By F. Lukar. Ramapo College of New Jersey.
Tube To Suction Tube From Patient 2 cm Suction Control Water Seal Collection Chamber Figure 8 buy doxepin toronto. This is the triangle bordered by the anterior border of the latissimus dorsi order 25mg doxepin otc, the lateral border of the pectoralis major muscle discount doxepin online american express, a line superior to the horizontal level of the nipple generic doxepin 25mg without prescription, and an apex below the axilla. Thoracic surgical drainage system • Suction of 0–20cmH2O can be applied if the is lung not fully infated by attaching an additional underwater drain bottle and attaching to wall with low pressure suction. Electronic drainage systems electronic systems driven by battery and/or mains have potential benefts for thoracic surgery. The pump applies continuous suction and is small and has no fuid level which allows easier patient mobility. The pump applies a constant level of suction and gives a digital display of air leak in mL/minute. This allows better quantifcation of air leak and the drains can generally be removed when the air leak falls below 50mL/hour. Further reading Laws D, neville e, Dufy j; Pleural Diseases Group, Standards of Care Committee, British Thoracic Society. Initial treatment often involves drainage of the pleural space which can be difcult as there is often loculation of the empyema. The chronic infection in the pleural space progressively results in debility and weight loss. Spillage of infected pleural fuid into the airway contaminates the good lung and results in recurrent chest infection. A rapid sequence induction with pre-oxygenation and accurate placement of a double-lumen tube with the help of a fbre- scope is the technique of choice. Alternative ventilation strategies such as the use of jet ventilation or high-frequency oscillation may have a place when the air leak is persistent and severe. After initial stabilization, investigations and diagnosis lead to defni- tive treatment. Aetiology of airway obstruction • foreign body • Trauma (post intubation, burns, and other forms of trauma) • neoplasm of the trachea or major bronchus • Mediastinal lymphoma • Thymic tumours. Relief of airway obstruction may require initial intubation and treatment with steroids and/ or radiological placement of airway stents prior to defnitive treatment with further surgery or chemotherapy/radiotherapy. The surgical removal of emphy- sematous lung areas reduces the hyperexpanded lung volume and gives mechanical advantage. Lesser forms of surgery such as simple bullectomy may also be performed in emphysematous patients. It does yield a survival advantage for patients with both predominantly upper-lobe emphy- sema and low baseline exercise capacity. The major complications seen are respiratory failure often complicated by persistent air leaks from staple lines in the poor quality lungs. The requirement for positive pressure ventilation carries a very high morbidity and mortality. Further reading fishman A, Martinez f, naunheim K, Piantadosi S, Wise R, Ries A, et al. A randomized trial com- paring lung-volume-reduction surgery with medical therapy for severe emphysema. A ‘simple’ patent ductus arteriosus may manifest in the adult as eisenmenger syndrome with pulmonary hypertension. Adults may require cardiac intervention (surgical or transcatheter) in several circumstances: • Primary repair of anatomy • repair of sequelae of primary anatomical repair • Intervention for unrelated problem, e. Blood pressure may be falsely low in the ipsilateral arm Concordance Connection of two structures on the same side morphologically—right atrium to right ventricle Congenitally Atrioventricular and ventriculo-arterial discordance (double corrected discordance): pulmonary venous return to left atrium to right transposition of ventricle to aorta. Augments aortic or sub-aortic hypoplasia/stenosis and provides adequate systemic outfow. If coronary sinus unroofed or fenestrated may act as potential source of right-to-left shunt Mustard Atrial switch procedure for transposition of the great arteries. Left ventricular outfow is bafed through a ventricular septal defect to the malpositioned aorta. Similar to the Mustard procedure but using atrial tissue and no prosthetic material Single ventricle Also known as univentricular. Functionally one pumping chamber, although there is often a vestigial remnant of a second ventricular chamber Straddling Valve with chordal attachments crossing a ventricular septal defect, thus limiting defnitive repair Subclavian Surgical repair of coarctation of the aorta using the left aortoplasty subclavian artery to patch augment the coarctation segment. Primary repair now more common, but if unstable and cyanotic maybe palliated with shunts (Blalock–taussig, Waterston or Pott) to allow growth. Blue blood directed Single straight into lungs ventricle Tricuspid atresia Figure 9. Any arrhythmia with haemodynamic compromise should be managed in the standard way, with prompt electrical cardioversion. Atrial tachyarrhythmias are life-threatening to patients with single ventricular physiologies. If an atrial tachyarrhythmia is diagnosed then prompt action is required to manage the patient: • Electrical cardioversion is treatment of choice. Hypoxaemia is caused by right-to-left shunts or mixing of pul- monary venous and systemic venous returns in a common chamber. A sec- ondary erythrocytosis results with an elevated haematocrit and subsequent hyperviscosity. If eisenmenger physiology, remember that systemic and pulmonary pressures are similar; if hypertensive, avoid vasodilators, and treat with β-blockers ± sedation. A small-volume bleed may be the herald of a life-threatening haemoptysis and so should be investi- gated thoroughly. In patients with tracheostomy or prolonged ventilation a tracheo-arterial fstula may form. In patients with aortic aneurysm including coarctation repairs and Marfan syndrome there may be erosion into the airway (or oesophagus). If major bleeding, consider selective intubation of non-bleeding bron- chus or bronchial blocker. Access to achieve Crt may be challenging and may require an epicardial lead to be positioned. However, oxygen saturations should be monitored with consideration of the patient’s usual saturation. Similarly, cerebral abscesses may form due to paradoxical emboli into the systemic circulation. Arterial access should be sited to avoid pressure damping from previous shunts or coarctation repairs. Central venous lines should avoid cavopulmonary connections as these connect directly with the pulmonary arteries. Adult congenital heart disease: inten- sive care management and outcome prediction. Transposition of the great arteries—Mustard or Senning repair Surgery in adults with previous Mustard or Senning repair may be for obstructed or leaking bafes. Standard heart failure strategies should be instigated although the response is not predictable. Transposition of the great arteries—switch repair operative indications in patients with previous arterial switch include repair of the pulmonary, aortic, or coronary artery anastomoses, or valve repair or replacement of the aortic or pulmonary valves. Cardiac output in the Fontan physiology requires an adequate preload and avoidance of elevated pulmonary vascular resistance. In addi- tion to the systemic problems already described, potential cardiovascular problems include: • Systemic ventricular dysfunction: manage with standard strategies. Preliminary evidence suggests that calcium sensitizers such as levosimendan may be benefcial. Maximizing cardiac output may require aggressive management of pleural efusions and ascites (which may splint diaphragmatic function), optimization of ventilator parameters in combination with bronchodilatation and reduction of pulmonary vascular resistance with pulmonary vasodilators (potentially in combination for maximal efect). Arrhythmias are poorly tolerated and prompt electrical cardioversion should be considered. Chapter 20 201 The obstetric patient with cardiac disease Introduction 202 The physiology of pregnancy 204 Anaesthetic techniques and the delivery 206 Special consideration for cardiac intensive care 207 202 ChApTer 20 The obstetric patient with cardiac disease Introduction Cardiac disease can complicate pregnancy and can result in admission to a critical care unit. Increasingly women with severe cardiac disease are opting for pregnancy with the expectation of good maternal and neonatal outcomes.
Based on report cheapest generic doxepin uk, gr eat er t h an on e-t h ir d of the splen ic mass was pr eser ved order generic doxepin line. Which of the following st u dies may be h elpfu l t o det ermin e if the pat ient h as ret ain ed splenic funct ions following h is operat ion? W hich of the following is the most appropriate recommendat ion for this pat ient at t his t ime? Laparoscopic splenectomy because she has a favorable but unsustained response to steroids therapy B purchase doxepin in united states online. Sinistral portal hypertension refers to left-sided portal hypertension discount 25 mg doxepin visa, which is associated with thrombosis of the splenic vein. Under this circum- stance, blood flow from the spleen has to return to the central venous system through the short gastric veins resulting in marked dilatation of the short gas- tric veins (gastric varices). T h e p er ip h er al sm ear can b e h elp fu l t o d et er m in e if this patient h as m ain - tained splenic functions following his injuries and surgery. A platelet count of 40,000 mm is not gen er ally con sid er ed so cr it ically low that it would r equ ir e sp ecific t r eat m en t. Continued monitoring for bleeding symptoms and further drop in platelet cou nt is the best appr oach at this t ime. The explanat ions t o t he answer choices describe t he rat ionale, including which cases are r elevant. A53-year-oldmanpresentstotheemergencydepartment with4-dayhis- tory of nausea and vomiting. The patient reports that he has not been able to tolerate any food or liquids by mouth over this period of t ime. The emergency medicine provider not i- fies you that the p at ient h as some sign ifican t ly abn or mal ser u m labor at or y valu es. Start Lactated Ringers at 200 mL/ h and titrate to keep a urine output of 30 to 50 mL/ h B. Start 5% salt-poor albumin at 100 mL/ h and continue until his sodium normalizes R-2. Shedevelops acut e respirat ory insufficiency during hospit al day 1 t hat required endot ra- ch eal int ubat ion an d mech an ical vent ilat ion. O n h ospit al day 3, sh e st abi- lizes from the h emodynamic st andpoint and remains on the vent ilat or. O n examinat ion, she is awake wit h abdominal dist ension and some epigast ric tenderness on examination. She is expected to require mechanical ventila- tion for several more days based on the intensivist’s best estimation. Placement of feeding jejunostomy tube by laparoscopy and initiate feeding on ce the t ube is placed R-3. A 73-year-old woman with past history of diverticulitis presents to the emergency cent er wit h fever, abdominal pain, abdominal t enderness, and hypotension (blood pressure of 90/ 50). The patient reports that the pain is ver y sim ila r in p at t er n, lo cat io n, a n d ch a r act er ist ics t o h er p r evio u s b o u t s o f diverticulitis. Which of the following choices represents the best sequence of prioritized t reatments for this pat ient? Lab o r at o r y b lo o d wo r k s, I V flu id s, C T scan of ab d o m en an d p elvis, surgical consult at ion and broad-spect rum ant ibiot ics C. A 24-year-old man suffered deep partial-thickness burn wounds to the ent ire ant erior ch est and abdomen, and circumferent ial burns t o bot h arms wh en h is clot h es caught fire at a barbecue pit. Based on the P ar klan d for m u la for b u r n patient r esu scit at ion, wh at is the est imat ed volume of fluid t o be administ ered for t he init ial 8 hours? W hich of t he following operat ions is t he most appropriate for this patient with this condition? A43-year-old man with a12-cm distal,right thigh massarisingfrom the anterior thigh muscle compart ment undergoes core needle biopsy of the mass, which reveals moderately well-differentiated liposarcoma. Which of the following choices is considered the most appropriate surgical approach for this patient? Wide local excision of the tumor with a 2-cm margin including right gr oin sent in el lymph n od e biop sy D. Wide local excision of the tumor with a 2-cm margin including right gr oin lymph n od e dissect ion E. A63-year-oldmanwithhistoryofhypertensionandcoronaryarterydisease presents for the evaluation of pain in his right calf whenever he attempts to walk more than one cit y block. Because of this pain, he has been having significant problems performing daily act ivit ies, such as shopping, going to the bank, and going to visit friends. Despite your advice for him to stop smoking, he cont inues t o smoke one and a half packs of cigarett es daily. The examination of his peripheral pulses reveal normal femoral pulses bilaterally, normal left popliteal and pedal pulses, and absence of right pop- lit eal and pedal pulses. T h ere is no evidence of crit ical t issue isch emia in eit h er lower ext remit y. W hich of t he following diagnost ic st udies is the most appropriate next step for this patient? A63-year-oldwoman isbrought totheemergencydepartment after being foun d t o h ave collapsed in side h er h ome. H er family repor t s that sh e st ayed home from work because she woke up with upper abdominal pain and chills. An ultrasound of the abdomen reveals no free fluid in the abdomen, normal abdominal aorta, gallstones in the gallbladder, and dilatation of the intrahepatic bile ducts. Whichofthefollowingpatientswithmassoftheheadofthepancreasisa can did at e for su r gical r esect ion? A 43-year-old woman with a 2-cm mass in the head of the pancreas and a 2-cm lymph node along t he lesser curve of t he mid-body of the st omach. A 46-year-old woman who underwent pancreaticoduodenectomy 14 months ago presents with new 1-cm lesion in segment 2 of the liver. A 43-year-old woman with a 12-cm cystic neoplasm in the body of the head and body of the pancreas. Imaging studies demonstrate invasion of the dist al stomach, left kidney, left adrenal gland, and the aort a R-10. A 59-year-old post men opau sal woman is foun d on h er an nual mam- mogram to have a cluster of suspicious pleomorphic microcalcifications. A stereotactic image-guided core needle biopsy was performed, and the radiologist reports that 15 separate core biopsy specimens were obtained. Pathology of the core needle biopsy procedure revealed benign breast tissue wit hout evidence of malignancy. W hich of t he following factors is helpful in det ermining t hat t he lesions are benign? Two sent in el lymph n odes an d t wo en larged n on sent i- nel lymph nodes were identified and removed. T h e false n egat ive r at e of sen t in el lym p h n o d e b io p sies is 1 0 % C. Random lymph node sampling yielding more than 2 negative lymph nodes from the axilla is sufficient for axillary staging D. Sentinel lymph node biopsy has not been validated for the axillary st aging of male breast cancer E. Sentinel lymph node biopsy and axillary dissections are associated wit h ident ical rates of complicat ions R-12. Clinical observations have reported that 60% of adrenal corticocarci- nomas are > 6 cm at the time of diagnosis B. Density of the adrenal incident alomas by imaging is based on the levels of water content of the tissue C. Functional analyses of adrenal incidentalomas consist of serum mea- surement s of cort isol and cat echolamines levels E. Fine-needle aspiration is important to obtain whenever the decision is made to observe a patient’s adrenal incidentaloma R-13.
Pat ient s t ypi- cally present wit h hyperkalemia an d a m ild h yp er ch lor em ic met abolic acid osis purchase 25mg doxepin amex. T h e hyperkalemia is usually managed with a low potassium diet and use of loop or thiazide diuretics generic doxepin 25mg with mastercard. Re s p i r a t o r y Ac i d o s i s Respiratory acidosis can o ccu r acu t ely or ch r on ically quality 10mg doxepin. T h e 2 most common cause of acute respiratory acidosis in hospitalized patients is drug- induced respiratory depression wit h hypovent ilat ion cheap 75 mg doxepin with visa, due to narcot ics, sedat ives, or anesthesia. It can be a respon se t o any disease that causes hypoxia, such as a pulmonary embolism, but is also often seen as a manifest ation of an anxiety disorder with hyperventilation. H ypocapnia causes decreased cerebral blood flow, so symptoms manifest as light-headedness or dizzi- ness. With acute alkalosis, there is increased affinity between albumin and calcium, so more calcium becomes protein bound. Patients may then experience symptoms of hypocalcemia (perioral numbness, paresthesias). These disorders require correction of the metabolic alkalosis which requires treat- ment of the underlying condition (eg, primary aldosteronism, renal artery st enosis, Cushing syndrome). T his alkalosis is termed “c h l o r i d e r e s i s t a n t ” or “s a l i n e r e s i s t a n t,” m e a n i n g t h a t i t c a n n o t b e c o r r e c t e d b y the a d m i n i s t r a t i o n o f sodium chloride solut ion. H e has edema of the optic disc, and his neurologic examination does not reveal any focal neurologic deficits. W ith alkaline urine and hypercalciuria, patients are predisposed to recurrent calcium phosphate stones. Urine chloride is useful for judging the volume status of patients with metabolic alkalosis, and is used to classify them as either volume depleted (low urine Cl) or volume repleted (high urine Cl). If low urine chloride, they are considered chloride responsive, and t he alkalosis can be corrected wit h the infusion of saline. T h e m ost likely int oxicat ion is methanol, which is metabolized to formic acid. This toxic metabolite causes mental status depression, papilledema, optic neuritis, and metabolic acidosis. Ethylene glycol may cau se the for mat ion of calcium oxalat e cr yst als in the ur in e. H e complains of pain with passive motion of the hip and on physical examination the hip has limited range of motion upon internal rotation. Which of the below series of serum laboratory values are consistent wit h t he underlying condi- tion predisposing to this patient’s fracture? A24-yearoldAfrican-Americanmancomesintoclinicfromareferralafter having significant bleeding following a wisdom tooth extraction 1 week ago. H e has no significant medical history and took aspirin 1 week ago for a headache. H e report s no family history of diagnosed bleeding disorders but endorses his mother easily bruises and has heavy menstrual bleeding. O n physical examination there are white plaques visible in the oral cavity and posterior pharynx that are easily removed with a tongue blade. An endoscopy is performed that demonstrates additional white plaques in the proximal esophagus. She has required multiple major surgeries as well as mechanical ventilation for the past week. Vital signs have been st able during t his t ime and her chest x-rays have been clear. A 60-year-old man with a history of hyperlipidemia controlled on simvastatin and well-controlled hypertension complains of nonbloody, watery diarrhea for over 1 year. H e complains of episodes of wh eezing and increased redness and heat in his face, neck, and upper chest that last up to 5 minutes. O n physi- cal examination there is hepatomegaly and a 2/ 6 holosystolic murmur is aus- cultated on the left lower sternal boarder that is accentuated with inspiration. Blood pressure is 135/ 85 mm H g, heart rate is 85 bpm, and respiratory rate is 16 breaths per minute. A 61-year-old man presents to the hospital complaining of substernal ch est pain an d malaise. H e reports increased pain when taking deep breaths but denies shortness of breath or palpitations. A 4 5 - y e a r - o l d m a n w i t h h i s t o r y o f s e i z u r e d i s o r d e r a n d a l c o h o l a b u s e is h ospit alized aft er a 30-minut e t onic-clonic seizure. Laboratory valu es in clu d e the followin g: S erum so dium 143,serum p o ta ssium 5. W h at is the most likely underlying pat h ophysiology t o this pat ient ’s con d it ion? A 6 5 - y e a r - o l d m a n w i t h a 3 0 - y e a r h i s t o r y o f s m o k i n g 2 p a c k s p e r d a y complains of increased swelling in both of his legs, increased dyspnea, and fat igue on exert ion. On physical examination there is distention of the right ju gu lar vein wh en fir m pr essu re is applied over the liver, presen ce of a para- st ernal heave, and t here are diffuse expirat ory wheezes heard on auscult a- tion of the lungs. A 4 0 - y e a r - o l d w o m a n c o m e s i n t o c l i n i c c o m p l a i n i n g o f a 1 5 - l b w e i g h t g a i n over the past 6 months despite a decrease in appetite. She states she is more bothered by cold temperatures, her hair is thinner, and recently has more difficulty passing bowel movements. She states that 8 months ago she was experiencing diarrhea, felt like her heart was beat ing quickly, and was always h ot. Today h er blood pressu r e is 125/ 85 mm H g, h ear t rat e is 70 bpm, and she is afebrile. O n physical examination there is no exoph- thalmos, thyroid is nontender and diffusely enlarged with a rubbery texture wit hout any isolated nodules, and her skin is dry to the touch. Furthermore, decreased kidney function impairs the excretion of phosphate, causing serum levels to become elevated, sometimes requiring treatment with phosphate binders. In sarcoidosis immune cells in the granulomas outside of the kidney increases the active form of vitamin D. H ip fractures secondary to osteoporosis are unlikely to demonstrate abnormal laboratory values where those caused sec- ondary to Paget disease will show an elevated alkaline phosphatase (See Case 35 [Osteoporosis] and Case 50 [H ypercalcemia]). This man has both platelet and clotting factor dysfunction inherited in an autosomal dominant fashion. If vW F is decreased or absent, platelets are unable to bind to the damaged endothelium, which causes clinical manifestations of platelet dysfunction (increased bleeding time) such as petechiae, epistaxis, and increased bruising without affect- ing the number of platelets. Choice B (Bernard-Soulier syndrome) is also an isolated dys- function of platelets whereby there is a deficiency of the receptor GpIb pre- ven t in g p lat elet s t o b in d t o the vW F exp r essed b y the d am aged ep it h eliu m. Esophagitis presents with primary com- plaints of odynophagia (painful swallowing), dysphagia, and a substernal burning chest pain. W hite plaques that are easily removed with a tongue blade are consistent with oral thrush caused by the opportunistic fungus— Candida that can cause esophagitis when it extends beyond the oral cavity to the proximal esophagus. Candida esophagitis is the most likely diagnosis in patients presenting with oral thrush. Endoscopy and biopsy are not necessary before initiating treatment with oral fluconazole. H owever, if patients show no improvement and have no signs of oral thrush, endoscopy with biopsy is warranted. This patient is likely in end-stage liver failure due to known alcoholic cirrhosis. It is associat ed wit h a h igh m or t alit y rate (20%-30%) and is likely to reoccur. Common symptoms include fever, diffuse abdominal pain, and altered mental status in a patient with known cirrhosis. H owever, empiric treatment should be initiated with a third-generation cephalosporin (ceftriaxone, cefotaxime) while awaiting cul- ture results given the most common cause is gram-negative organisms. Choice A (oral lactulose) would be the appropriate treatment for hepatic encepha- lopathy to prevent reabsorption of the toxic metabolite ammonia.