida, Aspergillus, and Pneumocystis jiroveci are common pathogens. Other postoperative surgical complications include damage to the phrenic, vagus, and left recurrent laryngeal nerves. Double-Lung or Heart­Lung Transplantation A "clamshell" transverse sternotomy can be used for double-lung transplantation. Posttransplantation Management After anastomosis of the donor organ or organs, 8 ventilation to both lungs is resumed. Squamous cell carcinomas account for the majority of esophageal tumors; adenocarcinomas are less common, whereas benign tumors (leiomyomas) are rare. After esophageal resection, the stomach is pulled up into the thorax, or the esophagus is functionally replaced with part of the colon (colonic interposition). Gastroesophageal reflux is treated surgically when the esophagitis is refractory to medical management or results in complications such as stricture, recurrent pulmonary aspiration, or a Barrett esophagus (columnar epithelium). A variety of antireflux operations may be performed (Nissen, Belsey, Hill, or Collis­Nissen) via thoracic or abdominal approaches, often laparoscopically. Achalasia and systemic sclerosis (scleroderma) account for the majority of surgical procedures performed for motility disorders. The former usually occurs as an isolated finding, whereas the latter is part of a generalized collagen­vascular disorder. Cricopharyngeal muscle dysfunction can be associated with a variety of neurogenic or myogenic disorders and often results in a Zenker diverticulum. This may result from obstruction, altered motility, or abnormal sphincter function. In fact, most patients typically complain of dysphagia, heartburn, regurgitation, coughing, or wheezing when lying flat. Dyspnea on exertion may also be prominent when chronic aspiration results in pulmonary fibrosis. Esophageal cancer patients usually have a history of cigarette smoking and alcohol consumption, so patients should be evaluated for coexisting chronic obstructive pulmonary 9 Regardless of the procedure, a common anes- disease, coronary artery disease, and liver dysfunction. Patients with systemic sclerosis (scleroderma) should be evaluated for involvement of other organs, particularly the kidneys, heart, and lungs; Raynaud phenomena is also common. In patients with reflux, consideration should be given to administering one or more of the following preoperatively: metoclopramide, an H2-receptor blocker, sodium citrate, or a proton-pump inhibitor. The anesthesiologist may be asked to pass a large-diameter bougie into the esophagus as part of the surgical procedure; great caution must be exercised to help avoid pharyngeal or esophageal injury. The former requires an upper abdominal incision and a left cervical incision, whereas the latter requires posterolateral thoracotomy, an abdominal incision, and, finally, a left cervical incision. During the transhiatal approach to esophagectomy, substernal and diaphragmatic retractors can interfere with cardiac function. Colonic interposition involves forming a pedicle graft of the colon and passing it through the posterior mediastinum up to the neck to take the place of the esophagus. This procedure is lengthy, and maintenance of an adequate blood pressure, cardiac output, and hemoglobin concentration is necessary to ensure graft viability. Goal-directed fluid therapy using hemodynamic measures (eg, stroke volume variation) may be helpful in perioperative fluid management of the esophagectomy patient. Lung protective ventilation and multimodal perioperative analgesia should be used postoperatively. Tracheal compression may produce dyspnea (proximal obstruction) or a nonproductive cough (distal obstruction). Asymptomatic compression is also common and may be evident only as tracheal deviation on physical or radiographic examinations. Flow­volume loops will also detect subtle airway obstruction and provide important information regarding the location and functional importance of the obstruction (see earlier discussion).

Pulmonary venous hypertension may result from left ventricular failure symptoms you need glasses cheap 500 mg tranexamic otc, mitral stenosis medicine rising appalachia lyrics cheap 500mg tranexamic overnight delivery, or left atrial obstruction treatment 1860 neurological order tranexamic with amex. Increases in pulmonary blood flow that exceed the capacity of the pulmonary vasculature will also raise Pc daughter medicine tranexamic 500 mg discount. Marked increases in pulmonary blood flow can be the result of large leftto-right cardiac or peripheral shunts treatment 3rd degree av block purchase tranexamic with american express, hypervolemia (fluid overload), or extremes of anemia or exercise. The released secondary mediators increase pulmonary capillary permeability, induce pulmonary vasoconstriction, and inhibit hypoxic pulmonary vasoconstriction. Treatment Management of cardiogenic pulmonary edema involves decreasing the pressure in the pulmonary capillaries. Generally, this includes measures to improve left ventricular function, correct fluid overload with diuretics, or reduce pulmonary blood flow. Pharmacological treatment of acute cardiogenic pulmonary edema has included oxygen, morphine, diuretics (especially loop diuretics), vasodilators such as nitrates, and inotropes such as dobutamine or milrinone. By reducing left atrial pressure, pulmonary congestion is relieved; by reducing systemic vascular resistance, cardiac output may be improved. Positive airway pressure therapy is also a useful adjunct for improving oxygenation. When pulmonary edema is a consequence of left ventricular failure from acute coronary ischemia, intraaortic balloon counterpulsation, acute revascularization, or other assist devices may be needed. The lung is often affected in a nonhomogeneous pattern, although dependent areas tend to be most affected. Ventilatory failure may be seen in severe cases due to respiratory muscle fatigue or marked destruction of the capillary­alveolar membrane. Pulmonary hypertension and low or normal left ventricular filling pressures are characteristic hemodynamic findings. The protective effect of plasma oncotic pressure is lost as increased amounts of albumin "leak" into the pulmonary interstitium; normal-or even low-capillary hydrostatic pressures are unopposed and result in transudation of fluid into the lungs. Milder cases may be treated with noninvasive respiratory support, but most patients require intubation and mechanical ventilation. Increased Pplt pressures (>30 cm H2O) and high Vt (>6 mL/kg) should be avoided because overdistention of alveoli can induce iatrogenic lung injury, as (likely) can high Fio2 (>0. These three techniques improve oxygenation in many such patients but are not risk free and have not been associated with an improved survival. Among the most common serious complications are sepsis, renal failure, and gastrointestinal hemorrhage. Nosocomial pneumonia is often difficult to diagnose; antibiotics are generally indicated when there is a high index of suspicion (fever, purulent secretions, leukocytosis, and change in chest radiograph). Brushings and bronchoalveolar lavage sampling via a flexible bronchoscope may be useful. Breach of mucocutaneous barriers by catheters, malnutrition, and altered host immunity contribute to a frequent incidence of infection. Kidney failure may result from various combinations of inadequate renal blood flow and perfusion pressure, sepsis, or nephrotoxins. Negative Pressure Pulmonary Edema Forceful inspiration against a closed glottis or an obstructed airway may lead to negative pressure pulmonary edema. In adults this is often the consequence of laryngospasm during or after a general anesthetic, whereas in children it is often a consequence of airway obstruction from infection (eg, epiglottitis) or tumor. Other potential causes include endotracheal tube obstruction or occlusion, and virtually any other cause of airway obstruction. In adults the incidence seems greater in healthier (American Society of Anesthesiologists class 1 or 2) than sicker patients, and greater in males than females, possibly a consequence of more forceful inspiratory efforts by healthy male patients. The onset is extremely rapid and with appropriate treatment the recovery may also be much more rapid than for other forms of pulmonary edema. Neurogenic Pulmonary Edema Head injury, intracranial bleeding, and abrupt reversal of opioid overdosage with naloxone can all precipitate pulmonary edema. Although the precise pathophysiology of this condition is not well understood, it has long been assumed that an abrupt, large increase in sympathetic tone is the precipitating event. Often, neurogenic pulmonary edema presents very rapidly after the inciting event and then dissipates over 24 h or so. Major neurological injuries may produce effects on the heart, so distinguishing between neurogenic and cardiogenic pulmonary edema is not always easy, and the two conditions may overlap. Survival depends on the intensity and duration of the hypoxia and on the water temperature. If water does not enter the airways, the patient primarily suffers from asphyxia; however, if the patient inhales water, marked intrapulmonary shunting also takes place. Ninety percent of drowned patients aspirate fluid: fresh water, seawater, brackish water, or other fluids. Although the amount of liquid aspirated is generally small, marked ventilation/perfusion mismatching can result from fluids in the lung, reflex bronchospasm, and loss of pulmonary surfactant. Aspiration of gastric contents can also complicate drowning before or after loss of consciousness or during resuscitation. The hypotonic water aspirated following fresh water drowning is rapidly absorbed by the pulmonary circulation; water cannot usually be recovered from the airways. If a significant amount is absorbed (>800 mL in a 70-kg adult), transient hemodilution, hyponatremia, and even hemolysis may occur. In contrast, aspiration of salt water (which is hypertonic) draws out water from the pulmonary circulation into the alveoli, flooding them, and sometimes also causing hemoconcentration and hypernatremia. Hypermagnesemia and hypercalcemia have also been reported following near-drowning in salt water. Patients who suffer from cold water neardrowning lose consciousness when core body temperature decreases below 32°C. Ventricular fibrillation occurs at about 28°C to 30°C, but relative to normothermic near-drowning, hypothermia has a protective effect on the brain and may improve outcome provided that resuscitation is successful. In-line stabilization of the cervical spine is necessary when intubating patients who suffer from near-drowning following a dive. Institution of cardiopulmonary resuscitation should not be delayed by attempts to drain salt water from the lungs. Resuscitation efforts should not be suspended for futility until the patient is rewarmed following cold water near-drowning. Complete recovery is possible in such instances even after prolonged periods of asphyxia. Burn victims who suffer from smoke inhalation have a mortality rate significantly greater than other comparably burned patients without smoke inhalation. Any exposure to smoke in a fire requires a presumptive diagnosis of smoke inhalation until proved otherwise. A suggestive history might include loss of consciousness or disorientation in a patient exposed to a fire, or a burn acquired in a closed space. Clinical Manifestations Nearly all patients with a true near-drowning episode will have hypoxemia, hypercarbia, and metabolic acidosis. Patients may also suffer from other injuries, such as spine fractures following diving accidents. Brain damage is generally related to duration of submersion and severity of asphyxia. Pathophysiology the consequences of smoke inhalation are complex because they can involve three types of injuries: heat injury to the airways, exposure to toxic gases, and a chemical burn with deposition of carbonaceous particulates in the lower airways. The pulmonary response to smoke inhalation is equally complex and depends on the duration of the exposure, composition of the material that burned, and presence of any underlying lung disease. Combustion of synthetic materials may produce toxic gases such as carbon monoxide, hydrogen cyanide, hydrogen sulfide, hydrogen chloride, ammonia, chlorine, benzene, and aldehydes. When these gases react with water in the airways, they can produce hydrochloric, acetic, Treatment Initial treatment of near-drowning is directed at restoring ventilation, perfusion, oxygenation, and acid­base balance as quickly as possible. After smoke inhalation direct mucosal injury may result in edema, inflammation, and sloughing. Clinical Manifestations Patients initially may have minimal symptoms after smoke inhalation. Suggestive physical findings include facial or intraoral burns, singed nasal hairs, cough, carbonaceous sputum, and wheezing. The diagnosis is confirmed when bronchoscopy of the upper airway and the tracheobronchial tree reveals erythema, edema, mucosal ulcerations, and carbonaceous deposits. Arterial blood gases initially may be normal or reveal only mild hypoxemia and metabolic acidosis due to carbon monoxide. Heat injury to the airways is usually confined to supraglottic structures unless there is prolonged exposure to steam. Progressive hoarseness and stridor suggest impending airway obstruction, which may develop over 12 to 18 h. Carbon monoxide poisoning is usually defined as greater than 15% carboxyhemoglobin in the blood. Carbon monoxide also has a 60-fold greater affinity than oxygen for myoglobin, which may lead to myocardial depression. Carbon monoxide dissociates slowly from hemoglobin: the half-life of approximately 5 h when breathing room air decreases to 72 min when breathing 100% oxygen. Carboxyhemoglobin levels greater than 20% to 40% are associated with neurological impairment, nausea, fatigue, disorientation, and shock. Lower levels may also produce symptoms because carbon monoxide also binds cytochrome c and myoglobin. Compensatory mechanisms include increased cardiac output and peripheral vasodilation. Cyanide toxicity may occur after fires that contain synthetic materials, particularly those containing polyurethane. Patients present with neurological impairment and lactic acidosis, often accompanied by arrhythmias, increased cardiac output, and marked vasodilation. A chemical burn of the respiratory mucosa follows inhalation of large amounts of burned or burning debris, particularly when combined with toxic fumes. Bronchial edema and sloughing of the mucosa lead to obstruction of the lower airways and atelectasis. In patients who are not intubated, we suggest performing it with a tracheal tube loaded over the bronchoscope so that intubation can quickly be performed if edema threatens the patency of the airway. Early 3 elective tracheal intubation is advisable when there are obvious signs of heat injury to the airway. Carbon monoxide or cyanide poisoning accompanied by obtundation or coma also requires prompt tracheal intubation and ventilation with oxygen. The diagnosis of carbon monoxide poisoning requires co-oximetry: pulse oximeters cannot reliably differentiate between carboxyhemoglobin and oxyhemoglobin. The half-life of carboxyhemoglobin is markedly reduced with 100% oxygen, and hyperbaric oxygen therapy is useful when the patient does not respond to 100% oxygen. The enzyme rhodanese normally converts cyanide to thiocyanate, which is subsequently eliminated by the kidneys. Treatment for severe cyanide toxicity consists of administering sodium nitrite, 300 mg intravenously as a 3% solution over 3 to 5 min, followed by sodium thiosulfate, 12. Sodium nitrite converts hemoglobin to methemoglobin, which has a higher affinity for cyanide than cytochrome oxidase; the cyanide, which is slowly released from cyanomethemoglobin, is converted by rhodanese to the less toxic thiocyanate. Corticosteroids are ineffective, increase the rate of infections, and should not be used. Pathophysiology Most myocardial infarctions occur in patients with more than one severely narrowed (>75% narrowing of the cross-sectional area) coronary artery. The occlusion is nearly always due to thrombosis at a stenotic atheromatous plaque. The size and location of the infarct depend on the distribution of the obstructed vessel and whether collateral vessels have formed. Anterior, apical, and septal infarcts of the left ventricle are usually due to thrombosis in the left anterior descending circulation; lateral and posterior left ventricular infarcts result from occlusions in the left circumflex system, whereas right ventricular and posterior­inferior left ventricular infarcts result from thrombosis in the right coronary artery. Following brief episodes of severe ischemia, persisting myocardial dysfunction with only a slow and incomplete return of contractility can be observed. Relief of the ischemia in these areas can restore contractile function, albeit not immediately. Stunning may be observed following aortic cross-clamping during cardiopulmonary bypass as a reduced cardiac output upon attempted separation from bypass (see Chapter 22). When severe hypokinesis or akinesis is observed in the setting of severe chronic ischemia, the myocardium in these noninfarcted but poorly contractile areas may be said to be "hibernating. More than one half of these deaths occur shortly after onset, usually due to arrhythmias (ventricular fibrillation). With recent advances in interventional cardiology, the in-hospital mortality rate has been reduced to less than 10%. Perioperative diagnosis can be vexing and may depend primarily on troponin measurements. These latter are usually diagnosed by elevations of biomarkers, most commonly troponin. Based on local resources, timing, and anatomic findings during angiography, stenting or coronary artery bypass surgery may be indicated. If angina persists or if there is a contraindication to -blockers, calcium channel blockers should be administered. Intraaortic balloon counterpulsation was in the past commonly used for hemodynamically compromised patients with refractory ischemia; however, there is limited evidence for improved outcomes with this therapy. Emergency treatment of arrhythmias constantly evolves, and we recommend that the guidelines for Advanced Cardiac Life Support be followed. In general, ventricular tachycardia, if treated medically is best managed with amiodarone (150 mg intravenous bolus over 10 min).

What is the significance of a full stomach in a patient with an open globe injury Managing patients who have sustained penetrating eye injuries provides a challenge because of the need to deal with at least two conflicting objectives: (1) preventing further damage to the eye by avoiding increases in intraocular pressure medications excessive sweating discount tranexamic 500 mg on-line, and (2) preventing pulmonary aspiration in a patient with a full stomach medications qt prolongation buy discount tranexamic online. However treatment toenail fungus purchase tranexamic 500mg amex, many of the common strategies used to achieve these objectives are in conflict with one another (Tables 36­5 and 36­6) symptoms 28 weeks pregnant buy tranexamic online from canada. For example medications not to mix discount 500 mg tranexamic free shipping, although regional anesthesia (eg, retrobulbar block) minimizes the risk of aspiration pneumonia, it is relatively contraindicated in patients with penetrating eye injuries because injecting local anesthetic behind the globe increases intraocular pressure and may lead to expulsion of intraocular contents. Therefore, these patients require general anesthesia-despite the increased risk of aspiration pneumonia. A brief examination by the ophthalmologist reveals intraocular contents presenting at the wound. The ideal induction agent for patients with full stomachs would provide a rapid onset of action in order to minimize the risk of regurgitation. Propofol and etomidate have essentially equally rapid onsets of action and lower intraocular pressure. Although investigations of the effects of ketamine on intraocular pressure have provided conflicting results, ketamine is not recommended in penetrating eye injuries, owing to the increased risk of blepharospasm and nystagmus. Although etomidate may prove valuable in some patients with cardiac disease, it is associated with an incidence of myoclonus ranging from 10% to 60%. An episode of severe myoclonus may have contributed to complete retinal detachment and vitreous prolapse in one patient with an open globe injury and limited cardiovascular reserve. Propofol has a rapid onset of action and decreases intraocular pressure; however, it does not entirely prevent the hypertensive response to laryngoscopy and intubation or entirely prevent the increase in intraocular pressure that accompanies laryngoscopy and intubation. How does the choice of muscle relaxant differ between these patients and other patients at risk of aspiration Succinylcholine moderately increases intraocular pressure, but that is a small price to pay for a rapid onset of action that decreases the risk of aspiration and profound muscle relaxation that decreases the chance of a Valsalva response during intubation. Advocates of succinylcholine point to the lack of evidence documenting further eye injury when succinylcholine has been used with open eye injuries. Nondepolarizing muscle relaxants do not increase intraocular pressure, but the onset of deep muscle relaxation is much slower than with these strategies are not recommended for patients with penetrating eye injuries. The risk of aspiration in patients with eye injuries is reduced by proper selection of drugs and anesthetic techniques. Evacuation of gastric contents with a nasogastric tube may lead to coughing, retching, and other responses that can dramatically increase intraocular pressure. Metoclopramide increases lower esophageal sphincter tone, speeds gastric emptying, lowers gastric fluid volume, and exerts an antiemetic effect. It should be given intravenously (10 mg) as soon as possible and repeated every 2 to 4 h until surgery. Ranitidine (50 mg intravenously), cimetidine (300 mg intravenously), and famotidine (20 mg intravenously) are H2-receptor antagonists that inhibit gastric acid secretion. Because they have no effect on the pH of gastric secretions present in the stomach prior to their administration, they have limited value in patients presenting for emergency surgery. Nonparticulate antacids (preparations of sodium citrate, potassium citrate, and citric acid) lose effectiveness within 30 to 60 min and should be given immediately prior to induction (15­30 mL orally). Regardless of the muscle relaxant chosen, intubation should not be attempted until a level of paralysis is achieved that will reliably prevent coughing on the endotracheal tube. How do induction strategies vary in pediatric patients without an intravenous line A hysterical child with a penetrating eye injury and a full stomach provides an anesthetic challenge for which there is no perfect solution. Once again, the dilemma is due to the need to avoid increases in intraocular pressure yet minimize the risk of aspiration. Attempting to sedate children with rectal suppositories or intramuscular injections often heightens their state of agitation and may worsen the eye injury. Similarly, although preoperative sedation may increase the risk of aspiration by obtunding airway reflexes, it is often necessary for establishing an intravenous line for a rapid-sequence induction. Although difficult to achieve, an ideal strategy would be to administer enough sedation painlessly to allow the placement of an intravenous line, yet maintain a level of consciousness adequate to protect airway reflexes. However, the most prudent strategy is to do everything reasonable to avoid aspiration-even at the cost of further eye damage. Patients at risk of aspiration during induction are also at risk during extubation and emergence. Therefore, extubation must be delayed until the patient is awake and has intact airway reflexes (eg, spontaneous swallowing and coughing on the endotracheal tube). Intraoperative administration of antiemetic medication and nasogastric or orogastric tube suctioning may decrease the incidence of emesis during emergence, but they do not guarantee an empty stomach. Allergic reaction to hyaluronidase after retrobulbar anaesthesia: A case series and review. Ophthalmic patients on antithrombotic drugs: A review and guide to perioperative management. Complications associated with eye blocks and peripheral nerve blocks: An American Society of Anesthesiologists closed claim analysis. Factors associated with postoperative pain and analgesic consumption in ophthalmic surgery: A systematic review. Postoperative pain in complex ophthalmic surgical procedures: Comparing practice with guidelines. Real-time visualization of ultrasound-guided retrobulbar blockade: An imaging study. Ophthalmic regional blockade complication rate: A single center audit of 33,363 ophthalmic operations. Anesthetic management for pediatric strabismus surgery: Continuing professional development. During jet ventilation, chest wall motion must be monitored and sufficient exhalation time allowed in order to avoid air trapping and barotrauma. This risk can be moderated by minimizing the fraction of inspired oxygen (Fio2 <30% if tolerated by the patient) and can be eliminated when there is no combustible material (eg, flammable endotracheal tube, catheter, or dry cotton pledget) in the airway. Techniques to minimize intraoperative blood loss include topical vasoconstriction with cocaine or an epinephrine-containing local anesthetic for vasoconstriction, maintaining a slightly head-up position, and providing a mild degree of controlled hypotension. If there is serious preoperative concern regarding potential airway problems, intravenous induction may be avoided in favor of awake direct or fiberoptic laryngoscopy (cooperative patient) or direct or fiberoptic intubation following an inhalational induction, maintaining spontaneous ventilation (uncooperative patient). In any case, the appropriate equipment and qualified personnel required for emergent tracheostomy must be immediately available. Infiltration of the carotid sheath with local anesthetic will usually moderate these problems. Bilateral neck dissection may result in postoperative hypertension and loss of hypoxic drive due to denervation of the carotid sinuses and bodies. Patients undergoing maxillofacial reconstruction or orthognathic surgical procedures often pose airway challenges. If there are any anticipated signs of problems with mask ventilation or tracheal intubation, the airway should be secured prior to induction of general anesthesia. Cooperation and communication between surgeon and anesthesia provider are critical elements of all surgery within or adjacent to the airway. Establishing, maintaining, and protecting an airway in the face of abnormal anatomy and simultaneous surgical intervention are demanding tasks. An understanding of airway anatomy (see Chapter 19) and an appreciation of common otorhinolaryngologic and maxillofacial procedures are invaluable in handling these anesthetic challenges. Preoperative Considerations Patients presenting for endoscopic surgery are often being evaluated for voice disorders (often presenting as hoarseness), stridor, or hemoptysis. Possible diagnoses include foreign body aspiration, trauma to the aerodigestive tract, papillomas, tracheal stenosis, tumors, or vocal cord dysfunction. Thus, a preoperative medical history and physical examination, with particular attention to potential airway problems, must precede any decisions regarding the anesthetic plan. In some patients, flow­volume loop (see Chapter 6), radiographic, computed tomography, ultrasound, or magnetic resonance imaging studies may be available for review. Many patients will have undergone preoperative indirect laryngoscopy or fiberoptic nasopharyngoscopy, and the information gained from these procedures may be of critical importance. Important initial questions that must be answered are whether adequate positive-pressure ventilation via face or laryngeal mask is feasible, and whether the patient can be intubated using conventional direct or video laryngoscopy. However, even the initial securing of an airway with tracheostomy does not prevent intraoperative airway obstruction due to surgical manipulation, a foreign body, or hemorrhage. Sedative premedication should be avoided in a patient with threatening upper airway obstruction. Intraoperative Management 1 the anesthetic goals for laryngeal endoscopy include an immobile surgical field and adequate masseter muscle relaxation for introduction of the suspension laryngoscope (typically profound muscle paralysis will be sought), adequate oxygenation and ventilation, and cardiovascular stability despite rapidly varying levels of surgical stimulation. Given that profound muscle relaxation is often needed until the very end of the operative procedure, endoscopy remains one of the few remaining indications for succinylcholine infusions. Use of sugammadex (Bridion) to reverse profound degrees of rocuronium or vecuronium neuromuscular blockade is an alternative approach. Oxygenation & Ventilation Several methods have successfully been used to provide oxygenation and ventilation during endoscopy, while simultaneously minimizing interference with the operative procedure. Most commonly, the patient is intubated with a small-diameter endotracheal tube through which conventional positivepressure ventilation is administered. Standard endotracheal tubes of smaller diameters, however, are designed for pediatric patients, and therefore are too short for the adult trachea and have a low-volume cuff that will exert increased pressure against the tracheal mucosa. A simple alternative is insufflation of high flows of oxygen through a small catheter placed in the trachea. Although oxygenation may be maintained in patients with good lung function, ventilation will be inadequate for longer procedures unless the patient is allowed to breathe spontaneously. Another option is the intermittent apnea technique, in which positive-pressure ventilation with oxygen by face mask or endotracheal tube is alternated with periods of apnea, during which the surgical procedure is performed. The duration of apnea, usually 2 to 3 min, is determined by how well the patient maintains oxygen saturation, as measured by pulse oximetry. Risks of this technique include hypoventilation with hypercarbia, failure to reestablish the airway, and pulmonary aspiration. Another attractive alternative approach involves manual jet ventilation via laryngoscope side port. During inspiration (1­2 s), a high-pressure (30­50 psi) jet of oxygen is directed through the glottic opening and entrains a mixture of oxygen and room air into the lungs (Venturi effect). Chest wall motion must be monitored and sufficient exhalation time allowed in order to avoid air trapping and barotrauma. A variation of this technique is high-frequency jet ventilation, which utilizes a small cannula or tube in the trachea, through which gas is injected 80 to 300 times per minute (see Chapter 58). Cardiovascular Stability Blood pressure and heart rate often fluctuate markedly during endoscopic procedures for two reasons. First, some of the patients undergoing these procedures are elderly and have a long history of heavy tobacco and alcohol use that predisposes them to cardiovascular disease. In addition, the endoscopic procedure is, in essence, a series of physiologically stressful laryngoscopies and interventions, separated by varying periods of minimal surgical stimulation. Attempting to maintain a constant level of anesthesia invariably results in alternating intervals of hypertension and hypotension. Providing a modest baseline level of anesthesia allows supplementation with shortacting anesthetics (eg, propofol, remifentanil) or sympathetic antagonists (eg, esmolol), or both, as needed during periods of increased stimulation. Alternatively, some anesthesia providers utilize regional nerve block of the glossopharyngeal nerve and superior laryngeal nerve to help minimize intraoperative swings in blood pressure (see Case Discussion, Chapter 19). These characteristics offer the surgeon excellent precision and hemostasis with minimal postoperative edema or pain. Unfortunately, lasers introduce several major hazards into the operating room environment. The uses and side effects of a laser vary with its wavelength, which is determined by the medium in which the laser beam is generated. As the wavelength increases, absorption by water increases, and tissue penetration decreases. General laser precautions include suction evacuation of toxic fumes (laser plume) from tissue vaporization because they have the potential to transmit microbial diseases. When a significant laser plume is generated, individually fitted respiratory filter masks compliant with U. Operating room windows should be covered and appropriately placed signage should be used to alert those entering the room that a laser device is in use. If an endotracheal tube is used, it must be relatively resistant to laser ignition (Table 37­1). These tubes not only resist laser beam strikes, but they also possess double cuffs that should be inflated with saline instead of air in order to better absorb thermal energy and reduce the risk of ignition. If the proximal cuff is struck by the laser and the saline escapes, the distal cuff will continue to seal the airway. Type of Tube Polyvinyl chloride Red rubber Advantages Inexpensive, nonreflective Puncture-resistant, maintains structure, nonreflective Nonreflective Combustionresistant,1 kink-resistant Disadvantages Low melting point, highly combustible1 Highly combustible1 Silicone rubber Metal Combustible,1 turns to toxic ash Thick-walled flammable cuff, transfers heat, reflects laser, cumbersome Combustibility depends on fraction of inspired oxygen and laser energy. Although specialized, laser-resistant endotracheal tubes may be used, it must be emphasized that no endotracheal tube or currently available endotracheal tube protection device is reliably laser-proof. Therefore, whenever laser airway surgery is being performed with an endotracheal tube in place, the following precautions should be observed: Inspired oxygen concentration should be as low as possible by utilizing air in the inspired gas mixture (many patients tolerate an Fio2 of 21%). Assess airway damage with bronchoscopy, serial chest x-rays, and arterial blood gases. Preoperative Considerations Patients undergoing nasal or sinus surgery may have a considerable degree of preoperative nasal obstruction caused by polyps, a deviated septum, or mucosal congestion from infection. This may make face mask ventilation difficult, particularly if combined with other causes of difficult ventilation (eg, obesity, maxillofacial deformities). Patients who also have a history of allergic reactions to aspirin should not be given any nonsteroidal antiinflammatory drugs (including ketorolac) for postoperative analgesia. Because of the rich vascular supply of the nasal mucosa, the preoperative interview should concentrate on questions concerning medication use (eg, aspirin, clopidogrel) and any history of bleeding problems.

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