By Y. Silas. Pacific College of Oriental Medicine. 2019.
If the patient has Ogilvie syndrome order 100 mg suhagra, or a paralytic ileus of the colon discount 100mg suhagra otc, a rectal tube proven 100 mg suhagra, colonoscopic decompression, or neostigmine should be considered. A urinary indwelling catheter should also be in place, not only for monitoring of intraabdominal pressures and urine output, but also to decompress the bladder and to reduce the abdominal volume. Continuous venovenous hemodialysis and slow extended daily dialysis has been studied in a small series. With such limited data, no recommendation regarding hemodialysis was made by the World Society of Abdominal Compartment Syndrome . Five required percutaneous drainage only and four failed percutaneous drainage and underwent decompressive laparotomy. In the percutaneous drainage-only group, 38 ± 28 mL per kg of fluid were drained by the catheter and 45 ± 20 mL per kg were removed initially in the percutaneous/decompressive laparotomy group. The author’s conclusions were that drainage is a viable technique as no patient experienced any complications directly related to the percutaneous drainage . Percutaneous drainage was successful for 81% of the patients with the remaining 19% of the patients requiring a decompressive laparotomy. Important predictors of failure of percutaneous drainage were drainage of less than 1,000 mL via the catheter and failure to reduce measured intraabdominal pressure by 9 mm Hg. Given that the abdominal cavity is not completely rigid, another medical management technique may include increasing the abdominal volume by relaxing the abdominal musculature with heavy sedation and neuromuscular blockade. Vigilance is therefore still required after surgical decompression and it would seem prudent to continue to monitor abdominal pressures. Enterocutaneous fistula, intraabdominal abscesses, and organ failure are associated with an open abdomen . After laparotomy, a variety of techniques have been employed for coverage of the abdominal viscera to prevent the development of entero- atmospheric fistulae, control fluid losses, and allow re-exploration. While there are commercially available products and suction devices, standard operating room equipment can be fashioned into a system. The benefit of this technique is that it (1) prevents the intraabdominal viscera from becoming adherent to the abdominal wall; (2) the negative pressure controls and removes fluid; (3) the negative pressure may prevent fascial retraction allowing for easier delayed abdominal wall closure; (4) dressing changes can be performed every 3 to 4 days simplifying wound management. Abdominal closure can be facilitated by placing tension on the fascia to prevent fascial retraction . Protocols that specify scheduled re- exploration and partial closure with each trip to operating room has been advocated and their use has been associated with abdominal wall closure rates up to 100% . Other techniques to obtain closure include acute component separation, or planned hernia with delayed component separation. This technique has not been studied for acutely ill patients who are not medically optimized and likely malnourished. The failure of component separation in the acute setting makes this method unavailable in the future for that patient when it would likely be successful. Current recommendations are to reserve component separation for elective repairs for medically optimized patients . If the decision is to allow the patient to have a large abdominal wall hernia, coverage of the abdominal viscera with a split thickness skin graft or skin-only closure will usually be required. This concept emphasizes early control of hemorrhage, transfusion of blood and blood products, and reduced administration of crystalloids . The type of fluid as well as the volume infused may prove consequential in secondary compartment syndrome. A meta-analysis suggested albumin use decreased the occurrence of all compartment syndromes but this study did not differentiate between the types of compartment syndromes . Damage control surgery and deciding not to close the abdomen at the index operation is also an important part of prevention. For trauma patients, major liver injury or any other injury requiring packing for hemostasis is one consideration. A small series examined the outcomes of 27 patients with a ruptured abdominal aortic aneurysm who were repaired by the open technique. Current societal recommendations for trauma and emergency surgery patients suggest the following intraoperative markers to consider leaving the abdomen open: large volume resuscitation defined as transfusion of greater than 10 units of packed red blood cells or the administration of greater than 15 L of crystalloid. Sugarman H, Windsor A, Bessos M, et al: Intra-abdominal pressure, sagital abdominal diameter, obesity comorbidity. Starkopf J, Tamme K, Blaser A: Should we measure intra-abdominal pressures in every intensive care patient. Risin E, Kessel B, Ashkenazi I, et al: A new technique of direct intra- abdominal pressure measurement: a preliminary study. De Waele j, Pletinckx P, Blot S, et al: Saline volume in transvesical intra-abdominal pressure measurement: enough is enough. Cavaliere F, Cina A, Biasucci D, et al: Sonographic assessment of abdominal vein dimensional and hemodynamic changes induced in human volunteers by a model of abdominal hypertension. Dalfino L, Tullo L, Donadio I, et al: Intra-abdominal hypertension and acute renal failure in critically ill patients. Wauters J, Claus P, Brosens N, et al: Relationship between abdominal pressure, pulmonary compliance, and cardiac preload in a porcine model. Gunst M, Ghaemmaghami V, Sperry J, et al: Accuracy of cardiac function and volume status estimates using the bedside echocardiographic assessment in trauma/critical care. Renner J, Gruenewald M, Quaden R, et al: Influence of increased intra- abdominal pressure on fluid responsiveness predicted by pulse pressure variation and stroke volume variation in a porcine model. Citerio G, Vascotto E, Villa F, et al: Induced abdominal compartment syndrome increases intracranial pressure in neurotrauma patients: a prospective study. De Laet I, Deeren D, Schoonheydt K, et al: Renal replacement therapy with net fluid removal lowers intra-abdominal pressure and volumetric indices in critically ill patients. De lae I, Hoste E, Verholen E, et al: the effect of neuromuscular blockade in patients with intra-abdominal hypertension. Djavani K, Wanhainen A, Bjorck M: Intra-abdominal hypertension and abdominal compartment syndrome following surgery for ruptured abdominal aortic aneurysm. Maternal mortality has been decreasing each year since 1990, with the greatest reductions in these deaths coming in developed countries. It is unknown if this difference is due to an improvement of identifying and coding for pregnancy-related deaths , or if it should be attributed to increases in maternal age, body mass index, and comorbidities. The leading cause of maternal mortality in the United States is cardiovascular disease and cardiomyopathy. Other common causes of mortality include thromboembolic events, hemorrhage, infections, and amniotic fluid embolism . This chapter will review the maternal anatomic and physiologic adaptations to pregnancy, considerations of potential fetal harm from diagnostic studies or medication administration, and specific pregnancy disease states that may complicate the care of the critically ill pregnant patient such as preeclampsia, eclampsia, obstetric hemorrhage, and trauma. Specifics related to the diagnosis and treatment of respiratory failure and other common medical problems in pregnancy is discussed elsewhere in the text (Chapter 164). These changes start early in the first trimester, peak in the second trimester, and remain constant until delivery . Cardiac output rises up to 50% above baseline during pregnancy, with half of this rise coming in the first trimester. Cardiac output increases by several mechanisms including: (1) increasing preload (rise in blood volume), (2) decreasing afterload (decrease in vascular resistance) and (3) a rise in heart rate . Initially, the increase in cardiac output comes from the rise in stroke volume, and later in pregnancy, heart rate is the major factor.
Mortality associated with empyema is high: 8-15% in young patients purchase suhagra with a mastercard, and 40-70% in elderly ones buy suhagra once a day. These products slow the growth of bacteria purchase suhagra visa, lengthening doubling times by a factor of 20-70. The slow growth of the bacteria renders them less sensitive to the cidal effects of antibiotics. At the margin between fluid and aerated lung, egophony and bronchial breath sounds are commonly heard, reflecting areas of pulmonary consolidation or atelectasis. A lateral decubitus view with the pleural effusion side down can demonstrate layering of 5-10 mL of free fluid. Ultrasound is very useful in determining the dimensions of the effusion, and it is the most effective method for guiding thoracentesis. Septations are readily visualized by this technique and indicate the development of a loculated collection that requires drainage. Ultrasound guidance of thoracentesis is strongly recommended because of the associated decreased incidence of complicating pneumothorax. If the fluid is not overtly purulent, the fluid should also be analyzed for pH, glucose, lactate dehydrogenase, and total protein. When a significant pleural fluid collection is apparent, a more prolonged course of antibiotics (2-4 weeks) is generally required. Parapneumonic effusions that move freely and that are less than 1 cm in width on lateral decubitus film can be managed medically; thoracentesis is not required. If the collection is larger or does not flow freely, thoracentesis should be performed. If biochemical evidence for empyema is present, drainage by chest tube is recommended. Repeated thoracentesis is rarely successful in completely draining the pleural fluid collection unless the fluid has a thin viscosity and is present in small volumes. Drainage by closed chest tube is usually successful with smaller effusions occupying up to 20% of the hemithorax, but it is often ineffective when the volume of fluid occupies more than 40% of the hemithorax. If tube drainage proves ineffective after 24 hours, intrathoracic urokinase (125,000 U diluted in 50-100 mL sterile normal saline) should be instilled to break down intrapleural fibrin and encourage free drainage of infected fluid. If thoracentesis and urokinase are unsuccessful, operative intervention is required. Empyema is a serious complication, with an associated 8-15% mortality in young, previously healthy patients and 40-70% mortality in patients who are elderly or have significant underlying disease. Patients with nosocomial pathogens and polymicrobial infection also have a worse prognosis. Delay in diagnosis and appropriate drainage increases the need for surgical resection of the pleura and manual re-expansion of the lung. Why should combination antituberculous therapy always be prescribed in active tuberculosis? In which areas of the country is histoplasmosis most commonly encountered, and why? In which areas of the country is coccidioidomycosis most commonly encountered, and why? About 5 months earlier, he had begun to notice night sweats that drenched his pajamas. He began bringing up small quantities of yellow sputum 1 month before presentation at the emergency room. At that time he noticed the sputum production, and he began experiencing increased shortness of breath, even after mild exertion (walking two blocks to the grocery store). During the past few months, he felt very tired, and he has lost 10 pounds despite a “good” diet. Epidemiologic history indicated city residence and visits with a number of old drinking buddies. The patient denied exposure to anyone with tuberculosis, and he had no family history of tuberculosis. Social history indicated that the patient had recently retired after 35 years of tending bar. He lives alone in a one-bedroom apartment and supports himself on social security. He is a former smoker (half a pack daily for 28 years) and drinks half a pint daily. On physical examination, his temperature was 38°C and his respiratory rate was 18 per minute, presenting a picture of a thin male breathing comfortably. Aside from mild clubbing of his nail beds, the physical findings (including lung examination) were within normal limits. Acid-fast stain of the sputum revealed multiple acid-fast bacilli per high-power field [see ure 4. See color image on color plate 1 Pathogenesis Mycobacterium tuberculosis is an aerobic, nonmotile bacillus with a waxy lipid-rich outer wall containing high concentrations of mycolic acid. Visualization of mycobacteria requires heating to melt the outer wall, which allows for penetration and binding of the red dye fuchsin. The lipids in the cell wall bind this dye with high affinity and resist acid–alcohol decolorization. The slow rate of growth may also be explained by the waxy cell wall, which limits access to nutrients. Mycobacteria survive and grow in macrophages, and they therefore induce a profound chronic inflammatory response. On gaining entry to the lungs, these organisms are ingested by alveolar macrophages and transported to the hilar lymph nodes. Here macrophages and dendritic cells present tubercular antigens to T cells, inducing a cell-mediated immune response. Accumulation of one of the cell wall waxes, cord factor, stimulates the formation of granulomas that contain clusters of epithelioid cells, giant cells, and lymphocytes. Over time, the centers of the granulomas become necrotic, forming cheesy debris called caseous necrosis. Interleukin 1 stimulates the hypothalamus to raise core body temperature, causing fever. Tumor necrosis factor interferes with lipid metabolism and causes severe weight loss. These cytokines are primarily responsible for the symptoms of fever, night sweats, and weight loss described in case 4. Person-to-person spread of infection is almost exclusively caused by inhalation of droplet nuclei that have been aerosolized by coughs or sneezes. The likelihood of inhaling infectious droplets is greatly increased in a closed, crowded environment. A single cough has been estimated to form 3000 infectious droplets, with a sneeze producing even higher numbers. The higher the number of organisms per microscopic field, the greater the infectious potential. Patients with laryngeal tuberculosis are particularly infectious and can release large numbers of organisms while speaking.
If the dose or dosing interval is unchanged buy cheap suhagra 100mg, reduced renal function leads to accumulation of the drug in body fluids and eventual drug toxicity generic 100 mg suhagra visa. Phenytoin purchase 100mg suhagra with visa, independent of its excretion, may reach toxic concentrations because a larger proportion of the administered drug is displaced from albumin-binding sites in uremia. Drug doses need to be altered in most instances to account for residual renal function and the effect of dialysis on drug removal. It is important to remember that as the patient recovers renal function, upward adjustment of the dosage of renally excreted drugs is necessary. The degree of catabolism reflects the level of the patient’s metabolic stress and is, in turn, a function of the severity of the underlying illness. Protein and caloric requirements are much higher for patients with catastrophic illness and multiple organ system failure than for those with mild or moderate illness. Although caloric replacement needs to be adequate to reduce tissue catabolism, prevent ketosis, and meet the patient’s basal nutritional needs, the clinician must avoid providing excessive substrate for generation of metabolic waste products. This is particularly challenging for patients who are not yet being dialyzed; once patients are on dialysis, they are allowed more liberal fluid intake and can receive a greater intake of carbohydrates, protein, and fat, limited only by the rate of dialytic fluid and solute removal. As discussed in Chapters 212 and 214, the need for nutritional support is becoming an indication for renal replacement therapy . Hyperkalemia Hyperkalemia is the most immediately life-threatening electrolyte imbalance encountered in patients with renal disease (see Chapter 199). Urine flow rate is an important determinant of tubular potassium secretion; therefore, oliguric patients are more prone to potassium imbalance than are nonoliguric patients. Metabolic Acidosis the kidneys’ ability to excrete metabolically produced acids may be reduced, particularly in parenchymal and obstructive disease. Indeed, pure tubular acid excretion abnormalities may exist independently of azotemia (renal tubular acidosis). Metabolic acidosis that results from failure of the tubules to excrete hydrogen ions or conserve bicarbonate normally produces a hyperchloremic or low anion gap acidosis (see Chapter 198). Bicarbonate supplementation in the setting of metabolic acidosis remains controversial as there are no studies demonstrating a beneficial effect of this approach. In addition, bicarbonate supplementation may cause volume overload and hypernatremia and may exacerbate hypocalcemia by lowering the ionized calcium level. Abnormal Salt and Water Metabolism Although most fluids administered to patients are hypotonic, plasma osmolality normally remains within tightly fixed limits. The process by which plasma tonicity is preserved depends on the suppression of vasopressin release and the movement of free water in the ascending limb of the loop of Henle. This situation, referred to as nephrogenic diabetes insipidus, is most common in tubulointerstitial disease and in partial obstruction of the urinary tract. High serum phosphorus levels lead to formation of insoluble calcium phosphate salts, which may precipitate in soft tissue. If the product of the serum calcium and phosphorus concentrations exceeds 70, precipitation in soft tissues becomes more likely. Although there is no published data correlating the treatment of hyperphosphatemia with improved outcomes, phosphate binders are typically initiated when phosphate levels rise to more than 6. The main phosphate binders available include calcium salts (calcium acetate and calcium carbonate), sevelamer, and lanthanum hydroxide. Although potent, aluminum- based binders are generally avoided because of concerns with aluminum toxicity. The exact identities of the so-called uremic toxins are not known, although many possibilities have been suggested. One cannot deduce on the basis of urea nitrogen and creatinine levels exactly when a patient will become uremic. Other, less subjective uremic manifestations constitute stronger indications for prompt initiation of dialysis, including bleeding diathesis, seizures, coma, and the appearance of a pericardial friction rub. Patients with intractable volume overload, hyperkalemia, metabolic acidosis, or frank uremia clearly meet criteria for dialysis. Nevertheless, several observational studies appear to show decreased morbidity and mortality for patients initiated on early dialysis. It has been argued that early dialysis results in improved volume control as well as the clearance of a variety of cytokines and/or toxins that may be harmful. Unfortunately, at this time, there is still not adequate data to establish the optimal time to initiate dialysis. Most of these individuals do not have multiorgan failure, and their improved survival may be the result of a less severe primary illness. Patients with prolonged episodes of ischemia or injury may have variable degrees of recovery [100–102]. Alternatively, a phased array cardiac probe gives serviceable images when configured with abdominal presets. Scanning Technique With the patient in the supine position, the probe is placed in the posterior axillary line over the lower lateral chest wall in order to obtain a transcostal coronal plane view of the left right or left kidney in their longitudinal axis (Video 200. Useful landmarks for locating the kidneys are the liver or spleen, as the kidneys are adjacent and caudal to these organs. A useful rule to locate the kidney is to place the “knuckles on the bed” when the operator is positioned ipsilaterally and scanning the contralateral kidney. Once identified, the probe is angled through the kidney in order to obtain multiple tomographic sections of its structure. The operator may rotate the probe counterclockwise by 90 degrees to obtain a transverse view of the kidney while angling through it to obtain multiple tomographic views. Using a transverse scanning plane, the scanning plane is angled in caudal direction in order to identify the bladder. Once identified, the probe is angled through the bladder in order to obtain multiple tomographic views of its structure. The operator may rotate the probe clockwise by 90 degrees to obtain a longitudinal view of the bladder while angling through it to obtain multiple tomographic views. The kidney parenchyma is formed by the outer renal cortex and centrally located medulla with contains the renal pyramids. Normally, the renal parenchyma is hypoechoic when compared to the adjacent liver or spleen, and the cortex is slightly hyperechoic relative to the underlying medulla. When comparing the echogenicity of the kidney parenchyma to the liver and spleen, the operator considers whether there is a disease process that may alter the echogenicity of the liver or spleen. Chronic renal failure is associated with loss of demarcation between the pelvocalyceal area and the parenchyma. The operator searches for bowel structures within the fluid filled structure; their presence indicates ascites. If uncertainty persists, injection of agitated saline into the bladder catheter with real- time imaging will generally resolve the issue. The examination can be performed in a short period of time, and is an essential part of competence in critical care ultrasonography (Video 200. The findings of hydronephrosis include dilation of the renal pelvis and calyces by urine with through transmission artifact. It can be classified as mild, moderate, or severe acute obstruction results in calyceal dilation that results in a dilation that ends with an acute angle point.
The Geneva Convention of 1925 banned the use of chemical warfare agents because of the physical and psychologic trauma they imposed on their victims cheap suhagra 100 mg otc. Gerhard Schrader 100 mg suhagra visa, began research into the development of stronger insecticides discount suhagra 100 mg free shipping, the first two of which were tabun and sarin. Later in the 1980s, reports implicated Iraq in the use of cyanide against the Kurdish population of northern Iraq . The first took place on June 27, 1994, in Matsumoto and resulted in 600 persons exposed, 58 admitted to the hospital, and seven deaths . The more famous and larger event took place the following year, on March 20, 1995, when they released sarin gas in the Tokyo subway system during rush hour. The subway system attack resulted in the deaths of 11 commuters and the medical evaluation of approximately 5,000 individuals . Four days later Russian Special Forces fumigated the building with a derivative of the narcotic fentanyl. Although this method broke the siege, all but two of the 41 terrorists and 129 hostages died from opiate toxicity . The most recent use of chemical weapons occurred in the early morning hours of August 21, 2013 in the Ein Tarma and Zamalka suburbs of Damascus, Syria. Social media reports and videos as well as satellite imagery demonstrated large numbers of sick adults and children with no visible trauma; medical personnel described the symptoms as most consistent with exposure to a nerve agent . Three Damascus hospitals received over 3,000 casualties where the principle antidote atropine was in short supply and exposure to contaminated patients at one hospital resulted in 41 staff members, including 10 doctors, becoming contaminated . However, hospital-based critical care physicians should understand basic concepts of these topics to better care for their patients and protect themselves and their facilities from potential harm. The most important tool for detecting the use of these agents is accurate and timely intelligence from military or law enforcement agencies. Unfortunately, hospitals are not usually in the information- sharing and decision-making circles with these groups. As a result, initial awareness of a chemical agent attack typically occurs with the first patient presenting to the emergency department. Hospitals and physicians can improve their preparedness for the management of chemical agent casualties by actively participating in disaster-planning activities at their respective communities. At the present time, all commercially available detection equipment uses point source technology; that is, proximity to the substance is required. The handheld Chemical Agent Monitor uses ion mobility spectrometry to detect mustard and nerve agents. Chemical agent detection papers, such as the M8 and M9 papers (Anachemia, Lachine, Quebec, Canada), can be used to detect mustard and nerve agents. The M256 Detection Kit (Anachemia, Lachine, Quebec, Canada) can detect mustard, nerve agents, phosgene, and cyanide. Standoff capability, that is, detecting agents from as far away as 5 km, has been developed to detect contaminated areas without being exposed . Many of the readily available detection strategies cannot detect lower levels of chemical agent, thus being less useful to confirm successful decontamination or detect chemical agents remotely from the site of exposure. Most hospitals will not have capability to confirm exposure or nature of chemical agents used in a timely manner to influence patient care or protect their facilities. As health care providers, use of samples from patients rather than environmental sampling may be helpful for clinical and forensic purposes. Sulfur mustard exposure can also be determined from hair analysis of patients with suspected exposure . Further development of rapid, easy, and affordable technology to help hospitals detect and identify chemical weapon agents is expected to make new technologies available. Unfortunately, most disaster victims bypass emergency medical system transport and arrive unannounced at the closest hospital. As a result, hospitals must be prepared to decontaminate chemical agent casualties prior to admission. Such processes are needed to protect the victims from further exposure and to prevent the spread of chemical agents within the hospital and among health care providers. Critical care physicians, nurses, and support personnel may be called on to help develop decontamination protocols and assist in the decontamination process. It is imperative that all individuals designated to serve on decontamination teams be thoroughly trained in the procedures, precautions, and protective clothing required by the decontamination process. Attempting to provide help in a contaminated environment without prior training puts the health care provider at risk of being exposed to a chemical agent and could impede the delivery of effective medical care for the victims of a chemical attack. One common (and potential fatal) error made by health care providers is to rely on personal protective equipment effective for protection from biologic hazards (such as N95 respirators) which provide insufficient protection during decontamination or care of contaminated chemical agent exposed casualties. The sarin gas release in Tokyo provides a clear example of the need for preparation and training prior to a chemical attack. None of the first responders wore protective clothing or face masks and off-gassing of the chemical agent from clothing of victims played a significant role in their complaints. It was reported that 23% of the staff at the hospital that received the patients also experienced symptoms . It provides guidance for the use of personal protective equipment and requires that written plans be developed for hospitals to train teams for the use of personal protective equipment to receive contaminated victims . Recurrent training and drills in the use of available and appropriate personal protective equipment by hospital staff is recommended to ensure readiness in the event of a chemical agent event. Mechanical removal without deactivation may result in spread of some agents at the decontamination area and create contaminated waste. For most situations, effective chemical decontamination can be performed by carefully removing the victim’s clothing and thoroughly washing the victim with soap and water. It has been reported that removing contaminated clothing alone can eliminate 85% to 90% of chemical contaminants . The M291 Skin Decontamination Kit has been in use by the military for many years, and can facilitate mechanical removal and partial deactivation of some agents. It is not used for prophylactic protection or total body decontamination, but, if applied early following exposure, is effective for neutralizing chemical warfare agents and T2 mycotoxins . In addition to skin and wound decontamination products, other strategies may be used to decontaminate personal protective equipment and external surfaces. Normally employed as a foam, it effectively neutralizes a variety of chemical agents including nerve gases and mustard . A recent study from the Czech Republic provides an excellent example of a comparative approach to chemical agent decontamination strategies, taking into consideration multiple factors relevant to different operating environments and expected exposures . Finally, medical facilities must consider environmental variables such as wind direction, wind velocity, temperature, and water runoff when setting up decontamination areas. These environmental considerations are important for protecting patients and employees from exposure to chemical agents, as well as minimizing the risk of contaminating buildings and equipment during the patient decontamination process.