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Extra care should be taken when considering the impact of associated sympathectomy and hypotension in patients with major comorbidities discount benicar 40mg mastercard, particularly severe aortic stenosis cheap benicar online amex. Prior to epidural or spinal anesthesia cheap 10mg benicar free shipping, a fluid bolus will help avoid a precipitous drop in blood pressure. Slow and controlled dosing through an epidural catheter can also prevent rapid hypotension. Both hyperbaric and isobaric local anesthetics can be used for a spinal anesthetic. As a result, some surgeons perform injections of a “cocktail” that may 3630 contain a local anesthetic, epinephrine, a nonsteroidal anti-inflammatory, a corticosteroid, and/or an antibiotic into the periarticular space. Some surgeons will place an epicapsular catheter for postoperative pain management. Utilization of these techniques can avoid urinary retention associated with epidural opioids and weakness associated with peripheral nerve blocks. Although superior to placebo, further studies are needed to60 establish noninferiority of this technique for pain control compared to percutaneous regional anesthesia techniques. Blood Loss and Transfusion Deliberate hypotension using neuraxial anesthesia during hip surgery decreases blood loss and intraoperative transfusion needs when compared to general anesthesia. In this setting, the inotropic effect of a low-dose epinephrine infusion prevents significant hypotension while maintaining cardiac output. Maximal relaxation is necessary while the leg is placed in traction to facilitate dislocation of the femoral head from the acetabulum for access to the hip joint. A potentially life-threatening complication of hip arthroscopy is extravasation of the arthroscopy fluid from the hip joint into the peritoneal cavity. Treatment ranges from clinical observation to diuresis and, in severe cases, abdominal laparotomy. Diagnosis can be made with bedside ultrasound utilizing the focused assessment with sonography in trauma exam. It is important to71 create an appropriate postoperative analgesia plan to ensure mobility and range of motion. Positioning and Anesthesia Technique Knee arthroplasties and arthroscopies are performed in the supine position to allow for easy access to and evaluation of the knee joint in extension and flexion. In patients with severe atherosclerosis, the tourniquet may not optimally compress the arteries. If a tourniquet is not applied, consider deliberate hypotension as described earlier for hip surgery. Epidural catheters with a continuous infusion of dilute local anesthetic and low-dose opioid can provide excellent pain control, particularly when paired with patient-controlled epidural analgesia. Management of an epidural catheter for postoperative analgesia must account for pharmacologic venous thromboprophylaxis. Ultrasound-guided regional anesthesia has led to a significant increase in use of peripheral nerve blocks and catheters as components of postoperative analgesic regimens. A balanced multimodal analgesic regimen can include pharmacologic treatment with anti- inflammatories, acetaminophen, opioids, and medications that manage neuropathic components of pain, such as pregabalin. Such a multimodal approach has the potential to maximize analgesic efficacy while minimizing side effects. These blocks can be performed in combination with a sciatic nerve block and/or an obturator nerve block. Literature and clinical practice continue to evolve regarding which blocks or combination of blocks best facilitate rehabilitation and postoperative mobilization, thereby reducing time to hospital discharge, enhancing cost effectiveness, and reducing the risk for complications such as ambulation-related falls. Performing the77 block requires ultrasound guidance and a low local anesthetic volume placed distally within the adductor canal to avoid motor blockade to the vastus medialis. A selective79 tibial nerve block is an alternative that provides similar analgesia without the corresponding foot drop. Liposomal bupivacaine can be added to periarticular injections as a means to prolong the effect of the local anesthetic. The benefit of liposomal bupivacaine over standard local anesthetics is not conclusive, however, and both the safety profile and cost84 85 should be taken into consideration. Ambulatory Knee Surgery Ambulatory knee surgery has increased because health-care costs have encouraged outpatient management of less complex cases. An optimal anesthetic has a rapid onset and fast offset with minimal side effects so as to prevent prolonged postanesthesia care unit stays or unexpected overnight admissions. Neuraxial anesthesia results in a lower rate of nausea and vomiting than general anesthesia. However, in a practice with rapid turnover time and/or limited postanesthesia care unit capacity, the need to wait for block resolution may not be practical. In such settings, the use of general anesthesia with multimodal antinausea prophylaxis may be appropriate. In performing a spinal anesthetic in an ambulatory setting, a short-to- intermediate–acting local anesthetic should be utilized. This may be due to concomitant use of the anti-inflammatory ketorolac and dexamethasone for nausea prophylaxis. Evidence has not demonstrated a clinically significant difference in patient outcome with respect to anesthetic technique for ambulatory knee surgery. In younger and more active patients the autograft is preferred, but patellar tendon and hamstring grafts cause 3634 significant postoperative pain. Anesthesia for foot surgery can be performed with an ankle block or a sciatic nerve block in the popliteal fossa with a saphenous nerve block as needed for coverage of the medial foot and ankle (see Chapter 36). Some surgeons prefer ankle blocks in order to avoid the foot drop caused by a sciatic nerve block. A neuraxial or general anesthetic may be required to minimize patient movement and allow for thigh tourniquet inflation. Surgery to the foot and ankle can cause severe postoperative pain, and regional anesthesia provides optimal postoperative analgesia, particularly in the outpatient setting. Long-acting local anesthetics such as bupivacaine and ropivacaine can provide up to 24 hours of analgesia, and the addition of adjuvants like preservative-free dexamethasone can consistently extend analgesia beyond 24 hours. Peripheral nerve catheters may be93 challenging for noncompliant patients or those with limited access to follow- up care. In the outpatient setting, care must be taken to prevent accidental trauma to an anesthetized extremity, and patients should be instructed on how to best protect the limb upon discharge.

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It is impaired in such disorders as interstitial lung disease order benicar on line amex, which affects the alveolar-capillary site discount benicar 10 mg on-line. Predicted postoperative diffusing capacity percent is the strongest single predictor of risk of complications and mortality after lung resection cheap 40 mg benicar visa. A simpler test that21 can be performed is exercise oximetry—a decrease of 4% during exercise is associated with increased risk. Brunelli and Fianchini had patients climb the maximum number23 24 2563 of stairs possible. The inability to do a maximal stair climbing has been correlated with an increased mortality following major lung resection. In a25 recent study, climbing to 20 m with a speed of at least 15 m/min, correlated with meeting qualifying criteria for pneumonectomy. An 11-point scoring scale has28 been developed for predicting postoperative pulmonary complications. The preoperative evaluation of the patient for lung resection is summarized in Figure 38-4. Preoperative Preparation The wide spectrum of physiologic changes that occur during thoracic surgery puts patients at great risk of developing postoperative complications. Morbidity and mortality increase when these changes are superimposed on an acutely or chronically compromised patient. Several conditions, including infection, dehydration, electrolyte imbalance, wheezing, obesity, cigarette smoking, cor pulmonale, and malnutrition, show particular correlations with postoperative complications. Proper, vigorous preoperative preparation can improve the patient’s ability to face the surgery with a decreased risk of morbidity and mortality. It is important that conditions predisposing to postoperative complications be rigorously treated before surgery. Smoking There is a high prevalence of smoking among patients presenting for surgery, and there is extensive evidence that these patients are at increased risk for development of postoperative respiratory complications. In contrast, cessation of smoking for a period of longer than 4 to 6 weeks before surgery is associated with a decreased incidence of postoperative complications. Furthermore, 2564 cessation of smoking 48 hours before surgery has been shown to decrease the percentage of carboxyhemoglobin, to shift the oxyhemoglobin dissociation curve to the right, and to increase oxygen availability. In one study, there was no evidence of a paradoxical increase in postoperative complications in patients who stopped smoking within 2 months before undergoing thoracic resection for lung tumor. Smoking is associated with increased mortality and31 pulmonary complications, but these can be decreased by preoperative cessation; the risk decreases with a longer cessation. A recent study32 indicated that the discontinuation of smoking for more than 8 weeks prior to surgery can help improve postoperative pulmonary function. One meta-33 analysis indicated that there was no improvement with cessation of smoking for less than 8 weeks but another meta-analysis indicated a progressive34 improvement with each week of abstinence from smoking. B: The split-lung function tests are regional tests to determine the involvement of the diseased lung to be removed. Treatment of the acutely ill patient depends on the results of the Gram stain of the sputum and blood cultures. Unless there are other modifying circumstances such as allergic history or patients are already receiving antibiotics, cefazolin is routinely administered perioperatively. In one prospective study, the incidence of mortality was lower in36 the group treated with prophylactic antibiotics compared with the untreated group (9% vs. Although not all surgeons routinely administer37 antibiotics prophylactically to their patients, any infection present before surgery should be vigorously treated. Hydration and Removal of Bronchial Secretions Correction of hypovolemia and electrolyte imbalance should be accomplished before surgery because adequate hydration decreases the viscosity of bronchial secretions and facilitates their removal from the bronchial tree. The use of mucolytic drugs, such as acetylcysteine (Mucomyst), or oral expectorants (potassium iodide) can be beneficial to patients with viscous secretions. Commonly used methods for removing secretions from the bronchial tree include postural drainage, vigorous coughing, chest percussion, deep breathing, and the use of an incentive spirometer. These modalities often require patient cooperation and frequent verbal encouragement to maximize the benefit. Wheezing and Bronchodilation The presence of acute wheezing represents a medical emergency, and elective surgery should be postponed until effective treatment has been instituted. The efficacy of1 bronchodilators in reversing the bronchospastic component is extremely important. A trial of bronchodilators and measurement of their effects on 2566 pulmonary function should be performed in any patient who shows evidence of airflow obstruction. Sympathomimetic drugs, such as epinephrine, isoproterenol, isoetharine, and ephedrine, all have mixed β and β sympathetic agonist1 2 effects. Selective β sympathomimetic drugs, such as albuterol,2 terbutaline, and metaproterenol, given as inhaled aerosols, are the preferred drugs for the treatment of bronchospasm, particularly in patients with cardiac disease. In addition, aminophylline improves diaphragmatic contractility and increases the patient’s resistance to fatigue. Therapeutic blood levels of aminophylline are 5 to 20 μg/mL and can be achieved by infusing a loading dose of 5 to 7 mg/kg over 20 minutes, followed by a continuous intravenous infusion of 0. Aminophylline may cause ventricular dysrhythmias, and this side effect should be borne in mind when treating patients who have myocardial ischemia. Because newer medications have fewer side effects, aminophylline is now rarely used. Steroids Although not true bronchodilators, steroids are traditionally considered to decrease mucosal edema and may prevent the release of bronchoconstricting substances. Steroids may be administered orally, parenterally, or in aerosol form, such as beclomethasone by inhaler. Cromolyn Sodium Cromolyn sodium stabilizes mast cells and inhibits degranulation and 2567 histamine release. It is useful in the prevention of bronchospastic attacks but is of little value in the treatment of the acute situation (see Chapter 8). Parasympatholytic Drugs Parasympatholytics include atropine and ipratropium (see Chapter 14). However, atropine blocks the formation of cyclic guanosine monophosphate and therefore has a bronchodilator effect. The pulmonary rehabilitation included education in a variety of areas37 such as breathing, exercise, and nutrition. Preoperative physical therapy in patients undergoing surgery for lung cancer led to better oxygenation and shortened hospital stay in the treatment group. A chest stethoscope may be placed over the dependent hemithorax to assess dependent lung ventilation.

The imager slides along a ceiling-mounted rail system buy benicar 10mg cheap, bringing prasellar extension order 20 mg benicar with amex. The table height order 10mg benicar with visa, as well as the longitudi- low-up of 38 months, showed overall radiographic tumor nal and lateral angles, may be modifed. In patients with invasive adenomas, only 39% un- troscopy23 into the intraoperative imaging sequences. However, the authors surgical treatment of growth hormone–secreting adeno- prefer to perform the entire operation within the magnetic mas. A series of 139 patients with a median follow-up of feld using nonferromagnetic instrumentation, thus mini- 5. It was estimated that tumor re- rate, with 91% remission in microadenomas and 60% remis- section with intraoperative imaging took one-third longer sion in macroadenomas. Gross to- some suites, a single switch can be created that will shut tal tumor evacuation was documented in 100% of microade- down all electronic equipment. Care must macroadenomas and in 91% of patients with microadenomas; be taken to prevent contact of any cables with the patient’s 16% of patients with postoperative remission were noted to skin to avoid burns. A process of a similar recurrence rate of 15% in patients who had postop- “troubleshooting” is often required to fnd sources of noise erative remission of Cushing’s disease. Al- of patients who, by the surgeon’s impression, had complete though initial scans may need to be repeated several times tumor resection achieved long-term disease control. Fourteen percent of these patients underwent repeat surgery to ob- tain adequate decompression of neural structures. Median I Pituitary Surgery Outcomes follow-up of 53 months revealed recurrence in 83 of 436 patients (19%). The operation takes place outside the 5-gauss line, and the table is moved into the feld when imaging is required. Tumor re- tients who underwent transnasal pituitary resection with section was performed using an operating microscope with the assistance of the 0. The group initially reported its expe- underwent primary resection, whereas the remaining nine rience with a 0. Subsequently, macroadenomas37 and 23 growth hormone–secreting ade- additional T1-weighted sagittal sequences were obtained nomas. Contrast- tained T1-weighted sagittal and coronal spin echo sequences enhanced imaging was performed toward the end of the followed by high-resolution T2-weighted turbo spin echo se- resection to precisely localize residual tumor. Each imaging session caused an approximately 15- tion completion, a T1 sagittal and a gradient echo sequence minute-long interruption in the operation. Irrigation of the were performed to evaluate the extent of resection and to sellar foor with saline and application of bone wax to mimic make certain that an evolving hematoma was not visual- the sellar foor decreased imaging artifact from pooled blood ized. Porcelain-coated drills also decreased imaging ar- visualized by the surgeon in seven cases (41%), leading to tifact. In the nonfunctioning macroadenoma group, initial complete evacuation of the tumor remnants in all patients. The postresection gradient echo sequence diagnosed an Among the remaining 57 patients, 37 underwent additional expanding hematoma after the fat graft was put in place. In the overall group, to- The hematoma was evacuated, and complete hemostasis tal resection was intended in 85 patients and intraoperative was achieved prior to completion of the operation. Among the 23 acromegalic patients, that occurred during resection of tumor adherent to the complete resection was intended in 18 patients. The patient accrual and follow-up period in this In our institution, pituitary surgery is performed using study span 3 years, and no recurrence was noted during purely endoscopic technique. Thirty-one patients were included subsequently visualized with a 45-degree endoscope and in the series, with 15 patients having pituitary adenomas resected, leading to completion of tumor evacuation. The operation was converted to a craniotomy and transplanum approaches, which allowed direct visual- and an A1 injury was identifed. It is our impression that the combi- ing patients undergoing additional exploration and tumor nation of extended approaches with angled endoscopes will evacuation. They also reported a 14% decrease in Endoscopic surgery has become an indispensable part of total hospital costs for patients with frst-time resections. Intraoperative imaging may result in doscopic exploration of all suspicious areas should result in more complete resection of pituitary lesions, particularly adequate tumor resection in most cases. However, high-power magnets may be benefcial geons are more likely to be less aggressive with the resec- in pituitary surgery if they have adequate resolution to dif- tion, knowing that they will continue the operation after the ferentiate tumor remnants from postsurgical artifact. If the goal is are rapidly becoming part of the armamentarium of neu- to decompress the optic apparatus and to deliver postopera- rosurgeons. The large microsurgical series with extensive tive radiation therapy to the residual tumor, intraoperative follow-up times and information about outcomes specif- imaging with a high-power magnet may be useful in deter- cally related to tumor grades and hormonal activity are dif- mining whether an adequate distance between remaining fcult to compare with the currently available publications tumor and the optic chiasm was achieved. The Currently, most of the intraoperative imaging systems endoscopic and intraoperative imaging series are limited by incorporate frameless stereotaxy. Thus, all of the required smaller numbers, paucity of grade and hormonal activity preoperative and postoperative imaging may be performed information, and much shorter follow-up times. Prior both technologies show great promise and have already be- to the start of the operation, the initial navigation sequences come incorporated into many academic centers. Subsequently, needle biopsy, cyst aspira- outcome studies are in progress to validate and assess the tion, catheter positioning, tumor resection, or even deep efcacy and relative contributions of each technique. If required, postoperative adjuvant treatment can be tuitary adenomas with a transsphenoidal approach. Neurosurgery discussed and planned immediately after the operation, 2005;56:249–256, discussion 249–256 rather than at the time of delayed postoperative imaging. Avoidance of carotid artery injuries in transsphenoidal surgery with the Doppler probe and micro-hook blades. Neurosurgery 2007;60(4, Suppl 2):322–328, discussion 328–329 I Financial Considerations 4. Pituitary 1999;2:133–138 A few authors have addressed the fnancial justifcation of 5. Hall et al44 reported a 55% decrease in the duration of sphenoidal surgical approach for the removal of large macroadeno- hospital stay in patients who underwent frst-time surgery mas. J Neurooncol 2006;77:297– resonance imaging system: preliminary results for 36 patients and 303 analysis of advantages, disadvantages, and future prospects. Prolactin secreting pi- surgery 2000;46:900–907, discussion 907–909 tuitary adenomas: analysis of 429 surgically treated patients, efect 7. Advances in mobile intraoper- of adjuvant treatment modalities and review of the literature.

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