Thomas Richard Gehrig, MD

• Associate Professor of Medicine

https://medicine.duke.edu/faculty/thomas-richard-gehrig-md

First blood pressure chart for 14 year old cheap cardizem 60mg free shipping, if nitrous oxide is contraindicated hypertension uncontrolled icd 9 code discount 180 mg cardizem mastercard, such as in the newborn with bowel obstruction heart attack grill quadruple bypass burger cardizem 60mg sale, air is mixed with oxygen to prevent the administration of only 100% oxygen blood pressure near death cardizem 120 mg with mastercard. Second hypertension occurs when purchase cardizem 180mg visa, some patients heart attack but i cover up 180mg cardizem overnight delivery, such as those with hypoplastic left heart syndrome, may benefit from the administration of air with additional oxygen. Induction of Anesthesia There is no one method of induction and maintenance of anesthesia that is best for all patients. The current medical status of the patient, the surgical condition, the presence of ongoing fluid or blood losses, the gestational age of the patient, recent fasting, and the experience of the anesthesiologist are all important considerations. Most neonates who come to the operating room will have vascular access already established; if not, the first task before induction is to establish adequate vascular access after applying monitors. Although it may rarely be appropriate to use an inhalational induction if vascular access is difficult in the older newborn, near a month of age, it is mandatory to establish access first in the newborn who is preterm, medically unstable, has a full stomach, has a potentially difficult airway, or has ongoing fluid losses. Airway Management Establishing the airway in the neonate requires an appreciation of the differences between the newborn and the adult airway, as discussed earlier. It 2970 is rare to administer anesthesia in the newborn period without establishing an artificial airway. Although, with meticulous technique, a mask airway can successfully be used for short periods of time, the tolerances of mask fit, adequate airway pressure, and avoidance of gastric distention are small, making this a poor choice for any but the briefest of operations. In addition, controlled ventilation is used more commonly today than spontaneous ventilation for surgical procedures, making an artificial airway necessary. Awake intubation has been used to secure the airway without the danger of loss of airway during the procedure, but it can be a traumatic experience for both the patient and the anesthesiologist, accompanied by pain, bradycardia, breath holding, desaturation, and tissue trauma. However, this technique is usually reserved for patients with severe hemodynamic compromise, an extraordinarily distended and tense abdomen, or a presumed difficult airway, especially the newborn with micrognathia. In the latter situation, the addition of sedation with an opioid or topical application of local anesthetic can help decrease some of the trauma of the procedure. It has also been suggested that an awake intubation may be best for the anesthesiologist who is not very experienced in intubating newborns. It may be better to have a more experienced clinician, if available, attend to the airway in that situation. If there is concern about the difficulty of intubation, it may be prudent to induce anesthesia, ensure adequacy of mask ventilation, and then give the muscle relaxant. Positioning for intubation is based on the known differences in the neonatal airway. No changes in position are usually needed, although additional extension of the head may be accomplished by a shoulder roll. Sliding the blade down the right side of the mouth allows the blade to be seated with minimal overlap by the tongue. The tip of the blade is advanced to lift the epiglottis directly instead of placing it in the vallecula, as is commonly done with older patients. If the 2971 glottis is not easily seen, cricoid pressure can be applied with the little finger of the hand holding the handle or by an assistant, often improving the view. Uncuffed tubes have traditionally been used in newborns to minimize cuff pressure on the subglottic larynx, especially at the level of the cricoid cartilage. Modern cuffed endotracheal tubes make minimal sacrifice in tube diameter to allow for the presence of a cuff, which has renewed interest in cuffed endotracheal tubes. Although various formulas have been proposed for how far to advance an uncuffed tube, it is prudent to use the depth markers at the end of the tube to ensure under direct vision that the tip is advanced 2 or 3 cm past the vocal cords. Once inserted, the presence of a positive capnograph tracing, bilateral expansion of the thorax, and bilateral breath sounds are used to ensure proper placement. Although some anesthesiologists prefer to advance the endotracheal tube past the carina and then withdraw until bilateral breath sounds are heard, there are two major disadvantages to the technique: trauma to the airway and lack of a guarantee that the tip of the tube is not sitting right at the carina, increasing the chance of migration into a bronchus with head movement. Finally, listen for an air leak at an airway pressure of about 20 cm H2O to ensure that the tube is not too large for the airway, increasing the chances of subglottic edema and damage. Fiberoptic laryngoscopy, the most flexible of intubating tools routinely used in older children and adults, can also be used in the newborn. After establishing a baseline of acceptable ventilation, it is important to continuously monitor the peak airway pressures, chest expansion, return volume, pulse oximetry, and capnograph tracings for changes. Initial tidal volumes of 6 to 7 mL/kg and rates of 20 to 25 breaths per minute are a reasonable starting point for most patients. With this rate 2973 and volume setting, it would be expected that peak airway pressures be approximately 20 cm H2O. Of course, this strategy must be modified for some patients with severe coexisting disease. Mechanical ventilation of the neonate can be challenging for the anesthesiologist. Modern anesthetic systems make ventilation much easier than in the past, even in the smallest patients. Although the standard has been to use pressure control ventilation in this population, all modes of ventilation are now readily available on modern anesthesia machines. Table 42-4 shows the modes of ventilation and breath synchronization most commonly used in neonates. Use of high frequency ventilation in the operative setting will require use of a specialized ventilator and close consultation with a critical care physician and respiratory therapist. Table 425 lists some of the advantages and disadvantages to use of pressure control, volume targeted, and high frequency ventilation. Table 42-4 Common Ventilator Strategies in Neonates Impact of Surgical Requirements on Anesthetic Technique Every procedure has its own unique challenges. With any surgery, issues related to presurgical resuscitation, perioperative fluid and blood loss, 2974 heat loss from the surgical field, likely perioperative complications, and the likely need for postoperative intubation and ventilation should be anticipated, both on the basis of experience and communication about the unique needs of the upcoming procedure. There is a dramatic increase in the use of laparoscopic and thoracoscopic approaches to lesions, even in the smallest neonates. There may be less blood, fluid, and heat loss, but there are additional issues related to positioning, insufflation pressures in the chest and abdomen, and prolonged surgical time. As new techniques evolve, close communication between the anesthesiologist and the surgeon is necessary to ensure adequate preparation, monitoring, and resolution of problems or complications. One not well-recognized factor that may result in higher concentrations of volatile anesthetics being administered to infants has to do with the use of nonrebreathing systems such as the Bain or a Mapleson "D" circuit. When an adult circle system is used with infant tubes and bag, the clinician experienced with this equipment is used to reading the inspired, end-tidal, and dialed concentrations of the volatile anesthetic. In the circle system, the inspired concentration is a result of the combination of the end-tidal concentration that is rebreathed through the soda lime absorber and the dialed concentration. The inspired concentration is always lower than the dialed concentration, unless the flow rates are so high that a nonrebreathing system has been created. In the nonrebreathing system, the dialed concentration is the inspired concentration. However, if the clinician switches back and forth between the circle system and a nonrebreathing circuit, but does so infrequently, there is a danger of not recognizing the possibility of excessive overpressure of volatile anesthetics with the nonrebreathing systems. The newborn infant has elevated progesterone levels, similar to those of the mother. Elevated levels of -endorphin and -lipotropin have been demonstrated in infants in the first few days of postnatal life. Regional Anesthesia 2976 There has been a tremendous increase in the use of regional anesthesia in infants and children. In general, regional techniques are combined with general anesthesia to permit early extubation and provide postoperative pain relief. Useful regional anesthesia techniques include spinal anesthesia, caudal anesthesia, epidural analgesia, penile block, and other peripheral nerve blocks (Table 42-6). Regional anesthesia may even have other applications outside surgery, including management of neonatal limb ischemia. The use of ultrasonography has revolutionized the use of regional anesthesia as vascular structures can be easily avoided while still providing a regional blockade. The use of sole regional anesthesia in neonates and infants is for avoidance of general anesthetics, for either theoretical decreased risk of apnea or decreased risk of neurotoxicity. Although neurotoxicity trials are still ongoing, it has been shown that spinal anesthesia decreases early apnea following surgery in premature neonates, but does not decrease the risk of overall apnea following surgery in premature neonates. Some patients may benefit from providing a caudal block in addition to the spinal anesthetic. Total spinal anesthesia, produced either with a primary spinal technique or secondary to an attempted epidural puncture, will present as apnea, rather than as hypotension, because of the lack of sympathetic tone in infants. The exact mechanism for the lack of cardiovascular change with spinal anesthesia in infants and young children is not clear. Consequently, the first indication of a high spinal is falling oxygen saturation rather than a falling blood pressure. Sedation can be added to regional anesthesia but may cause problems with apnea in ex-premature infants. The landmarks are the coccyx, the two sacral cornua, and the posterior superior iliac spines. Several needle types may be used, but the "pop" through the sacrococcygeal ligament is best observed with a blunt-tipped needle, whereas an intravenous catheter advanced over a needle may provide additional confirmation of sacral canal entry. The caudal space is identified by "pop" through the sacrococcygeal ligament, ease of local anesthetic injection, and absence of subcutaneous swelling upon dose delivery. Once the sacrococcygeal ligament is penetrated and there is a loss of resistance, gentle aspiration is applied to the needle to determine if there is blood or cerebrospinal fluid. If there is difficulty in injecting the solution, and the tip of the needle is not in the caudal space and it needs to be repositioned. The needle is not advanced up the sacral canal after proper placement in the caudal epidural space has been accomplished, this avoids dural puncture and accidental intrathecal injection. Other methods to identify the caudal space have been described, including stimulating technique129 and ultrasound guidance. Evidence of an intravascular injection include (1) peaked T waves (which may be of relatively short duration), (2) increase in heart rate, and (3) increase in blood pressure. Another technique to minimize the potential difficulties of an intravascular injection is to fractionate the dose by dividing the total dose into three aliquots and waiting approximately 20 to 30 seconds between each aliquot before continuing the injection. In addition, a single-injection caudal anesthetic can provide analgesia for 6 to 8 hours. Epinephrine, 1:200,000, is added to local anesthetics to assist in determining if there has been an intravenous injection. Ropivacaine has been reported to be less cardiodepressant than equipotent doses of bupivacaine. If a caudal catheter is placed, an infusion of ropivacaine, bupivacaine, lidocaine, or chloroprocaine can be administered and provide analgesia for several days postoperatively. Current recommendations for infusions in neonates and young infants are for an initial loading dose of 0. However, caution must be exercised in neonates and infants who may be prone to apnea with even moderate doses of opioids in the epidural space. Ultrasonography can be used for localization of the caudal space in infants whose anatomy may not be apparent. This provides analgesia for hernia repair, circumcisions, and lower abdominal surgeries. Epidural Analgesia With the introduction of newer and smaller needles and epidural catheters, we are able to provide epidural analgesia in neonates and infants. Although some practitioners prefer using a caudal route to place catheters in the epidural space, lumbar and thoracic epidural catheters can be easily placed in neonates. It is imperative to limit the dose of local anesthetic solution in neonates and children to avoid toxicity. The dorsal nerves of the penis are located on either side of the shaft of the penis. A ring block using local anesthetic without epinephrine can be used to provide analgesia following circumcision. Because the penis is innervated by the two dorsal penile nerves which are branches of the bilateral pudendal nerves and also inntervated by the perineal nerves which are also branches of the pudendal nerves, the ventral surface of the penis may need a ring block with care to avoid the urethra for complete block of the penis. However, we find that blockade of these nerves can provide adequate postoperative analgesia. Immediately medial to the anterior superior iliac spine, a needle is inserted toward the umbilicus and local anesthesia is fanned into the area. The advantage with the use of ultrasonography is the ability to significantly reduce the dose of local anesthesia. The layers of the abdomen including the external oblique, transversus abdominis, and iliacus muscles are identified. The ilioinguinal and 2981 iliohypogastric nerves are located under the internal oblique muscle and in the plane between the internal oblique and the transversus abdominis muscle. This block has successfully been used to provide analgesia for infants and neonates undergoing major abdominal surgery, including colostomy placement. This block is particularly useful in neonates who undergo muscle biopsies of the lateral thigh. Using ultrasonography during the axillary approach to identify each branch of the brachial plexus allows selective block of each nerve,138 thus reducing the total dose of local anesthetic. A single shot supraclavicular approach to the brachial plexus can also be used for providing analgesia for upper extremity surgery. It is important to visualize using ultrasonography because the pleura is relatively close to the area of interest and injection. For sustained pain relief, an infraclavicular catheter may be used and is easily held in place by additional muscle and fascial layers which make this a preferable approach to catheter placement for upper extremity surgery. Neurosurgical Blocks Peripheral nerve blocks of the head and neck are useful for many surgical procedures. Peripheral nerve blocks of the trigeminal nerve and occipital nerve branches may be used to provide analgesia while avoiding general anesthesia. The use of intraoperative epidural anesthesia followed by postoperative epidural local anesthetics or opioids has been popular in older children and adults, and these techniques are being applied to neonates.

Meperidine Meperidine is no longer recommended as an analgesic because of the risk of seizures (from normeperidine) and the accumulation of normeperidine after repeated doses of meperidine hypertension treatment guidelines order cardizem online. The context-sensitive half-life (the time to decrease the blood concentration by 50%) of remifentanil is 3 to 8 minutes hypertension jnc 8 summary buy 120mg cardizem fast delivery. When administered in large doses blood pressure chart stage 2 purchase 180 mg cardizem overnight delivery, remifentanil may cause hypotension blood pressure chart log template cheap cardizem 120 mg without a prescription, bradycardia heart attack questions to ask doctor generic cardizem 180mg overnight delivery, and chest wall rigidity arteria 90 entupida generic cardizem 60 mg with mastercard. Recent evidence suggests that nitrous oxide may attenuate the risk of tachyphylaxis. Metabolism is extensive (95%) via a single pathway to hydromorphone-3-glucuronide. Codeine Codeine has been the mainstay of postoperative analgesia in children for decades. This has led to codeine no longer being prescribed for postoperative pain in children in many jurisdictions. Oral codeine reaches a peak blood level after 1 hour and an elimination half-life of 3 hours. More than 50 polymorphisms of 2D6 have been identified to date resulting in variability in the analgesia conferred from no analgesia (poor metabolizer) to an opioid overdose (an ultrarapid metabolizer), the latter being implicated in postoperative brain damage in one case and death in a second. Acetaminophen has no anti-inflammatory properties and is also free of platelet-inhibiting properties. Although its mechanism of action is not completely understood, it is believed to act on the peroxidase receptors of prostaglandin H2 or via p-aminophenol. Postoperative rectal dosing 20 mg/kg every 6 hours maintains blood concentrations after a rectal loading dose. Absorption after oral administration is rapid (10 to 15 minutes) whereas after rectal administration it is slow and variable (1 to 2 hours). With an elimination half-life of 2 to 4 hours after any route, repeat doses may be administered every 4 to 6 hours, while maintaining the maximum 24-hour dose at less than 100 mg/kg confer both analgesia and antipyresis. Current evidence indicates that ketorolac increases the incidence of bleeding after adenotonsillectomy in adults but not children. It is a potent analgesic, almost twice as effective for acute pain than acetaminophen during and after surgery. Ibuprofen Ibuprofen is a widely used analgesic, antipyretic, and anti-inflammatory agent in the perioperative period in children. Sedatives Midazolam this benzodiazepine is the most widely used anxiolytic in children in North America. It is water soluble, with a rapid onset of action when administered orally and a brief elimination half-life. Dexmedetomidine Dexmedetomidine is an 2-agonist sedative whose relative affinity for 2:1 receptors is eightfold greater than clonidine. This infusion rate must be carefully transcribed because unlike other drugs, the infusion rate is in g/kg/hr, not g/kg/min. When a loading dose is administered before the infusion, the risk of hypotension in the peri-induction period increases. Unlike other sedative/anxiolytics, dexmedetomidine exerts its clinical effects via 2 receptors with sedation in the locus coeruleus, hemodynamic manifestations via direct and indirect action on the sympathetic nervous system, and a host of miscellaneous side effects. Bradycardia has been reported after larger infusion rates (up to 2 to 3 g/kg/hr) and in younger age infants, with an incidence as great as 16%. Hypotension (>20% decrease from baseline) has occurred during dexmedetomidine infusions. Preoperative Assessment Fasting Guidelines the American Society of Anesthesiologists framed the fasting guidelines for infants and children in 2006. Gastric emptying times after breast milk and formula have only been evaluated in infants185; there are no data for comparable emptying times in children (1 year of age). The child who presents chewing gum must expectorate the gum or surgery 3069 will be cancelled as aspirated gum will be very difficult to extricate from the airway. Gastric fluid volume after chewing sugar or sugarless gum is doubled, with approximately 50% showing a gastric fluid volume more than 0. Thus, induction of anesthesia does not need to be delayed in the child who has been chewing gum. Table 43-7 Fasting Guidelines for Children Requiring Elective Anesthesia184 the risk of regurgitation and aspiration in children who present for emergency surgery is far more difficult to assess. Several factors relate to this risk including the severity and nature of the trauma, existing medical conditions, drugs that were administered, and the timing and nature of the foods ingested. The only evidence upon which to assess the risk of a full stomach relates to the interval between the last food ingested and the trauma or injury. There is no evidence in children that administration of a prokinetic drug empties the stomach after trauma. Auscultation of bowel sounds in the abdomen does not ensure gastric emptying, although passing gas does imply peristalsis of the small and large bowels is present but does not ensure return of gastric motility. We consider children who ingested solid foods within 8 hours of a trauma to be at risk for regurgitation and aspiration and take appropriate precautions for managing the airway. Although diabetes mellitus delays gastric emptying, this may require years before the gastroparesis develops. Laboratory Testing 3070 Preoperative laboratory testing is infrequently ordered in healthy children without a pre-existing medical condition. A preoperative hemoglobin is indicated in those who are at risk for massive bleeding, those with preexisting anemia in whom bleeding is highly probable, those with chronic nutritional deficiency, and those with sickle cell disease (see later). A preoperative pregnancy test is required before anesthesia and sedation in most children of childbearing years in most jurisdictions. The reason for this test is the risk that some drugs that are administered in the perioperative period may cause a miscarriage or, less likely, teratogenicity of an unborn fetus. The former test yields more rapid results, is cheaper but has a false-negative rate early after conception. Many institutions and states require preoperative pregnancy testing in females who have reached menarche; some require testing in all females who are older than a specific age. If the pregnancy test is positive and the surgery is elective, the results must be conveyed to the patient. Due consideration should be given to the risk that anesthesia and surgery might pose to the unborn fetus if surgery proceeds. If, however, the surgery is emergent, then the risk benefit ratio of proceeding must be carefully assessed. Additional factors that increase the risk of adverse airway events include cigarette smoking in the house, atopy, asthma, prematurity, young age, and secretions. Care must be taken to use a dilute solution of neosynephrine, as concentrated solutions may cause a hypertensive crisis. We prefer to manage these children with a face mask if possible in order to minimize the risk of triggering airway reflex responses. However, if the airway must be manipulated, a supraglottic airway is less likely to trigger airway reflex responses than a tracheal tube. Asthma Up to 20% of children have asthma or an asthmatic history, but many fewer present with severe asthma that may complicate anesthesia. In the preoperative assessment, the age of onset of asthma, number and date of the most recent hospital admissions for asthma, treatment (2-agonists or steroids by inhalation), and current state of asthma should be recorded. Most children with asthma have never been admitted to hospital because of their asthma. If oral steroids have been prescribed recently for an acute exacerbation of asthma, careful preoperative examination of the chest must be performed to ensure that there is no lingering reactive airway component. If wheezing is present, the child should be instructed to cough deeply to clear any airway secretions present, and bronchodilator therapy should be initiated. Preoperative bronchodilator therapy should be administered to children with mild to moderate asthma even if they are not wheezing, as this reduces airway resistance by approximately 25% during sevoflurane anesthesia and 3072 tracheal intubation. Preoperative bronchodilator therapy should be administered to children who are wheezing and present for emergency or urgent nonairway surgery. Equipment should be prepared to administer intraoperative bronchodilator therapy should the need arise. In these cases, the diagnosis is made "clinically" by the presence of loud snoring, witnessed apneas, nocturnal enuresis, attention deficit disorder and behavioral problems, and inability to concentrate in school or poor school performance. In contrast to general anesthesia, regional anesthesia does not increase the risk of perioperative apnea and does not require perioperative monitoring, unless the infant also received sedation, has multisystem disease, or has a history of perioperative apneas. A trigger-free anesthetic includes propofol, opioids, benzodiazepines, nondepolarizing muscle relaxants, nitrous oxide, and regional anesthesia. The initial dose should maintain blood concentrations of dantrolene (>3 g/mL) for 6 hours, after which its elimination half-life is 10 hours. This is sufficient dantrolene in a single vial for a loading dose in a 100 kg patient, far more dantrolene than is needed to treat the initial reaction in a child. If dantrolene is administered, a urinary catheter may be indicated depending on the dantrolene formulation used. There is a host of additional strategies that may be used to stabilize the child including cooling strategies, and antiarrhythmics. Becker dystrophy is a milder form of the disease with an onset in the second decade of life. The dystrophin protein complex is essential for the stability of the cytoskeleton of muscles. The administration of an inhalational anesthetic (halothane > sevoflurane > isoflurane) as well as succinylcholine may cause skeletal muscle contractions, damaging membranes and releasing intracellular contents. Mitochondrial myopathies are a complex group of disorders that result from defects in the protein complexes of the respiratory chain in mitochondria. Vaso-occlusive crises may involve a number of areas including bone, chest, and brain. Some children suffer from repeated vaso-occlusive crises whereas others never experience them. These crises are not related to hypoxia, hypovolemia, or hypothermia, but rather to a systemic inflammatory response, the nature of which remains unclear. This disorder presents few problems during routine general and regional anesthesia and surgery provided extreme conditions, such as hypothermia and cardiopulmonary bypass, are not employed. Preoperatively, a history of the frequency, severity, and precipitating triggers of sickle and vaso-occlusive crises in the child should be elicited. Consultation with the treating hematologist should provide insight into the current local strategies for managing this patient. The sickledex test is unreliable in infants under 6 months of age because Hb F interferes with the sickling process and renders the test nonconfirmatory. Infants under 6 months of age rarely sickle because of the presence of Hb F, which gradually wanes in concentration beyond 3 months of age. If the test is positive or if the child is suspected of having sickle hemoglobin from history, then a hemoglobin electrophoresis should be performed to identify the particular hemoglobinopathy that is present. Optimal management of these children includes maintaining neutral thermoregulation and adequate hydration and oxygenation throughout the perioperative period. Understanding the pathophysiology of the disease enables the clinician to anticipate complications and prepare the anesthetic to avoid them. In children, anesthesia is usually required to delimit the extent of and tumor effects on mediastinal structures in radiology as well as for tissue biopsy and chronic chemotherapy access in the operating room. The decision to proceed with local, regional, or general anesthesia depends on the age and level of cooperation of the child, the extent of mediastinal organ compromise, and the accessibility of the node or tumor being biopsied. A multidisciplinary team that includes the surgeon, anesthesiologist, and oncologist should review all radiologic and preoperative data before embarking on the surgery. Older children often can tolerate the surgery under local anesthesia and sedation. Younger children and those whose tumor severely compromises the airway and/or pulmonary artery may require general anesthesia. However, these alternatives should not be used without first a multidisciplinary discussion with the oncologists216 because there is a risk of widespread tumor necrosis that may both render the diagnosis of the cell type difficult and/or induce tumor lysis syndrome. If the child cannot lie flat, anesthesia can be induced and the trachea intubated with the child positioned in the left lateral decubitus or less desirably, in the sitting position. The trachea should be intubated at induction of anesthesia to ensure a patent airway should it become necessary to turn the child prone to reverse circulatory collapse. Tracheal intubation is performed without muscle relaxation to preserve spontaneous respiration. Spontaneous respiration best preserves the negative intrathoracic pressure gradient to suspend the tumor above the mediastinal structures and avoid pressure on the pulmonary artery and right atrium as well as the tracheobronchial tree. It is important to remember that the capnogram may be a very useful monitor to confirm the adequacy of the pulmonary circulation (and cardiac output); the sudden loss of or reduction in the capnogram may herald compression of the pulmonary artery before systemic cardiovascular sequelae occur. In order to refine drug dosing in obese children, additional scalars should be defined. Ninety-five percent of obesity is attributable to environmental and lifestyle factors. The increased work of breathing compounds the reduced lung volumes as the closing volume approaches the 3080 tidal volume and V/Q mismatch occurs. Nocturnal hypoxemia from the above factors combined with large tonsils (see later) sets the stage for the development of pulmonary hypertension and right heart failure. Cardiovascular effects of obesity include systemic hypertension, left ventricular hypertrophy, and premature atherosclerosis.

Calcium channel blockers have been best studied for renal protection of cyclosporine-treated hypertensive transplant patients blood pressure medication used for hot flashes order line cardizem. But after surgery arteria spinalis discount cardizem amex, angiotensin-converting enzyme inhibitors blood pressure chart stress generic cardizem 60 mg online, increasingly used arteria zygomaticoorbitalis cardizem 60mg lowest price, and -blockers may be as effective as calcium channel blockers arrhythmia quality services cheap 180mg cardizem mastercard. These goals are usually achievable without vasopressors arteria3d discount cardizem online visa, using isotonic fluids and adjustment of anesthetic doses. Hemodynamic management varies widely from center to center, so close communication between surgeon and anesthesiologist is imperative. In some centers, anesthesiologists are asked to administer the first doses of immunosuppression. A kidney graft is defective in concentrating urine and reabsorbing sodium, so attention to electrolytes is important. The common postoperative complications are ureteral obstruction and fistulae, vascular thromboses, lymphoceles, wound complications,94 and bleeding. Nonsteroidal anti-inflammatory agents and cyclooxygenase-2 inhibitors are contraindicated. Chronic pain after kidney transplantation is common,98 suggesting that more attention should be given to early postoperative pain management. Adult donor kidneys may have to be placed in the retroperitoneum of small children. Although chronic peritoneal dialysis may help expand the abdominal volume,99 attention to peak inspiratory pressures at closure is important, and increased pressures should be reported to the surgical team. Pediatric renal transplantation is associated with somewhat lower rates of success than adult transplantation, with vascular thromboses of the grafts more common in 3672 younger children as well as problems with adherence to immunosuppressive regimens. Though overall mortality after liver transplantation did not change with Share 35, some regions experienced poorer outcomes. Mathematical modeling suggests that this change will save about 60 lives per year. Liver transplant programs vary considerably in the number of transplants performed; however, the number of transplants performed in a given center is only a percentage of patients evaluated for liver transplantation, for which anesthesiology expertise will be sought. With the availability of pharmacologic cures for hepatitis C, the number of these patients requiring transplantation is expected to fall, and these drugs open new opportunities for treating posttransplant recurrence of hepatitis C virus. For pediatric patients, exception diagnoses are urea cycle disorders, organic acidemia, and hepatoblastoma. As for other solid-organ transplants, major infection and malignancy may exclude patients from consideration for transplantation. Serum creatinine levels are not extremely useful in capturing renal function in patients with liver disease. Difficult decisions about patient candidacy are common in evaluating liver transplant candidates. Several are discussed here to highlight the need for regular involvement of a transplant anesthesiologist in the candidacy evaluation process. Because cardiovascular disease is the most common cause of 30-day mortality following liver transplantation,104 a rigorous cardiac workup is warranted. Most patients are screened for cardiac disease using dobutamine stress echocardiography or myocardial stress scintigraphy, although the effectiveness of diagnosing coronary artery disease in these patients is not well established. These studies can be done safely even in patients with significant renal dysfunction. Functional assessment of patients in addition to laboratory and imaging studies is important, and one study found that achieving a distance of less than 250 m on a 6-minute walk test is an independent predictor of death on the transplant waiting list. Patients with patent foramen ovales may be at risk for intraoperative stroke, and some centers work with cardiologists to close larger shunts noninvasively before surgery. Nonalcoholic steatohepatitis is increasingly an indication for liver transplantation and may be associated with increased major postoperative cardiac events. Contrast echocardiography is used to diagnose intrapulmonary vasodilation using agitated saline. The microbubbles act as a contrast, and, if intracardiac shunts are present, they appear within three heartbeats after injection in the left ventricle. Some patients with refractory ascites and normal renal function can have relief from ascites with terlipressin treatment. Recently, a large number of new drugs for the treatment of hepatitis C have entered the market,120 including protease inhibitors, viral polymerase inhibitors, viral replication complex inhibitors, new interferon formulations, and new ribavirin formulations. For anticipated difficult cases, many centers place two arterial catheters; one can be in the femoral artery (left femoral if a kidney transplant is planned). A rapid infusion system with the ability to deliver at least 500 mL/min of warmed blood is primed and is in the room. Normothermia, essential for optimal hemostasis, is maintained with fluid warmers and convective air blankets over the legs and over the upper body. Liver transplantation is traditionally described in three phases: dissection, anhepatic phase, and neohepatic phase, with reperfusion of the graft marking the start of the neohepatic phase. The major issues during the first phase of transplantation are coagulation management and renal protection, so the major anesthetic goals of this phase are correction of coagulopathies and maintenance of intravascular volume for renal protection. The incision in patients with massive ascites is a rapid paracentesis, and albumin infusion is warranted to prevent postparacentesis circulatory dysfunction, because cirrhotics often have very low albumin levels as well as poorly functioning albumin. Though many transplants can be done with minimal transfusions, predicting bleeding is an inexact science, and anesthesiologists should be prepared for massive transfusion in these cases. Infusion of calcium chloride (CaCl2), adjusted to ionized Ca2+ levels, is better at maintaining constant calcium (Ca2+) levels than are intermittent boluses. Platelet transfusion has traditionally been used to maintain platelet counts above 50,000/mm3; however, platelet transfusion has been associated with worse graft and patient survival. Cell-saver blood may also be used to limit allogeneic transfusions, although it is generally not used in patients with hepatocellular carcinoma. Many other factors contribute to poor hemostasis in liver transplant patients besides poor clotting factor synthesis, including renal failure, infection, endothelial dysfunction, and high portal pressures. For example, patients with autoimmune liver diseases may have antiphospholipid antibodies. Many authors have suggested that the coagulation status of cirrhotics is "balanced" when procoagulant abnormalities are balanced by anticoagulant abnormalities. A formal hypercoagulability workup should be done as part of liver transplant evaluation. For the majority of patients with coagulopathy dominated by synthetic dysfunction, thrombocytopenia, and hypofibrinogenemia, whole-blood clotting is delayed. If these patients have insufficient hemostasis, many centers supplement transfusion therapy with antifibrinolytic agents. Considerable center-dependent variation in use and dosing of antifibrinolytics makes generalizations difficult. Fibrinolysis acutely worsens immediately after reperfusion to varying degrees, depending largely on the amount of tissue plasminogen activator released from the graft. Dopamine is not useful for preserving renal function during liver transplantation. The anhepatic phase begins when the liver is functionally excluded from the circulation. Historically, the vena cava was clamped above (suprahepatic anastomosis) and below (infrahepatic anastomosis) the liver, and the portal vein and hepatic artery were clamped. With complete cava cross-clamping, venous return falls by 50% to 60%, often resulting in hypotension. Communication between the surgical and anesthesia teams is essential in precise preparation for reperfusion. Caval clamps are removed first, and the integrity of the caval anastomoses are ensured. The original descriptions of reperfusion syndrome emphasized (often severe) hypotension and bradycardia with portal reperfusion. For particularly prolonged acidosis, tris(hydroxymethyl)aminomethane infusion is useful. Lidocaine, atropine, and norepinephrine are available at the time of reperfusion in case of ventricular dysrhythmias, bradyarrhythmias, and severe hypotension. Usually within 30 minutes, the base deficit improves with graft metabolism of citrate and lactate. Bile is made in the first half-hour after reperfusion in a well-functioning graft. Often, renal function improves after reperfusion, probably because of graft metabolism of renal vasoconstrictors. Thromboelastometry may be more sensitive than thromboelastography in detecting fibrinolysis,150 but decision to add or increase antifibrinolytics after reperfusion should be made by assessing surgical hemostasis as well as point-of-care tests. During the neohepatic period, biliary anastomoses are completed and sources of surgical bleeding are corrected. Fast-tracking protocols for liver transplant patients are common in experienced centers. In small children, a radial artery catheter and at least one large (18g) peripheral intravenous line are placed after induction of anesthesia. Children with previous Kasai operations for biliary atresia may have massive bleeding during dissection because of adhesions. Small children receiving large grafts may have respiratory compromise with abdominal closure. If flow is inadequate (by poor Doppler signals) in the artery after anastomosis, intraoperative reanastomosis or a new anastomosis may be required acutely. Use of split livers (one liver for two patients) puts a strain on transplant teams but is important for extending the donor pool. When antihypertensive therapy is required, labetalol does not cause significant cerebral vasodilation in these patients. Pancreas and Islet Transplantation the majority of pancreas transplants (about 75%) are done as simultaneous pancreas and kidney transplants from a single deceased donor. Pancreata grafted in these procedures have historically had better long-term survival than grafts done after kidney transplantation or independent pancreas grafts. Independent pancreas grafts are usually performed for patients with type 1 diabetes, who have frequent metabolic complications (hypoglycemia) but preserved renal function. With proper donor selection and aggressive attention to targeted antibiotic coverage, better graft survival rates after isolated pancreas transplant have recently been reported. Optimal immunosuppression for islet transplantation, to ward off both allo- and autoimmunity, remains a significant problem. Encapsulation of islets to create a barrier to immune cells has also been a surprisingly hard problem. Nonetheless, cardiovascular disease is present in many patients undergoing pancreas transplantation, although they tend to be younger than liver transplant recipients. The major difference between pancreas transplantation and other procedures is that strict attention to control of blood glucose is indicated to protect newly transplanted cells from hyperglycemic damage. No formula for controlling blood glucose has emerged as a standard of intraoperative management. In general, if adult patients arrive with glucose above 250 mg/dL, 10 units of insulin can be given intravenously, followed by an infusion of insulin. The infusion starting rate varies, depending on the initial 3685 blood glucose level. Once blood glucose levels are controlled (<150 mg/dL), intravenous 5% dextrose (about 100 mL/hr) should also be infused as the insulin infusion is continued. The most important issue is to check the response to insulin frequently and adjust infusions as necessary. Little literature exists for a patient with an implanted insulin pump, though more than 400,000 have been implanted in the United States. Since that time, islets have been cultured after isolation in many centers, which makes surgical scheduling easier. Islets are generally infused into the portal circulation; acute portal hypertension may result from the infusion. In general, intestinal transplantation is usually performed only in patients with life-threatening complications of intestinal failure, mostly in children, but increasingly in adult recipients. A major hurdle for these transplants is line placement adequate for transfusion of blood products and fluids, need for which may be substantial during these long cases. Anesthesiologists should review angiographic studies to determine venous patency before attempting central line placement. Ultrasound devices are helpful in identifying the known patent vessels for cannulation, but surgical cutdowns for venous access may be necessary, including transhepatic or intraoperative renal vein catheterization. Superior vena cava or inferior vena cava obstruction may require preoperative 3686 intervention (surgical and/or lytic) for adequate vascular access for surgery. Like reperfusion of liver grafts, intestinal graft reperfusion is associated with an acute release of acid and potassium from the graft and a postreperfusion syndrome. Anticipatory bicarbonate and CaCl2 administration is useful to counteract the effects of acid and potassium on the heart. Epidural anesthesia is useful for pain management in both intestine donors and recipients. More than 85 patients have received hand or arm transplants, with the longest survivor 11 years posttransplant. For face donors, surgeons prefer to procure the face first, before other organs are procured. The graft recovery is complex, with isolation of motor and sensory nerves as well as venous and arterial vessels. Recipient nose and mouth deformities will certainly require individualized airway care.

Syndromes

• Alcohol abuse
• Severe abdominal cramps
• Platelet count and fibrin degradation products, to check for bleeding risk
• Normal appearance of cells
• Ketoacidosis and similar medical conditions
• 1 - 3 years: 150 mcg/day
• Unusual head
• Rapid, irregular heartbeat
• Limited range of motion

Blood should be sent for identification of the specific gene defect and a MedicAlert bracelet ordered blood pressure of 12080 purchase cardizem 180mg amex. Identification of the specific gene defect depends on the laboratory analysis of pseudocholinesterase activity and gene identification blood pressure limits purchase discount cardizem on line. When benzoylcholine is added to the blood heart attack fever purchase cardizem with amex, dibucaine suppresses the degradation of benzoylcholine by normal pseudocholinesterase by more than 71% (hence a dibucaine number of 71 is normal) whereas the degradation by A/A is only suppressed by 20% (hence the dibucaine number is 20) blood pressure 140 80 cheap 60mg cardizem with mastercard. When fluoride is added to blood hypertension hypotension discount cardizem 60mg on-line, it inhibits normal pseudocholinesterase but the atypical variant to a much smaller extent blood pressure charts readings by age generic cardizem 180mg without prescription. Succinylcholine causes bradycardia via acetylcholine-associated activation of the vagal nerves. Hyperkalemia may occur in children with myopathies, upper and lower motor neuron disorders, burns, severe sepsis, and chronic immobilization. This occurs because the potassium concentration increases the resting membrane potential such that it approaches the threshold potential, triggering depolarization of myocardial cells. Adolescents with muscular builds are at an increased risk of developing postoperative muscle pain after succinylcholine. To prevent this problem, pretreat with small doses of a nondepolarizing relaxant or simply avoid succinylcholine in this age group. Some assert that fasciculations increase the risk of regurgitation by increasing the abdominal muscle tone. However, the crura of the diaphragm comprise skeletal muscle, also fasciculates, thus preventing any decrease in gastric barrier pressure. Late signs include increases in core body temperature, disseminated intravascular coagulopathy, and sepsis. It is eliminated almost exclusively by the liver; hence liver failure may prolong the duration of action. The potency of rocuronium is greatest in infants, least in children, and intermediate in adults. Sevoflurane potentiates the effect of rocuronium compared with balanced anesthesia, a pharmacodynamic, not pharmacokinetic effect. Recovery after rocuronium in infants is prolonged compared with that in children as a result of the reduced clearance and increased volume of distribution in the former. However, this dose and route provide poor intubating conditions after 4 minutes and a duration of 80 minutes. Atracurium Atracurium is a benzylisoquinolinium muscle relaxant that undergoes spontaneous degradation in blood primarily by Hofmann elimination yielding the major metabolite, laudanosine, which is devoid of neuromuscular blocking properties. Side effects associated with atracurium include cutaneous erythema, bronchospasm, and wheezing after a rapid large bolus administration; rarely has anaphylaxis been reported. Cis-atracurium Cis-atracurium is one of the 10 isomers of atracurium that has supplanted atracurium. Its potency is threefold greater than that of atracurium resulting in more specificity for the receptor and fewer side effects such as histamine release. Neostigmine this author strongly recommends antagonizing all neuromuscular blocking agents in infants and children when extubation is planned,140 provided the time interval from the last dose has not exceeded 2 hours. In order to successfully antagonize the relaxant, vital signs including temperature must be normal. Neostigmine is an anticholinesterase compound that antagonizes neuromuscular blockade by preventing the degradation of acetylcholine. The acetylcholine competitively displaces the muscle relaxant from the neuromuscular junction. The dose of neostigmine in infants and children is 3062 30% to 40% less than that in adults, or 20 to 40 g/kg, which should be administered when at least one twitch is present in the train-of-four. If the recovery of neuromuscular blockade is incomplete, repeat doses of neostigmine may be administered up to 70 g/kg. Care must be taken to avoid exceeding 100 g/kg as acetylcholine-associated weakness may occur. Neostigmine should be preceded by an anticholinergic, atropine 20 g/kg or glycopyrrolate 10 g/kg, to minimize the effect of neostigmine on the nicotinic receptors. Atropine causes a greater increase in heart rate but has a shorter duration of action than glycopyrrolate. Sugammadex this -cyclodextrin compound is a cylindrical oligosaccharide that uniquely binds rocuronium (and to a lesser extent vecuronium) to eliminate its activity. Sugammadex has been used extensively in Europe but only recently in the United States. In children and adolescents, a single dose of 2 mg/kg or more sugammadex after partial recovery (two twitches of the train-of-four) from rocuronium yielded a train-of-four of 0. Most recently, two reports of sugammadex reversal of rocuronium-induced anaphylaxis refractory to vasopressors suggest another possible clinical role for sugammadex. Side effects after morphine include dose-dependent respiratory depression and incidence of vomiting (particularly at >100 g/kg). Histamine release 3063 and urticaria at the site of injection are local, nonimmunologic reactions. Fentanyl this semi-synthetic opioid is the most widely used intraoperative analgesic in children. This very lipid-soluble opioid, which is bound primarily to 1-acid glycoprotein in blood, has a very rapid onset of action, hemodynamic stability, and brief duration of action after a single dose. There is very little evidence that fentanyl augments the analgesia provided by a lumbar epidural block in a child with an effective local anesthetic concentration. The action of clinical doses of parenteral fentanyl is terminated by redistribution and, secondarily, by clearance in the liver. The initial redistribution is rapid; however, once tissue binding sites become saturated, the elimination half-life of fentanyl increases. The context-sensitive half-life of fentanyl in adults after a brief infusion for 1 hour, 20 minutes, increases dramatically to 4 hours after an 8-hour infusion. To offset the increasing context-sensitive half-life with time, the dose of fentanyl must be gradually reduced over time. After a prolonged infusion of fentanyl, it is necessary to slowly taper the dose and monitor for opioid withdrawal. Table 43-11 Drug Dosing for Obese Children Insulin resistance and metabolic syndrome are present in 40% of moderately obese children and 50% of severely obese adolescents. Increased abdominal weight predisposes to gastroesophageal reflux, which occurs in approximately 20% of children with severe obesity. Gastric emptying rates and the risk of pneumonitis from aspiration (based on gastric fluid pH and volume) in obese children do not differ from those in normal children. Fatty infiltration of the liver leads to nonalcoholic fatty liver disease, which leads to abnormal liver function tests and possibly hepatic fibrosis. Drug dosing in obese children is complex, varying with several factors including lipid solubility, volume of distribution, and the route of elimination, hepatic or renal. These children should be positioned 25-degree head-up during preoxygenation to reduce V/Q mismatch and to facilitate tracheal intubation. The tragus should be positioned above the level of the sternal notch to ensure that tracheal intubation will be successful. However, if the child has asthma or is exposed to smoking, sevoflurane may be preferrable. Compression devices should be applied to the legs to prevent stasis and deep vein thrombosis. The details of all allergies should be carefully elicited in terms of the clinical manifestations and severity. Allergies Most allergies that are reported in hospital records are of little relevance to the conduct of anesthesia. All allergies reported by patients and families are dutifully transcribed into the hospital record with neither censure nor regard for their relevance or authenticity. Examples of recognized side effects that do not constitute allergies include headaches after epinephrine, vomiting after opioids, and diarrhea or rash after amoxicillin. Only true allergies should be recorded on the anesthetic record: these include anaphylactic reactions and allergic reactions diagnosed and confirmed by an allergist/immunologist. The remainder should be identified as hypersensitivity or idiosyncratic reactions, although this is not the current practice. Cross-sensitivity between penicillin allergy and first-generation cephalosporins is possible; however, there is no cross-reactivity with second or later generation of cephalosporins. Although the package insert for propofol cautions against the use of propofol in children with egg allergy, the only egg allergy that precludes the use of propofol is possibly egg anaphylaxis. However, it may carry trace concentrations of yolk proteins with it into the formulation. The manufacturer 3082 states that no soy protein is present in their North American formulation of propofol. Latex allergy should be documented when preparing the operating room for children although its significance is waning. Children who are latex allergic and who touch toy balloons to their lips or in whom dentists insert a rubber dam, will react with lip or tongue swelling, respectively. Because latex products both in and out of hospital have been replaced with nonlatex substitutes, the prevalence of latex allergy in the children is decreasing; this is an acquired, not a congenital condition. It is imperative to avoid contaminating the surgical (and anesthetic) setup with latex in order to prevent latex anaphylaxis. Removing all latex products from the operating room has eliminated latex anaphylactic reactions and should be adopted worldwide. Epinephrine, in a dose of 1 to 10 g/kg, is the drug of choice to reverse latex anaphylaxis; 1 to 2 g/kg reverses isolated bronchospasm (but may need to be repeated), whereas 10 g/kg is reserved for cardiac arrests. Preoperative Physical Examination the airway, respiratory, and cardiovascular systems should be examined preoperatively in every child. The airway examination should include visual inspection of the face in the anterior and profile views to detect any disproportions in facial features that might suggest a congenital facial or airway anomaly. The child should open their mouth fully, stick out their tongue, and extend their neck. Piercings in and around the mouth should be removed as these may become dislodged and aspirated if they are intraoral. The respiratory examination includes auscultation of the chest (front and back) with full inspiration and expiration through the mouth. If rales or rhonchi do not clear with deep coughing, then a chest x-ray and pulmonary consultation should be ordered. If a murmur is detected, then further inquiry regarding the presence of cardiac symptoms (syncope, arrhythmias, tachycardia, heart failure, shortness of breath) should be solicited. If the murmur is heard during diastole, has not been diagnosed previously, or is associated with any cardiac symptomatology, then a cardiology consultation 3083 should be sought. If the child has a history of cardiac surgery, then a recent cardiology note together with an electrocardiogram and echocardiogram should be reviewed. Anesthetic Risks; Consent/Assent the mortality associated with anesthesia in healthy children is 1:10,000 or less. This author does not give a number for the risk of cardiac arrest to parents of healthy children undergoing elective anesthesia (unless specifically requested to do so) but rather uses an analogy that the risk is greater that they would be hit by a car crossing the busy street outside the hospital than to have a serious adverse outcome during general anesthesia. Specific risks discussed preoperatively include the most common complications, pain, nausea, and vomiting. In addition, the author reviews the small risk of unforeseen complications that may result from as yet latent diseases, dental damage, corneal abrasion, aspiration, awareness, allergic reactions, and cardiac arrest. If asked about awareness, this author informs the parents/guardians that the incidence of awareness in children is extremely rare (1:60,000),222 although some have reported an 1% incidence of awareness in their center. If asked about cognitive dysfunction after anesthesia, the author informs the parents/guardians that neuroapoptosis has been reported after almost every anesthetic in neonatal animals and some nonhuman primates. Induction of Anesthesia 3084 Equipment To ensure that the anesthetizing location is properly and completely prepared, it is useful to use a checklist. Reliance on oral airways in establishing a patent upper airway in children has been supplanted, in part, by an appropriately applied jaw thrust maneuver. For laryngoscopy the child should be positioned flat on the table, with the head stabilized to prevent lateral movement. In infants and children with limited oxygen reserve, or when performing tracheal intubation during sedation, the Oxyscope, a straight blade fitted with a source of oxygen at the tip of the blade, may prevent oxygen desaturation. Because the tone of the gastroesophageal sphincter is reduced in children, compared with adults, children may be at greater risk for regurgitation in the presence of a full stomach or positive pressure ventilation. For children above 2 years of age, the size of uncuffed tubes may be estimated using the formula: Age (in years)/4 + 4 (or 4. The length of a tube from the lips to mid-trachea in infants less than 1,000 g in weight is 6 cm, 1,000 to 3,000 g is 7 to 9 cm, in term neonates 10 cm, and for infants and children, 10 + age (years) mm. In the past, uncuffed tracheal tubes were commonly used to secure the airway of children under 8 years of age. The circular shape of the tracheal tube was suited to the round shape of the lumen within the cricoid ring,234 which allowed for a good seal without the need for a cuff on the tube. Cuffs were avoided in children out of the concern that compression of the loosely adherent pseudostratified columnar epithelium that lines the cricoid ring would swell and encroach on this narrowest portion of the upper airway and cause stridor. To preclude this potentially serious airway complication, the tracheal tube was carefully selected so that it either passed through the cricoid ring without resistance or did so with an audible leak at a peak inspiratory pressure 10 to 20 cm H2O. Recently, there has been a shift from uncuffed to cuffed tracheal tubes in infants and children. Cuffed tubes contaminate the environment less with anesthetic gases, are associated with fewer laryngoscopies and reintubations, and deliver more consistent tidal volumes (as chest wall and abdominal compliance change during surgery) and positive end-expiratory pressure than uncuffed tubes. Microcuff tubes seal the airway at much lower cuff pressures (11 cm H2O) than other cuffed tubes. All cuffs expand when nitrous oxide is used, although the time interval until the cuff pressure in the Microcuff tube reaches 25 cm H2O exceeds that with other tubes because the former seals the airway at lower pressures. The cuff pressure should be monitored during surgery to preclude excessive cuff pressures.

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