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By: Q. Kalan, M.B. B.CH., M.B.B.Ch., Ph.D.

Medical Instructor, Yale School of Medicine

Maternal hypotension is a common complication of blockade of sympathetic nerves blood pressure 160100 purchase generic midamor online, most characteristically cardiac sympathetic nerves blood pressure normal heart rate high buy cheapest midamor. This complication can lead to a sudden drop in heart rate with low cardiac output arrhythmia when falling asleep midamor 45 mg mastercard, and if aorto-caval compression is not avoided there will be persistent hypotension that can compromise the baby. The height of a sympathetic block can be a few dermatomes higher than the measured sensory level. This complication is seen more in women who come for elective sections more often than in those who are already in labor, because the reduced amount of fluids after the rupture of the membranes causes less aorto-caval compression, and because maternal physiological adjustments have already taken place. Supplementation of intraoperative analgesia can be used, when performed with vigilance for sedation. Regarding the risk of hemorrhage, it appears that there is less bleeding to be expected in cesarian section under regional blocks. In contrast, general anesthesia, when using inhalation agents, carries the risk of uterine relaxation and increased venous bleeding from pelvic venous plexuses. Although there is a traditionally held view that regional anesthesia should be avoided whenever hemorrhage is expected in gestosis, the favorable influence of regional blocks on this disease may on the contrary be an argument for regional anesthesia. Postoperative pain is better managed after regional anesthesia in both obstetric and nonobstetric patients, perhaps due to a reduction in centrally transmitted pain, as suggested in laboratory work. Postoperative recovery is improved, and mothers are able to bond with their babies sooner. The lack of drug effects in the newborn, seen when regional anesthesia is used, means less intervention for the baby. Whenever the newborn is already distressed and acidotic, attention must be paid to avoiding aortocaval compression and maternal hypotension. The full lateral position must be adopted in all mothers expected to develop severe hypotension. Rapid infusion of a large volume of fluid can cause a sudden rise in central venous pressure and lead to pulmonary edema in predisposed parturients. Intravenous crystalloid preload will not reduce the need for vasopressors, and the infusion must consist of a very large quantity. With the smaller needles, with their atraumatic pencilpoint tips, the rate of headache is less than 1% unless the mother is very short or very tall. Factors like patient 132 positioning and the size of pregnancy can influence the spread and extent of the block. Increasing the dose beyond this recommended dose does not seem to provide better analgesia intra- or postoperatively. Patient positioning does not seem to influence the final level or height of the block, but it interferes with the rate of onset and spread of the local anesthetic. The sitting position is commonly used by many anesthesiologists, but a lateral position can be used too. The block extended to T5 to light touch is an effective level for this type of surgery, using either the epidural or spinal technique. The only difference may be that a more profound block is achieved more easily with the intrathecal block. The epidural must be topped up as soon as possible, unless a very recent top-up has been given during labor, and then 20 mL of plain 0. Once the top-up has been given, the anesthesiologist must stay with the patient all the time, check her blood pressure, and have diluted ephedrine at hand. The safest position for the mother during transport to the operating room is the full lateral position. If there is any inequality in the spread of the block on initial assessment, put the mother in the full lateral position on the side of the poor block and give the topup. Pearls of wisdom There are a variety of pharmacological options for managing the pain of parturition. Opioids administered systemically act primarily by inducing somnolence, rather than by producing analgesia. Moreover, placental transfer of opioids to the fetus may produce neonatal respiratory depression. An adequately trained midwife or obstetrician is able to provide excellent nurse- or physician-controlled analgesia in locations where an anesthesiologist is not available or if regional analgesia (epidural and/or spinal) is contraindicated. Regional analgesic techniques are the most reliable means of relieving the pain of labor and delivery. Furthermore, by blocking the maternal stress response, epidural and spinal analgesia may reverse the untoward physiological consequences of labor pain.

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There were no postnatal complications and this infant was discharged from the hospital at 48 hours of life blood pressure chart tracker generic midamor 45 mg. Her family history is also unremarkable in that there is no history of seizures blood pressure medication help lose weight buy cheap midamor 45 mg line, mental retardation high blood pressure medication and sperm quality discount midamor 45 mg overnight delivery, or consanguinity. She has multiple small 1-2 cm oval, irregular hypopigmented macules on her trunk and extremities. Tuberous sclerosis was probably first described by Friedrich Daniel von Recklinghausen in 1862, when he presented a baby who died "after taking a few breaths". Therefore, it is in the same family of disorders, which includes neurofibromatosis, Sturge-Weber disease, von Hippel-Lindau disease, ataxia telangiectasia, linear nevus syndrome, hypomelanosis of Ito, and incontinentia pigmenti (2). The estimated frequency is 1 in 6000, and there is no racial predilection; therefore, we have seen several of these patients in Hawaii. Also, because of the variable expression of this disease, it is imperative that in obtaining a family history, one asks if there is a history of mental retardation; seizures; obstructive hydrocephalus; brain or cardiac tumors; cardiac dysrhythmias at an early age; stillbirths (especially with hydrops); kidney, lung, or bone cysts; pulmonary failure; spontaneous pneumothorax; renal angiomyolipomas or failure; fibromatous growths around or under the nails or on gums; enamel pits; retinal phakomas; skin lesions such as hypopigmented macules, facial angiofibroma and shagreen patches; poliosis (premature white hair) or canities (white hairs) of the scalp, lashes, or brows; and iris depigmentation, in addition to recognizing that these signs can be mistaken for vitiligo, refractory acne, or autosomal dominant polycystic kidney disease. Tuberous sclerosis is a multiorgan disease and does not only include the brain pathology; therefore, "tuberous sclerosis complex" may be a better term for this disease (4). Infantile spasms usually begin between the ages of 4 and 8 months, and present with brief symmetrical contractions of the neck, trunk, and extremities, which can either be in flexion or extension, or both. Clusters of seizures may last for minutes with a brief period occurring between each seizure, and may be preceded or followed by a cry. Although they can occur at all ages, they usually occur in the first year of life. The most common seizure types, besides infantile spasms, are partial simple, partial complex, and partial with secondary generalization (6). Two hamartomatous brain lesions are subependymal nodules and subependymal giant cell tumors. Subependymal nodules are growths that are usually on the outer walls of the lateral ventricles, nearly always next to or within the caudate nucleus. These tumors usually lie adjacent to the foramen of Monro and are histologically identical to the subependymal nodules. The difference between the giant cell astrocytomas and subependymal nodules is the propensity for growth in the former. After seizures, mental retardation and other psychiatric problems are also commonly seen in tuberous sclerosis patients. Patients who have never had seizures, infrequent seizures, or seizures after 4 years of age, will most likely have normal intelligence and development. They appear on the trunk and extremities, number anywhere from 3 to 4, to more than 100, and are usually 1. At times, numerous tiny macules are grouped together, resembling confetti, and are usually located in the distal parts of the extremities. Although ash leaf spots appear at birth and may last throughout life, they can become less obvious with time and disappear. They are tiny red or pink papules with a glistening surface found bilaterally over the cheeks, chin, and nasolabial folds in a butterfly fashion. They are yellowish brown or pink in color, feel like pigskin or an orange peel, and can be few millimeters to over 10 cm in size. For ophthalmologic lesions, the most common retinal hamartoma is the noncalcified tumor, which appears as a smooth, salmon-gray colored, circular lesion with indistinct borders. Despite the lesions that can occur in the eye, blindness is rare, except in cases where the tumor involves the fovea or optic nerves (10). Echocardiography is an essential component in the work-up of these individuals (11). There are many causes of seizures, however, it is important to note whether any neurocutaneous stigmata such as ash leaf spots or cafe au lait spots are present since they will be clues that neurocutaneous syndromes like tuberous sclerosis or neurofibromatosis may be the cause. There are many manifestations and degrees of severity of tuberous sclerosis; therefore, management should be aimed at treatment and evaluation of the symptoms.

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Film dressings have the advantage that the inner layers of the dressing can assist with debridement blood pressure 9070 purchase 45 mg midamor amex. The authors stressed that strong evidence supporting the superiority of one dressing over another is not available blood pressure cuff name purchase midamor 45 mg line. Ultimately sheer heart attack buy discount midamor line, the treating surgeon will need to choose an approach that is cost efficient and associated with maximum compliance. A time-tested approach is to combine compression with moisture and medication, such as the Unna Boot. This device is inexpensive but must be changed weekly 56 American College of Surgeons facs. Surgical Approaches to Venous Ulceration Direct surgical approaches to the venous ulcer may be helpful. We previously mentioned the importance of ulcer debridement and cleansing before wound dressing and compression. In long-standing venous ulcers, excision of the ulcer and the underlying, often fibrotic, fascia with skin grafting may accelerate the rate of healing. This procedure also gives an opportunity to obliterate any incompetent perforating veins that might underlie the ulcerated area. Surgical approaches to superficial varicosities with incompetent valves might also improve prospects of ulcer healing. Howard and coauthors149 presented a systematic review of available data on using superficial vein procedures to treat venous ulceration in the European Journal of Vascular and Endovascular Surgery, 2008. The authors reviewed 61 surgical literature articles to evaluate the evidence for or against the role of superficial saphenous ligation and stripping in managing venous ulceration. The authors concluded, after their extensive literature review, that superficial vein procedures for treatment of venous ulcers improve the rates of recurrence but not the rates of ulcer healing. Overall, the results of ulcer treatment are not as good when deep venous valve dysfunction or venous outflow obstruction exists in conjunction with the ulcer. This observation raises the question whether direct interventions to improve venous outflow are indicated to improve the rates of venous ulcer healing. Meissner and coauthors141 stated that improvements in venous outflow can be achieved in patients with stenoses of proximal deep veins of greater than 50%. Endovascular stents, repair of deep venous valves in the popliteal vein and more proximally, and vein bypass of stenoses are measures discussed by Meissner and colleagues. The authors stressed that careful diagnostic evaluation using intravascular ultrasound and contrast venography are important parts of the evaluation before any of the mentioned procedures. Their report also emphasized that patency rates are generally in the 90% range at three and five years after stenting, and bypass and mortality rates are less than 1%. In addition, Meissner cited several studies of the various interventions indicating improvements in venous severity scores and quality of life in the majority of patients after successful interventions. Seager and coauthors150 reviewed endovascular stenting for chronic venous obstruction in the European Journal of Vascular and Endovascular Surgery, 2016. There was significant heterogeneity of the studies, but the data suggested that improved ulcer healing and improved quality of life were frequently cited in the available studies. While the authors affirmed the need for prospective randomized trials, they also stressed that endovascular stenting should be considered for patients with symptomatic chronic venous obstruction. Delis and coauthors151 presented additional data confirming the utility of deep venous procedures to improve venous outflow in Annals of Surgery, 2007. This analysis evaluated venous outflow and muscle pump function as well as intensity of venous claudication in 16 patients with documented venous outflow obstruction in one limb. All outflow veins were successfully stented and the authors observed improvements in muscle pump function and venous outflow. Reflux increased in all patients, but this did not prevent a significant improvement in the intensity of venous claudication. The authors concluded that symptomatic improvement, coupled with improved venous outflow and muscle pump function, make stenting to improve venous outflow an attractive alternative in these highly-selected patients. Meissner and associates141 confirmed that there have been encouraging results with the use of vein bypass of deep venous obstructions. Readers are encouraged to read this article for details of this procedure that might be helpful for carefully selected patients.

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General Aspects of Peripheral Vascular Injuries Vascular injuries are encountered uncommonly in civilian trauma practice blood pressure range buy 45 mg midamor with amex. Major arterial injuries requiring intervention are observed in less than 5% of the total population of injured patients blood pressure medication with low side effects order 45 mg midamor amex. Most vascular injuries involve arteries and veins of the extremities; the clinical guidance article by Feliciano and coauthors1 cited data confirming that up to 70% of vascular injuries seen in U zartan blood pressure medication best midamor 45mg. Additional data cited by the authors showed that most extremity vascular injuries are due to penetrating mechanisms. Low-velocity gunshot wounds cause 50% of these injuries and stab wounds cause 30% of the injuries. Blunt vascular injury frequencies vary from 5% to 25% of those reported, depending on the data source. The main danger of extremity vascular injuries is mortality due to exsanguination. With continued military and civilian efforts to increase the use of wound compression and tourniquets to control bleeding in the prehospital and early inpatient care phases, death from exsanguination has decreased. Data supporting the benefit of tourniquet use to reduce blood loss from combatrelated vascular injuries were presented in an article by Kragh and coauthors13 in Annals of Surgery, 2009. The authors conducted a prospective study of tourniquet use at a single military hospital in Iraq. The data analysis disclosed that prehospital tourniquet application before development of hemorrhagic shock after extremity injury was associated with a mortality of 10%, while delayed tourniquet application after arrival at the hospital had a mortality risk of 24%. All delayed tourniquet applications were in patients with clinical signs of shock. Passos and coauthors14 focused on using tourniquets to control bleeding in civilian vascular injuries in Injury, 2014. The article was a retrospective review of data from two Canadian trauma centers; outcomes in 190 patients seen over a nine-year interval were recorded. Eight patients in this group had tourniquets applied in the prehospital phase of care or within one hour of arrival at the hospital; all eight patients survived. Six patients with massive blood loss did not have tourniquets applied and all died. The authors concluded that their data suggests a potential benefit for tourniquet use in patients with extremity vascular injuries and massive hemorrhage. Prolongation of the interval from injury to revascularization beyond six hours, overall injury severity, and the extent of skeletal, neurologic, and soft tissue damage (usually reported as the mangled extremity score) have been cited as predictors of limb loss in patients with lower extremity injuries. Data cited by Feliciano and coauthors1 show that penetrating injury results in amputation in 2%­6% of patients. Blunt injuries result in limb loss in 10%­20% of patients mainly because of associated fractures and extensive nerve and soft tissue injuries. The abiding belief among surgeons caring for patients with extremity vascular injuries is that injuries to upper extremity vessels do not carry the same limbloss risks as injuries to lower extremity vessels. Possible reasons for improved results in upper extremity injuries include more effective collateral circulation in the upper extremity, redundancy of the innervation to distal extremity structures, and observed lower frequency of postrevascularization compartment syndromes. Simmons and coauthors15 presented data that support improved outcomes for vascular injuries of the upper extremities in the Journal of Trauma, 2008. In this group, there were four deaths and among the 37 surviving patients, four amputations were required. In 28 patients with overtly ischemic limbs on admission, 24 were revascularized successfully with limb salvage. Amputation was necessary in four patients because of severe associated nerve injury, not because of failure of vascular repair. Amputation was required in only four of 23 patients with significant neurologic deficit. Although more severe injuries and higher mangled extremity scores were associated with amputation, these indicators were not predictive of amputation.

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