The equipment needed includes an 18to 22-gauge intravenous catheter muscle relaxant bath order generic imitrex, three-way stopcock muscle relaxant high blood pressure cheap imitrex master card, and a 10to 50-mL syringe muscle relaxant skelaxin 800 mg buy imitrex with american express. The lower abdomen is prepared with antiseptic such as alcohol or povidoneiodine solution and the area is draped zerodol muscle relaxant buy imitrex 100mg otc. If the bladder is distended spasms sternum discount 50mg imitrex free shipping, it is drained with manual pressure or a urinary catheter spasms in 6 month old baby cheap imitrex 50 mg mastercard. A local anesthetic such as 1% lidocaine (Xylocaine) is inltrated into the subcutaneous tissues when possible spasms in 7 month old safe 50 mg imitrex. The catheter should be inserted either in the midline or immediately lateral to the rectus sheath spasms symptoms order imitrex paypal, at a level one-third of the distance between the umbilicus and the symphysis pubis. Once the tip is below the skin, the connected syringe should be aspirated as the catheter is advanced approximately 1 cm until the resistance of passing through the abdominal wall diminishes or uid is obtained. Five to 10 mL of uid is removed for diagnostic paracentesis while 10 to 20 mL/kg should be removed for therapeutic effects. Ultrasound guidance can be useful, especially in situations when the volume of intraperitoneal uid is minimal enough that there is concern that the uid may be difficult to locate or that an abdominal organ could accidentally be punctured during the procedure. Cardiovascular effects, including tachycardia, hypotension, and decreased cardiac output may result from rapid redistribution of intravascular uid to the peritoneal space following removal of large amounts of ascites. Bladder or intestinal aspiration may occur more frequently in the presence of a dilated bladder or bowel. These puncture sites usually heal spontaneously and without signicant clinical ndings. Neonatal meningitis: what is the correlation among cerebrospinal uid cultures, blood cultures, and cerebrospinal uid parameters The 2002 Hospital Infection Control Practices Advisory Committee Centers for Disease Control and Prevention guideline for prevention of intravascular device-related infection. Preventing and Treating Pain and Stress among 67 Infants in the Newborn Intensive Care Unit Carol Spruill Turnage and Michelle A. Both humanitarian considerations and scientic principles favor improved management strategies to prevent pain and stress whenever possible and, when discomfort is unavoidable, to provide prompt and appropriate treatment. Peripheral nerve receptors develop very early in gestation and are abundant by 22 weeks of gestation on most of the fetal body. Evidence of functional thalamocortical connections that are required for conscious perception of pain has been demonstrated as early as 29 weeks of gestation. Autonomic and endocrine responses to noxious stimuli are present even earlier in development. Although this stress response may not indicate fetal pain perception at a conscious level, it has harmful effects on the developing fetus, and the administration of analgesia has been shown to suppress these responses. Early in development, overlapping nerve terminals create local hyperexcitable networks, enabling even low-threshold stimuli to produce an exaggerated pain response. Fetal wounds heal more quickly and with less scarring than those of infants, children, or adults. The process, in part, involves sprouting of sensory nerve endings in and near the site of tissue injury. Although it seems to enhance wound healing, hyperinnervation results in hypersensitivity to painful stimuli that persists after wound healing has occurred. Repeated noxious stimuli further alter sensitivity to painful stimuli and appear to lower the pain threshold, slow the recovery, and adversely affect long-term outcomes. Physiologic responses to painful or stressful stimuli include increases in circulating catecholamines, increased heart rate and blood pressure, and elevated intracranial pressure. The fetus is capable of mounting a stress response beginning at approximately 23 weeks of gestation. The autonomic and other markers of the stress response of the immature fetus or preterm infant, however, are less competent than that of the more mature infant or child. Therefore, among immature infants, neither the common vital sign changes associated with pain or stress. Even when the infants stress response is intact, persistence of painful stimuli for hours or days fatigues or deactivates the sympathetic nervous system response, obscuring the signs of pain or discomfort. Neonatal responses to pain may worsen the compromised physiologic states such as hypoxia, hypercarbia, acidosis, hyperglycemia or respiratory distress. Early studies of surgical responses showed more stable intraoperative course and improved postoperative recovery among infants who received perioperative analgesia and anesthesia. Changes in intrathoracic pressure due to diaphragmatic splinting and vagal responses produced in response to pain following invasive procedures precipitate hypoxemic events and alterations in oxygen delivery and cerebral blood ow. Behavioral and neurologic studies suggest that preterm infants who experience repeated painful procedures and noxious stimuli are less responsive to painful stimuli at 18 months corrected age. However, at 8 to 10 years of age, unlike their normal birth weight peers, infants who were born at or below 1,000 g birth weight rate medical pain intensity greater than measures of psychosocial pain. These data provide evidence that neonatal pain and stress inuence neurodevelopment and affect later perceptions of painful stimuli and behavioral responses, and that prevention and control of pain are likely to benet infants. We use opioids to treat procedural or post operative pain but do not routinely use continuous opioid infusions for all ventilated preterm neonates. Morphine infusions should be used cautiously with extreme prematurity or preexisting hypotension. Analgesics or sedatives which have less cardiovascular effects, such as fentanyl or ketamine, may be better alternatives if required in these neonates. Neuroanatomic components and neuroendocrine systems of the neonate are sufficiently developed to allow transmission of painful stimuli. Infants who have experienced pain during the neonatal period respond differently to subsequent painful events. Severity of pain and effects of analgesia can be assessed in the neonate using validated instruments. A lack of behavioral responses (including crying and movement) does not necessarily indicate the absence of pain. The pain intensity of the anticipated painful procedure from venipuncture to abdominal surgery differs dramatically. Newborns should be assessed for pain routinely, and before and after procedures, by caregivers who are trained to assess pain using multidimensional tools. The pain scales that were used should help guide caregivers to provide effective pain relief. Because small variations in scoring points can result in undertreatment or overtreatment, the prociency of individual caregivers using the chosen pain scale should be reassessed periodically to maintain reliability in assessing pain. Laboratory tests or procedures should be reviewed daily to reduce the number of unwarranted skin punctures and painful tests. The combination of either oral sucrose or glucose, breastfeeding, and other nonpharmacologic pain-reduction methods (nonnutritive sucking, kangaroo care, hand containment or facilitated tuck, and swaddling) are evidence-based interventions that reduce the pain response to heel stick or acutely painful events. Anticipation and planning for pain management is essential to the success of any pain management program. Health care facilities providing surgery for neonates should establish a protocol for pain management in collaboration with anesthesia, surgery, neonatology, nursing, and pharmacy. Such a protocol requires a coordinated, multidimensional strategy, and a priority in perioperative pain management. Sufficient anesthesia and analgesia is provided to prevent intraoperative pain and stress responses and decrease postoperative analgesic requirements. Utilizing a written tool for the hand off report may decrease confusion from misinterpreted or lost information and delays in postoperative analgesia. Pain is routinely assessed using a valid, reliable scale designed for postoperative or prolonged pain in neonates. Opioids are the basis for postoperative analgesia after a major surgery in the absence of regional anesthesia. During the immediate postoperative period, opioids are most effective when scheduled at regular intervals. Although there is little evidence indicating a benet of continuous opioid infusion over intermittent dosing, for safety and simplicity reasons, continuous infusions are recommended for major surgery in the neonate. Postoperative analgesia is used for as long as pain assessment documentation indicates that it is required. Elimination of opioids may be inuenced by enterohepatic recirculation and elevated plasma concentrations, so monitoring for side effects should be maintained for several hours after opioids are discontinued. Acetaminophen is sometimes used after surgery as an adjunct to regional anesthetics or opioids, but there are inadequate data on pharmacokinetics at gestational ages 28 weeks to permit calculation of appropriate dosages. Acetaminophen signicantly reduces the pain response to tissue excision and pain scores during circumcision in some studies. Analgesic efficacy is disputed in other reports where acetaminophen did not relieve acute pain during heel stick or the postoperative pain from cardiac surgery. Slow inltration of the skin site with a local anesthetic before incision, unless there is life-threatening instability. Data show anesthetic drops, oral sucrose administration, and containment reduce the pain response to eye exams for retinopathy of prematurity. There are no data on the effects of bright lighting following dilatation for eye exams. A thoughtful approach to minimize discomfort after an exam may be to decrease lighting or shield the infants eyes from light for 4 to 6 hours. Retinal surgery should be considered as a major surgery, and effective opiate-based pain relief should be provided. Biochemical markers for pain and stress such as plasma cortisol or catecholamine levels are not typically used in the clinical setting but may be useful for research. Physiologic responses to painful stimuli include release of circulating catecholamines, heart rate acceleration, blood pressure increase, and a rise in intracranial pressure. Among preterm infants who are experiencing pain, a change in vital signs associated with the stress response. Even among infants with an intact response to pain, a painful stimulus that persists for hours or days exhausts the sympathetic nervous system output and obscures the clinicians ability to objectively assess the infants level of discomfort. Changes in vital signs are not specic to pain and may be unreliable when used alone to identify pain. Changes in facial activity and heart rate are the most sensitive measures of pain that were observed in term and preterm infants. Before that, various facial components of a grimace may be observed separately such as eye squeeze. Selecting the most appropriate tool for evaluating neonatal pain is essential to its management. In general, pain scores that are documented along with vital signs can be monitored more easily for trends and subtle patterns so pain, unrelieved pain, or opioid tolerance can be identied early. Physicians, nurses, and parents express different perceptions of pain cues when presented with the same infant pain responses. A caregivers bias can inuence both judgment and action when they are evaluating and treating pain. A pain-scoring tool with appropriate age range, acceptable psychometric properties, clinical utility, and feasibility may reduce bias even though none is perfect. Pain responses are inuenced by the gestational age and behavioral state of an infant. Most pain scales that have been tested use acute pain for the stimulus (heel stick), and very few tools that measure acute-prolonged or chronic pain have been adequately tested. Critically ill infants may not be able to exhibit indicators of pain due to their illness acuity. Few scales include parameters of nonresponse that may be present when an infant is severely ill or extremely premature. In that case, the caregiver will need to base treatment decisions on other data such as type of disease, health status, pain risk factors, maturity, invasive measures. Existing pain instruments do not account for the extremely low birth weight infant whose immature physiologic and behavioral responses are challenging to interpret. Infants with neurologic impairment can mount a similar pain response as healthy term infants, although the intensity may be diminished. The pain response can be increased in individual infants based on prior pain history and handling before a painful event. Infants in intermediate or newborn nurseries experience painful procedures that require assessment and management. Pain scales that rely on many physiologic measures will not be appropriate for use in healthy newborns when cardiorespiratory monitoring is typically not used. Physiologic and behavioral indicators can be markedly different when pain is prolonged. Infants may become passive with few or no body movements, little or no facial expression, less heart rate and respiratory variation, and, consequently, lower oxygen consumption. Caregivers may erroneously interpret these ndings to indicate that these infants are not feeling pain due to their lack of physiologic or behavioral signs. Quality and duration of sleep, feeding, quality of interactions, and consolability combined with risk factors for pain may be more indicative of persistent pain. There is evidence that repetitive and/or prolonged exposure to pain may increase the pain response (hyperalgesia) to future painful stimulation and may even result in pain sensation from nonpainful stimuli (allodynia). Because no pain tool is completely accurate in identifying all types of pain in every infant, other patient data must be included in the assessment of pain. Pain that is persistent or prolonged, associated with end-of-life care, or inuenced by medications cannot be reliably measured using current pain instruments. Painful or stressful procedures should be reviewed daily and be limited to those based on medical necessity to decrease redundant or unwarranted blood sampling. Combining painful procedures with nonurgent routine care or prior handling may intensify the pain experience. The infants eyes should be shielded when procedural lights are used or the infant is positioned where light is directed toward the face. Once the procedure is nished, a caregiver should stay to comfort and support the infant until physiologic and behavioral cues conrm recovery from the event. Physiologic interventions consist of taste-mediated analgesia combined with nonpharmacologic strategies. For procedures that last longer than 5 minutes, repeated dosing should be considered. Sweet-tasting solutions (sucrose and glucose) decrease the pain response in infants up to 12 months of age. Long-term outcomes from repeated dosing of sweet solutions in early infancy and in preterm infants are not known. Sucrose must be given on the tongue where taste buds for sweet taste are concentrated. Breast milk administered on the tongue before or during painful procedures is as effective as sucrose/glucose for single events. Repeated use of breastfeeding for pain has not been studied, so effects over time are unknown. Potential refusal of breast milk or breastfeeding, especially in preterm infants, should be considered until more is known about repeated use and whether the association with pain affects later feeding success. A number of considerations are relevant to the pharmacologic management of neonatal pain. Environmental and behavioral interventions should be applied to all infants experiencing painful stimuli. These measures and sucrose analgesia are often useful in conjunction with pharmacologic treatments. Opioid analgesia given on a scheduled basis results in a lower total dose and improved pain control compared with as needed dosing. Pain should be assumed and treatment should be initiated in the immature, acutely ill infant who may be incapable of mounting a stress response to signal his or her discomfort. The inability of the infant to mount an appropriate response is especially relevant when the infant is extremely immature or the painful stimulus is severe and/or prolonged. It is contraindicated in infants less than 1 year of age who concurrently take methemoglobin-inducing agents. Therefore, treatment with analgesics is recommended over sedation without analgesia. Except in instances of emergency intubation, newborns should be premedicated for invasive procedures. Examples of procedures for which premedication is indicated include elective intubation (Table 67. Fentanyl must be infused slowly (no faster than 1 mcg/kg/minute) to avoid complications of chest wall rigidity and impaired ventilation. Among infants at or near-term gestation undergoing an isolated procedure such as intubation, midazolam 0. For tracheal intubation, the addition of a short-acting muscle relaxant given after analgesia administration Table 67. Before adding a shortacting muscle relaxant (vecuronium, rocuronium) for intubation, airway control, and the ability to perform, effective bag-mask ventilation must be assured. For the rst few days of mechanical ventilation, if analgesia is needed, medication with fentanyl 1 to 3 mcg/kg or morphine 0. For circumcision, pretreatment includes both oral (24%) sucrose analgesia and acetaminophen 15 mg/kg preoperatively and, for the procedure, dorsal penile block or ring block with a maximum lidocaine dose of 0. Developmental positioning of the upper extremities using a blanket and restraining only the lower limbs may decrease the stress of a 4-point restraint. Sedatives and opioids may cause respiratory depression and their use should be restricted to settings where respiratory depression can be promptly treated by medical staff experienced in airway management. Paradoxical reactions to benzodiazepines including seizure-like myoclonus have been reported, especially in preterm neonates. Limited data is available on the long term effects of benzodiazepines in preterm and term infants. Tissue injury, which occurs during all forms of surgery, elicits profound physiologic responses. Thus, minimizing the endocrine and metabolic responses to surgery by decreasing pain has been shown to signicantly improve the outcomes in neonatal surgery. Improving pain management and improving outcomes in the neonate requires a team approach and coordinated strategy of multidimensional pain reduction.
The ush associated with gasto increased brous tissue have been reported including tric carcinoids is also reddish in color but patchy in disretroperitoneal brosis causing urethral obstruction spasms in head order 100 mg imitrex overnight delivery, tribution over the face and neck muscle relaxant zolpidem 100 mg imitrex free shipping. It may be provoked by Peyronies disease of the penis muscle relaxant adverse effects discount imitrex express, intraabdominal brosis spasms groin area imitrex 100 mg with visa, food and have accompanying pruritus spasms 5 month old baby buy 100mg imitrex otc. The diarrhea is usually described as watery muscle relaxant dogs buy cheap imitrex 25 mg line, with 60% having <1 L/d of In different studies muscle relaxant names order imitrex 50mg, carcinoid syndrome occurred in 8% diarrhea spasms in 6 month old baby purchase imitrex online pills. Steatorrhea is present in 67%, and in 46% it is of 8876 patients with carcinoid tumors with a rate of 1. It only occurs when sufficient concentrations is histologically indistinguishable from that observed in car357 of secreted products by the tumor reach the systemic cinoid disease. In 91% of cases this occurs after distant receptor agonists used for Parkinsons disease (pergolide, metastases to the liver. Rarely, primary gut carcinoids cabergoline) cause valvular heart disease that closely with nodal metastases with extensive retroperitoneal resembles that seen in the carcinoid syndrome. Studies on cultured interstitial cells from metastasize and cause the carcinoid syndrome. Both the magnitude of serotonin 50% of dietary tryptophan can be used in this synthetic overproduction and prior chemotherapy are important pathway by tumor cells, which can result in inadequate predictors of progression of the heart disease. Atrial supplies for conversion to niacin; hence, some patients natriuretic peptide overproduction is also reported in (2. Foregut carciush is likely due to histamine release, because it can be noids are most likely to cause an atypical carcinoid prevented by H1 and H2 receptor antagonists. However, octreotide can cations of the carcinoid syndrome is the development relieve the ushing induced by pentagastrin in these of a carcinoid crisis. Patients develop brotic reactions involving the heart, causing Peyronies intense flushing, diarrhea, abdominal pain, cardiac disease and intraabdominal brosis. The exact mechanism abnormalities including tachycardia, hypertension, or of the heart disease is unclear. If not adequately treated, it can be a tercaused by the appetite-suppressant drug dexfenuramine minal event. If the diagnosis of carcinoid syndrome relies on measurepatients still have symptoms, serotonin receptor antagoment of urinary or plasma serotonin or its metabolites in nists or somatostatin analogues are the drugs of choice. False-positive elevations may occur if the patient is onists for most are not available. A combination of H1 and H2 receptor antagonists tion rate; however, plasma and platelet serotonin levels, if. Similar results are reported the carcinoid syndrome, by recurrent abdominal sympwith lanreotide. Ileal carcinoids, which are 25% of all preventing symptoms during known precipitating clinically detected carcinoids, should be suspected in events such as surgery, anesthesia, chemotherapy, or patients with bowel obstruction, abdominal pain, ushstress. Important long-term side effects include some recommend total gastrectomy, whereas others gallstone formation, steatorrhea, and deterioration in recommend antrectomy in type I to reduce the hyperglucose tolerance. The overall incidence of gallstones/ gastrinemia; antrectomy produced regression of the carbiliary sludge in one study was 52%, with 7% having cinoids in a number of studies. Hepatic artery embolization alone or with chemotherapy (chemoembolization) has been used to control the symptoms of carcinoid syndrome. Hepatic artery of the disease does the tumor per se cause prominent 360 symptoms such as abdominal pain. Three cases with two extraabTherefore, the diagnoses are frequently missed for extended dominal sites have been described: gastrinomas of the left periods of time. Ectopic hormone secretion usually causes the presenting symptoms and Diagnosis can cause life-threatening complications. Therefore, when the diagnosis is suspected, a fasting gastrin level should be determined rst. Gastric acid hypersecretion in patients with gastrinomas can be controlled in almost every case by oral gastric Diagnosis antisecretory drugs. Because of their long duration of the diagnosis of insulinoma requires the demonstration action and potency, allowing onceor twice-a-day dosof an elevated plasma insulin level at the time of hypoing, the proton pump inhibitors are the drugs of choice. The most reliable test to diagnose insuliincreases the sensitivity to gastric antisecretory drugs noma is a fast up to 72 h with serum glucose, C-peptide, and decreases the basal acid output. If at any point With the increased ability to control acid hypersecrethe patient becomes symptomatic or glucose levels are tion, >50% of the patients who are not cured (>60% of persistently <2. At presenterminated and repeat samples for the above studies tation, careful imaging studies are essential to localize obtained before glucose is given. One-third of patients present will develop hypoglycemia during the rst 24 h and 98% with hepatic metastases, and in <15% of those with by 48 h. Surreptitious use of insulin or hypoglycemic agents may be difficult to distinguish from insulinomas. Characteristically, these levels proposed to be characteristic of insulinomas by attacks are associated with fasting. Before surgery, the hypoglycemia can longed fasting, or familial hyperglucagonemia. Surgical debulking somatostatin analogues such as octreotide are acutely in patients with advanced disease or other antitumor effective in 40% of patients. Long-acting to be used with care because it inhibits growth horsomatostatin analogues such as octreotide or lanreotide mone secretion and can alter plasma glucagon levels; improve the skin rash in 75% of patients and may therefore, in some patients it can worsen the hypoimprove the weight loss, pain, and diarrhea but usually glycemia. Glucagonomas 173 cases of somatostatinomas, only 11% were associated principally occur between 45 and 70 years of age. The mean age of tumor is clinically heralded by a characteristic dermatitis patients is 51 years. The rash starts usually as an annular somatostatinomas: diabetes mellitus (95% vs 21%), gallerythema at intertriginous and perioricial sites, espebladder disease (94% vs 43%), diarrhea (92% vs 38%), cially in the groin or buttock. It subsequently becomes steatorrhea (83% vs 12%), hypochlorhydria (86% vs raised and bullae form; when the bullae rupture, eroded 12%), and weight loss (90% vs 69%). It is a potent inhibitor of many processes including release of almost all hormones, acid Diagnosis secretion, intestinal and pancreatic secretion, and intestithe diagnosis is conrmed by demonstrating an increased nal absorption. Most of the clinical manifestations are plasma glucagon level (normal is <150 ng/L). A plasma Diagnosis glucagon level >1000 ng/L is considered diagnostic of glucagonoma. Other diseases causing increased plasma In most cases somatostatinomas have been found by glucagon levels include renal insufficiency, acute accident either at the time of cholecystectomy or during endoscopy. The presence of psammoma bodies in a duoDiagnosis 363 denal tumor should particularly raise suspicion. A stool volume of <700 mL/d is proposed to these do not cause the somatostatinoma syndrome. By fasting the patient, diagnosis of the somatostatinoma syndrome requires the a number of causes can be excluded that cause marked demonstration of elevated plasma somatostatin levels. Surgery is the treatment of choice for those without widespread hepatic metastases. The mean age of patients with Octreotide will control the diarrhea in 87% of this syndrome is 49 years; however, it can occur in children patients. In nonresponsive patients the combination of and when it does, it is usually caused by a ganglioneuglucocorticoids and octreotide has proved helpful in a roma or ganglioneuroblastoma. Treatment of advanced disease with sists during fasting, and is almost always >1 L/d and embolization, chemoembolization, and chemotherapy >3 L/d in 70%. Its known actions include stimulaproducts do not cause a specic clinical syndrome. The tion of small-intestinal chloride secretion, effects on symptoms are due entirely to the tumor per se. The average time plasma insulin-like growth factor I levels similar to those from the beginning of symptoms to diagnosis is 5 years. The diagnosis is established by histologic conrmation in a patient without either clinical symptoms or elevated plasma hormone levels. Treatment is cer with hypercalcitoninemia develop diarrhea, likely directed against the tumor per se using chemotherapy, secondary to a motility disorder. The true freAlthough it is detectable immunohistochemically in most quency of this syndrome is not known. Localization of the primary tumor and dening the the pancreatic tumors are usually large (>6 cm), and extent of disease are essential to the proper manageliver metastases are present in 39%. With gastrinomas, the 5-year suring hormone gradients after intraarterial calcium survival without liver metastases is 98%, with limited injections in insulinomas (insulin) or gastrin gradients metastases in one hepatic lobe it is 78%, and with difafter secretin injections in gastrinoma is a sensitive fuse metastases it is 16%. Howties are reported to be effective in advanced disease ever, this method gives only regional localization and including cytoreductive surgery (removal of all visible therefore is reserved for cases where other imaging tumor), treatment with chemotherapy, somatostatin modalities are negative. Emboliza50 lobe metastases tion, when combined with treatment with octreotide and (n = 14) 40 p =. Diffuse liver metastases 10 (n = 27) Radiotherapy with radiolabeled somatostatin ana0 logues that are internalized by the tumors is an approach 0 5 10 15 20 25 under investigation. These results 20 (n = 46) suggest this novel therapy may be helpful, especially in 10 patients with advanced metastatic disease. However, recurrence-free survival from 199 patients with gastrinomas modied from F Yu et al: was low (<24%). How long tumor stabilization lasts or whether it proagement of functioning insulinoma at the Mayo Clinic, 1987longs survival has not been established. Menin interacts with JunD, suppressing the distinct genetic disorders predispose to endocrine JunD-dependent transcriptional activation. It is unclear gland neoplasia and cause hormone excess syndromes how this accounts for Menin growth regulatory activity, (Table 23-1). The variable penetrance of the range of clinical features that may be manifested in the several neoplastic components can make the differan individual patient. This syndrome is characterized by Hypercalcemia may develop during the teenage years, neoplasia of the parathyroid glands, enteropancreatic tumors, and most individuals are affected by age 40. Screening for hyperparathyroidism involves include calcium-containing kidney stones, kidney failure, measurement of either an albumin-adjusted or ionized nephrocalcinosis, bone abnormalities. The diagnosis is established by osteitis brosa cystica), and gastrointestinal and muscudemonstrating elevated levels of serum calcium and loskeletal complaints. Management is challenging because of early onset, signicant recurrence rates, and the multi45 plicity of parathyroid gland involvement. Hyperplasia of one or more parathyroid 10 glands is common in younger patients; adenomas are usually found in older patients or those with longstand5 ing disease. Data derived from retthese tumors secrete peptide hormones that cause sperospective analysis for each endocrine organ hyperfunction in cic clinical syndromes. Age at onset is the age at rst symptom have an insidious onset and a slow progression, making or, with tumors not causing symptoms, age at the time of the their diagnosis difficult and in many cases delayed. These sis of hyperparathyroidism increased sharply between ages silent tumors are usually found during radiographic 16 and 20 years. Metastasis, most commonly to the liver, is not et al: Ann Intern Med 129:484, 1998. The represent a complex interaction between glucagon and robust acid production may cause esophagitis, duodenal ghrelin overproduction and the nutritional status of the ulcers throughout the duodenum, ulcers involving the patient. The ulcer diathesis is the Verner-Morrison, or watery diarrhea, syndrome concommonly refractory to conservative therapy such as sists of watery diarrhea, hypokalemia, hypochlorhydria, antacids. The diarrhea can be voluminous gastric acid secretion, elevated basal gastrin levels in the and is almost always found in association with an islet cell serum [generally >115 pmol/L (200 pg/mL)], and an tumor, prompting use of the term pancreatic cholera. Howexaggerated response of serum gastrin to either secretin ever, the syndrome is not restricted to pancreatic islet or calcium. Other causes of elevated serum gastrin levtumors and has been observed with carcinoids or other els, such as achlorhydria, treatment with H2 receptor tumors. These essary to subject the patient to a supervised 12to 72-h secondary interactions add complexity to the diagnosis fast to provoke hypoglycemia (Chap. Intraoperative ultrasonogearly as possible; the rationale of this screening strategy is raphy is frequently used to localize these tumors. The the concept that surgical removal of islet cell tumors at trend to earlier diagnosis of, hence, smaller tumors has an early stage will be curative. Other approaches to reduced the usefulness of octreotide scanning, which is screening include measurement of serum gastrin and positive in a minority of these patients. These tumors can the closed circles show the relative distribution of mutations, exhibit aggressive behavior and local invasiveness that mostly inactivating, in each exon. Prolactinomas from the Human Gene Mutation Database from which more are most common. Diagof genetic testing in a kindred with an identiable nosis of pituitary Cushings disease is generally best mutation is the assignment or exclusion of gene carrier accomplished by a high-dose dexamethasone suppression status. It is presumed that these mutaAdrenal cortical tumors are found in almost one-half of tions are somatic and occur in a single cell, leading to gene carriers but are rarely functional; malignancy in the subsequent transformation. Mediastinal carcinoid tumors is not curative and patients frequently require multiple (an upper mediastinal mass) are more common in men; surgical procedures and surgery on two or more bronchial carcinoid tumors are more common in women. Ranges for acceptbecause of their high rate of malignant transformation able management are discussed below. In the rst, all parathyroid createctomy at an early age may be considered to pretissue is identied and removed at the time of primary vent malignancy. Hormonal abnormalities can sometimes formed because of the potential for later development be controlled. If reoperation for hyperreceptor antagonists or proton pump inhibitors; the parathyroidism is necessary at a later date, transplanted somatostatin analogues, octreotide or lanreotide, are parathyroid tissue can be resected from the forearm useful in the management of carcinoid, glucagonoma, with titration of tissue removal to lower the intact and the watery diarrhea syndrome. Islet cell carcinoglands from the neck (leaving ~50 mg of parathyroid mas frequently metastasize to the liver but may grow tissue), carefully marking the location of residual tissue slowly. Hepatic artery embolization, radiofrequency so that the remaining tissue can be located easily during ablation, or chemotherapy (5-uorouracil, streptozocin, subsequent surgery. Second, performance of a total pantion therapy may be useful for large or recurrent tumors. These features make it difficult to formuresult, other neoplastic manifestations that develop later late clear-cut guidelines, but some general concepts in the course of this disorder, such as carcinoid syndrome, appear to be valid. However, the prognoroid, reecting the high density of C cells in this location; sis is not invariably bad even in patients with metastatic tumors >1 cm in size are frequently associated with disease, as evidenced by a number of multigenerational local or distant metastases. About half of the are the most distinctive features and are recognizable in tumors are bilateral, and >50% of patients who have had childhood. Neuromas are present on the tip of the tongue, unilateral adrenalectomy develop a pheochromocytoma under the eyelids, and throughout the gastrointestinal in the contralateral gland within a decade. A second featract and are true neuromas, distinct from neurobroture of these tumors is a disproportionate increase in the mas. The most common presentation in children relates secretion of epinephrine relative to norepinephrine. A codon 918 mutation is the most common somatic kinase receptor have been identied. Each germline mutation changes a cysteine at carcinoma; Signal, the signal peptide; Cadherin, a cadherin-like codons 609, 611, 618, 620, or 634 to another amino acid.
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Nitromusks muscle relaxant 500 mg trusted 100mg imitrex, such as musk ketone spasms 1982 discount imitrex 25 mg free shipping, are synthetic able adverse evidence spasms symptoms cheap 25 mg imitrex free shipping, in 2008 muscle relaxant herbs cheap imitrex amex, the European Union allowed scent chemicals whose structure contains nitrogen muscle relaxants order imitrex with mastercard. Polycyclic continued use of both musks in consumer products (Summary musks such as Galaxolide and Tonalide contain more than Risk Assessment 2008) back spasms 6 weeks pregnant discount imitrex 100mg visa. New types of ies with cultured cells suggest that these musks may affect the synthetic musks are developed frequently and substituted endocrine system by interfering with estrogen muscle relaxer kick in purchase line imitrex, androgen and/or for older nitromusks that are being banned or phased out on progesterone hormone receptors (Seinen 1999; Schreurs 2005) spasms from colonoscopy order imitrex 100 mg with mastercard. A number of studies have found musks toxic to researchers posit: These fndings could be due to the higher aquatic life (Luckenbach 2005; Snell 2009). Both nitromusks and Studies on toxicity of synthetic musks Galaxolide and polycyclic musks such as Galaxolide and Tonalide can accuTonalide: mulate in the food chain (Dietrich 2004). The combination of widespread human exposure, environmental contamination Endocrine disruption potential and persistence raises questions about the safety of their widespread use in fragranced products. A 1996 study found of estrogen-responsive human breast cancer cells (Bitsch Galaxolide and Tonalide in body fat and breast milk after use 2002). A survey on routes of exposure linked body lotion to and Tonalide were shown to exert antiestrogenic effects higher Galaxolide concentrations (Hutter 2005; 2009). Galaxolide concentration with frequent use of perfumes, Musks also interfere with important detoxifcation enzymes in fsh (Schnell 2009). Hedione 16 Synthetic fragrance ingredient, Only one published toxicity study is found in the online scione of the most commonly used ence library PubMed, a developmental toxicity study conducted in perfumes and colognes, with a by the New Jersey-based Research Institute for Fragrance jasmine smell. More than 1,000 Materials, which reported no gross malformations of rat pups metric tons of hedione is used every exposed to high doses in utero (Politano 2008). Myrcene, especially when oxidized upon air expointermediate for production of many sure, can be an irritant and a weak sensitizer. Galaxolide has been reported to interfere with estrogen and androgen (male) hormones. Galaxolide is bioaccumulative (builds up in the adipose tissue) and has been found in the bodies of humans, in breast milk and in wildlife (van der Burg 2008). Oxidation of linalool esters upon storage and air exposure leads to formation of allergenic oxidation products (Hagvall 2008). Diethyl 12 A fragrance solvent commonly used Diethyl phthalate has been tested for reproductive system phthalate at high concentrations in perfumes impacts and estrogenic activity. Oxidation of linalool esters upon storage and air exposure leads to formation of allergenic oxidation products (Hagvall 2008). Known under the names p(reduced density and number of synapses) in laboratory animals cymene and p-isopropyl-toluene. Minimal in nature; commonly included in developmental toxicity reported; no studies on mutagenicity, cleaning and deodorizing (air freshgenotoxicity or carcinogenicity conducted (Ham 2009). Ethylene brassylate has been reported to induce biochemical changes in skin cells, but no genotoxicity or estrogenicity (Abramsson-Zetterberg 2002; Bitsch 2002; Kim 2006). Hexyl acetate 7 A scent ingredient and a synthetic No safety studies identifed in open scientifc literature. Cis-2,67 Decomposition product from other No toxicity studies identifed in PubMed. Inhalation exposure to high concentrations associscent ingredient in a wide range of ated with irritation of the respiratory airways. Isopropyl 6* A thickening agent and an emolEnhances skin penetration and absorption of other ingredients; myristate lient. Tonalide 5 A synthetic polycyclic musk also Has been reported to interfere with estrogen and androgen known by its chemical name abbre(male) hormones. Alpha-ionone, a such as rose oil and also produced structurally similar chemical, is a recognized consumer allergen. Extensively used as Two recent industry reports on ionone toxicity noted the absence fragrance and favoring ingredients. Upon storage and air exalso used as a solvent in cleaning posure, limonene breaks down to form potent sensitizers. Studies in the open scientifc literature are focused primarily on sensitization; studies on chronic toxicity, reproductive toxicity or carcinogenicity have not been done (Bhatia 2008). Alpha-cedrene 3 A scent ingredient No studies on alpha-cedrene toxicity have been identifed in PubMed. A related compound, acetyle cedrene, has been associated with allergic contact dermatitis (Handley 1994; Lapczynski 2006). Eugenol 2* Scent chemical that occurs natuA known sensitizer; listed by the European Union as one of rally in clove oil. Lilial 2* Synthetic scent chemical also A skin sensitizer; listed by the European Union as a recogknown under the name butylphenized consumer allergen in fragrances. Dimethylbenzyl 2 A scent ingredient; commonly No toxicity studies for this compound have been identicarbinyl butyrate used as favoring agent. Dihydro-alpha1 A scent ingredient, found in pine Published literature limited to irritation and sensitization terpinol oil; also known as dihydro-alphastudies. Inhalation exposure has been associated with irritation, systemic toxicity and degeneration of the olfactory epithelium (David 2001). Isododecane 1 A volatile hydrocarbon used as No toxicity studies identifed in PubMed. For these ingredients, the number listed in the column How many products contain it Cotton Creek Soap and Sundries Alchemilla Daily Essence Alexami Cosmetics Dancing Dingo Luxury Soap Alima Cosmetics, Inc. Production of p-cymene from absence of genotoxicity in the Ames test and the in vivo Micronucleus assay. Caserta D, Maranghi L, Mantovani A, Marci R, Maranghi F, Moscarini Available. Toxicological profle of diethyl phthalate: a vehicle for fragrance and cosmetic ingredients. In: the Handbook of Chemicals/ Environmental Chemistry, volume 3, part X: 233-244 (Springer Berlin/ Heidelberg). Assessment of the phototoxic hazard of some essential oils European Union L 66/26-35. Phototoxic properties of perfumes containing bergamot from the Cosmetic Labeling Manual. Guidance for Industry: product use predicts urinary concentrations of some phthalate monoesters. Environ Drug Administration Compliance Program Guidance Health Perspect 111(9): 1164-9. Amendment Available: Lavender oil lacks natural protection against autoxidation, forming strong. Crit Rev fragrances Lyral and acetyl cedrene in separate underarm deodorant prepaToxicol. Loden, Strategy to decrease the risk of adverse effects of Hattori S, Kawaharada C, Tazaki H, Fujimori T, Kimura K, Ohnishi M, fragrance ingredients in cosmetic products. Degradation products tween 1985-86 and 1997-98, with a special view to the effect of preventive of monoterpenes are the sensitizing agents in tea tree oil. Urinary phthalate metabolites and semen quality: a review of a potential biomarker of susceptibility. Role of nutrition and environmental endoaquatic organisms and humans from the United States. A mixture of fve phthalate esters vitro genotoxicity of polycyclic musk fragrances in the micronucleus test. Higher blood concentrations of synthetic musks in women above ffty years than in younger women. Indoor residential chemical emissions as risk factors for rats for risk assessment. Four weeks inhalation exposure of rats to p-cymene affects regional and synaptoNakagawa Y, Suzuki T. Increased airway 131-57-7) Administered Topically and in Dosed Feed to F344/N Rats and responsiveness of a common fragrance component, 3-carene, after skin B6C3F1 Mice. Toxicity of seven phthalate esters to embryonic development of the abalone Haliotis diversicolor supertexta. Cleaning products and air fresheners: exposure to primary and secondary air pollutants. Retrospective monitorPenetration Enhancers on Skin Permeation Kinetics of Terbutaline Sulfate ing of synthetic musk compounds in aquatic biota from German rivers and From Pseudolatex-Type Transdermal Delivery Systems Through Mouse and coastal areas. Phototoxicity, photoallergy, mammary gland tumors in animals signal new directions for epidemiology, and contact sensitization of nitro musk perfume raw materials. Endocr benzophenone-2 and benzophenone-3 on the expression pattern of the esRelat Cancer. Gruetter M, Herzog I, Reolon S, Ceccatelli R, Faass O, Stutz E, Jarry H, Wuttke W, Lichtensteiger W. Endocrine active compounds affect thyrotropin agents of photoallergic contact dermatitis diagnosed in the national institute and thyroid hormone levels in serum as well as endpoints of thyroid horof dermatology of Colombia. Endocrine disruptors and the thyroid gland-a combined profles through dermal application. Estrogen-like endocrine disrupting chemicals affecting puberty in humans-a review. Mol Cell Endocrinol Schnuch A, Oppel E, Oppel T, Rommelt H, Kramer M, Riu E, Darsow 304(1-2):3-7. Experimental inhalation of fragrance allergens in predisposed subjects: effects on skin and airways. Br J Steinberg P, Fischer T, Arand M, Park E, Elmadfa I, Rimkus G, Brunn H, Dermatol. In vitro and in vivo antiestrogenic effects of polycyclic Suzuki T, Kitamura S, Khota R, Sugihara K, Fujimoto N, Ohta S. Decrease in anogenital distance among male infants with prenatal phthalate exposure. Cutaneous and Ocular Toxicology 2(2-3): Takahashi K, Sakano H, Numata N, Kuroda S, Mizuno N. Prioritized ate metabolites in humans using liquid chromatography-atmospheric preschronic dose-response values for screening risk assessments, Table 1, June sure chemical ionization tandem mass spectrometry. Autoxidation of linalyl acetate, the Analytical Methods for the Identifcation of Synthetic Musk Compounds main component of lavender oil, creates potent contact allergens. Endocrine disruptors, genital development, Actions to Address Chemicals of Concern, Including Phthalates: Agency and hypospadias. Endocrine effects of polycyclic musks: do we smell a of larval development of the marine copepod Acartia tonsa by four synthetic rat Contact Effects of synthetic polycyclic musks on estrogen receptor, vitellogenin, Dermatitis 61(4): 217-23. Characterization of products formed in the reaction of ozone with alpha-pinene: case for organic peroxides. Endocrine disruptors and rat adrenocortical function: studies on freshly dispersed and cultured cells. Symptoms of prostate cancer can be: Dull pain in the lower pelvic area Frequent urinating Trouble urinating, pain, burning, or weak urine flow Blood in the urine (Hematuria) Painful ejaculation Pain in the lower back, hips or upper thighs Loss of appetite Loss of weight Bone pain Updated August 2018 Causes What Causes Prostate Cancer Autopsy studies show 1 in 3 men over the age of 50 have some cancer cells in the prostate. Eight out of ten "autopsy cancers" found are small, with tumors that are not harmful. Even though there is no known reason for prostate cancer, there are many risks associated with the disease. Damaged or abnormal prostate cells can begin to grow out of control and form tumors. But, smoking and being overweight are more closely linked with dying from prostate cancer. They are also more like to have aggressive tumors that grow quickly, spread and cause death. The reason why prostate cancer is more prevalent in African American men is unclear yet it may be due to socioeconomic, environmental, diet or other factors. Other ethnicities, such as Hispanic and Asian men, are less likely to get prostate cancer. Family History Men with a family history of prostate cancer also face a higher risk of also developing the disease. A man is 2 to 3 times more likely to get prostate cancer if his father, brother or son had it. However, within 10 years of quitting, your risk for prostate cancer goes down to that of a nonsmoker the same age. World Area Prostate cancer numbers and deaths vary around the world but are higher in North America and Northern Europe. Higher rates may be due to better or more screening procedures, heredity, poor diets, lack of exercise habits, and environmental exposures. Your risk may be higher if you eat more calories, animal fats, refined sugar and not enough fruits, vegetables. Obesity (or being very overweight) is known to increase a mans risk of dying from prostate cancer. Eating right, exercising, watching your weight and not smoking can be good for your health and help you avoid prostate cancer. Some healthcare providers believe drugs like finasteride (Proscar ) and dutasteride (Avodart ) can prevent prostate cancer. Studies do show that men taking these drugs were less likely to be diagnosed with prostate cancer. Still, it is not clear if these drugs are affective so you should talk to your doctor about the possible side effects. To find out if prostate cancer screening is a good idea, take our Know Your Stats Risk Assessment Test. Tell your results to your healthcare provider when you talk about the benefits and risks of. For this exam, the healthcare provider puts a lubricated gloved finger into the rectum. During this test, the doctor feels for an abnormal shape or thickness to the prostate. When found early, it can be treated early which helps stop or slow the spread of cancer. Or, the test may be a "false positive," suggesting something is wrong when you are actually healthy. The test might also detect very slow growing cancer that will never cause problems if left untreated. For a prostate biopsy, tiny pieces of tissue are removed from the prostate and looked at under a microscope. The pathologist is the doctor who will look carefully at the tissue samples to look for cancer cells. Your doctor will also consider your family history of prostate cancer, ethnicity, biopsy history and other health factors. Prostate biopsy is usually done using an ultrasound probe to look at the prostate and guide the biopsy. Your healthcare provider will note the prostate glands size, shape and any abnormalities. The prostate gland is then numbed (anesthetized) with a needle passed through the probe. Then, the provider removes very small pieces of your prostate using a biops device. If cancer cells are found, the pathologist will assign a "Gleason Score" which helps to determine the severity/risk of the disease (see Stages for more information). Grading (with the Gleason Score) and staging defines the progress of cancer and whether it has spread: Grading When prostate cancer cells are found in tissue from the core biopsies, the pathologist "grades" it. The grade is a measure of how quickly the cells are likely to grow and spread (how aggressive it is). With this system, each tissue piece is given a grade between three (3) and five (5). A high grade of five (5) indicates a highly aggressive, high-risk form of prostate cancer. The Gleason system then develops a "score" by combing the two most common grades found in biopsy samples.
All of the inhaled anesthetics muscle relaxant vs painkiller buy generic imitrex 50mg on-line, with the exception of nitrous oxide spasms after gallbladder surgery purchase imitrex with amex, are bronchodilators and may be useful in those with reactive airways gut spasms order imitrex 25mg amex. The onset of anesthetic induction as well as emergence from anesthesia is based on the lipid solubility characteristics of the inhaled anesthetic: the more insoluble the anesthetic agent muscle relaxant drugs over the counter purchase 100mg imitrex with mastercard, the faster the induction of anesthesia zyprexa spasms generic imitrex 50mg amex. Isoflurane C o m p a r e d w i t h o t h e r i n h a l e d a n e s t h e t i c s (s e v o f l u r a n e muscle relaxant tramadol buy 100mg imitrex with mastercard, d e s f l u r a n e) spasms of pain from stones in the kidney buy generic imitrex 25mg line, i s o flurane has a relatively high lipid solubility muscle relaxant radiolab buy imitrex on line, leading to increased induction and emergence time. Isoflurane causes minimal cardiac depression and decreased blood pressure secondary to decreased systemic vascular resistance. Like other volatile anesthetics, isoflurane causes respiratory depression with a decrease in minute ventilation (Table 1. D e s p i t e i t s a b i l i t y t o c a u s e airway irritation, isoflurane induces bronchodilation. Desflurane Other than the substitution of a fluoride atom for a chloride atom, the structure of desflurane is very similar to that of isoflurane. Because of its low lipid solubility, 44 Handbook of OtolaryngologyHead and Neck Surgery Table 1. Respiratory Can cause airway irritation and cause bronchodilation Respiratory depression Neurologic At high concentrations, increased cerebral blood flow and intracranial pressure can develop. The time required for patients to awaken is approximately half as long as that observed following isoflurane administration. Desflurane has cardiovascular and cerebral effects similar to those of isoflurane. Like isoflurane this agent is irritating to the airway making gas induction difficult. Nonpungency and a rapid increase in alveolar anesthetic concentration make it an excellent choice where inhalational induction is necessary. Sevoflurane mildly depresses myocardial contractility and systemic vascular resistance. Arterial blood pressure declines slightly less than with isoflurane or desflurane. Like isoflurane and desflurane, sevoflurane causes slight increases in cerebral blood flow and intracranial pressure. Nitrous Oxide the uptake and elimination of nitrous oxide are relatively rapid compared with other inhaled anesthetics. Nitrous oxide produces analgesia, amnesia, mild myocardial depression, and mild sympathetic nervous system stimulation. Nitrous oxide is a mild respiratory depressant, although less so than the volatile anesthetics. N Muscle Relaxation Neuromuscular blocking agents are used most commonly for facilitation of endotracheal intubation and when patient movement is detrimental to 1. Ventilation can be achieved with a mask until the endotracheal tube is placed in the trachea. Neuromuscular blockers have no intrinsic sedative or analgesic properties and must be used in concert with anesthetic agents. Inadequate sedation and hypnosis while using neuromuscular blockers can produce recall by patients causing long-term side effects. There are two classifications of neuromuscular blocking agents: depolarizing and nondepolarizing. Depolarizing Muscle Relaxants Depolarizing agents have a similar chemical structure to acetylcholine. They induce paralysis by binding to acetylcholine receptors at the skeletal muscle neuromuscular junction causing depolarization. Paralysis ensues because these agents have a higher affinity for the postsynaptic receptor preventing the reestablishment of its ionic gradient. The only medication in this class that is still in use today is succinylcholine (Table 1. Nondepolarizing Muscle Relaxants Nondepolarizing muscle relaxants induce paralysis by binding to the postsynaptic receptor at the skeletal muscle neuromuscular junction. Essentially, these medications compete with acetylcholine for binding sites Table 1. Fasciculations with receptor activation typically occur and can result in myalgias postop. Potassium release with succinylcholine-induced depolarization can increase by 0. Transient increases in intracranial and intraocular pressure Avoid in patients with a history of malignant hyperthermia Metabolized by pseudocholinesterase 46 Handbook of OtolaryngologyHead and Neck Surgery Table 1. Rocuronium undergoes no metabolism and is eliminated in the bile and slightly by the kidneys. Onset: 23 min Hepatic metabolism with renal excretion Duration: 2530 min Lacks hemodynamic side effects Can be administered as an infusion (12 %g/kg/min) Cisatracurium Dose: 0. Duration: 5060 min May be safely administered to patients with renal or liver failure Lacks hemodynamic side effects Pancuronium Dose: 0. Unlike depolarizing blockade, the postsynaptic receptors are not activated and fasciculations do not occur. Nondepolarizing blockade can be reversed by increasing the acetylcholine concentration at the neuromuscular junction. This is achieved by administration of medications such as neostigmine, which prevent the breakdown of acetylcholine. Importance of prevention, early recognition, and prompt appropriate management are common to all potential anesthetic emergencies. In particular, airway fire and malignant hyperthermia are conditions with the potential for high morbidity or mortality and are thus reviewed here. Lower oxygen concentration to 21 to 40% FiO2 as tolerated when using cautery intraorally. Laser precautions such as the use of a laser-safe endotracheal tube and packing and covering surrounding field with wet gauze or towels must be standard. Turn off oxygen temporarily when using cautery during facial procedures requiring sedation and nasal cannula. If there is a fire, turn off the oxygen, turn off the nitrous oxide, immediately remove the endotracheal tube, extinguish and remove any burning material, and reintubate the patient. The underlying pathophysiology is an inability of the sarcoplasmic reticulum to control intracellular calcium causing prolonged activation of muscle contractile units. G Attention to fluids and electrolytes is especially important in the patient who is not capable of maintaining normal oral intake. Surgical patients, especially head and neck cancer patients, may be incapable of adequate oral intake. An important rule is that if the gut is available and functional, it should be used, i. N Daily Electrolyte Requirements Sodium: 23 mEq/kg per day Potassium: 12 mEq/kg per day Chloride: 23 mEq/kg per day See Table 1. N Perioperative Fluid Management I n t r a o p e r a t i v e l y, t h e r e a r e f o u r a s p e c t s o f f l u i d m a n a g e m e n t t h a t s h o u l d b e c o n sidered: maintenance requirement, fluid deficit, third space loss, and blood loss. Maintenance Requirement (Rough estimate, based on weight) G First 10 kg: 4 mL/kg per hour G Second 10 kg: add 2 mL/kg per hour G Above 20 kg: add 1 mL/kg per hour (Note: for patients above 20 kg, add 40 to weight to get maintenance rate in mL/kg per hour). Third Space (Redistribution Loss) Made up of third space (redistribution) and evaporative losses; amount based on tissue trauma. G Minimal: 02 mL/kg per hour G Moderate: 24 mL/kg per hour G Severe: 48 mL/kg per hour Blood Loss (see also Chapter 1. Perioperative Care and General Otolaryngology 51 An overview of blood components, disorders, and transfusion complications is provided in this chapter. Blood Component Therapy the archaic perioperative axiom of transfusing patients to maintain Hb of 10 and a hematocrit of 30 has fallen by the wayside. Although these are indeed safe guidelines for patients with coronary artery disease, transfusions are currently guided by hemodynamics, intraoperative blood loss and laboratory values such as the arterial blood gas. Intraoperative bleeding increases 52 Handbook of OtolaryngologyHead and Neck Surgery with counts between 40,000 and 70,000/mm3, and spontaneous bleeding can occur with counts! During most surgeries, platelet transfusions are probably not needed unless the count is less than 50,000/mm3. G Cryoprecipitate: Indications include hypofibrinogenemia, von Willebrand disease, and hemophilia A. N Universal Donor Blood Group O, Rh-negative blood should be reserved for patients close to exsanguination. If time permits, crossmatched or uncrossmatched type-specific blood should be administered. The serum contains high anti-A and anti-B titers, which may cause hemolysis of recipient blood. If more than 4 units of group O, Rh-negative whole blood is administered, type-specific blood should not be given subsequently because the potentially high anti-A and anti-B titers could cause hemolysis of the donor blood. N Complications of Transfusions Immune Reactions (Hemolytic versus Nonhemolytic) Hemolytic Reactions G Acute Hemolytic Reaction. Symptoms include fever, chills, chest pain, anxiety, back pain, dyspnea; in anesthetized patients, the reaction may present with fever, tachycardia, hypotension, hemoglobinuria, and diffuse oozing in the surgical field. The symptoms are generally mild and may include malaise, jaundice, and fever; treatment is supportive. The reaction is the result of the action of recipient antibodies against donor antigens present on leukocytes and platelets; treatment includes stopping or slowing the infusion and antipyretics. A urticarial reaction occurs in 1% of transfusions; it is thought to be due to sensitization of the patient to transfused plasma proteins. Patients with IgA deficiency may be at an increased risk because of the transfused IgA reaction with anti-IgA antibodies. Graft-versus-Host Disease Graft-versus-host disease is most commonly seen in immunocompromised patients. Cellular blood products contain lymphocytes capable of mounting an immune response against the compromised host. Posttransfusion Purpura Due to the development of platelet alloantibodies; the platelet count typically drops dramatically one week after the transfusion. Immune Suppression T r a n s f u s i o n o f l e u k o c y t e c o n t a i n i n g b l o o d p r o d u c t s a p p e a r s t o b e i m munosuppressive. Blood transfusions may increase the incidence of 54 Handbook of OtolaryngologyHead and Neck Surgery serious infections following surgery or trauma. Blood transfusions may worsen tumor recurrence and mortality rate following resections of many cancers. Specific bacterial reactions transmitted by blood include syphilis, brucellosis, salmonellosis, yersiniosis, and various rickettsioses. G Citrate toxicity: citrate metabolism to bicarbonate may contribute to metabolic alkalosis; binding of calcium by citrate could result in hypocalcemia and the ability of the liver to metabolize citrate to bicarbonate. Microaggregates Microaggregates consisting of platelets and leukocytes form during the storage of whole blood. Hypothermia the use of blood warmers (except for platelets) greatly decreases the likelihood of transfusion-related hypothermia. Perioperative Care and General Otolaryngology 55 Dilutional Thrombocytopenia Dilutional thrombocytopenia is a common cause of abnormal bleeding in the setting of massive transfusion. Send donor unit and newly obtained blood sample to blood bank for recross match. Send patient blood sample for direct antiglobulin (Coombs) test, free Hb, haptoglobin; send urine for Hb. Platelet Function Detailed evaluation of possible platelet aggregation disorders requires complex hematology testing. N Hematologic Disorders Sickle Cell Anemia Sickle cell anemia is a hereditary hemolytic anemia resulting from the formation of an abnormal Hb (HbS); sickle Hb has less affinity for oxygen and decreased solubility. Vigorous physical activity, high altitude, air travel in unpressurized planes and anesthesia are potentially hazardous. Perioperative Care and General Otolaryngology 57 the disease manifests as periodic exaggeration of symptoms or sickle crises. There are four types of crises: G Vasoocclusive crisis: caused by sickled cells blocking the microvasculature; characterized by sudden pain frequently without a precipitating event. G Sequestration crisis: red blood cells are sequestered in the liver and spleen leading to splenohepatomegaly and acute fall in hematocrit. G Aplastic crisis: characterized by transient episodes of bone marrow depression; often occurs after viral illness. N Management of Sickle Cell Anemia the practice of transfusion to an end point of 70% HbA and less than 30% HbS preoperatively is controversial. Patients should be well oxygenated and hydrated intraoperatively to lessen the chance of sickling. Doses may be repeated at intervals of 12 to 24 hours for continued bleeding or for postoperative use. Such deviations may present with a change in exam findings, a subjective complaint from the patient, or with laboratory test or vital sign anomalies. Timing is important, as postoperative fever within the first 24 hours suggests atelectasis, possibly an early wound infection, or a urinary tract infection. Also, a possible transfusion reaction, a deep vein thrombosis, or an infected decubitus ulcer should be considered. Perioperative Care and General Otolaryngology 59 Workup A b e d s i d e e x a m i n a t i o n i n c l u d e s t a k i n g v i t a l s w i t h p u l s e o x i m e t r y a n d c h e c k ing the wound for erythema, edema, fluctuance, drainage, and warmth. Consider possible sepsis if the patient has tachypnea, tachycardia, or hypotension. Consider ordering a chest x-ray, blood cultures, sputum cultures, and/or a urinalysis with cultures. For atelectasis/pneumonia, empiric treatment may include a chest physical exam, supplemental oxygen, and respiratory therapy with incentive spirometry, mucolytics, nebulized bronchodilators, and empiric antibiotics (determined after the results of culture specimens have been received). A wound abscess will require opening the wound, draining it, initiating a gram stain with culture, and changing the packing. If other vital signs are abnormal, you may want to transfer to the patient to a monitored bed, with continuous pulse oximetry and arterial blood gas assessment. N Confusion (Mental Status Change) this is one of the most common calls in otolaryngologyhead and neck surgery regarding postoperative patients. Although the possible causes for a mental status change are many, it is prudent to consider the cause to be hypoxia until proven otherwise. Resist the request for benzodiazepine to calm him or her down; instead instruct the nurse to obtain a full set of vitals, including pulse oximetry. Typically, the patient has an underlying chronic lung disease and has had inadequate tracheopulmonary toilet, allowing for accumulation of secretions and mucus plugging. Pulmonary Embolism I n t h e c a s e o f a p o s s i b l e P E, c u r r e n t l y a s p i r a l C T i s c o m m o n l y o b t a i n e d, a l t h o u g h v e n t i l a t i o n / p e r f u s i o n (V / Q) s c a n s c a n b e p e r f o r m e d a n d l a b o r a tory testing for D-dimer may be useful. This develops from inspiration against a closed glottis due to laryngospasm or other obstruction. This may occur in children or adults following surgery to correct severe obstructive sleep apnea. In both cases, a sudden decrease in intrathoracic pressure leads to increased pulmonary venous return and transudation from the capillary bed into the interstitium. In patients who are stable, medical management with oxygen supplementation, diuretics, and close observation may be appropriate. Other Causes of Mental Status Change If the hypoxia workup is normal, other testing may reveal an obvious cause. The fingerstick glucose test is a rapid way to exclude a common cause for mental 1. Perioperative Care and General Otolaryngology 61 status change, especially in known diabetics. Mental status change in a patient with a high fever should prompt consideration of meningitis, especially if the patient has had skull base or otologic surgery. Alcohol Withdrawal Many head and neck patients have a history of alcohol abuse, often underreported. Thus, in the absence of other obvious causes for mental status change, attempting to obtain an honest alcohol use history is important. Psychiatric Disorders Severe anxiety, delirium, or psychosis can be seen in the postoperative patient. It is important to exclude hypoxia or other obvious medical causes for mental status change or agitation. N Wound Problems A variety of wound problems can arise following head and neck surgery, including hematoma, seroma, infection, dehiscence, development of a pharyngocutaneous fistula, exposure of the carotid artery leading to rupture or carotid blowout,chyle leak, or reconstructive flap complications such as venous edema or arterial ischemia. As with most situations, prevention is helpful: proper preoperative assessment, management of identified risk factors such as malnutrition or coagulopathy, and meticulous surgical technique. Preoperative radiation therapy is a common issue that greatly increases the risk of healing problems. Assessment and Management of Wound Problems Hematoma and Seroma In cases of hematoma and seroma, the wound will be swollen, usually fluctuant but possibly tense or discolored. A fluid collection can lead to 62 Handbook of OtolaryngologyHead and Neck Surgery infection, dehiscence, or decrease skin flap viability. Most commonly, this is seen the day of surgery and presents with an expanding mass and discomfort, which may progress to dyspnea, stridor, and severe airway compromise. This is due to venous back-pressure causing the rapid development of laryngeal edema. If this remains difficult, a tracheotomy should be simple to perform because the thyroidectomy has exposed the subglottic trachea. Wound Infection An infected neck wound is typically warm, red, swollen, and tender; it may present with purulent drainage, a fluctuant collection, or abscess formation. Management includes opening the wound, culture of drainage, appropriate antibiotics, and packing change. Clorpactin or acetic acid gauze packing have antimicrobial properties and promote granulation tissue formation. However, if there is carotid exposure, it is prudent to perform surgery to cover the carotid with vascularized tissue, such as a pectoralis flap. Pharyngocutaneous Fistula Salivary drainage increasing in suction drains or draining via an incision indicates development of a fistula.
