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Deep hypothermia (<30°C [86°F]) is rarely used as it is 3 associated with a much greater risk for severe side effects order cialis professional 20mg amex impotence reasons and treatment. In fact discount cialis professional 20mg online doctor who cures erectile dysfunction, a recent international generic cialis professional 20 mg on line impotence at 19, multicenter cheap cialis professional online visa erectile dysfunction l-arginine, randomized trial suggested that a temperature <36°C (96. At the same time, there is 5 an increase in the levels of free fatty acids, ketones, and lactate. Another important consequence of hypothermia is decreased insulin secretion and moderate to severe insulin resistance leading to hyperglycemia, particularly in patients with diabetes. Even though his insulin pump settings suggested that he was reasonably sensitive to insulin, his current insulin requirement clearly indicated severe insulin resistance. All steps involved in mediating insulin action on glucose transport and intracellular metabolism are diminished by lower temperature. The mechanism of this impairment is said to include diminished intracellular metabolism of glucose and slower rates of fusion and fission of insulin-containing secretory vesicles in the pancreatic β-cells under hypothermic conditions. As a result, in some patients, hyperglycemia can be extreme approaching or exceeding 1,000 mg/dL (55. Insulin requirement is greatly increased and, frequently, insulin infusion even at the very high rate is unable to control hyperglycemia. At that point, a gradual rewarming phase was initiated, and his insulin sensitivity increased rapidly with a rapid decrease in insulin requirement (Table 57. With the core temperature rising, insulin action improves dramatically, and with large quantities of insulin on board, hypoglycemia may ensue precipitously. Insulin infusion rate must be decreased aggressively in the rewarming phase to avoid hypoglycemia. In practical terms, the danger of hypoglycemia during the rewarming phase is the most important point to remember during the management of glycemia in patients with therapeutic hypothermia. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. Therapeutic hypothermia in the intensive care unit: practical considerations, side effects, and cooling methods. Hyperglycemia is a well-known phenomenon in critically ill patients during the postoperative period. It is associated with increased risks of infection, inpatient mortality, and other adverse events in both diabetic 1 and nondiabetic patients. Heart transplant patients are some of the most challenging to treat; they receive high-dose steroids, have several comorbidities, are treated by multiple providers, and often have 3 prolonged hospital stays. Hypoglycemia can be a limiting factor, and safe and effective implementation of insulin protocols can be difficult in 4 these patients. Here, we present an example of a particularly challenging subset of these patients who are very insulin resistant, require very high doses of insulin, and are particularly prone to 4 hypoglycemia. This protocol has effectively achieved good glycemic 4,5 control with an acceptable amount of hypoglycemia in such patients. When transferred to the floor, glycemic control continues with subcutaneous insulin. While she was on the insulin drip, she was also being treated with several pressors (dobutamine, epinephrine, isoproterenol, and vasopressin). The dose was reduced by 50% every hour for the next 5 h until the drip was stopped. Several questions are raised in the management of a patient like this: 1) How do we predict the severe insulin resistance? With a small number of patients, we have not been able to develop a profile to predict insulin resistance for such patients. Whether the insulin receptors are saturated at such high insulin doses still remains unclear. Frequent monitoring, peak drip alerts, and endocrine and pharmacy consultation for those above certain parameters may be necessary. Certain institutions have already developed maximum drip rates allowed and have these parameters in place. She did not require any diabetes medications during the last 3 days of hospitalization or at discharge. This patient illustrates problems that may arise for a particular subset of patients with extreme insulin resistance. Such patients are important to recognize to avoid periods of prolonged hyperglycemia and to avoid hypoglycemia when the resistance suddenly “breaks. Hyperglycemia: an independent marker of inhospital mortality in patients with undiagnosed diabetes. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Intensive glycemic control after heart transplantation is safe and effective for diabetic and non-diabetic patients. He had difficulty weaning off of cardiopulmonary bypass despite an intraaortic balloon pump placement and inotropic support. His home insulin regimen was glargine 85 units once daily and glulisine 6 units with meals 3 times a day. His initial total daily insulin requirements were 100–170 units and his daily blood glucose average was 130–160 mg/dL (7. High insulin requirements are common in patients with type 2 diabetes and advanced chronic heart failure. The mechanisms of increased insulin resistance are thought to be multifactorial because of numerous positive and negative hormonal and hemodynamic effects on various proinflammatory and anti- inflammatory cytokines, leading to a worsening of insulin resistance: 1. Its increased levels have been associated with peripheral insulin resistance and decreased 2 insulin-mediated glucose disposal. There are suggestions in the literature that downregulation of adiponectin receptors may result in its functional 3 resistance with a loss of its protective “insulin sensitizing” role. Because resistin is found in higher concentrations in patients with heart failure, this association may contribute to increased insulin 4 resistance in heart failure. At the time of consultation, his workup showed the following: Weight 108 kg Blood pressure 110/76 mmHg Temperature 36. Several insulin regimens can be used for patients during continuous enteral nutrition. We used a basal-bolus regimen with long-acting glargine insulin and scheduled doses of regular insulin in addition to correction of blood glucose levels >180 mg/dL (10 mmol/L) every 6 h. A lower dose of long-acting insulin and administration of regular insulin every 6 h allowed us to avoid institution of standing orders of D-10% i. The patient was transferred to an acute inpatient rehabilitation unit on December 19, 2012. Because of small insulin requirements and stable kidney function, a decision was made to transition the patient to oral hypoglycemic agents. Mealtime lispro was replaced with sitagliptin 100 mg once daily and glargine was discontinued a few days later. The patient was sent home on January 10, 2013, on monotherapy with sitagliptin 100 mg once daily. Increased levels of retinol binding protein 4 in patients with advanced heart failure correct after hemodynamic improvement through ventricular assist device placement.
Craniofacial There is an unusual facial appearance with hy- pertelorism and a fat down-slanting nose order cialis professional 40 mg mastercard erectile dysfunction treatment diet. Cleft palate was re- Background The earliest reported case of multiple pterygia ported  along with ptosis cheap 40mg cialis professional erectile dysfunction age 40, down-slanting palpebral fssures quality 20mg cialis professional impotence for males, was by Matolcsy in 1936 discount generic cialis professional uk impotence zoloft. The eponym Escobar syndrome reduced facial movements, and conductive deafness . Females have aplasia of the labia Etiology Escobar syndrome is inherited as an autosomal re- majora and a small clitoris. Presentation Escobar syndrome is divided into two types: prenatally lethal and nonlethal (Escobar). The condition can be diagnosed References prenatally  and progresses after birth with advancing age. The condition has been reported among fami- asthenia caused by disruption of the acetylcholine receptor fetal lies living in the Arabian Gulf region including Kuwait and gamma subunit. Escobar variant with pursed  There may be decreased muscle mass and severe muscle mouth, creased tongue, ophthalmologic features, and scoliosis in 6 children from Oman. Multiple pterygium syn- in the literature as camptodactyly or distal arthrogryposis rep- drome: evolution of the phenotype. Note the secondary distortion of fexion contractures of the index, long and ring digits. Soft tissue webbing was also present tight intrinsic muscles and fbrous cords (fbrous substrata), which are in both popliteal regions 274 19 Congenital Ulnar Drift (Windblown Hand) Waardenburg Syndrome small patch of white hair, which is prematurely gray, on the anterior forehead. Musculoskeletal involvement is dependent Waardenburg syndrome with upper limb anomalies on the type. At birth dig- hannes Waardenburg, a Dutch ophthalmologist who died in its and thumb may be hypoplastic and tapered, and give the 1979 and was the frst to notice that people with two different appearance of an arthrogrypotic hand (. These genes all are involved in the formation of is no bone coalition at the phalangeal level. Carpal coali- melanin, which contributes to skin, hair, and eye color and tions have been described. The medial canthal distortion has been syndrome, have hearing loss, changes in pigmentation, and called “dystopia canthorum” (. Patients often abnormalities of the upper extremities, including congenital have pale blue eyes, but additionally may have different col- ulnar drift, digital and thumb contractures, syndactyly, and ored eyes or two segments of the same eye with different digital hypoplasia. Eyes are widely displaced due to Shah syndrome, have skin, hair, and auditory changes plus lateral displacement of the inner canthal ligaments. Philtral length is decreased in dence is 1:40,000 live births and accounts for 2 to 5% of the upper lip and anthropomorphic measurements show lower those with hearing loss. The hands resembled those Waardenburg Syndrome 275 276 19 Congenital Ulnar Drift (Windblown Hand) Fig. A new syndrome combining developmental anoma- lies of the eyelids, eyebrows and nose root with pigmentary defects of the iris and head hair and with congenital deafness. Waardenburg’s syndrome patients have mutations in the human homologue of the Pax-3 paired box gene. Brachymetacarpia 20 The Latin term brachy means short and brachymetacarpalia associated with brachymetacarpia include brachymetatarsia denotes short metacarpal bone. However, the thumb to the 4th and 5th metacarpal heads, which will intersect with deformity is not specifc for a defnite syndrome. Short meta- the 3rd metacarpal head, whereas in a normal hand it does carpals are seen with a plethora of other congenital differ- not (. In many patients with severe recession of of short metacarpals of middle, ring, and small fngers. Re- the ffth or fourth metacarpals, a “knuckle” which normally represents the metacarpal head appears to be absent, but in actuality is not. One report suggested that brachymetacarpia is caused by idiopathic early closure of the epiphyseal plate,  and serial early radiographs in these patients’ show that this does indeed occur. The condition may be isolated to one metacarpal – most often the ring fnger and occasionally, the index fnger. The short metacarpal can be of normal width but sometimes it may have greater diameter than adjacent normal metacarpals. Substantial shortening of the metacarpal shaft will disturb the anatomy of the transverse metacarpal arch and may adversely affect power grasp. A line drawn tangential to the distal portion but may be requested by the family to improve esthetics in of the fourth and ffth metacarpal heads should not intersect the third particular to lengthen the digit, correct the imbalance, and re- metacarpal head (negative sign). The right side appears these patients the foot deformity is more extensive, involving more rays shorter than the left. In addition, the ports of anomalies associated with Bell’s brachydactyly are short stature, glaucoma, aortic stenosis, and duplication of the uterus . One study showed that familial short stature was reported among patients with short ffth metacarpals and children with familial short stature had a signifcantly higher prevalence of brachymetacarpia V (64 %) than children with normal stature (21. This radiograph and clinical ap- pearance show a short thumb in conjunction with short fourth and ffth metacarpals (not seen here). The tuft of the distal phalanx is wide but is not any larger than the opposite side. Hallmarks Albright hereditary osteodystrophy is charac- Presentation Although this phenotype resembles parathyroid terized by short stature, obesity, round facies, subcutaneous hormone defciency, the patient’s renal function is normal. Mental retar- three patients with short stature, round face, short neck, obe- dation may be present but is not common. One of the original pa- original flms is calcifcation of the basal ganglia and the subcutane- tients described by Albright was an adult seen at the Beth Israel Hos- ous tissue planes of the scalp. The patient’s endocrine Endocrine work-up revealed hypocalcemia and hyperphosphatemia. The term brachydactyly has been used often to describe brachymetacar- pia or shortening of middle ring and small fnger metacarpals along with a short thumb distal phalanx, which are the typical fndings of Albright pseudopseudohypoparathyroidism. This phenotype has been reported in 70 % of patients on radiologic examinations . Short- ening was present in at least one bone in each subject, with a prevalence of 100%. Brachymetacar- pia and brachytelephalangy characterized the hands of the subjects. Brachymesophalangia may be encountered causing small fnger clinodactyly along with carpal synostosis and mild Madelung deformity (. Visceral The mammogram showed calcifed breast nodules  and reproductive dysfunction is common . Pseudo-hypoparathy- roidism – an example of ‘Seabright-Bantam syndrome’: report of three cases.
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Bisoprolol and nebivolol may be exceptions that chronic therapy are probably due chiefly to reduced cardiac can be tried at low doses in patients with mild asthma and a output with reduced peripheral blood flow purchase cialis professional pills in toronto erectile dysfunction treatment fort lauderdale, rather than to strong indication for b-blockade safe 40mg cialis professional erectile dysfunction at age 23. The main Hepatic blood flow may be reduced by as much as 30% buy cialis professional without a prescription erectile dysfunction market, practical use of b1-selective blockade is in diabetics purchase genuine cialis professional on line erectile dysfunction pills cost, where prolonging the t½ of the lipid-soluble drugs whose metab- b2 receptors mediate both the symptoms of hypoglycaemia olism is limited by hepatic blood flow, i. The fall Effects in cardiac output may be less, and fewer patients may expe- Within hours of starting treatment with a b-blocker, blood rience unpleasantly cold extremities. This reflects the acute effect on cardiac tion may be worsened by b-blockade whether or not there output (heart rate and contractility) but this is not sus- is partial agonist effect. Both classes of drug can precipitate tained and on chronic administration the blockade of renin heart failure, and indeed no important difference is to be secretion appears to be the main cause of blood pressure expected because patients with heart failure already have reduction. An additional contributor may be the two- to high sympathetic drive (but note that b-blockade can be three-fold increase in natriuretic peptide secretion caused used to treat cardiac failure, p. Abrupt withdrawal may be less likely to lead to a rebound A substantial advantage of b-blockade in hypertension is effect if there is some partial agonist action, as there may be that physiological stresses such as exercise, upright posture less up-regulation of receptors, such as occurs with pro- and high environmental temperature are not accompanied longed receptor block. With (quinidine-like or local anaesthetic) effect, a property that b-blockade these necessary adaptive a-receptor constrictor is unimportanThat clinical doses but relevant in overdose mechanisms remain intact. Additionally, agents having this effect will At first sight the cardiac effects might seem likely to anaesthetise the eye (undesirable) if applied topically for be disadvantageous rather than advantageous, and in- glaucoma (timolol is used in the eye and does not have this deed maximum exercise capacity is reduced. Note: hybrid agents having b-receptor block plus vasodilatation unrelated to adrenoceptor have been developed, e. What selectivity 1 1 2 really means is that 300 times more of the blocker is required to achieve the same blockade of the b2-receptor as for the b1-receptor. Therefore, as the dose (concentration at receptors) rises, the benefit of selectivity is gradually lost. The relationship between the concentration reflex is being relied on in diagnosis and management of of the parent drug in plasma and its effect is further ob- hypothyroidism. Additionally, for some of the lipid-soluble b-blockers, especially timolol, plasma t½ may not reflect Pharmacokinetics the duration of b-blockade, because the drug remains The plasma concentration of a b-adrenoceptor blocker bound to the tissues near the receptor when the plasma may have a complex relationship with its effect, for several concentration is negligible. First-order kinetics usually apply to elimination Most b-adrenoceptor blockers can be given orally of drug from plasma, but the decline in receptor block once daily in either ordinary or sustained-release formu- is zero order. The practical application is important: lations because the t½ of the pharmacodynamic effect within 4 h of giving propranolol 20 mg i. Surprisingly, tachyarrhythmias are not less have a high apparent volume of distribution. Maximum benefit is in the first pranolol reaches concentrations in the brain 20 times those 24–36 h, but mortality remains lower for up to 1 year. Contraindications to early use include bradycardia Water-soluble agents show more predictable plasma con- (<55 beats/min), hypotension (systolic <90 mmHg) centrations because they are less subject to liver metabolism, and left ventricular failure. A patient already taking a being excreted unchanged by the kidney; thus their half-lives b-blocker may be given additional doses. The drug is started between t and an action terminated by renal elimination are best 4 days and 4 weeks after the onset of the infarct and is ½ 21 avoided in patients with renal disease. Fallot’s tetralogy (cyanotic attacks): hypertrophic subaortic stenosis (angina); some cases of mitral valve Classification of b-adrenoceptor- disease. But it is desirable that they (carvedilol, a-blocker as well) and b1-selective (metoprolol be known, for they can sometimes matter and they may and bisoprolol) agents. The negative inotro- pic effects can still be significant, so the starting dose is low b-Adrenoceptor blockers not listed in Table 24. Hyperthyroidism: b-blockade reduces unpleasant symptoms of sympathetic overactivity; there Uses of b-adrenoceptor-blocking drugs may also be an effect on metabolism of thyroxine (periph- eral de-iodination from T4 to T3). A non-selective agent Cardiovascular uses: Angina pectoris: b-blockade re- (propranolol) is preferred to counteract both the cardiac duces cardiac work and oxygen consumption. Hypertension: b-blockade reduces renin secretion and cardiac output; there is little interference with homeostatic reflexes. Reduced peripheral blood flow, especially with non- selective members, leading to cold extremities which, rarely, can be severe enough to cause necrosis; intermittent Other uses: claudication may be worsened. Non-selective • Eyes: b-blockers, by blocking b receptors, impair the normal 2 n glaucoma: carteolol, betaxolol, levobunolol and sympathetic-mediated homeostatic mechanism for main- timolol eye drops act by altering production and taining blood glucose levels, and recovery from hypogly- outflow of aqueous humour. Further, as a adrenoceptors are not blocked, hypertension (which may be severe) can occur Adverse reactions due to b-adrenoceptor as the sympathetic system discharges in an ‘attempt’ to re- verse the hypoglycaemia. The symptoms of hypoglycaemia, blockade in so far as they are mediated by the sympathetic nervous Bronchoconstriction (b2 receptor) occurs as expected, espe- system (anxiety, palpitations), will not occur, except cially in patients with asthma22 (in whom even eye drops (cholinergic) sweating, and the patient may miss the are dangerous23). In elderly chronic bronchitics there warning symptoms of hypoglycaemia and slip into coma. Patients with hyperlipidae- Cardiac failure may arise if cardiac output is dependent mia needing a b-blocker should generally receive a on high sympathetic drive (but b-blockade can be intro- b1-selective one. Sexual function: interference is unusual and generally not The degree of heart block may be made dangerously worse. Incapacity for vigorous exercise due to failure of the Abrupt withdrawal of therapy can be dangerous in angina cardiovascular system to respond to sympathetic drive. The existence and cause of a b-blocker withdrawal phenomenon is debated, but probably occurs 22 due to up-regulation of b2 receptors. It is particularly inad- A 36-year-old patient with asthma collected, from a pharmacy, chlorphenamine for herself and oxprenolol for a friend. She took a visable to initiate an a-blocker at the same time as with- tablet of oxprenolol by mistake. Wheezing began in 1 h and worsened drawing a b-blocker in patients with ischaemic heart rapidly; she experienced a convulsion, respiratory arrest and ventricular disease, because the b-blocker causes reflex activation of fibrillation. She was treated with positive-pressure ventilation (for 11 h) the sympathetic system. The b-blocker withdrawal phe- and intravenous salbutamol, aminophylline and hydrocortisone, and survived (Williams I P, Millard F J 1980 Severe asthma after inadvertent nomenon appears to be least common with partial agonists ingestion of oxprenolol. Rebound pharmacological – link between the use of timolol as eye drops and hypertension is insignificant. For local administration, a drug needs high potency, so that a high degree of receptor blockade is achieved using a physically small (and therefore locally administrable) dose of drug. As the majority of this will be swallowed and a few milligrams orally will block systemic b2 receptors, it is These include loss of general well-being, tired legs, fatigue, apparent why one drop of timolol down the lachrymal duct (of the depression, sleep disturbances including insomnia, dream- wrong patient) is hazardous. Mu¨ller M E, van der Velde N, Krulder J W M, van der Cammen T J M 2006 Syncope and falls due to timolol eye drops. British Medical Oculomucocutaneous syndrome occurred with chronic use Journal 332:960–961. With prompt treat- so rarely do so that they are under suspicion only and, ment, death is unusual. The mechanism of the syndrome is un- Interactions certain but appears immunological. Pharmacokinetic b-blockers that are metabolised in the liver exhibit higher plasma concentrations when Overdose co-administered with drugs that inhibit hepatic metabo- lism, e.
Because neuraxial anesthesia techniques are allowed to drink fuids afer an overnight fast and commonly employed for many patients during patients who receive a bowel preparation experience major abdominal buy cialis professional online from canada erectile dysfunction and testosterone injections, vascular buy cialis professional amex erectile dysfunction drugs over the counter canada, thoracic and orthope- dehydration purchase cialis professional from india impotence hernia, which may increase discomfort and dic surgery buy cheap cialis professional 40 mg on line impotence divorce, appropriate timing and administration cause drowsiness and orthostatic lightheadedness. International recommendations on the ration during induction of anesthesia, this beneft management of anticoagulated patients receiving must be weighed against the detrimental aspects of regional anesthesia have been recently revised and this practice. For instance, research suggests that avoiding preoperative fasting and ensuring adequate hydra- Antibiotic Prophylaxis tion and energy supply may moderate postoperative insulin resistance. All international fasting guide- Appropriate selection and timing of preoperative lines allow clear fuids up to 2 h prior to induction antibiotic prophylaxis reduces the risk of surgi- of anesthesia in patients at low risk for pulmonary cal site infections. Tis practice has proved tered within 1 h before skin incision and, based on to be safe even in morbidly obese patients. Further- their plasma half-life, should be repeated during more, recent studies have shown that preoperative prolonged surgeries to ensure adequate tissue con- administration of carbohydrate drinks (one 100-g centrations. Antibiotic prophylaxis of surgical site dose administered the night before surgery and a infections should be discontinued within 24 h afer second 50-g dose 2–3 h before induction of anes- surgery (current guidelines permit cardiothoracic thesia) is safe; can reduce insulin resistance, hun- patients to receive antibiotics for 48 h following ger, fatigue, and postoperative nausea and vomiting surgery). Moreover, postoperative nitrogen loss and the loss Strategies to Minimize the of skeletal muscle mass are attenuated. Surgical Stress Response Magnetic resonance imaging studies in healthy The surgical stress response is characterized by neu- volunteers have shown that the residual gastric vol- roendocrine, metabolic, and infammatory changes ume 2 h afer 400 mL of oral carbohydrate (12. The safety of this practice has been tested and physiologically compromised patients. A laparoscopic 3 the surgical stress response is related to the approach is also associated with less morbidity in intensity of the surgical stimulus; can be amplifed elderly surgical patients. Regional Anesthesia/ erative interventions, including deeper planes of Analgesia Techniques general anesthesia, neural blockade, and reduction A variety of fast-track surgical procedures have taken in the degree of surgical invasiveness. Much recent advantage of the benefcial clinical and metabolic efort has focused on developing surgical and anes- efects of regional anesthesia/analgesia techniques thetic techniques that reduce the surgical stress (Table 48–1). Neuraxial blockade of nocicep- 4 response, with the goal of lowering the risk of stress- tive stimuli by epidural and spinal local anes- related organ dysfunction and perioperative compli- thetics has been shown to blunt the metabolic and cations. An overview of several techniques that have neuroendocrine stress response to surgery. However, the advantages invasive procedures in the hands of adequately of neuraxial blockade are not as evident when mini- trained and experienced surgeons. Lumbar cholecystectomy results in shorter length of hos- epidural anesthesia/analgesia should be discouraged pital stay and fewer complications compared with for abdominal surgery because it ofen does not pro- open cholecystectomy, and similar results have vide adequate segmental analgesia for an abdominal been reported for colorectal surgery. The introduction of ultra- dence of systemic opioid-related side efects, epidural short-acting intrathecal agents such as 2-chloropro- analgesia facilitates earlier mobilization and earlier caine (still controversial at present) may further resumption of oral nutrition, expediting exercise speed the fast-track process. Neural ciated with side efects such as nausea, pruritus, and blockade minimizes postoperative insulin resistance, postoperative urinary retention. Adjuvants such as attenuating the postoperative hyperglycemic response clonidine are efective alternatives to intrathecal opi- and facilitating utilization of exogenous glucose, oids, with the goal of avoiding untoward side efects thereby preventing postoperative loss of amino acids that may delay hospital discharge. Administering a lumbar plexus needed to defne the safety and efcacy of regional block along with a sciatic nerve block decreases anesthesia techniques in fast-track cardiac surgery hospital length of stay, postoperative urinary reten- (and many clinicians avoid them due to concerns tion, and ileus associated with lower extremity total about neuraxial hematomas). Although some stud- joint replacement when compared with general or ies have shown that spinal analgesia with intrathecal neuraxial anesthesia followed by intravenous opi- morphine decreases extubation time, decreases oids. The same benefts of fewer opioid side efects length of stay in the intensive care unit, reduces pul- and accelerated discharge have been shown with monary complications and arrhythmias, and pro- regional anesthesia/analgesia for hand, shoulder, vides analgesia with less respiratory depression, anorectal, and inguinal hernia repair surgery. Rectus caine, because of its lower toxicity relative to bupiva- abdominis block can be used for midline incisions. Intravenous α -Agonist Therapy 2 thetic wound infusions are widely used to improve Both clonidine and dexmedetomidine have anes- postoperative pain control and reduce the necessity thetic and analgesic properties. Intravenous Lidocaine Infusion axial and peripheral nerve local anesthetic blockade. Lidocaine (intravenous bolus of 100 mg or 7 In patients undergoing cardiovascular fast-track 1. Inhalational Anesthetics sion for various surgical procedures remains to be Compared with other volatile anesthetic agents, determined; even short duration of lidocaine infu- desfurane and sevofurane can shorten anesthesia sion may have beneft. Nitrous oxide, because response during laryngoscopy and intubation and to of its anesthetic- and analgesic-sparing efects, rapid attenuate the surgical stress-induced increase in cir- pharmacokinetic profle, and low cost, is frequently culating catecholamines. Moreover, the use of nitrous oxide intraoperative period and during emergence from during laparoscopic surgery may distend the bowel anesthesia. Opioids properties, which may be explained by reduced Short-acting opioids such as fentanyl, alfentanil, and energy requirements associated with decreased remifentanil are commonly used during fast-track adrenergic stimulation. A positive protein balance surgery in combination with inhalation agents or has been reported in critically ill patients when propofol, and with regional analgesia techniques. Tey are chosen in a large, randomized, multicenter trial of patients to facilitate tracheal extubation while decreasing the undergoing elective and emergent laparotomy. Finally avoidance of bedrest, and moregulation, exposure to the relatively cool sur- encouraging early mobilization and physiotherapy, gical environment, and intraoperative loss of heat can also improve postoperative central and periph- through the surgical feld can lead to intraoperative eral tissue oxygenation. Periop- quent complication associated with anesthetic drugs erative hypothermia, by increasing sympathetic that delay early feeding and recovery from surgery. A decrease in core body tempera- sensus guidelines for prevention and management of ture of 1. The risk of bleeding and blood transfusion issues are discussed in Chapters 17 and 56. Furthermore, by impairing the metabolism of many Goal-Directed Fluid & anesthetic agents, hypothermia signifcantly pro- Hemodynamic Therapy longs anesthesia recovery. Tese issues are discussed Intraoperative and postoperative fuids are com- in Chapter 52. Despite numerous studies seeking to defne fuid Maintenance of Adequate strategy (amount and type of fuid administered, Tissue Oxygenation crystalloid versus colloid, etc), “liberal,” “standard,” Surgical stress leads to impaired pulmonary function or “restrictive” fuid regimens have failed to con- and peripheral vasoconstriction, resulting in arterial sistently improve postoperative outcomes. Perioperative hypoxia fuid administration and sodium excess lead to can increase cardiovascular and cerebral complica- fuid overload, increase postoperative morbidity, tions, and many strategies should be adopted during and prolong hospitalization. Furthermore, excess fuids com- comes without increasing the risk of postoperative monly increase body weight by 3–6 kg and may complications. On the other romuscular blockade can reduce early postoperative hand, restrictive fuid management does not ofer hypoxemia. Intraoperative and postoperative (for any substantial, clinically relevant advantage, except 2 h) inspired oxygen concentration of 80% has been possibly improving pulmonary function and reduc- associated with increased arterial and subcutaneous ing postoperative hypoxia. Postoperative shivering can greatly increase oxygen The concept of goal-directed fuid therapy is consumption, catecholamine release, cardiac out- based on the optimization of hemodynamic mea- put, heart rate and blood pressure, and intracerebral sures such as heart rate, blood pressure, stroke vol- and intraocular pressure. It increases cardiovas- ume, pulse pressure variation, and stroke volume cular morbidity, especially in elderly patients, and variation obtained by noninvasive cardiac output increases length of stay in the postanesthesia care devices such as pulse-contour arterial waveform unit. Shivering is uncommon in elderly and hypoxic analysis, transesophageal echocardiography, or patients: the efcacy of thermoregulation decreases esophageal Doppler (see Chapter 5). The type of with aging, and hypoxia can directly inhibit shiver- fuid infused is also important: isotonic crystal- ing. Many drugs, notably meperidine, clonidine, and loid should be used to replace extracellular losses, tramadol, can be used to reduce postoperative shiv- whereas iso-oncotic colloids are needed to replace ering; however, prevention of hypothermia is the intravascular volume (Table 48–3 ). Multimodal Analgesia perspiration The scientifc rationale for multimodal 8 analgesia is to combine diferent classes of Closed abdomen 0.