Dan Engelhard, M.D.

• Associate Professor
• Department of Pediatrics
• The Hebrew University Hadassah Medical School
• Chief
• Department of Pediatrics
• Hadassah University Hospital
• Jerusalem, Israel

Brightness is amplified by the image intensifier on the order of 5000- to 20 symptoms vaginal cancer cheap zyloprim amex,000-fold medications and mothers milk 2014 buy zyloprim 100mg visa. The operator can manually adjust the collimation window to conform to a particular region of clinical interest medicine zanaflex buy zyloprim online pills. Incorrect needle placement has been described for multiple procedures without fluoroscopy medicine advertisements 300mg zyloprim mastercard. Thus medications multiple sclerosis buy zyloprim uk, lifetime exposure for a 50-year-old radiation worker would be 500 mSv (50 rem) medications xanax best 100 mg zyloprim. Eyeglasses that do not provide wraparound capability may not provide adequate protection. Furthermore, lead gloves are expensive and may decrease the tactile sensation, which is so important to needle placement. Keeping hands completely out of the beam (and therefore never visible on the monitor) is advisable with or without lead gloves. Group I Procedures performed less than 25 times were not listed in this table; however, they were utilized in calculating the exposure and per procedure. Over the past 20 years, fluoroscopy has revolutionized the medical treatment of pain. The history of the discovery of fluoroscopy dates back to November 8, 1895, when Professor Wilhelm Roentgen discovered x-rays. When high-velocity electrons collide with metal, the kinetic energy contained within the electrons is converted to electromagnetic energy released in the form of x-rays. The function of the fluoroscope is to provide a steady stream of high-velocity electrons in order to produce a continuous, controllable stream of x-ray radiation. The term fluorescence describes a property of certain materials that emit visible light when exposed to stimulation by chemicals, electricity, or ionizing radiation. The fluoroscopic picture that is produced is composed of shadows created as x-rays are absorbed preferentially by body tissues of various densities. The fluoroscopic imaging chain consists of various components including an x-ray tube with cathode and anode, an image intensifier, and a fluorescent phosphor screen to capture the image created. Direct current from the x-ray generator is transmitted into the x-ray tube during an x-ray exposure. The image intensifier takes the incoming x-rays and converts them to electrons in a series of steps that take place within the input layer and brighten the viewable image. The modern fluoroscope provides the ability to collimate and incorporate optical coupling. Radiation exposure may be associated with risks to the physician, patient, and personnel. Most interventional procedures in the management of chronic pain require fluoroscopic exposure only for short periods of time. Acknowledgments this book chapter is modified and updated from a previous book chapter, "Fluoroscopy in the Interventional Pain Unit: A Physician Perspective" by David M. Interventional techniques 9 Fluoroscopy in Interventional Pain Management in chronic spinal pain. Risk of whole body radiation exposure and protective measures in fluoroscopically guided interventional techniques: a prospective evaluation. Radiation exposure of the spinal interventionalist performing fluoroscopically guided lumbar transforaminal epidural steroid injections. Radiation exposure to the physician performing fluoroscopically guided caudal epidural steroid injections. Epidural steroids for treating "failed back surgery syndrome": is fluoroscopy really necessary The role of fluoroscopy in cervical epidural steroid injections: an analysis of contrast dispersal patterns. The growth of interventional pain management in the new millennium: a critical analysis of utilization in the Medicare population. Evaluation of lumbar transforaminal epidural injections with needle placement and contrast flow patterns: a prospective, descriptive report. Fluoroscopic guided lumbar interlaminar epidural injections: a prospective evaluation of epidurography contrast patterns and anatomical review of the epidural space. Contrast flow characteristics in the cervical epidural space: an analysis of cervical epidurograms. Incidence of intravascular penetration in transforaminal cervical epidural steroid injections. Acute radiation dermatitis following radiofrequency catheter ablation of atrioventricular nodal reentrant tachycardia. Radiation-induced skin injury after percutaneous transluminal coronary angioplasty: case report. Lens injuries induced by occupational exposure in non-optimized interventional radiology laboratories. Occupational radiation exposure to interventional radiologists: a prospective study. Effectiveness of protective measures in reducing risk of radiation exposure in interventional pain management: a prospective evaluation. Fluoroscopy radiation safety for spine interventional pain procedures in university teaching hospitals. Schultz 10 Introduction Placing needles and other instruments of interventional pain management safely into the body requires advanced tactile skills, comprehensive knowledge of anatomy, and expertise with fluoroscopy [1]. Specialists within the new specialty of interventional pain management come from diverse backgrounds including anesthesiology, radiology and physiatry. Practitioners with an anesthesiology background often begin interventional pain practice with excellent tactile skills honed from years of performing "blind injections" for regional anesthesia but may lack expertise in the use of fluoroscopic imaging. Those with radiology background may be expert in the use of fluoroscopy but may not have developed the learned tactile techniques of regional anesthesia. Physical medicine physicians may have an excellent understanding of anatomy and physical diagnosis with little experience in regional anesthesia or fluoroscopy. The aspiring interventional pain specialist physician must develop expertise in regional anesthesia, radiological imaging, and anatomy in order to become an effective and safe practitioner. The following step-by-step outline for performing interventional pain procedures is based on the premise that consistency and preparedness in the preinjection routine fosters efficiency, effectiveness, and safety. Set Up the Room Prior to performing injection procedures, the procedure room should be thoughtfully set up for optimum efficiency and safety. Facilities that provide interventional treatments must have on-site nursing staff trained in resuscitation techniques and resuscitation equipment including a complete crash cart with D. Orient the Fluoroscope Prior to performing the procedure, the practitioner must first orient the fluoroscope. Schultz from a familiar position and viewing an image with similar orientation every time, the brain will form associations that enhance hand-eye coordination and facilitate quick and efficient needle placement. Once the fluoroscope is powered up and its image oriented, the injectionist may commence with the procedure. Position the Patient Positioning the patient optimally on the procedure table is extremely important and may make the difference between success and failure of the procedure. Most interventional pain procedures are performed with the patient in the prone position, although for certain procedures the patient is positioned supine or lateral. Radiolucent foam bolsters, pillows, wedges, and other assorted positioning aids are available commercially or can be produced from common radiolucent materials. These aids are helpful for comfortable and stable patient positioning especially when the patient is prone. For supine and prone positions, the patient should be oriented on the table as straight as possible along the long table axis and as flat as possible in the horizontal plane of the table. Rotated or contorted patient postures will translate into difficulty with subsequent image interpretation and may require awkward positioning angles for the C-arm, adding unnecessary complexity to the procedure. After the patient is comfortably positioned on the fluoroscopy table, the fluoroscopy technician should move the fluoroscope up to the table and orient it into the neutral position over the patient. The neutral position of the fluoroscope is defined as the position at which all rotation axes are zero. An image should then be obtained and manipulated on the monitor so that the top of the image on the screen represents the cephalad part of the patient and the left side of the image represents the left side of the patient when the patient is prone. This image orientation should remain standard and should be checked and reestablished at the beginning of each day and after restarting the machine for any reason. As the injectionist gains experience working 10 Needle Manipulation Techniques 127. The fluoroscope base unit should be positioned square to the table at a distance that allows the forward-sliding shaft of the C-arm to move the image intensifier to the left and right edges of the table. The various angle arms of the C-arm should be aligned with each other and the C-arm should project outward at a 90 degree angle from the base unit. A scout image should be obtained and the image should be manipulated on the monitor until it is straight and square. An initial image on the monitor that is straight and square allows the injectionist to begin from a position of familiarity. As the C-arm is moved during the procedure, the view on the fluoroscopic monitor will change. Starting with easily identifiable anatomic landmarks viewed with standard orientation allows the injectionist to maintain an understanding of the anatomic landmarks as their fluoroscopic appearance adjusts with changing fluoroscopy views. Especially with more complex procedures in severely degenerative spines, as the procedure progresses and the C-arm is moved into increasingly unfamiliar oblique angles with cephalad or caudad tilt, fluoroscopic anatomy may appear much less familiar and the injectionist may become disoriented and lose an understanding of the fluoroscopic shadows that were previously identified as known anatomic structures. If these later images in a sequence of images were viewed in isolation, the injectionist may not be able to identify any relevant anatomic landmarks. Choose the Skin Insertion Point Choosing the proper skin insertion point is one of the most important aspects of successful fluoroscopic injection. If the skin insertion point is not properly chosen, the injectionist will be "fighting against" this suboptimal starting point for the entire procedure. The appropriate skin insertion point for any particular procedure must be carefully selected so that the needle can be directed to the target in as straight a line as possible without obstruction by bony elements between the skin insertion point and the target. Although needles can be steered around bony obstacles to some degree, the more a needle must deviate from a straight line to arrive at the target, the more difficult the procedure becomes. The simplest procedures are those such as an uncomplicated posterior interlaminar lumbar epidural steroid injection where an unobstructed fluoroscopic view of the target can be obtained readily and the needle can follow a straight line to its destination. During this procedure, the injectionist may be required to advance the needle down a long, narrow corridor extending from the skin insertion point to the target. The needle may have to initially move medial from the skin insertion point in order to avoid the ileum at an approximate depth of 2, then move lateral to avoid the superior articulating pro- Visualize the Target In order to successfully advance a needle through the skin and into a pain-generating target within the body, one should first be able to visualize the path leading to the target with the fluoroscope. The fluoroscope reveals tissues of varying densities which are represented by varying shades of gray on the monitor screen. Once the needle tip penetrates the skin, it is of course no longer visible to the naked eye but can be readily tracked with the fluoroscope. Advance the Needle in Small, Incremental Fashion to the Target Advancing needles in small, incremental steps to specific targets within the body is the essence of interventional pain management. The remainder of this chapter describes the various techniques used for accurate, efficient, safe, and humane needle placement. Local Anesthesia Pain relief during interventional procedures is of primary importance. Almost all patients have fear and anxiety regarding spinal injections and many patients who are undergoing interventional pain procedures have experienced a high degree of persistent pain leading up to the procedure. Reassurance and a professional manner in the preinjection phase will go a long way toward alleviating preinjection anxiety, but this must be followed up by a procedure that is minimally uncomfortable for the patient. For certain advanced procedures such as percutaneous disc decompression or vertebroplasty, intravenous conscious sedation may be indicated to reduce the pain of the procedure. For more minor procedures, the effective use of local anesthetic may make the difference between a patient who is smiling and happy in the recovery room and one who will harbor bad memories and resentment for a lifetime. Patients often do not forget painful experiences and will most assuredly tell friends, family, and the referring physician all about it. The liberal use of local anesthetic to lessen the pain of needle placement requires minimal time and effort and need not add significant risk to the procedure. Once the needle is advanced through the initial skin and subcutaneous wheal, the needle stylet can be removed so that small, incremental doses of local anesthetic can be injected as the needle is advanced further. It is sometimes advisable to advance the needle with the local anesthetic syringe attached in order to expedite local anesthetic injection. In more advanced procedures, such as percutaneous disc decompression where relatively large introducer needles are inserted, it is often advisable to use a 22 g or 25 g Quincke spinal needle to separately anesthetize a path to the target at the start of the procedure. In most therapeutic injections, it is certainly reasonable to use liberal amounts of local anesthetic to assure patient comfort. The toxic dose of 1% lidocaine without epinephrine is greater than 30 cc although far less volume will usually provide excellent pain relief during a procedure if the lidocaine is injected liberally prior to incremental needle advancements and/or whenever the patient begins to experience discomfort. As a point of reference, an uncomplicated interlaminar lumbar epidural injection in an anxious patient may require 5 cc of local anesthetic injected from the skin to the ligamentum flavum in order to keep the patient comfortable during needle placement.

Step-by-step unilateral complete cleft rotation advancement: m = medial mucosal flap; l = lateral mucosal flap medications listed alphabetically buy zyloprim online from canada. In the first stage (A-C) medicine school order zyloprim line, bilateral straight line repairs are done after the prolabium is divided vertically into three forks symptoms rheumatic fever order genuine zyloprim line. The lateral forks are "banked" at the alar bases for later use in constructing a columella symptoms your having a boy purchase zyloprim with american express. At the second stage (D-E) treatment ketoacidosis order zyloprim on line, bipedicle flaps from the nasal floor symptoms exhaustion discount zyloprim 100 mg with mastercard, which include the banked forks, are used in combination with a membranous septum incision to elongate the columella and increase tip projection. In large clefts, a lip adhesion may be performed as an initial stage several months before the actual definitive correction of the cleft lip. This procedure basically involves creating a wound on either side and suturing the muscles, mucosa, and skin together. Presurgical orthopedic devices may be placed and manipulated, instead of a lip adhesion, to bring a wide, bony cleft into better opposition for a tension-free complete repair. The mildest form of cleft palate is the submucous, or occult cleft, in which there is no visible cleft but, rather, a nonunion of the soft-palate muscles. This is followed by the incomplete soft-palate cleft and, finally, the complete cleft, which includes soft and hard palates and may extend through the alveolar portion of the maxilla. Repair involves mobilizing the lateral soft tissue and moving it toward the midline to close the cleft and elongate the palate, if necessary. The most important goal of cleft-palate repair is the attainment of normal speech. Children with unrepaired or inadequately repaired clefts develop nasal-sounding speech patterns termed rhinolalia. In addition to closing the cleft itself, an important goal of palate repair is normal anatomic approximation of the levator palati muscles, which are responsible for oronasal valving in speech and swallowing. The cleft palate is closed by elevating the mucoperiosteum from the underlying bones and approximating it in the midline (von Langenbeck technique;. In either method, the levator muscles are specifically dissected and the levator sling is reconstructed. A layered closure usually is accomplished, including repositioning of the uvular muscles. Bilateral, unipedicled mucoperiosteal flaps, based on the greater palatine arteries, are elevated. B: Anteriorly, the nasal floor is repaired by suturing the vomerine mucosa to the nasal mucosa on the cleft side. C: the levator muscles are dissected free from the oral and nasal mucosa and released from the posterior edge of the hard palate. D: the oral mucosa is reapproximated in the midline with interrupted horizontal mattress sutures. The other procedures basically involve direct closure of the muscles and a push-back to lengthen the palate. The typical repair would be a palatal Z-plasty or superiorly based pharyngeal flap. The flaps are based superiorly and repositioned horizontally to meet above and behind the soft palate. Although they act to augment the posterior pharyngeal wall, they also are intended to maintain their innervation and, therefore, augment sphincter activity. Obstructive sleep apnea may be caused by these procedures and may make airway management difficult. The size of the cleft is variable; it may be unilateral or bilateral and is associated with cleft lip and palate. The alveolar segments are often collapsed such that orthodontic expansion is required before bone graft and repair. These devices are maintained to stabilize the graft in situ for a 3-mo healing period. The surgical procedure involves raising mucosal-gingival-periosteal flaps, advancing them, and performing a layered closure, starting with the nasal floor and working toward the oral cavity. Cancellous bone usually is taken from the iliac crest or corticocancellous bone from the outer table of the skull. This can be accomplished via limited access and a trephine or via an open technique, depending on the amount of bone required. Most nasal and lip revision surgery should be put off until the alveolus is reconstructed because this is the base on which the lip and nose sit. Variant procedure or approaches: In young children, the alveolar cleft procedure may be performed without the use of bone grafts at the time of lip or hard palate closure (gingivoalveoloplasty. Gingival and mucosal incisions are shown on the palate (A) and vestibular (B) surfaces, extending along the cleft borders. Brusati R, Mannucci N: Primary repair of the lip and palate using the Delaire philosophy. These subsequent deformities depend on the extent of the initial congenital anomaly, the quality of the surgical repair, and resulting oral/facial function. Short columella associated with the bilateral cleft nose, elongated by forked flaps. Correction involves switching tissue from the midline of the lower lip to the central portion of the upper lip, maintaining a pedicle of soft tissue between the lips, which usually contains the labial artery on one side. The redundant tissue in the midportion of the upper lip is transferred to the columellar portion of the nose at the same time, which elongates this section. To avoid disruption of the flap, the older child should be cautioned to avoid wide mouth opening in the postop period. The possibility of remaining intubated postop should be discussed with the surgical team and the family. The ear is examined in thirds to determine where the prominence lies, and the surgery is tailored to correct the specific excesses. The prominence of the ear, as measured by its projection from the mastoid process, is decreased accordingly. This usually involves an elliptical skin incision in the posterior ear area, dissection over the mastoid, and one or a combination of three techniques-mattress sutures, cartilage scoring, and/or resection. Variant procedure or approaches: All procedures are similar, with minor differences in suturing and amount of resected tissue. In addition to the posterior incisions, an anterior incision can be used in some approaches. Microtia is within the congenital anomaly spectrum of hemifacial microsomia, and the associated facial malformation may include a small asymmetric jaw, creating a difficult intubation. The second technique uses an alloplastic framework and is done in one longer stage. Stage one is the creation of a cartilaginous framework, with placement into a cutaneous pocket symmetric with the normal ear, if present. Stage three is the elevation with skin graft of the framework from the head posteriorly. The helical rim is obtained from a "floating" rib cartilage, the main pattern from the synchondrosis of two cartilages. To provide tension-free accommodation of the framework, the dissection is carried out well beyond the proposed auricular position. Using two silicone catheters, the skin is coapted to the framework by means of vacuum tube suction. Brent B: Technical advances in ear reconstruction with autogenous rib cartilage grafts: personal experience with 1200 cases. Preemptive transplantation is recommended when possible to minimize loss of growth potential and currently accounts for 25% of transplants. The source of the renal allograft may be a cadaveric (40%), living related, or living unrelated donor. A right curvilinear incision, starting at the pubic symphysis and extending to just below the ribs, is the approach most commonly used even for children as small as 10 kg. The donor renal artery and vein are anastomosed directly to the recipient aorta and vena cava, respectively. An adult-sized kidney may occupy the majority of the right upper quadrant in a small recipient. Meticulous attention to the positioning of the kidney will prevent kinking or twisting of the donor vasculature. This may require mobilization of the right lobe of the liver or even hepatectomy in some cases and almost always a right nephrectomy in small children. The donor kidney can be temporarily taken out of ice and placed into the recipient to determine the best site for the anastomoses. In this manner, the vessel length necessary to fashion straight, yet tension-free anastomoses can be determined. It is important to avoid redundancy in the vessels and ensure a straight line from the renal hilum to the aorta and vena cava without the hooking of one vessel over another. A small vascular bulldog clamp is then applied to the renal vein above the anastomosis to allow for removal of the vena caval clamp and reconstitution of lower extremity venous return to the heart. Heparin is administered, and the aorta is then crossclamped proximal and distal to the aortotomy. An end-to-side anastomosis is fashioned between the renal artery and aorta, taking care to interrupt the front wall sutures and prevent the purse-string effect of a running suture. Warm ischemia can be minimized during this time by intermittently placing iced slush around the kidney. As prophylaxis against ischemia-reperfusion injury, a single dose of iv mannitol is administered at the time of graft revascularization, and low-dose dopamine is also initiated. The type of ureteral reimplantation depends on the quality of the recipient bladder. An extravesicular ureteral reimplantation can be considered in a healthy bladder of adequate size. The bladder is reflected medially to accomplish the implantation near the postero lateral portion of the bladder with the ureteral orifice located close to the trigone. The detrusor muscle is divided, and a mucosal-to-mucosal anastomosis is fashioned between the bladder and the donor ureter over a ureteral stent. The detrusor muscle is reapproximated over the ureter for an adequate length to create an antireflux valve. If the bladder is of small capacity or defunctionalized, a transvesicular approach to ureteral reimplantation is required. A bladder cystotomy is made at the dome, and the transplant ureter is brought into a shallow, mucosa-denuded, rectangular trough extending from a superiorly placed ureteral hiatus distally to the trigone. The ureter is then spatulated and directly sutured to the urinary mucosa over a ureteral stent. The ureteral stent is sutured to a cystotomy tube brought out through a separate incision in the bladder for easy removal of the urethral catheter with its associated discomfort, while ensuring adequate drainage and prevention of clot obstruction. The cystotomy is then closed and the kidney inspected for perfusion and hemostasis. These children are often the recipients of a living-related transplant, and as such, the surgery proceeds as a somewhat elective procedure. Most patients have been on a well-established regimen of peritoneal or hemodialysis. Giessing M, Muller D, Winkelmann B, et al: Kidney transplantation in children and adolescents. Salvatierra O Jr, Millan M, Concepcion M: Pediatric renal transplantation with considerations for successful outcomes. Salvatierra O, Tanney D, Mak R, et al: Pediatric renal transplantation and its challenges. Uejima T: Anesthetic management of the pediatric patient undergoing solid organ transplantation. The indications for liver transplantation in children are broad and range from cholestatic cirrhosis secondary to biliary atresia to inborn errors of metabolism that, if untreated, result in devastating neurological injury. Absolute contraindications for liver transplantation include irreversible encephalopathy, uncontrollable infection, and untreatable extrahepatic malignancy. The main constraint to pediatric liver transplantation compounding the preexisting organ shortage involves the donor-to-recipient size ratio. The minimum acceptable graft-to-body weight ratio to provide adequate postop liver function is 1%. However, the suitability of a donor is more often determined by the maximum amount of donor liver that a recipient can accommodate in the abdominal cavity. This results in the utilization of several different types of grafts in pediatric liver transplantation. Although the type of graft used determines certain technical aspects of the hepatectomy and implantation, the general sequence of events consists of: 1. Anhepatic phase (during which portal venous inflow and hepatic venous outflow are reconstituted) 3. Biliary reconstruction A bilateral subcostal incision is used with a midline subxiphoid extension as needed. The abdomen is explored, and adhesions are lysed taking care to sutureligate varices in patients with portal hypertension.

With gentle blunt dissection symptoms graves disease zyloprim 300mg sale, the bladder and attached vesicouterine peritoneal flap are dissected off the lower uterine segment medications 5113 buy zyloprim overnight. The ascending uterine arteries and veins are identified bilaterally medicine 834 purchase zyloprim online pills, then clamped treatment 6th feb purchase 100mg zyloprim free shipping, transected medicine upset stomach generic zyloprim 300mg visa, and ligated treatment 2014 buy cheap zyloprim 300mg. If a subtotal hysterectomy is planned, the body of the uterus is amputated at this level, and the cervical stump is closed with interrupted sutures. If a total hysterectomy is planned, dissection of the bladder off the cervix is continued until the cervicovaginal margin is identified. The cardinal and uterosacral ligaments are clamped, transected, and ligated, with clamps placed as close to the cervix as possible without including cervical tissue. After the level of the lateral vaginal fornix is reached, a clamp is swung below the cervix, across the lateral vaginal fornix. Throughout the procedure, it is vital to clamp and ligate any bleeding vessels and to take extra care to avoid damage to the ureter or bladder. Following removal of the uterus and cervix, the vaginal cuff angles are sutured to the ipsilateral cardinal ligament stumps, and the vaginal cuff is closed with a running locked stitch. Hansch E, Chitkara U, McAlpine J, et al: Pelvic arterial embolization for control of obstetric hemorrhage: a five-year experience. The classic symptoms are "shearing" pain, cessation of uterine contractions, loss of fetal heart tones, and the onset of vaginal bleeding. Unfortunately, these warning symptoms occur only in a minority of uterine rupture cases. Extrusion of the placenta through the uterine rupture may result in late decelerations due to uteroplacental insufficiency. Extrusion of the umbilical cord may be manifested by recurrent variable decelerations. Causes of uterine rupture include breakdown of a previous uterine scar, obstructed labor, or uterine trauma. In cases where the uterine rupture occurs at the site of a prior uterine scar, the clinical course is usually less severe and the blood loss less than in cases of primary rupture of an intact uterus. This consists of a 2- to 3-layered closure of the defect, using synthetic absorbable sutures. A transverse abdominal incision is made ~3 cm above the symphysis pubis and carried to the anterior rectus fascia. The fascia is incised and the muscles of the anterior abdominal wall separated sharply and bluntly from the midline. Because of the emergent nature of this condition and the possible massive blood loss associated with rupture of a gravid uterus, the anesthesiologist must act quickly. Serious consideration should be given to the use of unmatched O(-) or type-specific blood until cross-matched blood becomes available. Kaczmarczyk M, Sparen P, Terry P, et al: Risk factors for uterine rupture and neonatal consequences of uterine rupture: a population-based study of successive pregnancies in Sweden. If performed after a vaginal delivery, a small infraumbilical incision is made in the skin and carried down through the parietal peritoneum. It is important to identify the fimbriated end of the tube to ensure that the structure ligated is not the round ligament. A midsegment portion of the tube over an avascular portion of mesosalpinx is selected, and tubal patency is disrupted by a variety of methods (Pomeroy, Parkland, Irving, Uchida, etc. The segment of tube grasped is ligated with absorbable suture, and the knuckle of tube formed is excised. The cut ends of the tubes should be hemostatic before replacing the tubes into the abdomen. The procedure is strictly elective and voluntary and must be considered permanent, even though reversal may be possible. Some patients will eventually regret the decision to undergo permanent sterilization. The risk of sterilization failure and an increased risk of ectopic pregnancy in case of failure must be reviewed. Often, it is more convenient for both the surgeon and the parturient with a functioning epidural catheter to have surgery immediately after delivery. Shorter hospital stays after vaginal delivery are encouraging more tubal ligations during the first 12 h after delivery and it is unknown whether this affects morbidity or mortality. Epidural catheters frequently become dislodged after a patient becomes ambulatory. Gupta L, et al: Ambulatory laparoscopic tubal ligation: a comparison of general anesthesia with local anesthetic and sedation. Rastogi S, Ruether P: Visceral pain during tubal ligation under spinal anesthesia for caesarean section. Adequate repair requires optimal surgical assistance, exposure, and patient comfort. Vaginal and cervical lacerations can extend into the perineum, rectum, urethra, bladder, lower uterine segment, broad ligament, or peritoneal cavity. Small, superficial lacerations that do not bleed often do not need repair, whereas larger ones should be approximated. Deep lacerations may cause profuse bleeding; if it persists despite placement of multiple stitches, brief tamponade may be adequate to achieve hemostasis or vaginal packing may be required. Lacerations involving the perineum are classified as follows: First degree- involves break in mucosa and skin. Second degree-involves deeper tissue (bulbocavernosus and levator ani fascia and muscle). First- and second-degree lacerations are repaired in layers with continuous or interrupted stitches. When the laceration extends into the rectum, the rectal mucosa usually is closed in two layers, with the second layer imbricating the first. With periurethral lacerations, a catheter may need to be placed in the urethra to prevent passing a stitch through it. A laceration involving the urethra or bladder should be closed in multiple layers, followed by bladder drainage for several days. Uterine bleeding and the umbilical cord of an undelivered placenta can obscure the field, and it can be difficult to determine if bleeding is vaginal or uterine. It is helpful to deliver the placenta and control uterine bleeding before proceeding. After visualization is adequate, it is important to place the first stitch above the apex of the laceration to control bleeding from vessels that may have retracted. Superficial lacerations of the cervix occur with most deliveries but usually do not require treatment. Deep lacerations can cause significant blood loss, especially when they involve larger branches from the uterine artery or extend into the lower uterine segment. Again, the first stitch must be placed above the apex of the laceration to control bleeding from vessels that may have retracted. A laparotomy may be necessary if a laceration extends into the lower uterine segment or broad ligament and is causing significant bleeding that cannot be controlled otherwise. These lacerations may be associated with severe postpartum hemorrhage and can extend into the lower uterine segment leading to considerable blood loss that may go undetected. Patients should be examined carefully for Sx of hypovolemia with appropriate volume resuscitation prior to anesthesia. Evaluation and exploration of all but the most superficial of lacerations needs to be done in the operating room to optimize anesthesia options, hemodynamic monitoring, and surgical exposure. If no epidural is in place and the patient is hemodynamically stable, a spinal anesthetic may be satisfactory. Melamed N, et al: Intrapartum cervical lacerations: characteristics, risk factors, and effects on subsequent pregnancies. With cervical incompetence, there is painless dilation of the cervix in the midtrimester of pregnancy. The membranes bulge through the cervix and rupture, followed by delivery of a severely premature infant. An elective cerclage is performed prophylactically before pregnancy or usually after the first trimester of pregnancy on a patient with a Hx of cervical incompetence. If cerclage is performed before pregnancy, it may need to be removed because of spontaneous abortion or fetal anomalies. It generally is performed between 14 and 16 wk gestation, but may be performed as early as 10 wk gestation. An emergent (rescue) cerclage is performed in a patient who presents in the second trimester with painless cervical dilation and/or effacement. Ultrasound is performed before the procedure to confirm viability and to r/o major congenital anomalies. An emergent cerclage should not be performed if there is advanced cervical dilation or any evidence of infection, contractions, or uterine bleeding. There are two types of cerclage procedures generally performed: the McDonald and the Shirodkar. The cerclage is removed electively at term or earlier if there is rupture of membranes, persistent contractions, bleeding, or evidence of infection. The Shirodkar cerclage involves incising the cervix transversely, anteriorly, and posteriorly and advancing the bladder off the cervix. A nonabsorbable monofilament suture is placed submucosally between the incisions, and the mucosa is closed, burying the stitch. A Shirodkar cerclage may be left for future pregnancies if abdominal delivery is performed. If the cervix cannot be adequately accessed through the vagina, cerclage may be attempted through laparotomy or laparoscopy. This patient population is generally healthy and little workup is needed unless otherwise indicated. When performed after 20 wk, relevant physiologic changes are as discussed under Cesarean Section. Women requiring a cerclage may also have uterine irritability and potentially receive drugs such as b-sympathomimetics. Although N2O is teratogenic in rodents, there is no evidence of human teratogenicity when used for cervical cerclage or other operations. Spinal anesthesia is ideal as it minimizes fetal drug exposure and provides good operating conditions. American College of Obstetricians and Gynecologists: Cervical Cerclage, Prophylactic. American College of Obstetricians and Gynecologists: Cervical Cerclage, Therapeutic. American College of Obstetricians and Gynecologists: Nonobstetric surgery during pregnancy. Drassinower D, et al: Perioperative complications of history-indicated and ultrasound indicated cervical cerclage. Lee G, et al: Spread of subarachnoid sensory block with hyperbaric bupivacaine in second trimester of pregnancy. A possible alternative to manual removal involves injection of 10 mL of oxytocin (10 U/mL) into the umbilical vein; however, the success of this procedure is unpredictable. An ultrasound evaluation of the uterus may help in the detection of a retained fragment. Frequently, the retained product will already have been flushed out of the uterus by brisk bleeding. In such cases, iv oxytocin, rectal misoprostol, im prostaglandins, or methylergonovine may be administered to contract the uterus prior to curettage. Bleeding from a retained placenta or fragment is frequently brisk, so the anesthesiologist must be ready to administer iv fluids and O2 and to correct any coagulopathy. Placenta accreta, if extensive, can cause profuse bleeding at delivery, and a hysterectomy is often necessary. Some patients may be hemodynamically unstable as a result of heavy and/or persistent bleeding in the postpartum period; others may have a retained placenta with minimal bleeding. Delays in delivery of placenta increases the risk of significant postpartum hemorrhage. If intravascular volume has been restored and an existing labor epidural catheter is in place, the sensory block can be extended to provide adequate anesthesia. Initiating spinal anesthesia is also an option if intravascular volume status is adequate, there is no significant active bleeding, and time permits. Small doses of iv opioids and midazolam sometimes provide sufficient analgesia and sedation to allow removal of a retained placenta without compromising maternal safety. Chedraui P, Insuasti D: Intravenous nitroglycerin in the management of retained placenta. Jha S, Chiu J, Yeo I: Intravenous nitroglycerine versus general anaesthesia for placental extraction-a sequential comparison. Yoo K, et al: the effects of volatile anesthetics on spontaneous contractility of isolated human pregnant uterine muscle: a comparison among sevolfurane, desflurane, isoflurane, and halothane. Vigorous fundal pressure or cord traction also can contribute to uterine inversion, which can be complete or incomplete. Complete inversion results in the inverted fundus extending beyond the cervix and appearing at the vaginal introitus, whereas in an incompletely inverted uterus, the fundus does not extend beyond the external cervical os. Uterine inversion can cause hemorrhage and shock out of proportion to observed bleeding and must be managed as an obstetrical emergency. An anesthesiologist must be called to the delivery room as soon as a diagnosis of uterine inversion is made. Three primary methods for uterine replacement are the Johnson, Huntington and Haultain procedures.

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A reverse Trendelenburg position further aids in distribution of blood into the abdomen and legs treatment yeast infection discount zyloprim american express. An extensive exposure can be created from the greater occipital protuberance to the thoracic spine medications with codeine cheap 100mg zyloprim visa. Dissection is carried down sharply through subcutaneous tissue and fat to the trapezius fascia with care taken to stay in the midline medications given for bipolar disorder buy zyloprim canada. A dry surgical dissection with electrocautery can be achieved in this manner as the ligamentum nuchae is relatively avascular bad medicine 1 cheap zyloprim 300mg free shipping. Subperiosteal dissection is then carried from the tip of the spinous processes over the laminae elevating the paraspinal muscles as a cuff xerogenic medications purchase zyloprim without a prescription. Depending on the intended surgery medications and grapefruit juice order zyloprim from india, procedures such as laminoforaminotomies, laminotomies, and laminectomies can be performed. Blood loss may be significant depending on the length of surgery as well as the extent of bony resection. Usual preop diagnosis: Cervical radiculopathy, cervical myelopathy, spinal cord syndromes secondary to trauma Suggested Readings 1. Audu P, Artz G, Scheid S, et al: Recurrent laryngeal nerve palsy after anterior cervical spine surgery: the impact of endotracheal tube cuff deflation, reinflation, and pressure adjustment. Hukuda S, Mochizuki T, Ogata M, Shichikawa K, Shimomura Y: Operations for cervical spondylotic myelopathy. Jung A, Schramm J, Lehnerdt K, Herberhold C: Recurrent laryngeal nerve palsy during anterior cervical spine surgery: a prospective study. Types of scoliosis include idiopathic, congenital, neuromuscular, myopathic, traumatic, tumor-related, and mesenchymal disorders. Normally, the cervical spine and lumbar spine are lordotic, whereas the thoracic spine is kyphotic. The instrumentation is intended to stabilize the spine until bony fusion of the spine has occurred. Nonscoliotic patients presenting for this surgery may have spinal instability as a result of trauma, metastatic cancer, or infection. The patients with metastatic cancer may need a careful workup with regard to respiratory, nutritional, and chemotherapeutic status. For operations in the prone position, use a wire-reinforced tube to prevent kinking and airway obstruction. Adamus M, Hrabalek L, Wanek T, Gabrhelik T, Zapletalova J: Intraoperative reversal of neuromuscular block with sugammadex or neostigmine during extreme lateral interbody fusion, a novel technique for spine surgery. Buvanendran A, Thillainathan V: Preoperative and postoperative anesthetic and analgesic techniques for minimally invasive surgery of the spine. Fritzell P, Hagg O, Wessberg P, et al: Chronic low back pain and fusion: a comparison of three surgical techniques: a prospective multicenter randomized study from the Swedish Lumbar Spine Study Group. Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: the Anatomic Approach, 2nd edition. Schubert A, Deogaonkar A, Lotto M, Niezgoda J, Luciano M: Anesthesia for minimally invasive cranial and spinal surgery. Suggested Viewing Links are available online to the following videos: Posterior Spinal Instrumentation & Fusion for Idiopathic Scoliosis. Major trauma mechanisms produce pelvic-ring injuries, and patients with pelvic-ring disruptions frequently have associated systemic injuries, which may be life-threatening. Pelvic stabilization and surgical control of hemorrhage may be performed acutely in the polytrauma patient who is hemodynamically unstable. This is in conjunction with an exploratory laparotomy performed by a trauma surgeon. Pelvic fractures that do not heal are "nonunions," whereas those that heal in an unsatisfactory position are "malunions. These procedures are often lengthy and are staged, requiring changes in patient position. The posterior approach requires a large operative field, which may prevent the use of an epidural catheter. The goal of pelvic reconstruction is to restore the anatomy and stability of the pelvis, which will decrease hemorrhage in the hemodynamically unstable patient, aid in mobilization of the multiply injured patient, and improve long-term function. Schematic view of the principal pelvis injury patterns, as determined by the vector of the provocative blow. The pins for the external fixator are inserted into the iliac crest either percutaneously or through small incisions. In some centers, this procedure is done in the emergency department as a lifesaving procedure. The goal of surgical treatment of acetabulum fractures is to preserve the hip joint by accurately reconstructing the supporting bony anatomy. Surgical treatments of these challenging injuries are performed by surgeons who have undergone specialized training in orthopedic pelvic surgery. Associated injuries to the pelvis are common, as are associated systemic injuries. The most difficult portion of the procedure is the reduction; it may be facilitated by neuromuscular relaxation, pelvic reduction instruments, and traction. A radiograph also is obtained at the end of the case to verify a satisfactory reduction and position of the implants. Patients are anticoagulated in the postop period to prevent thromboembolic complications. Weight-bearing restrictions are maintained until enough healing has occurred to permit functional ambulation. Ilioinguinal approach, right side: (i) Penrose drain around iliopsoas, femoral nerve, and lateral femoral cutaneous nerve; (ii) Penrose drain around femoral vessels; (iii) bladder and space of Retzius; (iv) pubis; (v) pubic tubercle; (vi) symphysis pubis; (vii) Penrose drain around spermatic cord. Extended iliofemoral approach: (i) Gluteus minimus tendon; (ii) gluteus medius tendon; (iii) gluteus maximus tendon; (iv) superior gluteal neurovascular bundle; (v) sciatic nerve; (vi) piriformis and conjoint tendons; (vii) hip joint capsule; (viii) greater trochanter; (ix) medial femoral circumflex artery overlying quadratus femoris. This condition of the hip produces joint incongruity and instability, eventually leading to arthrosis and a dysfunctional hip joint. In children, bone grafting alone may be sufficient; in adults, however, pelvic osteotomy, to reorient or broaden the weightbearing surface, is necessary. In certain instances following pelvic osteotomy, incongruity of the hip may persist. In this situation, the pelvic osteotomy is combined with a proximal femoral osteotomy to restore congruence. Pelvic and proximal femoral osteotomies usually are fixed internally with screws and plates to allow early mobilization without displacement. The incision follows the iliac crest from the anterior superior iliac spine past the convexity of the iliac tubercle; the aponeurosis of the external abdominal musculature is elevated from the iliac crest. A straight vertical incision is made just lateral to the posterior superior iliac spine. The origin of the gluteus maximus is elevated from its origin off the posterior ilium and sacrum and reattached laterally. Prevezas N: Evolution of pelvic and acetabular surgery from ancient to modern times. An anterior, racquet-shaped incision is made, and all muscles crossing the hip joint are incised or detached. The femoral artery, vein, and nerve; obturator vessels; sciatic nerve; and deep vessels are isolated and ligated. The gluteal flap is brought anteriorly and sewn to the anterior portion of the incision. In a hindquarter amputation, excision of the lower extremity, hip joint, and a portion of the pelvis is performed. Anterior and posterior incisions are used, the iliac wing is divided posteriorly, and the symphysis pubis is disarticulated anteriorly. Either the common iliac or external iliac vessels are ligated, as are all nerves to the lower extremity. These procedures are performed very rarely-for severe trauma, tumor, or infection-and are often lifesaving surgeries. They often are performed in conjunction with a general surgeon, and standard bowel prep is done. The operations are long and tedious, with extensive blood loss, in patients who are usually systemically ill. Usual preop diagnosis: Malignant tumor of femur, hip or pelvis; traumatic amputation to femur, hip, or pelvis; uncontrollable infection to leg, hip, or pelvis. If the patient can be made hemodynamically stable with volume resuscitation, a thorough evaluation for coexisting neurological, thoracic, or abdominal trauma should be undertaken before anesthesia. Because of large intraop blood loss and 3rd-spacing of fluids, invasive hemodynamic monitoring is necessary. Although epidural anesthesia is seldom adequate for surgery, postop epidural analgesia is an effective means of controlling the tremendous pain caused by this type of surgery. Other patient populations covered in this section include otherwise healthy patients with congenital or acquired hip dysplasia presenting for augmentation procedures. Regional anesthesia is generally inadequate for major pelvic surgery; however, in elective surgeries, serious consideration should be given to postop epidural analgesia. Harris T, Davenport R, Hurst T, Jones J: Improving outcome in severe trauma: trauma systems and initial management: intubation, ventilation and resuscitation. The femoral head is dislocated from the acetabulum, and the arthritic femoral head and a portion of the neck are excised. The acetabulum is reamed to accept a cemented or cementless cup made of metal and plastic. The femoral stem and head are usually modular, allowing for numerous shapes, sizes, lengths, etc. A hybrid total hip combines a cemented femoral stem and a cementless acetabular cup. After relocation of the new prosthetic hip joint and closure of the tissues, the patient may be given an abduction pillow to minimize the risk of dislocation. Revision procedures are more arduous and time consuming, as the "failed" or loose component(s) must be removed and the bone prepared to accept new cemented or cementless components. These procedures require more specialized equipment for extracting prostheses and cement and rebuilding the femoral or acetabular bone stock (allografts, autografts, etc. In the Girdlestone procedure (resection arthroplasty), the components are removed, but not replaced. Sugano N: Computer-assisted orthopaedic surgery and robotic surgery in total hip arthroplasty. Some form of internal fixation is usually employed; a spica cast is sometimes placed immediately postop or a few days later. The surgical procedure may be performed through anterior, lateral, or posterior incisions with the lateral being most common. Application of cobra plate after it has molded to the shape of the acetabulum and femur, and initial fixation with one proximal + distal outrigger compression screws. A capsulotomy is performed and is closed with reabsorbable sutures later in the case. Generally, the hip is not dislocated, but the cartilage surfaces are inspected and documented. The synovium, as well as any loose bodies, cartilage flaps, and osteophytes, are excised. These patients are usually elderly, and their anesthetic management is tailored to any concurrent disease. Rheumatoid and other inflammatory arthritides form another group of candidates for these procedures, and the special anesthetic considerations for these patients are outlined below. Avascular necrosis of the hip is seen in patients with sickle-cell disease and in heart transplant patients. Consider preemptive analgesia with: Gabapentin 600 mg po, celebrex 200 mg po, and acetaminophen 1 g po/iv to be given in the preop holding area. However, induction of regional anesthesia, with its attendant positioning requirements, can be uncomfortable in patients with limited joint mobility. Sedation or general anesthesia should be offered to supplement the regional technique. For patients with a high opioid tolerance, the use of a continuous epidural anesthetic (for either hip replacement or knee replacement) should be considered. In an effort to reduce adverse events associated with perioperative opioid consumption, there is emerging interest from the orthopaedic community in eliminating the routine use of opioids in spinal anesthetics. In elderly patients, the fracture occurs through osteoporotic bone in the femoral neck, intertrochanteric, or subtrochanteric area. Nondisplaced or minimally displaced femoral neck fractures are usually treated by closed reduction and percutaneous pinning of the fracture. Elderly patients frequently have numerous medical problems, which means that the fractures require prompt internal fixation/prosthetic replacement to facilitate early mobilization. These are normally much higher energy fractures, often associated with multiple traumas. Moja L, Piatti A, Pecoraro V et al: Timing matters in hip fracture surgery:, patients operated within 48 hours have better outcomes. It is indicated for virtually any fracture, from the lesser trochanter to the distal femur, within 7 cm of the articular surface. The procedure also is used for the treatment of nonunions and malunions of the femoral shaft.