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By G. Kalesch. Indiana University - Purdue University, Columbus. 2019.

Also used overnight prior to extubation on patients who have had prolonged sedation to allow decreasing other sedatives cheap 40/60mg cialis with dapoxetine with visa, rapid wean prior to extubation buy 40/60mg cialis with dapoxetine with amex. Prolonged administration can produce prolonged muscle weakness after stoppage • Uses: as a paralytic in patients who need prolonged mechanical ventilation with significant lung disease cialis with dapoxetine 20/60mg with mastercard, those with significant pulmonary hypertension order cialis with dapoxetine 20/60 mg overnight delivery, Pancuronium (Pavulon) (0. Can improve urine output in patients whose renal function is not responding to high dose loop diuretics. Antiarrhythmic Agents Adenosine (Adenocard) (50mcg/kg initial dose, then increase by 50 for each subsequent dose) • Class: endogenous nucleoside • Half-Life: <10 seconds • Metabolism: rapidly taken up by erythrocytes and vascular endothelial cells, becomes part of body pool of nucleosides • Dosing Frequency: repeat doses can be given as early as 2 minutes after initial dose • Administration: should be given in most central venous access site as rapidly as possible. Central venous access is preferred but not essential • Precautions: may produce a short-lasting first, second or third degree av block. It is used • exclusively in supraventricular tachycardia to convert to sinus rhythm. At high doses (10-20mcg/kg/min) alpha effects more prevalent • Use: good first line to improve cardiac output when used in mid-range • Risk: high doses may cause vasoconstiction. Long term use downregulates catecholamine receptors, decreasing effect, also increases myocardial oxygen demand Drugs to Improve Cardiac Output and cause Vasodilation Milrinone (0. May cause reflex tachycardia due to vasodilation • Use: afterload reduction, additional inotropic support when catecholamines already in use. Drugs to increase systemic vascular resistance (increase afterload) Norepinephrine (Levophed) (initial dose 0. The goal in any patient is for this ratio to approach 1, so there is equal blood flow to the lungs and body. In patients who have all of their pulmonary blood flow supplied by a shunt from the aorta (i. Sat (pulm venous) = as we usually cannot measure this we assume that, with healthy lungs the blood will be fully oxygenated, i. Qp 80%-60% = 20 = 1 Qs 100-%-80% 20 Oxygen Content (CxO2) (for any sample of blood) CxO2 = 1. It is essential to get comfortable with the idea of titrating drugs to effect--there is no “dose”. A dose of morphine that wouldn’t touch a narcotic-tolerant oncology patient could cause life-threatening respiratory depression in an adolescent with a broken arm. Onset of action--t1/2 reflects initial distribution from blood to highly perfused tissues. Volume of distribution--relates the amount of drug in the body to the concentration of drug in the blood or plasma--the fluid volume that would be needed to account for all the drug in the body. Small Vd implies that the drug is retained within the vascular compartment, large Vd implies distribution through the body of sequestration in certain tissues. Clearance--The ability of the body to eliminate a drug, expressed as a volume of blood cleared of drug per unit time. Bioavailability--the percent of the dose reaching the systemic circulation as unchanges drug following administration by any route. In addition to their analgesic properties, narcotics decrease responsiveness to external stimulation and reduce the level of consciousness. Nevertheless, the sedative properties of narcotics are inferior to those of the benzodiazepines, and amnesia following narcotic administration is incomplete. Depending on the drug you can see decreased ventilatory rate or tidal volume (thus, the rate may be ok, but the tidal volume may be inadequate). Pruritis--Several of the opioids cause itching, and there is significant inter-patient variability in susceptibility. Dependence is treated with gradual withdrawal of the drug, either using the initial drug, or converting to methadone for convenient dosing. Treatment of withdrawal can be difficult if the patient has been receiving narcotics for prolonged periods. In general, the longer the period of treatment, the longer the period of withdrawal needed. Alternatively, one can treat symptoms with alternative drugs (a method usually reserved for those who have a psychological as well as physical dependence on the drug). Benzodiazepines Benzodiazepines provide hypnosis, anxiolysis, aterograde amnesia, and anticonvulsant activity. They are useful for providing sedation and treating seizures, but one must remember to treat pain with an analgesic Midazolam has a short onset of action, short duration of action, and relatively short elimination Relative t1/2t1/2 t1/2t1/2 Vd Clearance Dose (redistribution)(redistribution) (elimination)(elimination) (Liter/kg) (ml/kg/min) (min) (hours) Diazepam 0. For these reasons, it is useful for short procedures, but inconvenient for prolonged sedation. Continuous administration may result in prolonged sedation even after the infusion is discontinued if the rate of administration is to high. There have also been reports of dystonia and choreoathetosis after midazolam infusion and may represent benzodiazepine withdrawal, persistent effects of the drug, or the combined effect of multiple drugs. Diazepam has a short onset of action, like midazolam, and slightly longer duration of action, but a long elimination half-life. Lorazepam is less lipid-soluble, and has a longer duration of action with a shorter elimination half-life, thus is more appropriate than diazepam for prolonged sedation. Choreoathetoid movement disorder--Usually improves with time Personality changes--Usually improves with time, though after long term, high dose use, personality changes may remain apparent to family members for weeks-months. Ketamine hydrochloride is water soluble at commercial concentrations, but is quite lipid soluble as well and quickly crosses the blood-brain barrier. With intravenous administration, the distribution half-life is less than 30 seconds, the redistribution half-life 4. The anesthetic state produced by ketamine has been classically described as a functional and electrophysiological dissociation between the thalamoneocortical and limbic systems. Ketamine is a potent analgesic at sub-anesthetic concentrations, and the effects may be mediated by different mechanisms. Its effect on intracranial pressure remains controversial in practice, but controlled studies in which ventilation was controlled showed no effect on intracranial pressure. Concordant treatment with a benzodiazepine has been shown to prevent the development of unpleasant emergence phenomena. It has a direct negative inotropic effect on the myocardium, and a direct vasodilatory action on vascular smooth muscle. This is generally overwhelmed by central sympathetic stimulation that occurs, however, leading to increases in heart rate, systemic arterial pressure, and possibly systemic vascular resistance. The cardiovascular effects of ketamine are attenuated by alpha and beta blocking agents, verapamil, benzodiazepines, and high epidural blockade. Respiratory effects Ketamine is a mild respiratory depressant, and there is a dose related increase in respiratory depression with incremental doses of ketamine. Ketamine generally preserves airway patency, and protective airway reflexes are not repressed. Transient stridor or laryngospasm are rarely reported, and are associated with coincident respiratory infection. Ketamine increases oral secretions, and this may be more clinically important in those children with upper respiratory infections. Laryngospasm and the potential for emesis/aspiration are more pronounced in infants and patients with a full stomach, hence these patients should be considered at risk for airway compromise. The mechanisms of this response is considered to be a combination of drug induced increase in circulating catecholamine, direct smooth muscle dilatation, and inhibition of vagal tone. Neuromuscular Effects Ketamine increases skeletal muscle tone, and there are frequently random movements of the head or extremities. Ketamine also appears to potentiate the effects of neuromuscular blocking agents, both depolarizing and non-depolarizing. Dosage Recommendations In the intensive care unit all anesthetic/analgesic/sedative agents should be titrated to effect, with the unique physiology of each patient kept in mind. These children may be compromised from a pulmonary, hemodynamic, or neurologic perspective, and judicial use of any agent is warranted. Ketamine, for example, while supporting hemodynamics in the majority of patients, can cause hypotension if the patient’s myocardial reserve is limited. Co-administration of benzodiazepines reduces the incidence of emergence phenomena in older children, but will prolong the duration of sedation. This is not generally problematic in the intensive care setting, but should be considered. Propofol Propofol (2,6 diisopropyl phenol, “Diprivan”) has low aqueous solubility, and the commercial preparation is a 1% (i. It has a rapid onset and short duration of action, and produces respiratory and cardiac depression that is dose related. It is most useful for short procedures or “short” continuous infusions (see below). Propofol’s unique pharmacokinetics are its most attractive feature-rapid onset of hypnosis and rapid resolution of effects after discontinuation of the drug. The distribution of propofol is describes by an open three-compartment model: rapid initial distribution from blood to highly perfused tissues (brain, heart, lung, liver)-t/12 1. Propofol has a large central volume of distribution, is highly protein bound, and has an apparent high volume of distribution at equilibrium. Propofol is extensively metabolized in the liver and possibly other sites to inactive glucuronide and sulfate conjugates which are excreted in the urine. In adults with renal or hepatic disease, propofol pharmacokinetic parameters are not significantly altered. Clinical effects are realized within 40 seconds of administration, and emergence occurs within 10 to 30 minutes, depending partially on the length of administration. Propofol may be an effective anti-convulsant for status epilepticus unresponsive to other drugs. Cardiovascular Propofol may produce hypotension by a direct vasodilatory effect on both arterial and venous beds and by reducing sympathetic tone.

The neurotransmitter then acts as a chemical signal to stimulate the next cell cheap cialis with dapoxetine 20/60 mg otc, described as the postsynaptic cell cheap cialis with dapoxetine 20/60 mg overnight delivery. On the receiving membrane buy 30mg cialis with dapoxetine overnight delivery, usually that of a dendrite purchase cialis with dapoxetine 20/60mg amex, sometimes another part of the cell, there are special sites, or receptors, ready to pick up and respond to specific neurotransmitters. Receptors in the cell membrane influence how or if that cell will respond to a given neurotransmitter. Acetylcholine (Ach) is the neurotransmitter released at the neuromuscular junction, the synapse between a neuron and a muscle cell. It is common to think of neurotransmitters as stimulating the cells they reach; infact, they have been described as such in this discussion. Note, however, that some of these chemicals act to inhibit the postsynaptic cell and keep it from reacting. The axon ending has vesicles containing, neurotransmitter, which is released across the synaptic cleft to the membrane of the next cell (Source: Carola, R. Receptor-the end of a dendrite or some specialized receptor cell, as in a special sense organ, that detects a stimuli. These neurons may carry impulses to and from the brain, may function within the brain, or may distribute impulses to different regions of the spinal cord. Most reflex arcs involve many more, even hundreds, of connecting neurons within the central nervous system. Use of the term peripheral is appropriate because nerves extend to outlying or peripheral parts of the body. Its two major structures, the brain and spinal cord, are found along the midsagittal plane of the body. The brain is protected in the cranial cavity of the skull, and the spinal cord is surrounded in the spinal column. Even moderate pressure can kill nerve cells, so nature safeguards the chief organs made of this tissue-the spinal cord and the brain-by surrounding them with three fluid-containing membranes called the meninges. The spinal meninges form tube like covering around the spinal cord and line the bony vertebral foramen of the vertebrae that surround the cord. They are the dura mater, which is the tough outer layer that lines the vertebral canal, the pia mater, which is the innermost membrane covering the spinal cord itself, and the arachnoid, which is the membrane between the dura and pia mater. The meninges that form the protective covering around the spinal cord also extend up and around the brain to enclose it completely. These illustrations can also help you visualize the location of the ventricles if you remember that these large spaces lie deep inside the brain and that there are two lateral ventricles. One 145 Human Anatomy and Physiology lies inside the right half of the cerebrum (the largest part of the human brain), and the other lies inside the left half of the cerbrum. It forms continually from fluid filtering out of the blood in a network of brain capillaries known as the choroid plexus and into the ventricles. It moves from the fourth ventricle into the small, tube like central canal of the cord and out into the subarachnoid spaces. Then it moves leisurely down and around the cord and up and around the brain (in the subarachnoid spaces of their meninges) and returns to the blood (in the veins of the brain). Lippincot Company) 147 Human Anatomy and Physiology Figure 7-3 Reflex arc showing the pathway of impulses and a cross section of the spinal cord (Source: Carola, R. Cerebrum Observe in Figure 7-5 the location and relative sizes of the medulla, pons, cerebellum, and cerebrum. It lies just inside the cranial cavity superior to the large hole in the occipital bone called the foramen magnum. Like the spinal cord, the medulla consists of gray and white matter, but their arrangement differs in the two organs. In the medulla, bits of gray matter mix closely and intricately with white matter to form the reticular formation (reticular means "netlike"). In the spinal cord, gray and white matter does not intermingle; gray matter forms the interior core of the cord, and white matter surrounds it. Sensory fibers conduct impulses up from the cord to other parts of the brain, and motor fibers conduct impulses down from the brain to the cord. The cardiac, respiratory, and vasomotor centers (collectively called the vital centers) are located in the medulla. Impulses from these centers control heartbeat, respirations, and blood vessel diameter (which is important in regulating blood pressure). Diencephalon The diencephalon is a small but important part of the brain located between the midbrain inferiorly and the cerebrum superiorly. The posterior pituitary gland, the stalk that attaches it to the undersurface of the brain, and areas of gray matter located in the sidewalls of a fluid-filled space called the third ventricle are extensions of the hypothalamus. Measured by 150 Human Anatomy and Physiology size, it is one of the least significant parts of the brain, but measured its contribution to healthy survival; it is one of the most important brain structures. Impulses from neurons whose dendrites and cell bodies lie in the hypothalamus are conducted by their axons to neurons located in the spinal cord, and many of these impulses are then relayed to muscles and glands all over the body. Among the vital functions that it helps control are the heartbeat, constriction and dilation of blood vessels, and contractions of the stomach and intestines. Some neurons in the hypothalamus function in a surprising way; they make the hormones that the posterior pituitary gland secretes into the blood. Their axons secrete chemicals called releasing hormones into the blood, which then carries them to the anterior pituitary gland. Releasing hormones, as their name suggests, control the release of certain anterior pituitary hormones. Therefore a marked elevation in body temperature in the absence of disease frequently characterizes injuries or other abnormalities of the hypothalamus. In addition, this important center is involved in functions such as the regulation of water balance; sleep cycles, and the control of appetite and many emotions involved in pleasure, fear, anger, sexual arousal, and pain. Just superior to the hypothalamus is a dumbbell- shaped section or largely gray matter called the thalamus. The thalamus is composed chiefly of dendrites and cell bodies of neurons that have axons extending up to the sensory areas of the cerebrum. The way that these pleasant and unpleasant feelings are produced is unknown except that they seem to be associated with the arrival of sensory impulses in thalamus. It contains important nuclei such as medial geniculate which is responsible for auditory sense and lateral geniculate which is responsible for vision. In the cerebellum, gray matter composes the outer layer, and white matter composes the bulk of the interior. Most of our knowledge about cerebellar functions has come from observing patients who have some sort of disease of the cerebellum and from animals who have had the cerebellum removed. From such observations, we know that the cerebellum plays an essential part in the production of normal movements. A patient who has a tumor of the cerebellum frequently loses balance and may topple over and reel like a drunken person when walking. Frequent complaints about being clumsy and unable to even drive a nail or draw a straight line are typical. The general functions of the cerebellum, then, are to produce smooth coordinated movements, maintain equilibrium, and sustain normal postures. If you were to look at the outer surface of the cerebrum, the first features you would notice might be its many ridges and grooves. The deepest sulci are called fissures; the longitudinal fissure divides the cerebrum into right and left halves or hemispheres. These halves are almost separate structures except for their lower midportions, which are connected by a structure called the corpus callosum(Figure 7- 5). Two deep sulci subdivide each cerebral hemisphere into four major lobes and each lobe into numerous convolutions. The lobes are named for the bones that lie over them: the frontal lobe, the parietal lobe, the temporal lobe, and the occipital lobe. A thin layer of gray matter, made up of neuron dendrites and cell bodies, composes the surface of the cerebrum. White matter made up of bundles of neuronal fibers (tracts), composes most of the interior of the cerebrum. Within this white matter, however, are a few islands of gray matter known as the basal ganglia, whose functioning is essential for producing automatic movements and postures. The corpus callosum is a broad band of fibres passing between corresponding cortical areas of the two hemispheres. In midsagital section it is the shape of a hook lying horizontally with its bend anteriorly and its point downwards. The pointed portion is known as the rostrum, the bend as genu, the horizontal part as the body and the expanded posterior end as the splenium. The callosum extends laterally into each hemisphere; the anterior fibres pass forwards into the frontal pole and are known as the forceps major, passes backwards into the occipital poles. A bundle of fibres within the lamina , the anterior commissure , unites the piriform areas and the olfactory tracts of the two sides. The fornix (hippocampal) commissure is found on the undersurface of the corpus callosum where the two crura meet and form the fornix. Many form a well defined layer, the internal capsule, between the lentiform nucleus laterally and the thalamus and caudate nucleus medially. Superiorly its fibres fan out as the corona radiate interdigitating with the fibres of the corpus callosum. It possesses an anterior limb (between the caudate nucleus and the lentiform nucleus and crossed by fibres and grey matter uniting the two structures), an apex (the genu) pointing medially, and a posterior limb lying between the thalamus and the lentiform nucleus. The anterior limb carries (a) frontopontine fibres from the frontal lobe to the pons, and (b) fibres from the thalamus (medial and ventro-anterior nuclei) to the frontal lobe. The posterior limb carries from before backwards, (a) pyramidal fibres from the motor cortex which pass to the cranial nerve nuclei (corticospinal fibres), (b) somatosensory fibres passing from thalamus (ventroposterior nucleus) to the postcentral (somatosensory) cortex, (c)temporopontine fibres from the temporal lobe to the pons, (d) the auditory radiations passing from the medial geniculate body under the lentfiform nucleus, to the superior temporal gyrus, (e) the visual radiations 157 Human Anatomy and Physiology passing from the lateral geniculate body around the lateral aspect of the posterior horn of the lateral ventricle to the visual cortex. The course of the fibres is such that many cross the midline (decusate) and end on the opposite (contralteral) side. The motor areas of each hemisphere control the voluntary muscles of the contralateral side of the body and the sensory areas receive information from the contralateral side.

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Oxygen delivery is therefore primarily dependent on systemic cardiac output purchase cialis with dapoxetine 40/60 mg fast delivery, - 58 - hemoglobin concentration cialis with dapoxetine 20/60 mg for sale, and oxygen saturation buy cialis with dapoxetine 60 mg low cost. Stroke volume is in turn dependent on preload purchase cialis with dapoxetine 30 mg with mastercard, afterload, and myocardial contractility. Both pulmonary blood flow (Qp) and systemic blood flow (Qs) are determined by these fundamental forces. In the patient with two ventricles, ventricular interdependence, or the affect of one ventricle on the other, may play a role in pulmonary or systemic blood flow. In some situations, including the post operative state, the pericardium and restriction due to the pericardial space may also play a role in ventricular output. When evaluating the loading conditions of the heart and myocardial contractility, it is important to consider the two ventricles independently as well as their affect on one another. In previously healthy pediatric patients without heart disease, right atrial filling pressures are commonly assumed to reflect the loading conditions of the left as well as the right ventricle. Pre-existing lesions and the affects of surgery may affect the two ventricles differently. For example, the presence of a right ventricular outflow tract obstruction will lead to hypertrophy of the right ventricle. That right ventricle will be non-compliant, and the right atrial pressure may therefore not accurately reflect the adequacy of left ventricular filling. Oxygen content (CaO2) is primarily a function of hemoglobin concentration and arterial oxygen saturation. Thus, patients who are cyanotic can achieve adequate oxygen delivery by maintaining a high hemoglobin concentration. Arterial oxygen saturation is commonly affected by inspired oxygen content, by mixed venous oxygen content of blood, by pulmonary abnormalities, and by the presence of a R to L intracardiac shunt. Arterial oxygen content in the patient with a single ventricle and parallel pulmonary and systemic circulations will depend on the relative balance between the circulations as well. In the patient with intracardiac shunt or the single ventricle patient, arterial oxygen content is also affected by the relative resistances of the pulmonary and systemic circuits, as this determines how much blood flows through the lungs relative to the systemic output. Low mixed venous oxygen content contributes to desaturation and suggests increased oxygen extraction due to inadequate oxygen delivery, which in turn is either due to inadequate systemic cardiac output or inadequate hemoglobin concentration. A thorough understanding of these fundamental principles of cardiac output and oxygen delivery is essential for the perioperative care of the patient with congenital heart disease. General Principles of Anatomy and Pathophysiology Affecting Pre-operative and Post- operative Management An understanding of the anatomy and pathophysiology of the congenital cardiac lesion under consideration allows one to determine the pre-operative care or resuscitation needed and to predict the expected post-operative recovery. Acyanotic Heart Disease Children with acyanotic heart disease may have one (or more) of three basic defects: 1) left-to-right shunts (e. These lesions may lead to decreased systemic oxygen delivery by causing maldistribution of flow with excessive pulmonary blood flow (Qp) and diminished systemic blood flow (Qs) (Qp/Qs >1), by impairing oxygenation of blood in the lungs caused by increased intra and extravascular lung water, and decreasing ejection of blood from the systemic ventricle. Maldistribution of Flow: Qp/Qs >1 In infants with left-to-right shunts, pulmonary blood flow (Qp) increases as pulmonary vascular resistance (Rp) decreases from the high levels present perinatally. As pulmonary flow increases, left ventricular volume overload may occur with cardiac failure, decreased systemic output, pulmonary congestion and edema. If pulmonary pressures exceed systemic pressures, right to left shunting predominates and the patient becomes cyanotic. Depending on the type and size of the lesion, pulmonary over circulation that remains uncorrected may lead to pulmonary vascular obstructive disease as early as 6 months of age. Pulmonary over circulation can lead to congestive heart failure through several mechanisms. Increased Qp leads to left (systemic) ventricular volume overload and raises left ventricular end diastolic, left atrial, and pulmonary venous pressures. The increases in pulmonary artery and pulmonary venous pressures raise the pulmonary hydrostatic pressure gradient and these promote transudation of fluid into the interstitial space and ultimately lead to alveolar edema. Right ventricular end diastolic pressure, and hence, right atrial and systemic venous pressures, are also elevated. High systemic venous pressure contributes to interstitial edema and may lead to decreased organ perfusion. The maldistribution of flow with reduced Qs is accompanied by a reduction in renal blood flow and resultant stimulation of the renin-angiotensin system (see Chapter 5 on Renal Function in Heart Disease). Pulmonary edema reduces CaO2 through increased intrapulmonary shunting in the lungs. In addition to pulmonary over circulation, other causes of pulmonary edema in patients with acyanotic heart disease include left ventricular inflow- or outflow obstruction and diastolic dysfunction of the left ventricle. These children demonstrate an increased respiratory rate, diffuse rales and increased work of breathing. Myocardial Dysfunction Diastolic and to a lesser extent systolic dysfunction decrease oxygen delivery in patients with cardiomyopathy. Cardiomyopathy represents the primary defect in a variety of heritable and inflammatory heart diseases (See Chapter 47 on Heritable Heart Disease and 44 on - 60 - Inflammatory Heart Disease). Patients with structural congenital heart defects may also develop myopathic changes in the heart. Cyanotic Heart Disease Children with cyanotic heart disease have a right-to-left shunt and therefore always demonstrate systemic arterial desaturation. Infants with cyanotic heart disease may be divided into two physiologically distinct groups, those with decreased pulmonary blood flow and those with increased pulmonary blood flow. Ductal Dependent Pulmonary Blood Flow (Decreased Pulmonary Blood Flow) These patients have decreased systemic venous blood entering the pulmonary circulation. Patients in this group may have obstruction to flow from the pulmonary ventricle either at the outlet (e. Patients whose pulmonary blood flow is dependent on a patent ductus arteriosus may present with severe hypoxemia and acidosis as the ductus closes. With decreased Qp and the obligatory presence of an atrial or ventricular septal defect, the blood in the systemic ventricle consists of desaturated systemic venous blood (via the septal defect) and a smaller volume of saturated pulmonary blood (Qp/Qs < 1). The decreased Qp results in decreased oxygen uptake from the lungs, and thus decreased systemic oxygen delivery. If systemic oxygen delivery remains inadequate, anaerobic metabolism and myocardial dysfunction develop, resulting in a further reduction in oxygen delivery. Patients with decreased Qp require a stable conduit for pulmonary blood flow and a high hemoglobin concentration (> 14 mg/dl) to maximize oxygen content CaO2) and oxygen delivery (D02). Ductal Dependent Systemic Blood Flow (Increased Pulmonary Blood Flow) Patients with ductal dependent systemic blood flow have increased pulmonary blood flow but decreased systemic blood flow due to obstruction of systemic output which can occur at a variety of locations. Systemic blood flow in patients with severe left ventricular outflow obstruction is dependent on flow through a patent ductus arteriosus into the aorta distal to the obstruction. Pre-op Stabilization, Surgical Planning The degree to which infants and children will require pre-operative stabilization will depend on the nature and severity of the lesion, the degree to which the lesion has affected the myocardial function, and the presence of other organ system involvement. Many of the concepts involved in pre-operative stabilization will be applicable to post operative care. Additionally, any abnormalities of other organ systems, such as pneumonia, renal insufficiency, or seizures, must be evaluated and corrected if possible. Manipulation of Qp and Qs and the balance between the pulmonary and systemic circulations is achieved by manipulation of the preload, afterload, and inotropic state of the right and left ventricle. Pulmonary vascular resistance is affected by pH, alveolar pO2, lung volume (atelectasis or overdistension), noxious stimuli, hematocrit, and many medications. The patient with excessive pulmonary blood flow and consequent low systemic oxygen delivery can be managed with maneuvers to increase pulmonary vascular resistance (Rp), which will lead to decreased Qp and increased Qs. In the patient with ductal dependent pulmonary or systemic blood flow, the balance of pulmonary and systemic flow can be manipulated by manipulation of pulmonary vascular resistance or the systemic vascular resistance if needed. Afterload reduction may improve myocardial function by decreasing ventricular wall tension, thus improving stroke volume and decreasing myocardial oxygen consumption. Vasodilator administration will not increase Qs, but rather may cause shock, myocardial ischemia, or life threatening arrhythmias. In this situation afterload reduction is accomplished by relief of the fixed obstruction by surgical or catheterization techniques. The myopathic ventricle requires a greater than normal preload to maintain output. On the other hand if the infant with a myopathic ventricle presents with hypoperfusion, hypotension and acidosis, carefully titrated fluid administration may be necessary to optimize preload and increase cardiac output. Unfortunately, inotropic drugs which increase cytosolic Ca++ concentration may also impair relaxation of the heart and decrease ventricular compliance (see Chapter 2 on Normal and Abnormal Myocardial Contraction) and limit preload. Therefore, in patients with a pressure overloaded ventricle and risk of myocardial ischemia, inotropic agents with minimal chronotropic activity should be selected. These children will benefit from oxygen administration to treat the hypoxia and diuretic therapy to reduce the intravascular volume and left atrial pressure. Assisted mechanical ventilation of the child with pulmonary edema may directly increase both CaO2 and systemic output. Post Operative Care Postoperative care requires a thorough understanding of the anatomic defect, the pathophysiology of the pre-operative heart as well as any other organ system involvement, the anesthetic regimen used, cardiopulmonary bypass issues, and the details of the operative procedure. Invasive and non-invasive monitoring and laboratory or radiographic monitoring is tailored to the needs of the individual patient and will depend on the lesion, the repair, and expected post-operative issues. Mechanical Ventilation and Pulmonary Support Patients who require mechanical ventilation post-operatively do so for a variety of reasons: airway control, abnormal lung function, reduction of oxygen delivery needs, assurance of stability during the immediate post operative period, because of the affect of positive pressure ventilation on cardiac loading conditions, or due to neurologic concerns or residual anesthesia. Mechanical ventilation, either in the operating room or the intensive care unit, is continued until there is adequate hemostasis, the heart rate and rhythm are stable and close to normal for age, cardiac output is adequate with minimal inotropic support, oxygen saturation is adequate and lung function is close to normal, and the patient is awake enough to have adequate respiratory drive and airway protective reflexes. Depending on a number of factors, these conditions may be met in the operating room or the intensive care unit much later in the post-operative course.

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An abnormally colored fluid may appear milky (chylous or pseudochylous) generic 30 mg cialis with dapoxetine, cloudy cheap 20/60 mg cialis with dapoxetine visa, or bloody on gross 429 Hematology observation order cialis with dapoxetine 20/60mg online. Blood-tinged fluid can be seen as a result of a traumatic tap cialis with dapoxetine 60 mg low cost, and grossly bloody fluid can be seen when an organ such as the spleen or liver or a blood vessel has rupture. Bloody fluids are also seen in malignant diseases states, after myocardial infarction, in tuberculosis, in rheumatoid arthritis, and in systemic lupus erythematosus. Clotting To observe the ability of the serous fluid to clot, the specimen must be collected in a plain tube with no anticoagulant. Red and white Blood cell count Cell counts are done on well-mixed anticoagulated serous fluid in a hemocytometer. If significant protein is present, acetic acid cannot be used as a diluent for white cell counts, owing to the precipitation of protein. In this case, saline may be used as a diluent and the red and white cell counts are done simultaneously. Red cell counts of more than 10000/µl may be seen as effusion with malignancies, infarcts, and trauma. The white cells generally resemble those seen in peripheral blood, with the addition of mesothelial lining cells. If any malignant tumor cells are seen or appear to be present, the slide must be referred to a pathologist or 431 Hematology qualified cytotechnologist. Normal synovial fluid is an ultrafiltrate of plasma with the addition of a high molecular-weight mucopolysaccharide called hyaluronate or hyaluronic acid. It is responsible for the normal viscosity of synovial fluid, which serves to lubricate the joints so that they move freely. This normal viscosity is responsible for some difficulties in the examination of synovial fluid, especially in performing cell counts. Normal synovial fluid Normal synovial fluid is straw colored and viscous, resembling uncooked egg white. About 1ml of synovial fluid is present in each large joint, such as the knee, ankle, hip, elbow, wrist, and shoulder. In normal synovial fluid the white cell count is low, less than 200/µl, 432 Hematology and the majority of the white cells are mononuclear, with less than 25% neutrophils. Since the fluid is an ultrafiltrate of plasma, normal synovial fluid has essentially the same chemical composition as plasma without the larger protein molecules. Aspiration and analysis The aspiration and analysis of synovial fluid may be done to determine the cause of joint disease, especially when accompanied by an abnormal accumulation of fluid in the joint (effusion). Morphologic analysis of cells and crystals, together with Gram stain and culture, will help in the differentiation. Effusion of synovial fluid is usually present clinically before aspiration, and therefore it is often possible to aspirate 10 to 20ml of the fluid for laboratory examination, although the volume (whit is normally about 1ml) may be extremely small, so that the laboratory receives only a drop of fluid contained in the aspiration syringe. The fluid is collected with a disposable needle and plastic syringe, to avoid contamination with confusing birefringent material. A plain tube (without anticoagulant) for clot formation, gross appearance, and chemical and immunologic procedures. This is especially true when only a small volume of fluid is aspirated, giving an excess of anticoagulant, which may crystallize. However, infectious and crystal-induced fluids tend to form fibrin clots, making an anticoagulant necessary for adequate cell counts and an even distribution of cells and crystals for morphologic analysis. Routine examination of synovial fluid The routine examination of synovial fluid should include the following 1. Other tests, as necessary Gross appearance The first step in the analysis of synovial fluids is to 435 Hematology observe the specimen for color and clarity. As the cell and protein content increases, or crystals precipitate, the turbidity increases, and the print becomes more difficult to read. In a traumatic tap of he joint, blood will be seen in the collection tubes in an uneven distribution with streaks of blood in the aspiration syringe. Xanthochromia in the supernatant fluid indicates bleeding in the joint, but is difficult to evaluate because the fluid is normally yellow. A dark-red or dark-brown supernatant is evidence of joint bleeding rather than a traumatic tap Viscosity Viscosity is most easily evaluated at the time of arthrocentesis by allowing the synovial fluid to drop from the end of the needle. However, this test is of questionable value, as results rarely change the diagnosis and are essentially the same as with the string test for viscosity. Red cell and White Blood cell count The appearance of a drop of synovial fluid under an ordinary light microscope can be helpful in estimating the cell counts initially and in demonstrating the presence of crystals. When cells are counted in other fluid, such as blood, the usually diluting fluid is dilute acetic acid. If it is necessary to lyse red blood cells, either hypotonic saline or saponinized saline can be used as a diluent. Since acetic acid cannot be used as a diluent, both red and white cells are enumerated at the same time. Cell counts below 200/µl with less than 25% polymorphonuclear cells and no red cells are normally observed in synovial fluid. A low white cell count (200 to 2000/µl) with predominantly mononuclear cells suggests a noninflammatory joint fluid, while a high white cell count suggests inflammation and a very high white cell count with a high proportion of polymorphonuclear cells strongly suggests infection. Eosinophilia may be seen in metastatic carcinoma to the synovium, acute rheumatic fever, and rheumatoid arthritis. It is also associated with parasitic infections and Lyme disease and has occurred after arthrography and radiation therapy. Each product or fraction varies in its individual composition, each contributing to the whole specimen. During ejaculation, 439 Hematology the products are mixed in order to produce the normal viscous semen specimen or ejaculate. These include assessment of fertility or infertility, forensic purposes, determination of the effectiveness of vasectomy, and determination of the suitability of semen for artificial insemination procedures. Collection of semen specimen Give the person a clean, dry, leak-proof container, and request him to collect a specimen of semen at home following 3-7 days of sexual abstinence. When a condom is sued to collect the fluid, this must be well- washed to remove the powder which coats the rubber. Coitus interruptus method of collection should not be used because the first portion of the ejaculate (often containing the highest concentration of spermatozoa) may be lost. Also the acid pH of vaginal fluid can affect sperm motility and the semen may become contaminated with cells and bacteria. This is best achieved by placing the container inside a plastic bag and 440 Hematology transporting it in a pocket in the person’s clothing. Laboratory assays The sample should be handled with car because it may contain infectious pathogens, e. When investigating infertility, the basic analysis of semen (seminal fluid) usually includes: • Measurement of volume • Measurement of pH • Examination of a wet preparation to estimate the percentage of motile spermatozoa and viable forms and to look for cells and bacteria • Sperm count • Examination of a stained preparation to estimate the percentage of spermatozoa with normal morphology Measurement of volume Normal semen is thick and viscous when ejaculated. Estimate the percentage of motile and viable spermatozoa Motility: Place 1 drop (one drop falling from a 21g needle is equivalent to a volume of 10-15µl) of well- mixed liquefied semen on a slide and cover with a 20x20mm or 22x22mm cover glass. Ensure the spermatozoa are evenly distributed (if not, re-mix the semen and examine a new preparation). When more than 60% of spermatozoa are non-motile, examine an eosin preparation to assess whether the spermatozoa are viable or non-viable. Use the low power objective to focus the specimen and the high power objective to count the percentage of viable and non-viable spermatozoa. A large proportion of non-motile but viable spermatozoa may indicate a structural defect in the flagellum. Using the low power objective with the condenser iris closed sufficiently to give good contrast, count the number of spermatozoa in an area of 2 sq mm, i. Estimate the percentage of spermatozoa with normal morphology in a stained preparation Make a thin smear of the liquefied well-mixed semen on a slide. Count 100 spermatozoa and estimate the percentage showing normal morphology and the percentage that appear abnormal. Abnormal semen findings should be checked by examining a further specimen, particularly when the sperm count is low and the spermatozoa appear non- viable and abnormal. When the abnormalities are present in the second semen, further tests are indicated in a specialist center. Each consists of an oval-shaped head (with acrosomal cap) which measures 3-5 x 2-3µm, a short middle piece, and a long thin tail (at least 45µm in length). Staining feature: Nucleus of head-dark blue; cytoplasm of head-pale blue; Middle piece and tail-pink-red. Abnormal spermatozoa: the following abnormalities may be seen: • Head: greatly increased or decreased in size; abnormal shape and tapering head (pyriform); acrosomal cap absent or abnormally large; Nucleus contains vacuoles or chromatin in unevenly distributed; two heads; additional residual body, i. One of the major technologic changes in the clinical laboratory has been the introduction of automated analysis. An automated analytic instrument 449 Hematology provides a means for transfer of a specimen within its complex assembly to a series of self-acting components, each of which carries out a specific process or stage of the process, ending in the analytic result being produced. Automation systems include some kind of device for sampling the patient’s specimen or other samples to be tested (such as blanks, controls, and standard solutions), a mechanism to add the necessary amounts of reagents in the proper sequence, incubation modules when needed for the specific reaction, monitoring or measuring devices such as photometric technology to quantitate the extent of the reaction, and a recording mechanism to provide the final reading or permanent record of the analytic result. Electronic cell counters have 450 Hematology replaced manual counting of blood cells even in clinics and physicians’ office laboratories. Prothrombin time and activated partial thromboplastin time determinations can be done automatically on various instruments. Several instruments are available for precise and convenient diluting, which both aspirate the sample and wash it out with the diluent.

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