睿学教育Wisdome Education

Melvin D. Cheitlin, MD, MACC

• Emeritus Professor of Medicine
• University of California, San Francisco
• Former Chief of Cardiology
• San Francisco General Hospital
• San Francisco, California

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As a result blood sugar after meals order actoplus met 500 mg with visa, warfarin produces a state that is functionally equivalent to vitamin K deficiency diabetes symptoms chart 500 mg actoplus met buy. If the dosage of warfarin is excessive blood glucose readings chart order 500 mg actoplus met with amex, hemorrhage can occur secondary to lack of prothrombin. Hyperbilirubinemia When administered parenterally to newborns, vitamin K derivatives can elevate plasma levels of bilirubin, thereby posing a risk for kernicterus. The incidence of hyperbilirubinemia is greater in premature infants than in full-term infants. Although all forms of vitamin K can raise bilirubin levels, the risk is higher with menadione and menadiol than with phytonadione. Therapeutic Uses and Dosage Vitamin K has two major applications: (1) correction or prevention of hypoprothrombinemia and bleeding caused by vitamin K deficiency and (2) control of hemorrhage caused by warfarin. Vitamin K Replacement As discussed, vitamin K deficiency can result from impaired absorption and from insufficient synthesis of vitamin K by intestinal flora. For children and adults, the usual dosage for correction of vitamin K deficiency ranges between 5 and 15 mg/day. To prevent hemorrhagic disease in neonates, it is recommended that all newborns be given an injection of phytonadione (0. Warfarin Antidote Vitamin K reverses hypoprothrombinemia and bleeding caused by excessive dosing with warfarin, an oral anticoagulant. Preparations and Routes of Administration Phytonadione (vitamin K ) is available in 5-mg tablets, marketed as Mephyton,1 and in parenteral formulations (2 and 10 mg/mL) sold generically. For example, this might be indicated in management of life- threatening bleeding due to vitamin K antagonists (e. Water-Soluble Vitamins The group of water-soluble vitamins consists of vitamin C and members of the vitamin B complex: thiamine, riboflavin, niacin, pyridoxine, pantothenic acid, biotin, folic acid, and cyanocobalamin. They are grouped together because they were first isolated from the same sources (yeast and liver). Vitamin C is not found in the same foods as the B vitamins and hence is classified by itself. Two compounds—pangamic acid and laetrile—have been falsely promoted as B vitamins. Vitamin C (Ascorbic Acid) Actions Vitamin C participates in multiple biochemical reactions. Among these are synthesis of adrenal steroids, conversion of folic acid to folinic acid, and regulation of the respiratory cycle in mitochondria. At the tissue level, vitamin C is required for production of collagen and other compounds that comprise the intercellular matrix that binds cells together. In addition, vitamin C has antioxidant activity and facilitates absorption of dietary iron. Sources The main dietary sources of ascorbic acid are citrus fruits and juices, tomatoes, potatoes, strawberries, melons, spinach, and broccoli. Deficiency Deficiency of vitamin C can lead to scurvy, a disease rarely seen in the United States. Symptoms include faulty bone and tooth development, loosening of the teeth, gingivitis, bleeding gums, poor wound healing, hemorrhage into muscles and joints, and ecchymoses (skin discoloration caused by leakage of blood into subcutaneous tissues). Many of these symptoms result from disruption of the intercellular matrix of capillaries and other tissues. Therapeutic Use The only established indication for vitamin C is prevention and treatment of scurvy. Vitamin C has been advocated for therapy of many conditions unrelated to deficiency, including cancers, asthma, osteoporosis, and the common cold. Claims of efficacy for several of these conditions have been definitively disproved. Studies have shown that large doses of vitamin C do not reduce the incidence of colds, although the intensity or duration of illness may be decreased slightly. Research has failed to show any benefit of vitamin C therapy for patients with advanced cancer, atherosclerosis, or schizophrenia. Preparations and Routes of Administration Vitamin C is available in formulations for oral and parenteral administration.

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These people are not considered addicts because they do not demonstrate the behavior pattern that constitutes substance dependence gestational diabetes test questions purchase discount actoplus met on line. Patients with terminal cancer diabetes symptoms missed period purchase actoplus met 500 mg free shipping, for example diabetic lunch ideas order cheap actoplus met online, are often physically dependent on opioids. However, because their lives are not disrupted by their medication (quite the contrary), their drug use does not meet the criteria for a substance use disorder. Similarly, some degree of physical dependence occurs in all patients who take phenobarbital to control seizure disorders. However, despite their physical dependence, patients with seizure do not carry out stereotypic addictive behavior and therefore do not have a substance use disorder. Having stressed that physical dependence and addiction are different from each other, we must note that the two states are not entirely unrelated. As discussed later, although physical dependence is not the same as addiction, physical dependence often contributes to addictive behavior. Factors That Contribute to Drug Abuse Drug abuse is the end result of a progressive involvement with drugs. Factors that play a role in the progression from experimental use to compulsive use are discussed next. The reinforcing properties of drugs can be clearly demonstrated in experiments with animals. In the laboratory, animals will self-administer most of the drugs that are abused by humans (e. When these drugs are made freely available, animals develop patterns of drug use that are similar to those of humans. Animals will self-administer these drugs (except for nicotine and caffeine) in preference to eating, drinking, and sex. These observations strongly suggest that preexisting psychopathology is not necessary for drug abuse to develop. Rather, these studies suggest that drug abuse results, in large part, from the reinforcing properties of drugs themselves. Physical Dependence As defined earlier, physical dependence is a state in which an abstinence syndrome will occur if drug use is discontinued. The degree of physical dependence is determined largely by dosage and duration of drug use. The more physically dependent a person is, the more intense the withdrawal syndrome. After dependence has developed, the desire to avoid withdrawal becomes a motivator for continued dosing. Furthermore, if the drug is administered after the onset of withdrawal, its ability to alleviate the discomfort of withdrawal can reinforce its desirability. Please note, however, that although physical dependence plays a role in the abuse of drugs, physical dependence should not be viewed as the primary cause of addictive behavior. Rather, physical dependence is just one of several factors that can contribute to the development and continuation of compulsive use. Psychological Dependence Psychological dependence is defined as an intense subjective need for a drug. Individuals who are psychologically dependent feel very strongly that their sense of well-being is dependent on continued drug use; a sense of “craving” is felt when the drug is unavailable. There is no question that psychological dependence can be a major factor in addictive behavior. For example, it is psychological dependence—and not physical dependence—that plays the principal role in causing renewed use of opioids by addicts who had previously gone through withdrawal. Social Factors Social factors can play an important role in the development of abuse. The desire for social status and approval is a common reason for initiating drug use. Also, because initial drug experiences are frequently unpleasant, the desire for social approval can be one of the most compelling reasons for repeating drug use after the initial exposure.

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In asthma blood sugar crash actoplus met 500 mg buy fast delivery, the increase in resistance is mostly due to airway mucosal inflam- mation and contraction of airway smooth muscle due to an exaggerated physiological response blood glucose daily log sheets buy discount actoplus met 500 mg on line, both of which are quickly reversible blood glucose ketoacidosis actoplus met 500 mg order amex. Pulmonary circulation The lungs receive the entire blood volume but unlike the systemic circula- tion the pulmonary circulation is a low-pressure system because: • Pulmonary arteries and arterioles contain only a small amount of smooth muscle compared with systemic vessels • Pulmonary capillary networks surround alveoli to produce sheet-like blood flow to maximize the surface area for gas exchange • With resting cardiac output pulmonary capillaries in non-dependent areas of the lung have little or no blood flow and can be ‘recruited’ if cardiac output increases • Pulmonary capillaries are distensible vessels, easily doubling in diameter to accommodate large increases in flow with little change in driving pressure. Pulmonary vascular resistance pulmonary vascular resistance = pulmonary driving pressure/cardiac output • The relationship is not linear due to flow being a mixture of laminar and turbulent forms. Alveolar capillaries lie between adjacent alveoli and so are compressed when lung volume increases. In the upright position hydrostatic pressure significantly affects blood flow as there may be a 20mmHg difference in vascular pressure between apex and lung bases • Alveolar pressure—pulmonary capillary blood flow and vessel patency depend on both vascular and alveolar pressures, and lungs are traditionally divided into three zones: • Zone 1—Palveolus > Partery > Pvenous: no blood flow and therefore alveolar dead space • Zone 2—Partery > Palveolus > Pvenous: blood flow depends on the difference between arterial and alveolar pressure; venous pressure has no influence • Zone 3—Partery > Pvenous > Palveolus: blood flow depends only on arterio-venous pressure difference • Systemic vascular tone—the systemic vascular system has greater vasomotor activity so blood is diverted into the pulmonary circulation when vasoconstriction occurs and vice versa • Left heart failure—pulmonary venous hypertension is likely to increase pulmonary blood volume and reduce flow in all three zones • Positive pressure ventilation increases alveolar pressure, changing zone 3 areas into zone 2, and also reduces venous return, reducing global cardiac output. Hypoxic pulmonary vasoconstriction This reflex occurs in response to regional hypoxia in the lung, and is believed to optimize V/Q· · matching by diverting pulmonary blood flow away from areas of low oxygen tension. The reflex occurs within a few seconds of the onset of hypoxia, with constriction of small arterioles. With prolonged hypoxia the reflex is biphasic, with the initial rapid response being maximal after 5–10min and followed by a second phase of vasoconstriction, occurring gradually and reaching a plateau after 40min. Hypoxic pulmonary vasoconstriction is patchy in its onset even in healthy individuals exposed to global alveolar hypoxia. At high altitude the response also may be highly variable between individuals, explaining why some patients develop pulmonary hyperten- sion with respiratory disease and some do not. There is likely to be a direct action on smooth muscle and an indirect effect on endothelium-dependent systems. Proposed components include the following: • Hypoxia may have a direct effect on pulmonary vascular smooth muscle by altering the membrane potential, affecting potassium channels, which in turn activate voltage-gated calcium channels to produce contraction. Primary pulmonary hypertension This condition occurs in the absence of hypoxia and has a strong familial association and a poor prognosis. It is characterized by remodelling of the pulmonary arterioles (proliferation of endothelial cells and smooth muscle hypertrophy) and pulmonary vessel thrombosis. Treatments include pul- monary vasodilator drugs (oral or intravenous prostacyclin analogues or oral endothelin antagonists) and ultimately lung transplantation. Secondary pulmonary hypertension Chronic or intermittent hypoxic pulmonary vasoconstriction can lead to pulmonary hypertension by remodelling of the pulmonary vascular smooth muscle, producing irreversible increases in vascular resistance. Distribution of ventilation The right lung is slightly larger so usually has 60% of total ventilation in either upright or supine positions. When lateral, the lower lung is always better ventilated but perfusion also preferentially goes to the lower lung · · and V/Q matching is maintained. Within each lung, regional ventilation is affected by gravity—lung tissue has weight, so alveoli in dependent areas become compressed. In the upright position alveoli at the lung apices will be almost fully inflated while those at the bases will be small. On inspiration the capacity of alveoli in non-dependent regions to expand is therefore limited, and regional ventilation increases with vertical distance down the lung. In a microgravity environment, where the lung has no weight, regional variation in ventilation disappears almost completely. The ability of a lung region to ventilate may be quantified by considering its time constant. Within the lung there are ‘fast alveoli’ with short time constants and ‘slow alveoli’ with long time constants. If the time constants are identical as the lung is inflated the pressure and volume changes will be identical so if inspiration stops there will be no redistribution of gas. The distribution is also independent of the rate, duration, or frequency of inspiration. However, if there are regions with different time constants within an area of the lung, gas distribution will be affected by the rate, duration, and frequency of inspiration. At the termination of gas flow there will be redistribution of gas because pressure and volume changes will be different between lung regions. Distribution of perfusion The pulmonary circulation is a low-pressure system and posture signifi- cantly alters blood distribution.

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Hyperuricemia—defined as blood uric acid above 7 mg/dL in men diabetes symptoms 3 year old order 500 mg actoplus met with amex, or 6 mg/dL in women—can occur through two mechanisms: (1) excessive production of uric acid and (2) impaired renal excretion of uric acid diabetes symptoms in men order actoplus met online from canada. Acute attacks are precipitated by crystallization of sodium urate (the sodium salt of uric acid) in the synovial space diabetic infections discount actoplus met 500 mg buy on line. Deposition of urate crystals promotes inflammation by triggering a complex series of events. A key feature of the inflammatory process is infiltration of leukocytes, which, when inside the synovial cavity, phagocytize urate crystals and then break down, causing release of destructive lysosomal enzymes. When hyperuricemia is chronic, large and gritty deposits, known as tophi, may form in the affected joint. Fortunately, when gout is detected and treated early, the disease can be arrested and these chronic sequelae avoided. In patients with infrequent flare-ups (less than three per year), treatment of symptoms may be all that is needed. In the past, colchicine was considered a drug of choice for acute gout—even though it has a poor risk-to- benefit ratio. Today, colchicine is generally reserved for patients who are unresponsive to or intolerant of safer agents. In patients with chronic gout, tophaceous gout, or frequent gouty attacks (three or more per year), drugs for hyperuricemia are indicated. Three types of drugs may be employed: agents that decrease uric acid production, agents that increase uric acid excretion (uricosuric drugs), and agents that convert uric acid to allantoin. Most patients experience marked relief within 24 hours; swelling subsides over the next few days. However, because the duration of treatment is brief, the risk for these complications is low. Because of their effects on carbohydrate metabolism, glucocorticoids should be avoided, when possible, in patients prone to hyperglycemia. Colchicine Colchicine [Colcrys, Mitigare] is an antiinflammatory agent with effects specific for gout. Acute Gouty Arthritis High-dose colchicine can produce dramatic relief of an acute gouty attack. Prophylaxis of Gouty Attacks When taken during asymptomatic periods, low-dose colchicine can decrease the frequency and intensity of acute flare-ups. Colchicine may also be given for prophylaxis when urate-lowering therapy is initiated because there is a tendency for gouty episodes to increase at this time. Mechanism of Action We do not fully understand how colchicine relieves or prevents episodes of gout. It may work, at least in part, by inhibiting leukocyte infiltration: in the absence of leukocytes, there is no phagocytosis of uric acid and no subsequent release of lysosomal enzymes. Because microtubules are also required for cell division, colchicine is toxic to any tissue that has a large percentage of proliferating cells. Pharmacokinetics Colchicine is readily absorbed after oral dosing, in both the presence and absence of food. Large amounts reenter the intestine through the bile and intestinal secretions and then undergo reabsorption. When given for gout prophylaxis (as opposed to familiar Mediterranean fever), colchicine is not recommended for patients younger than 16 years. Allopurinol may be given to children younger than 6 years for the purpose of treating hyperuricemia associated with cancer therapy. Probenecid has been given to children as young as 2 years for purposes unrelated to gout. Of the xanthine oxidase inhibitors, both febuxostat and allopurinol are Pregnancy Risk Category C; however, animal studies with febuxostat have demonstrated an increase in fetal mortality. For patients taking xanthine oxidase inhibitors, Canadian labeling contraindicates breastfeeding. Gastrointestinal Effects The most characteristic side effects are nausea, vomiting, diarrhea, and abdominal pain. Myelosuppression Injury to rapidly proliferating cells can suppress bone marrow function and can thereby cause leukopenia, granulocytopenia, thrombocytopenia, and pancytopenia.

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Inform patients taking isoniazid about symptoms of peripheral neuropathy (tingling can you reverse diabetes in dogs 500 mg actoplus met purchase with visa, numbness diabetes 4 less order genuine actoplus met, burning diabetes signs type 1 cheap actoplus met 500 mg buy on-line, or pain in the hands or feet) and instruct them to report symptoms if these occur. Inform patients taking rifampin that it may impart a harmless red-orange color to urine, sweat, saliva, and tears. Advise them to consult their eye care specialist (optometrist or ophthalmologist) about continued use of the lenses. When prescribing rifampin, advise women taking oral contraceptives to use a nonhormonal form of birth control. The most concerning adverse effects shared by two or more drugs are presented next. Daily ingestion of alcohol increases the risk for liver injury; therefore, efforts taken to help patients to decrease alcohol intake will decrease this risk. While this effect may be insignificant for a single drug, when combined this can be especially concerning for patients. Isoniazid Identifying High-Risk Patients Isoniazid is contraindicated for patients with acute liver disease or a history of isoniazid-induced hepatotoxicity. Use with caution in alcohol abusers, diabetic patients, patients with vitamin B6 deficiency, patients older than 50 years, and patients who are taking phenytoin, rifampin, rifabutin, rifapentine, or pyrazinamide. Ongoing Monitoring and Interventions Minimizing Adverse Effects Peripheral Neuropathy. Peripheral neuritis can be reversed by prescribing daily doses of pyridoxine (vitamin B ). Isoniazid can suppress the metabolism of phenytoin, thereby causing phenytoin levels to rise. Use with caution in alcohol abusers, patients with liver disease, and patients taking warfarin. Ongoing Monitoring and Interventions Minimizing Adverse Effects Discoloration of Body Fluids. Rifampin may impart a harmless red-orange color to urine, sweat, saliva, and tears. If your patient wears soft contact lenses, be certain that they are aware that permanent staining may occur. Rifampin can accelerate the metabolism of many drugs, thereby reducing their effects. Pyrazinamide Identifying High-Risk Patients Pyrazinamide is contraindicated for patients with severe liver dysfunction or acute gout. Ongoing Monitoring and Interventions Minimizing Adverse Effects Nongouty Polyarthralgias. Ethambutol Identifying High-Risk Patients Ethambutol is contraindicated for patients with optic neuritis. Symptoms include blurred vision, altered color discrimination, and constriction of visual fields. However, unlike nalidixic acid, the fluoroquinolones are broad-spectrum agents that have multiple applications. As a result, these drugs are attractive alternatives for people who might otherwise require intravenous antibacterial therapy. Although side effects are generally mild, all fluoroquinolones can cause tendinitis and tendon rupture, usually of the Achilles tendon. Bacterial resistance develops slowly but has become common in Neisseria gonorrhoeae, and hence these drugs are no longer recommended for this infection. Fluoroquinolones used solely for topical treatment of the eyes are discussed in Chapter 84. Ciprofloxacin Ciprofloxacin [Cipro] was among the first fluoroquinolones available and will serve as our prototype for the group. Oral ciprofloxacin has been used as an alternative to parenteral antibiotics for treatment of several serious infections. Antimicrobial Spectrum Ciprofloxacin is active against a broad spectrum of bacteria, including most aerobic gram-negative bacteria and some gram-positive bacteria. Most urinary tract pathogens, including Escherichia coli and Klebsiella species, are sensitive. Other sensitive organisms include Bacillus anthracis, Pseudomonas aeruginosa, Haemophilus influenzae, meningococci, and many streptococci.

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Prudent antimicrobial prescribing All trusts will have antimicrobial management teams who are responsible for the development blood sugar graph 500 mg actoplus met buy with mastercard, implementation diabetes mellitus blood glucose level 500 mg actoplus met order free shipping, and audit of antibiotic policies blood sugar index safe 500 mg actoplus met. Other methods employed to control anti- biotic prescribing include: • Alert antibiotic policies, i. It is now the most common cause of hospital-acquired diarrhoea and is associated with i morbidity and mor- tality. Decolonization therapy consists of: • Nasal application of 2% mupirocin ointment three times daily for 5 days. Infuenza Infuenza is one of the commonest causes of upper respiratory tract infec- tion. An ffp3 respirator and eye protection are recommended in patients undergoing aerosol generating procedures. In addition, there are specifc precautions which should be taken in relation to respiratory equipment. Septic screen • Blood cultures from intravascular catheters and a peripheral vein • pus samples (better than swabs at identifying organisms) • Wound swabs • Sputum or tracheal aspirates • Urine and faeces. Antibiotics β-lactam antibiotics • All members contain a β-lactam ring structure • Mode of action is to inhibit cell wall synthesis • Classifcation system: • Penicillins • Cephalosporins • Carbapenems. Allergy and side efects • Allergic reactions: • Anaphylaxis to penicillin (Type I, IgE-mediated reaction) presents with pruritus, fushing, urticaria, angioedema, and hypotension but is rare (–4/0,000 administrations). Due to advantages in oral absorption over penicillin V, amoxicillin is often used to treat community-acquired pneumonia in order to target S. Co-amoxiclav is a combination of clavulanic acid, which is a potent inhibitor of many β-lactamases and amoxicillin. Cephalosporins Classifcation • st generation—usually used for treatment of simple urinary tract infection, e. Clinical uses • Alternatives exist for most clinical infection syndromes, therefore cephalosporin use has fallen signifcantly in recent years. Carbapenems • Broad-spectrum antibiotics with activity against Gram-positive, Gram-negative, and anaerobic bacteria. Clinical uses • Used to treat a wide variety of severe infections such as intra-abdominal sepsis, complicated urinary tract infection, pneumonia, and bacteraemia. Allergy and side efects • Nephrotoxicity—incidence estimated at 0–20%, although toxicity is reversible. Quinolones • Quinolones inhibit bacterial nucleic acid synthesis and are bactericidal against both Gram-positive and Gram-negative organisms. Ciprofoxacin also has some activity against Legionella pneumophila, Mycoplasma pneumoniae and Chlamydophila pneumoniae. Classifcation • erythromycin and clarithromycin have similar antimicrobial spectrum as penicillin and are commonly used in patients labelled penicillin allergic. Clinical uses • Used to treat community-acquired pneumonia, usually in combination with a β-lactam. In Mandell Ge, Bennet Je, Dolin r (eds), Principles and Practice of Infectious Diseases (5th edn, pp. Chapter 32 339 Bedside echocardiography Introduction 340 Transthoracic echocardiography 342 Transoesophageal echocardiography 363 340 ChapTer 32 Bedside echocardiography Introduction Bedside echocardiography has developed into a valuable diagnostic and monitoring tool. When viewed from the front the most anterior structures are the right atrium and right ven- tricle and the most posterior structure is the left atrium. The ultrasound transducer produces a thin fan-shaped beam that slices through the heart. The slice or image that is achieved depends on the position of the probe on the chest. The images are displayed on a screen with the top of the screen representing the position of the transducer—structures closer to the transducer are seen nearer the top of the screen. Echocardiography windows There are three main echocardiography ‘windows’ in the chest and abdo- men that allow ultrasound waves to be transmitted to and refected from the heart. Subcostal window • place the transducer parallel to the skin inferior to the right costal margin and direct the ultrasound beam upwards towards the heart.

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Patients with interstitial lung disease who require intubation have a poor prognosis and only those with a reversible component to the disease should have mechanical ventilation instituted diabetes prevention in children order actoplus met 500 mg otc. Hypercapnia Hypercapnia is discussed in detail in b Hypercapnia while on a ventilator diabetic diet weekly menu order actoplus met 500 mg overnight delivery, p 296 diabetes mellitus feline purchase actoplus met without a prescription. Exhaustion This is probably the most common indication for mechanical ventilation. An experienced clinician will often know almost immediately that a patient requires intervention. Clues that the patient will not survive without inter- vention are: • Confusion and somnolence • Sweating 1. Airway protection Critical care physicians are commonly asked to assess patients for intuba- tion and ventilation in the case of a threatened airway associated with a decreased level of consciousness. Patients with impaired laryngeal reflexes are also at risk from aspiration of stomach contents, blood, or saliva. Assessment of patients with a decreased level of consciousness therefore requires assessment of airway patency and protection. An effective gag and cough indicates that laryn- geal reflexes are likely to be adequate. Gag reflex is absent in a significant percentage of the normal population, and its absence is therefore difficult to interpret. If there is doubt about whether a patient is protecting their airway, it is usually better to proceed to intubation unless the risks of such a procedure are significant (for example difficult airway or co morbid respiratory disease). Airway obstruction Airway obstruction may present as an emergency requiring immediate intervention. In patients with an ominous history (for example burns, neck trauma) a high index of suspicion is advisable and the airway should be secured (with awake fibreoptic intubation if necessary) at an early stage. To assist in the treatment of other conditions Controlled ventilation may be necessary to facilitate the treatment of other, non-respiratory conditions. Examples include therapeutic hypo- thermia post cardiac arrest and in preventing secondary brain injury in neurological intensive care. A common reason for ventilating patients post operatively who have undergone elective major surgery is to allow warming to normothermia, correction of peri-operative metabolic distur- bance and fluid shifts, and ensure good analgesia and smooth emergence prior to extubation. It is well established that patients should be stabilized prior to transfer to avoid potential difficulties en route in the event of a clinical deterioration, and intubation and ventilation are often considered part of this stabilization. While this is true in many situations, intubation inevi- tably delays transfer, and the sedation and paralysis necessary to allow ventilation removes the ability to assess neurological function and detect neurological deterioration. Therefore, the risks and benefits of intubation prior to transfer should be considered carefully in each individual case. Bear in mind the reason for transfer and clinical status, logistics of transfer (geography and length of journey, mode (air versus road), and accessibility of patient in transport vehicle), and skill of the transfer personnel. In 1774 he discovered that heating mercuric oxide released a gas which was ‘five or six times better than common air for the purpose of respi- ration and inflammation’, describing the gas as ‘dephlogisticateda air’. It was renamed oxygen by Antoine Lavoisier in 1775 from the Greek word meaning ‘acid former’. Although Priestly was credited with the discovery, a Swedish chemist, Carl Wilhelm Scheele, had independently made a similar discovery in 1772, but did not publish his findings until 1777. One hundred and seventy years before that, a Polish philosopher, Michał Sedziwój, dis-˛ covered that heating saltpeter released a gas which he described as ‘the elixir of life’. It is widely used to help prevent tissue hypoxia and forms the cornerstone of resuscitation in the patient with respiratory distress. The administration of oxygen is often (wrongly) perceived as being a risk-free intervention, and it is incorrectly thought that it is not possible to give too much. This chapter will discuss when oxygen is indicated and when it is not, the side effects of administration and the mode of oxygen delivery. Nevertheless the major deter- minants of oxygen delivery are cardiac output, haemoglobin concentra- tion, and oxygen saturation. Administration of supplemental oxygen therefore achieves maximum benefit in conditions where there is arterial hypoxaemia and haemoglobin desaturation.

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Portable x-rays are helpfl for confrmation of endotracheal tube positions and infiltrates or efusions that may signif pathology diabetes mellitus type 1 purchase actoplus met with american express. These "acoustic signals" can be translated into 2-dimensional images that represent the anatomy beneath the ultrasound probe diabete zuccheri actoplus met 500 mg buy mastercard. The images are displayed with those structures closest to the probe at the top of the image whereas those farthest away from the probe appear at the bottom of the image type 1 diabetes and xylitol 500 mg actoplus met order amex. Subcutaneous air and dense structures (eg, bones, gallstones, foreign bodies) can create artifacts that distort the ultrasound images. Body habitus and lack of skin-to-probe interface secondary to surgical dressings or wounds can also limit visibility and quality of images. Modem day echocardiography adds computerized fnctions such as color flow Doppler and waveform analysis to quantif flow patterns across (and within) anatomic regions of the heart. The addition of fow analysis and vol­ ume measurement software enhances the diagnostic range of echocardiograms. As with other forms of ultrasound, subcutaneous air, wounds, and body habitus all play a role in the quality of images obtainable in individual patients. Echocardiography is usefl for the determination of cardiac performance and intravascular volume statuses, especially in patients with clinical shock. One of the major advantages of these bedside proce­ dures is that transport during instability is avoided. Despite a reduction in image quality, bedside chest radiographs are helpfl in determining many diferent condi­ tions that warrant prompt intervention (Table 6-1 ). Patients with seemingly "normal" radiographs can have venous embolic disease as the source of their ventilation/perfsion mismatch. In a recent meta-analysis, this practice was compared to the practice of only per­ forming chest radiographs when clinically indicated (ie, "on demand"). Patients who received studies only when clinically indicated were exposed to less radiation and had lower hospital costs. It is more often available and can be repeated more easily than computed tomography. Accessibility and ease of use have made ultrasound an extension ofthe physical examination for the assessment of critically ill patients. In the thorax, ultrasound assessment of pleural approximation can reliably rule out pneumothorax. Cardiac fnction can be evaluated in a number of ways, including estimates ofejection faction and qualitative assessment ofwall motion symmetry. Real-time visualization of central venous structure during catheter insertions is associated with lower procedure­ related complications and is a practice endorsed by most professional organizations. Fluid in the pericardium can more safely be sampled using ultrasound guidance for pericardiocentesis. Infectious source control can sometimes be accomplished by ultrasound-guided drainage of fluid collections in the thorax, pericardium, abdo­ men, or soft tissues (Figures 6-1 to 6-4). Pleural slidingto rule out pneumothorax: the bright white line represents apposition ofvisceral and parietal pleura. The arrows represent "comet tails" artifacts created by the inter­ face of pleural layers. Real-time visualization fo r catheter place­ ment: the white arrows point to a needle entering the internal jugularvein fo r central venous access. Echocardiography can be used to estimate left ventricular wall motion, ejection fractions, right heart filling volumes, and pulmonary venous pressures. Information gleaned from such assessments can direct the initiation of inotropic agents, further volume resuscita­ tion, or addition of vasoconstrictors. Left ventricular function: Bedside echocardiography can qualitatively assess left ventricular wall motion and estimate ventricular function. These qualitative esti­ mates can be performed with most ultrasound machines by clinicians with basic ultrasound training. Such machines must be able to clearly image the endocardial layer and obtain ventricular areas or volumes during the cardiac cycle. By noting the change in measured areas or volumes of the ventricle during diastole and during systole, fractional area change or ejection fraction can be calculated. In critical illness, however, factors such as increased pulmonary vascular resistance, left ventricular dysfnction, or marked fuid overload may alter the pressures routinely found in the right ventricle. An acute increase in right ventricular pressures leads to right ventricular dysfnction and if severe, right ventricular failure.

Kent, 47 years: Most women in the United Kingdom and Europe are already immune so the advice about every pregnant woman avoiding people with chickenpox is unnecessary.

Makas, 37 years: Clinical examination shows a Tanner stage 2 male at fifth percentile for height with multiple perianal skin tags.

Gancka, 61 years: Pulmonary artery foatation catheter • the only way to directly measure right heart pressures.

Mojok, 21 years: This effect has not been studied in clinical trials, and hence the incidence is unknown.

Denpok, 65 years: Retroperitoneal sarcoma recurrence after resection is common because of the lack of clear anatomical boundaries that these tumors occur in.

Jesper, 54 years: In rats, large doses have caused renal tubular necrosis and tumors of the kidneys and uterus.

Sancho, 35 years: Preparations, Dosage, and Administration Miconazole is available in cream, liquid spray, and powder formulations for application to the skin; in cream and suppository formulations for intravaginal application; and as a 50-mg buccal tablet [Oravig] for oropharyngeal candidiasis.

Thorus, 64 years: Benefits derive from blocking the actions of adrenal androgens, which are not reduced by castration.

Innostian, 62 years: Unlike many anticancer drugs, the nitrosoureas are highly lipophilic and hence can readily penetrate the blood-brain barrier.

Sulfock, 28 years: This orally administered drug directly and selectively in women who are obese and smoke cigarettes.

Bengerd, 34 years: Also in chronic constrictive pericarditis (this third sound is called pericardial knock).

Oelk, 52 years: Because these seizures can be dangerous, and because delay of therapy may allow the condition to worsen, rapid control of seizures is desirable.

Luca, 49 years: In another randomized control trial reported in 2008 (The Corticus Trial), no diference in mortality was found with steroid administration in septic patients with or without appropriate responses to cosyntropin stimulation.

Silas, 59 years: Other grafting options can be ear Normal □ narrow □ wide □ cartilage and in some cases rib cartilage.

Dimitar, 57 years: Adverse effects of transmucosal fentanyl are like those of other opioid preparations.

Yussuf, 58 years: In a further trial to avoid external scarring, some authors15–18 described using cinching and bunching sutures to approximate the alae and narrow the nasal base, yet these Fig.

Mezir, 45 years: The degree of injury is directly related to the degree of pressure elevation: The higher the pressure, the greater the risk.

Bandaro, 51 years: A nulliparous woman had a precipitous, spontaneous vaginal delivery and sustained a third-degree tear.

Zarkos, 60 years: N These drugs have little therapeutic value beyond the use of nicotine in smoking cessation programs (see Chapter 32).

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• Clarkson P, Celermajer DS, Donald AE, et al. Impaired vascular reactivity in insulin-dependent diabetes mellitus is related to disease duration and low density lipoprotein cholesterol levels. J Am Coll Cardiol 1996;28:573-9.
• Lieu C, Shi J, Donat F, et al. Fondaparinux sodium is not metabolised in mammalian liver fractions and does not inhibit cytochrome P450-mediated metabolism of concomitant drugs. Clin Pharmacokinet 2002;41(Suppl 2):19-26.
• Win AK, Dowty JG, Cleary SP, et al. Risk of colorectal cancer for carriers of mutations in MUTYH, with and without a family history of cancer. Gastroenterology 2014;146(5):1208-1211.