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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS

R. Bryan Bell, MD, DDS, FACS

Cries Scale Date/Time Crying ­ Characteristic cry of pain is high pitched 0 ­ No cry or cry that is not high-pitched 1 ­ Cry high pitched but baby is easily consolable 2 ­ Cry high pitched but baby is inconsolable Requires O2 for SaO2 <95% - Babies experiencing pain manifest decreased oxygenation medications on backorder cheap 2 mg kytril with visa. A grimace may be characterized by brow lowering symptoms esophageal cancer effective 2mg kytril, eyes squeezed shut symptoms xanax abuse buy 1mg kytril visa, deepening naso-labial furrow symptoms 6 days after conception buy kytril 2 mg amex, or open lips and mouth symptoms 10 days post ovulation 2mg kytril fast delivery. It is important to be able to recognize and treat all types of pain medications for fibromyalgia purchase kytril 1 mg visa, including acute pain, chronic pain, recurring pain, procedurerelated pain, and end-of-life pain. Physiologic indicators such as vital sign changes, or behavioral indicators such as facial grimacing, may not be as reliable or may be absent in a chronically or critically ill infant. Characteristics of crying, oxygen requirement, changes in vital signs, facial expression, and sleep state are scored. To achieve adequate analgesia/sedation, medications optimally should be scheduled or given by continuous infusion with intermittent bolus doses as needed in order to avoid fluctuations in blood levels and breakthrough pain or discomfort. In addition, infants should always receive a bolus dose of narcotic or sedative prior to starting or increasing the infusion rate. Intranasal administration is an alternative option for patients who do not have intravenous access. It provides pain relief, elicits a sense of euphoria and promotes histamine release, which results in vasodilatory properties. These properties may decrease venous return, thereby decreasing cardiogenic pulmonary vascular congestion and resultant respiratory distress. Morphine may be less tolerance inducing than the synthetic opioids, given its longer half-life and therefore, should not have to be titrated up as quickly as the synthetic opioids. If a patient is habituated on an opioid infusion, the hourly dose of the infusion can be used for bolus dosing. These agents have specific anxiolytic effects in addition to sedative effects but do not provide pain relief to the patient. Sedatives - Benzodiazepines Habituated Patients If adequate sedation is difficult to achieve in a narcotic or benzodiazepine resistant patient, consultation with the Clinical Pharmacy Specialist or Anesthesia/Pain Management Service should be considered. Alternative Route Medications In the patient who does not have intravenous access, a combination of oral morphine and chloral hydrate may be used. Intranasal medications may also be given Intransal administration of fentanyl and midazolam has been found to be effective in pediatric palliative care. Repeat doses should be used with caution due to accumulation of drug and metabolites. Please see pharmacological management at End-of-life for details specific to therapy focusing on that time period of palliative care. Adjunct Medications 208 Guidelines for Acute Care of the Neonate, Edition 26, 2018­19 Section of Neonatology, Department of Pediatrics, Baylor College of Medicine Section 15-End-of-life Care Table 15-4. More children die in the perinatal and neonatal period than at any other time in childhood. It is therefore vital that the intensive care physician is well-versed in the grief process, and able to address end-of-life care issues with the family in a receptive and culturally sensitive manner. Professional and Societal Perceptions of Death and Grieving Definitions Grief - intense sorrow or deep mental anguish; arising from the loss of someone or something loved, usually through death. Mourning - a cultural complex of behaviors in which the Expectant parents have faith in modern medicine and are not likely to think that their child may die, especially after the first trimester of pregnancy. Further, in our culture, there is significant social pressure to believe in miracles and use as much technology as possible to save lives. Parents may feel obligated to choose to continue extensive and invasive medical interventions because these are seen by society as "heroic" and "courageous" choices. Parents who choose other options often feel judged, isolated and unsupported by their families, friends, and by society in general. Health professionals frequently are uncomfortable with the thought of death or grieving. Historically, professional support for grieving families and caregivers has been lacking. In addition, parents sometimes perceive healthcare provider behaviors to be thoughtless and insensitive. Health professionals realize the importance of honest communication and empathy with parents around the time of death, as well as the need for continued support of the grieving family after the death has occurred. Bereavement - the period of time during which grief is Hospice - provides support and care for patients and their families in the final phase of a terminal disease so that they can live as fully and comfortably as possible. Guidelines for Acute Care of the Neonate, Edition 26, 2018­19 Section 15-End-of-life Care Section of Neonatology, Department of Pediatrics, Baylor College of Medicine 15. Decisions about forgoing life sustaining treatment should be made by the health care team in collaboration with the parents, who must be well-informed about the condition and prognosis of their infant. Parents should be involved in the decision-making process to the extent that they choose. Compassionate comfort care should be provided to all infants, including those for whom intensive care is not provided. It is appropriate to provide intensive care when it is thought to be of benefit to the infant, and not when it is thought to be harmful, of no benefit, or futile. Definitions for "life threatening," "prolong dying" and "virtually futile" are in an appendix to 42 U. No federal law or Texas state law mandates delivery room resuscitation in all circumstances. Parents and health care providers must have accurate and current information regarding potential infant survival and outcomes. Joint decision making by both the parents and the physician should be the standard. Given the uncertainties of gestational age assessment and fetal weight determination, it will usually be necessary to examine the baby at birth before making firm statements to parents and others regarding providing or withholding resuscitation. In specific cases when parents request that all appropriate resuscitative measures be performed in the face of a high or uncertain morbidity and/ or mortality risk, it may be appropriate to offer the infant a trial of therapy that may be discontinued later. Alternatively, some parents may not want full resuscitation of their child; the appropriate response in these cases will depend upon the circumstances. Ethical and legal scholars agree that there is no distinction between withholding and withdrawing life-sustaining treatments. An irreversible condition is one that may be treated but is never eliminated, leaves a person unable to care for or make decisions for him- or herself, and is fatal without lifesustaining treatment provided in accordance with the prevailing standard of medical care. A terminal condition is an incurable condition caused by injury, disease or illness that according to reasonable medical judgment will produce death within six months, even with available life-sustaining treatment provided in accordance with the prevailing standard of medical care. One spokesperson (usually the attending physician of record) should be established to maintain continuity of communication. Because infants are incapable of making decisions for themselves, their parents become their surrogate decision makers. The physician serves as a fiduciary who acts in the best interest of the patient using the most current evidence-based medical information. In this role as an advocate for their patients, physicians oversee parental decisions. Guidelines for Acute Care of the Neonate, Edition 26, 2018­19 Section of Neonatology, Department of Pediatrics, Baylor College of Medicine Section 15-End-of-life Care Even in the best of circumstances people of good conscience may disagree. In circumstances of disagreement between the family and medical team, other professionals. In both instances, the director of nursing and the medical director should be notified. Differences between family caregivers or between the care team and family decisionmakers can be approached by using basic principles of negotiation and conflict resolution. It is often helpful to discuss ethical cases with colleagues with particular ethics expertise, or with a larger group. Building a therapeutic relationship and establishing good communication between the medical team and the family is paramount. When talking with the family, the following phrases and ideas can be used as a "communication toolbox," and the most important aspects of the conversation are highlighted in bold. If further agreement with the family cannot be reached, a clinical ethics consult may be obtained by contacting the chairpersons (below) through the page operator: the message concise and use lay language. Expect to repeat the message several times as the shock of the information you are conveying may interfere with the family member hearing what you have to say. If medical interventions do neither, it is no longer appropriate to continue those interventions. Offer choices, if possible - Inform the parents that there is nothing curative to offer their child. State that the current therapy can continue as it is, but that the outcome will not change. Alternatively, all artificial life support can be discontinued, comfort care provided, and the parents can give their dying infant the love of a mother and father. Please page for an ethics consult through the Ben Taub page operator 713-873-2010. Give a recommendation - in cases where there is a choice to make regarding further treatment or redirection of care. A unified approach and clear recommendation from the healthcare team is appropriate and may relieve parents of the some of the burden of decision making in the end-of-life context. The words "withdrawal of treatment", "withdrawal of care", or "there is nothing else we can do" should be avoided. Explain that the infant will continue to be cared for, the family will be supported, and that any symptoms of discomfort will be aggressively managed. Convey empathy - Parents recognize and appreciate sincerity, compassion, tenderness and emotional availability from the physician and team members conveying bad news. Statements such as "I wish (the test, the surgery, the diagnosis) was different" convey sincerity and help to forge a closer connection with the family. Ask if the parents have questions - Ask especially this documentation to be witnessed. However, if the patient is being electively transitioned to comfort care or withdrawal/limitation of support and adequate time exists, a Directive to Physicians should be utilized. The note should document that the surrogate decision maker agrees with the modification of the plan of care and should include the names of the witnesses. A Directive to Physicians may also be signed by the surrogate decision maker and two unrelated witnesses. If there is any uncertainty as to whether a specific intervention should be withheld, that decision should be discussed further with the family. The following persons may execute a directive on behalf of a qualified patient who is younger than 18 years of age: 1. In any circumstance in which this chapter requires the execution of an advance directive or the issuance of a non- written advance directive to be witnessed: 1. Affirming parental concerns and asking about seemingly forbidden topics can help to alleviate fear and anxiety. Knowledge about what can be expected, including color changes and reflexive gasping, decreases parental anxiety. The unpredictability of the time to death from the time of withdrawal of support should also be addressed. For example, a conversation might include the statement: "We will continue to provide the best medical care for your infant that will include frequent assessments by trained staff. Most parents are in a deep state of shock at the time the baby dies, and immediately afterward. Medical caregivers are to guide parents and family members through the process of making memories, however brief, of their child. Parents being present and able to participate in the care of their dying infant, at the level with which they are comfortable, is extremely important in the experience of anticipatory mourning, fosters a sense of control, and facilitates preparation for the event of death. The sequence of events should be described to parents in advance, and they may express preferences about the process. The parents should be educated about what to expect during the dying process and that not every newborn dies immediately after the ventilator is removed. Visiting restrictions should be relaxed, and the parents should be provided with an environment that is quiet, private and will accommodate everyone that the family wishes to include. Child life specialists may help counsel siblings prior to the death of the infant. A memory box should be created and given to the family based on their wishes before leaving the hospital, which may include: Hair locks Hand, foot, ear, lip and buttock prints, if desired Hand and foot molds Supporting the Family 9. Parents or other family members may want to hold the baby after the body has been chilled in the morgue. The body may be gently re-warmed prior to their arrival under an open warmer or isolette. The death summary should designate who the follow up doctor will be to contact the family one month after the death and following autopsy completion. The baby should be swaddled in warm blankets while being held, or kept warm by open warmer or isolette. Intramuscular vitamin K administration or erythromycin eye prophylaxis may not be necessary. Breast, bottle, or naso- or orogastric feedings and pacifier use may provide comfort. However, feeding may cause pulmonary edema, aspiration pneumonia, worsen cardiac failure, or cause abdominal distention. All unnecessary intravenous catheters and equipment should be removed and wound sites covered with sterile gauze. It is important to differentiate symptoms of respiratory distress including increased work of breathing, grunting, and nasal flaring from agonal reflexive respirations that occur sporadically with long periods of accompanying apnea.

In the hospital a uterine cancer with omental and liver metastasis was diagnosed medicine numbers generic kytril 2 mg mastercard, and adequate pain management was provided medications heart failure discount kytril 2 mg without a prescription. The prescription from the rural practitioner drew the attention of local health authorities medications hyperkalemia purchase 1 mg kytril fast delivery. They asked the clinician about his prescription and about his knowledge about Mexican practice guidelines for cancer pain management symptoms quitting tobacco buy discount kytril 1 mg online. The physician responded that he had heard of them but he did not know about their content or recommendations schedule 8 medications victoria cheap 2mg kytril with visa, although he had received education on Mexican practice guidelines for pain management: he had attended a 1-month fellowship in the regional hospital treatment molluscum contagiosum purchase kytril 2 mg overnight delivery, and was also encouraged to promote education to local organizations about the guidelines and their benefits. A follow-up program for pain management evaluation in his community was established. Guidelines are not rules or standards; they are helpful, flexible syntheses of all the available, relevant, good-quality information applicable to a particular clinical situation that the clinician and patient need to make a good decision. Assume, that a physician knows everything about a disease or its treatment on the basis of training and clinical judgement, but continuing medical education was not available. An optimal sequencing and timing of interventions for a particular diagnosis or procedure. A "care map" or multidisciplinary action plan extends the concept of a clinical pathway by including an outcome index, which allows for the evaluation of the interventions. A more complex set of instructions containing conditional logic, usually expressed in branching trees. Nowadays, different types of practice guidelines can be identified: (i) for the diagnosis and management of specific clinical circumstances, (ii) for risk management, (iii) for the improvement of quality systems, (iv) for medical regulation, (v) for education, and (vi) for preventive care. Additionally, pain has a significant impact on physical function and activity, return-to-work-quota, social and family relations as well as the general psychoaffective state of the affected patient. This may prove to be a burden for the family of the patient, but also to the society as a whole, since insufficient pain management is a major cause for increased use of health care resources. Therefore, health care policies need the implementation of rationalized instruments that can optimize and improve the quality of medical attention for the most relevant diseases including pain syndromes. The method for evidence selection must be explained and the criteria used to grade each recommendation must be explained. Protocols for developing guidelines have many common features: (i) Reviews of existing research findings are conducted, often with the aid of the National Library of Medicine. Pain is considered a health problem in few countries, but the number of countries where pain management becomes a health care priority is increasing. Setting up Guidelines for Local Requirements Table 2 Strategies used for developing practice guidelines Strategy Identification of a regional medical problem Selection of a group of experts Description A regional health problem is identified. The impact of this problem on the population and the usefulness of practice guidelines is analyzed. If needed, a consensus group for the development of guidelines (for management, care, diagnosis, etc. Selection criteria include experience (more than 5 years) in this particular field, in clinical research, in grading the evidence for recommendations, and/ or an academic profile. Clinical practitioners recommended from the national medical associations related to this specific area are also included. A questionnaire to evaluate the medical tendencies (for diagnosis, management, care, etc. Items on the questionnaire are based on the statements made by other consensus groups, clinical guidelines, clinical pathways, or clinical algorithms. Resources to obtain references are provided by the national institutes of health, national medical associations, and nonprofit organizations. Results from the review of the literature are send to the group of selected experts. The objective is that every participant have the opportunity to analyze the literature before the consensus meeting. A consensus meeting is held to analyze the results obtained from the questionnaire and to develop specific recommendations (for management, diagnosis, education, care, etc. Each of the recommendations is submitted to a focused review of the scientific evidence. Meta-analysis, systematic reviews, randomized controlled trials, randomized uncontrolled trials, and case reports for each specific recommendation are analyzed. If there are no studies, the recommendation is "based on consensus group expertise. Feedback from the group of experts about the evidence to endorse a recommendation is analyzed. Final notes from the participants are considered, and a final document is elaborated. The final document is sent to the participants for approval (as many times as needed). After this process is completed, the document is sent for publication in a peer-reviewed journal. Extensive education among clinicians, health care administrators, policy makers, benefit managers, and patients and their families is performed in every filiation center from each consensus participant. How does the scientific evidence grade the recommendations of practice guidelines? In 1979, the Canadian Task Force on Periodic Health Examination made the first efforts to characterize the level of evidence underlying health care recommendations and their strength. Since then, a wide variety of methods have been developed for "grading" the strength of the evidence on which recommendations are made. Grading methods take into account the study design, benefits and harms, and outcome (Canadian Task Force, U. A description of a strategy for grading the evidence according to the methodology of the study is described here: · Level 1: Evidence is extracted from systematic reviews of relevant controlled clinical trials (with meta-analysis when possible) 332 · Level 2: Evidence is extracted from one or more well-designed randomized controlled clinical trials · Level 3: Evidence is extracted from well-designed nonrandomized clinical trials or well-designed cohort studies or analytic case reports (if possible multicenter or performed at different times) · Level 4: Evidence is extracted from expert opinions and/or opinion leaders (supported if possible by the reports from other consensus statements) the evidence can be converted into recommendations (type A, B, or C) and the "strength of evidence and maximum benefit" (Class A to Class E), depending on how advisable the use of a specific treatment or intervention is (Class A = highly advisable and Class E = insufficient evidence). An implementation strategy relies on informing and educating physicians about the content of guidelines. Impersonal approaches that use the dissemination of written material alone or presentations to large audiences have not been very successful. Feedback can occur either as the service is being provided (concurrent feedback) or after that service has been provided (retrospective feedback). The quality of clinical practice guidelines must be evaluated and diverse methods to achieve this propose have been reported. There are three basic stages of evaluation: (i) evaluation during the development of guidelines and before their full dissemination and implementation (inception evaluation); (ii) evaluation of health care programs within which guidelines play a central role (guidelines-program evaluation); and (iii) evaluation of the effects of guidelines within defined health care environments (scientific evaluation). This evaluation process takes into account the benefits, harms, and costs of the recommendations, as well as the practical issues attached to them. Other studies show that physicians are generally positive about guidelines but that they do not integrate them into their practices to a large extent. The reason for this ambivalent behavior lies in problems associated with their production, dissemination, and use. Identified were: (i) awareness, (ii) familiarity, (iii) agreement, (iv) self-efficacy, (v) outcome expectancy, (vi) ability to overcome the inertia of previous practice, and (vii) absence of external barriers to perform recommendations. For example, Canadian family physicians show little resistance to guidelines and appear to need less threat of external control to incorporate them into their practice. The clarity and readability and the clinical applicability of a guideline are other elements that contribute to the acceptance of guidelines by clinicians. To give an example, the introduction of basic palliative care in East African Uganda was only possible when the essential drug list was amended by adding morphine. Also, certain national differences exist, due to cultural, ethnic/genetic, and traditional reasons, regarding the use of certain drugs and procedures. In Mexico, for example, 80% of the population use herbal medicine, and 3,500 registered medical plants with medicinal properties are available. Finally, potentially effective dissemination and education techniques developed in high-resource settings may also have to undergo some changes to be feasible in a specific low-resource setting. It will be necessary to get all stakeholders at one table: rural and academic practitioners, other health providers, patients and their families, local organizations, and academic institutions. It may be inevitable to make certain evidence-based approaches to diagnosis and treatment optional. The method for evidence selection must be explained, and the criteria used to grade each recommendation must be included. Grading methods take into account the study design, benefits and harms, and outcome. Guevara-Lуpez U, Covarrubias-Gуmez A, Rodrнguez-Cabrera R, Carrasco-Rojas A, Aragуn G, Ayуn-Villanueva H. A guide to the Canadian Medical Association handbook on clinical practice guidelines. It is necessary to explain to the patient what he/she will experience: · Some paresthesias and involuntary movements during needle insertion. There are no differences regarding the assessment of a patient between a general anesthesia or a regional anesthesia technique. The same care and considerations must be taken into account, with a history and relevant clinical examination. Special drug history is necessary Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Remember that the intercostal nerves derive from the ventral ramus of the spinal nerves and that they run along the inferior border of the ribs. To block the intercostal nerves, use the following technique: · Position the patient in a supine position. The needle is inserted perpendicularly to the skin and advanced slightly under the artery. Wrist block Wrist blocks may be used if a plexus block is incomplete, as a diagnostic block, or for pain therapy. The median nerve is located on the radial site of the palmaris longus tendon (better visible when flexing the wrist), and the ulnar nerve is located on its other (ulnar) side. To block the median nerve: · Insert the needle on the flexor side between the tendons of the flexor carpi radialis and palmaris longus tendon. Pearls of wisdom · Some peripheral nerve blocks are very easy to perform and very effective. Lower-extremity peripheral nerve blockade: essentials of our current understanding. Acute pain occurs mainly in connection with an illness or injury or as an effect of a treatment of an illness. Normally, the cause is noticeable, and the treatment is mostly rest and management of the cause of pain. The psychological effect is the hope that the treatment will be successful and the pain will be over soon. It is possible that anxiety and apprehension may appear within the period of acute pain, for example, the fear of surgery and anesthesia that could form part of the treatment. Practical consequences As part of preparation for surgery, interventions such as relaxation techniques, a good explanation of the procedure and possible outcomes, and an optimistic outlook have been proven to be helpful. Relaxation techniques can minimize psychological agitation patterns such as a high heart rate and inner restlessness. In the treatment of chronic pain, it is important to differentiate between benign and malignant pain. The prevalence of comorbidities such as anxiety and depression is common, as in other pain syndromes, and should be taken into consideration and treated. Additionally, patients have to cope with pain due to a tumor, as well as pain that may arise during the course of the treatment. Overcoming the consequences of chronic diseases differs significantly in developed countries in contrast to developing countries. Caring for the ill person is often very difficult for the family because of financial problems. A difficult financial situation and poor access to medical, nursing, or other social services can affect the process of healing negatively. At the time of diagnosis, there is often a loss of control and helplessness in the face of possible physical disfigurement, accompanying pain, and possible financial implications for adequate treatment, not least the fear and uncertainty surrounding the prospect of an untimely death. Good communication and explanations about the existing possibilities of therapy and about the prognosis can reduce fears and helplessness, and enable patients to cope better with the disease and its accompanying challenges. Chronic back pain, in most cases, is musculoskeletal in origin, accompanied by poor coping skills along with other "yellow flags. For example, a diagnosis of "nonspecific back pain" leads to an extreme uncertainty on the part of the patient, often leading to increased fear of serious pathology and the desire for repeated diagnostic procedures. Often there is an iatrogenic component when repeated investigations are ordered-partly because the patient insists on it, and partly because the physician may be uncertain: "Is there a tumor or a serious disk prolapse causing the pain? In the context of chronic abdominal pain, which is quite often difficult for the patient to locate and come to terms with, often together with the threat of incurability and looming death. Practical consequences A comprehensive compilation of all available findings, as well as discussion with colleagues about previous diagnosis and treatment, can be useful to get a complete picture about the patient. The patient should be advised against unnecessary and often very expensive invasive diagnostic procedures. After considering all possible factors including psychiatric comorbidity or risks of chronification, a treatment plan can be developed. Good models on interactions, for example between depression and chronic pain, can help the patient to cope successfully with pain. Practical consequences Indicators of stress mentioned above should be looked for, which can affect the development and maintenance of pain. Therapeutic interventions including a good explanation of the disease, continuing psychological support, advice on balanced nutrition, and so on should be added over time. Very often we find interactions between headache and dysfunctional patterns of the muscles, such as increased tension, which can then, by itself, become a trigger for headache. Social stress factors such as excessive demands at the workplace or poor coping strategies with stress, can make headaches intense and chronic. Chronic pain and psychopathology: research findings and theoretical considerations.

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Its apex is internal symptoms 6 days post iui order kytril 2 mg overnight delivery, and close to the pubic spine; its base is external treatment plan for depression discount kytril 2mg otc, sharp and concave treatment goals for depression order 1 mg kytril with amex, and in apposition with the sheath of the femoral vessels treatment diabetes type 2 discount kytril 1mg on line. It measures an inch symptoms electrolyte imbalance kytril 1 mg mastercard, more or less medications breastfeeding discount 1 mg kytril with amex, in width, and it is broader in the male than in the female-a fact which is said to account for the greater frequency of femoral hernia in the latter sex than in the former, (Monro. The falciform process also blends with the ligament; and thus it is that the femoral hernia, when constricted by either of these three structures, may well be supposed to suffer pressure from the three together. This structure consists of tendinous fibres, lying deeper than, but parallel with, those of the superficial arch. The deep arch spans the femoral sheath more closely than the superficial arch, and occupies the interval left between the latter and the sheath of the vessels. On its outer side are situated the anterior crural nerve, and the femoral parts of the psoas and iliacus muscles. Of the three compartments into which the sheath is divided by two septa in its interior, the external one, E. The inner compartment, G, is the femoral canal, and through it the femoral hernia descends from the abdomen to the upper and forepart of the thigh. The sheath of the femoral vessels, like that of the spermatic cord, is infundibuliform. The femoral sheath being broader above than below, whilst the vessels are of a uniform diameter, presents, as it were, a surplus space to receive a hernia into its upper end. There is, however, corresponding to each ring, a depression in the peritonaeal covering; and here it is that the bowel first forces the membrane and forms of this part its sac. On removing the peritonaeum from the inguinal wall on the inner side of the iliac vessels, K L, we find the horizontal branch of the os pubis, and the parts connected with it above and below, to be still covered by what is called the subserous tissue. The femoral ring is not as yet discernible on the inner side of the iliac vein, K; for the subserous tissue being stretched across this aperture masks it. The portion of the tissue which closes the ring is named the crural septum, (Cloquet. The ring is the point of union between the fibrous membrane of the canal and the general fibrous membrane which lines the abdominal walls external to the peritonaeum. This account of the continuity between the canal and abdominal fibrous membrane equally applies to the connexion existing between the general sheath of the vessels and the abdominal membrane. The difference exists in the fact, that the two outer compartments of the sheath are occupied by the vessels, whilst the inner one is vacant. From the femoral ring the canal extends down the thigh for an inch and a-half or two inches in a tapering form, supported by the pectineus muscle, and covered by the iliac part of the fascia lata. It lies side by side with the saphenous opening, but does not communicate with this place. On a level with the lower cornu of the saphenous opening, the walls of the canal become closely applied to the femoral vessels, and here it may be said to terminate. This vessel occasionally gives off the obturator artery, which, when thus derived, will be found to pass towards the obturator foramen, in close connexion with the ring; that is, either descending by its outer border, G*, between this point and the iliac vein, K; or arching the ring, G, so as to pass down close to its inner or pubic border. In some instances, the vessel crosses the ring; a vein generally accompanies the artery. As the course to be taken by the bowel, when a femoral hernia is being formed, is through the crural ring and canal, the structures which have just now been enumerated as bounding this passage, will, of course, hold the like relation to the hernia. The manner in which a femoral hernia is formed, and the way in which it becomes invested in its descent, may be briefly stated thus: the bowel first dilates the peritonaeum opposite the femoral ring, H. The crural septum has, at the same time, entered the canal as a second investment of the bowel. In general, it dilates the side of the canal, and this becomes the fascia propria, B G. Sometimes the hernia rests upon this ligament, and simulates, to all outward appearance, an oblique inguinal hernia. In this course, the femoral hernia will have its three parts-neck, body, and fundus-forming nearly right angles with each other: its neck [Footnote 3] descends the crural canal, its body is directed to the pubis through the saphenous opening, and its fundus is turned upwards to the femoral arch. With what difficulty and perplexity does this impenetrable fog of surgical nomenclature beset the progress of the learner! The neck of the sac may, indeed, be supposed always to suffer more or less constriction at the crural ring. The part which occupies the canal is also very much compressed; and again, where the hernia turns over the falciform process, this structure likewise must cause considerable compression on the bowel in the sac. There are no muscular fibres crossing the course of this hernia; neither are the parts which constrict it likely to change their original position, however long it may exist. In the inguinal hernia, the weight of the mass may in process of time widen the canal by gravitating; but the crural hernia, resting on the pubic bone, cannot be supposed to dilate the crural ring, however greatly the protrusion may increase in size and weight. Cooper (Crural Hernia) is of opinion that the stricture is generally in the neck of the sheath. The inguinal hernia, 3, arising above, 5, the crural arch, descends the canal, 3, 3, under cover of the aponeurosis of the external oblique muscle, obliquely downwards and inwards till it gains the external abdominal ring formed in the aponeurosis, and thence descends to the scrotum. The femoral hernia, commencing on a level with, 5, the femoral arch, descends the femoral canal, under cover of the fascia lata, and appears on the upper and forepart of the thigh at the saphenous opening, 6, 7, formed in the fascia lata; and thence, instead of descending to the scrotum, like the inguinal hernia, turns, on the contrary, up over the falciform process, 6, till its fundus rests near, 5, the very place beneath which it originated. Such are the peculiarities in the courses of these two hernial; and they are readily accounted for by the anatomical relations of the parts concerned. The infundibuliform fascia, 3, 3, of the spermatic vessels is like the infundibuliform sheath, 9, 9, of the femoral vessels. The ring of the femoral canal, 12, is situated immediately below, but to the inner side of the internal inguinal ring, 3. The epigastric artery, 1, marks the width of the interval which separates the two rings. When the bowel is about to protrude at either of the rings, it first dilates the peritonaeum, which covers these openings. As the space which the femoral arch spans external to the vessels is fully occupied by the psoas and iliacus muscles, and, moreover, as the abdominal fibrous membrane and its prolongation, the femoral sheath, closely embrace the vessels on their outer anterior and posterior sides, whilst on their inner side the membrane and sheath are removed at a considerable interval from the vessels, it is through this interval (the canal) that the hernia may more readily pass. The peritonaeum, 2, and crural septum, 13, form at this place the only barrier against the protrusion of the bowel into the canal. Neither will the hernia force a way at a point external to the femoral vessels in preference to that of the crural canal, which is already prepared to admit it. The septum crurale itself, having been dilated before the sac, of course invests it also. An incipient femoral hernia of the size of 2, 12, cannot, in the undissected state of the parts, be detected by manual operation; for, being bound down by the dense fibrous structures which gird the canal, it forms no apparent tumour in the groin. Cloquet has seen the hernia descend the sheath once in front of the vessels, and once behind them. The external form has never been met with by Hey, Cooper, or Scarpa; whilst no less than six instances of it have come under the notice of Mr. Still, the neck of the sac, 2, remains constricted at the ring, whilst the part which occupies the canal is also very much narrowed. The fundus of the sac, 9*, 12, alone expands, as being free of the canal; and covering this part of the hernia may be seen the fascia propria, 9*. This fascia is a production of the inner wall of the canal; and if we trace its sides, we shall find its lower part to be continuous with the femoral sheath, whilst its upper part is still continuous with the fascia transversalis. When the hernia ruptures the saphenous side of the canal, the fascia propria is, of course, absent. The direct hernia, 13, traverses the inguinal wall from behind, at a situation corresponding with the external ring; and from this latter point it descends the scrotum. An oblique external inguinal hernia enters the internal ring, 3, which exists further apart from the general median line, and, in order to gain the external ring, has to take an oblique course from without inwards through the inguinal canal. A femoral hernia enters the crural ring, 2, immediately below, but on the inner side of, the internal inguinal ring, and descends the femoral canal, 12, vertically to where it emerges through, 6, 7, the saphenous opening. The direct inguinal hernia, 13, owing to its form and position, can scarcely ever be mistaken for a femoral hernia. But in consequence of the close relationship between the internal inguinal ring, 3, and the femoral ring, 2, through which their respective herniae pass, some difficulty in distinguishing between these complaints may occur. An incipient femoral hernia, occupying the crural canal between the points, 2, 12, presents no apparent tumour in the undissected state of the parts; and a bubonocele, or incipient inguinal hernia, occupying the inguinal canal, 3, 3, where it is braced down by the external oblique aponeurosis, will thereby be also obscured in some degree. But, in most instances, the bubonocele distends the inguinal canal somewhat; and the impulse which on coughing is felt at a place above the femoral arch, will serve to indicate, by negative evidence, that it is not a femoral hernia. The inguinal hernia, 13, descends the scrotum, whilst the femoral hernia, 9*, turns over the falciform process, 6, and rests upon the fascia lata and femoral arch. Though in this position the fundus of a femoral hernia lies in the neighbourhood of the inguinal canal, 3, yet the swelling can scarcely be mistaken for an inguinal rupture, since, in addition to its being superficial to the aponeurosis which covers the inguinal canal, and also to the femoral arch, it may be withdrawn readily from this place, and its body, 12, traced to where it sinks into the saphenous opening, 6, 7, on the upper part of the thigh. An inguinal hernia manifests its proper character more and more plainly as it advances from its point of origin to its termination in the scrotum. A femoral hernia, on the contrary, masks its proper nature, as well at its point of origin as at its termination. If, on the other hand, the obturator artery descend external to the neck of the sac, the vessel will be comparatively remote from danger while the ligament is being divided. In addition to the fact that the cause of stricture is always on the pubic side, 8, of the neck of the sac, 12, thereby requiring the incision to correspond with this situation only, other circumstances, such as the constant presence of the femoral vein, 11, and the epigastric artery, 1, determine the avoidance of ever incising the canal on its outer or upper side. And if the obturator artery, [Footnote] by rare occurrence, happen to loop round the inner side of the neck of the sac, supposing this to be the seat of stricture, what amount of anatomical knowledge, at the call of the most dexterous operator, can render the vessel safe from danger? Quain (Anatomy of the Arteries) gives, as the result of his observations, the proportion to be as 1 in 3-1/2, and in this estimate he agrees to a great extent with the observations of Cloquet and Hesselbach. Numerical tables have also been drawn up to show the relative frequency in which the obturator descends on the outer and inner borders of the crural ring and neck of the sac. Cooper never met with an example where the vessel passed on the inner side of the sac, and from this alone it may be inferred that such a position of the vessel is very rare. It is generally admitted that the obturator artery, when derived from the epigastric, passes down much more frequently between the iliac vein and outer border of the ring. The researches of anatomists (Monro and others) in reference to this point have given rise to the question, "What determines the position of the obturator artery with respect to the femoral ring? When this cannot be effected by the taxis, and the stricture still remains, the cutting operation is required. But it is to be presumed that the sac and contained intestine suffer constriction throughout the whole length of the canal. In some instances, it will be the fibres of the deep crescentic (femoral) arch; in others, again, the neck of the sac itself, and produced by a thickening and contraction of the subserous and peritonaeal membranes where they lie within the circumference of the crural ring. This incision divides the skin and subcutaneous adipose membrane, which latter varies considerably in quantity in several individuals. On cautiously turning aside the incised adipose membrane contained between the two layers of the superficial fascia, the fascia propria, 9. This envelope, besides varying in thickness in two or more cases, may be absent altogether. The fascia closely invests the sac, 12; but sometimes a layer of fatty substance interposes between the two coverings, and resembles the omentum so much, that the operator may be led to doubt whether or not the sac has been already opened. The fascia is to be cautiously slit open on a director; and now the sac comes in view. The hernia having been drawn outwards, so as to separate it from the inner wall of the crural canal, a director [Footnote] is next to be passed along the interval thus left, the groove of the instrument being turned to the pubic side. The position of the director is now between the neck of the sac and the inner wall of the canal. The extent to which the director passes up in the canal will vary according to the suspected level of the stricture. A probe-pointed bistoury is now to be slid along the director, and with its edge turned upwards and inwards, according to the seat of stricture, the following mentioned parts are to be divided-viz. The crural canal being thus laid open on its inner side, and the constricting fibrous bands being severed, the sac may now be gently manipulated, so as to restore it and its contents to the cavity of the abdomen; but if any impediment to the reduction still remain, the cause, in all probability, arises either from the neck of the sac having become strongly adherent to the crural ring, or from the bowel being bound by bands of false membrane to the sac. The neck is then to be divided on its inner side, and the exposed intestine may now be restored to the abdomen. Through the groin, as through the axilla, the principal blood vessels and nerves are transmitted to , the corresponding limb. The main artery of the lower limb frequently becomes the subject of a surgical operation. The vessel is usually described as divisible into parts, according to the regions which it traverses. But, as in examining any one of those parts irrespective of the others, many facts of chief surgical importance are thereby obscured and overlooked, I propose to consider the vessel as a whole, continuous from the aorta to where it enters the popliteal space. The general course and position of the main artery may be described as follows:-The abdominal aorta, A, bifurcates on the body of the fourth lumbar vertebra. The level of the aortic bifurcation corresponds with the situation of the navel in front, and the crista ilii laterally. The aorta is in this situation borne so far forwards by the lumbar spine as to occupy an almost central position in the cavity of the abdomen. If the abdomen were pierced by two lines, one extending from a little to the left side of the navel, horizontally backwards to the fourth lumbar vertebra, and the other from immediately over the middle of one crista ilii, transversely to a corresponding point in the opposite side, these lines would intersect at the aortic bifurcation. The two arteries, G G,* into which the aorta divides symmetrically at the median line, diverge from one another in their descent towards the two groins. As both vessels correspond in form and relative position, the description of one will serve for the other. While the thigh is abducted and rotated outwards, if a line be drawn from the navel to a point, D, of the inguinal fold, midway between B, the anterior iliac spine, and C, the symphysis pubis, and continued thence to the inner condyle of the femur, it would indicate the general course of the artery, G I W. In this course, the vessel may be regarded as a main trunk, giving off at intervals large branches for the supply of the pelvic organs, the abdominal parietes, and the thigh. From the point where the vessel leaves the aorta, A, down to the inguinal fold, D, it lies within the abdomen, and here, therefore, all operations affecting the vessel are attended with more difficulty and danger than elsewhere, in its course.

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The student will demonstrate an understanding of quality improvement through participation in rounds and attendance at morbidity and mortality conference. The challenge is to identify children who require immediate evaluation for potentially life-threatening conditions. Chronic abdominal pain is also a common complaint in pediatric practices, as it comprises 2-4% of pediatric visits. At least 20% of children seek attention for chronic abdominal pain by the age of 15 years. Up to 28% of children complain of abdominal pain at least once per week and only 2% seek medical attention. The primary care physician, pediatrician, emergency physician, and surgeon must be able to distinguish serious and potentially life-threatening diseases from more benign problems (Table 10. The differential diagnosis is lengthy, differs from that in adults, and varies by age group. Although some disorders occur throughout childhood (constipation, gastroenteritis, lower lobe pneumonia, urinary tract infections), others are more common in a specific age group (see Table 10. Because of the relative localization of the noxious stimulation to the underlying peritoneum and the more anatomically specific and unilateral innervation (peripheral-nonautonomic nerves) of the peritoneum, it is usually easier to identify the precise anatomic location that is producing parietal pain. Even though surgical diagnoses are fewer than 10% of all causes of abdominal pain in children, they can be life-threatening if untreated. Approximately 55% of children evaluated for acute abdominal pain have a specific medical diagnosis; in another 45%, the cause is never defined. History Obtaining an accurate history is critical for making an accurate diagnosis but is dependent both on the ability and willingness of the child to communicate and on the skill of the parent or guardian as an observer. Some children give a good account of their illness when they are simply asked to describe it; most children must be asked open-ended, non-leading questions. The answers are often quite different from the responses to the more general questions "Are you hungry? While the history is obtained, there is no particular reason that the child should be undressed. The clinician must resist the urge to speed things up by examining the child while taking the history. On occasion, when seeing a seriously ill child, the physician may need to abbreviate the diagnostic process, but taking short cuts may lead to inaccurate conclusions. Visceral Pain Visceral pain receptors are located on the serosa surface, in the mesentery, within intestinal muscle, and mucosa of hollow organs. Pain is initiated when receptors are stimulated by excessive contraction, stretching, tension or ischemia of the walls of hollow viscera, the capsule of a solid organ (liver, spleen, kidney), or of the mesentery. Increased contraction of the smooth muscle of hollow viscera may be caused by infection, toxins (bacterial or chemical agents), ulceration, inflammation, or ischemia. Increased hepatic capsule tension may be secondary to passive congestion (heart failure, pericarditis) or inflammation (hepatitis). Afferent fibers involved in processing visceral pain are unmyelinated C-fibers that enter the spinal cord bilaterally, resulting in dull, poorly localized pain. Visceral pain is often of gradual onset, and although localization may be imprecise, some general rules may be helpful. Parietal Pain Parietal pain arises from direct noxious (usually inflammation) stimulation of the contiguous parietal peritoneum. Parietal pain is transmitted through A-delta fibers to specific dorsal root ganglia and thus is usually sharp, and more intense. It can usually be exacerbated by movement or cough, is accompanied by tenderness over the site of Essential Components of the History Time of onset of pain. Pain lasting from 6-48 hours is more apt to have a cause that warrants medical intervention, although delays in presentation and diagnosis in children are not unusual. The location of the pain at its onset and any change in location are very important (Table 10. Most intraperitoneal visceral pain is a response to the stimulation of stretch fibers in the bowel wall and is mediated through the spinal nerves. Pain caused by inflammation of the parietal peritoneum (acute appendicitis) is localized to the area of the inflamed organ or is diffuse if the inflammation is extensive and involves more of the peritoneal cavity. Pain resulting from obstruction of an organ is localized to the area of that organ and radiates to the commonly innervated region. Pain that is migratory or fleeting in location is rarely suggestive of a problem requiring operative intervention. Some older children may be able to differentiate cramping, aching, and burning sensations, but most children do not do this well. Children can relate whether the pain comes and goes or is continuous and unrelenting. The character of the pain is usually unknown in the toddler and infant, although the parent can determine whether the discomfort is constant, cramping, or intermittent. If the child intermittently draws the legs up in a flexed position and cries, the clinician can assume that intermittent pain is present. If the pain is sufficiently severe to awaken the child from a sound sleep, it is of much more significance than pain that occurs only at school and never on weekends. If a child has had to avoid a favorite activity, the pain is more apt to have a defined organic cause. This applies only to children with acute abdominal pain because children with chronic functional abdominal pain may wake up from sleep and may miss favorite activities due to pain and disability. Asking whether motion worsens the pain helps differentiate peritoneal irritation or musculoskeletal diseases from more nonspecific problems. The child with acute appendicitis lies motionless, whereas the child with a renal stone, gallstone, gastroenteritis, or pancreatitis may toss and turn and writhe in discomfort. Localized, superficial, tender trigger points in the Downloaded for Sarah Barth (s. Gastroenteritis indicates intestinal infection with viral, bacterial, protozoal, or parasitic agents. Giardiasis and cryptosporidiosis are particularly common and may produce acute or chronic pain. The localized pain results from entrapment of cutaneous terminal branches of intercostal nerves (7th-12th) penetrating the rectus abdominis muscle and can easily be missed without the proper history or exam. The presence or absence of gastrointestinal symptoms may differentiate intestinal problems (acute appendicitis, gastroenteritis, acute cholecystitis) from those arising from other intraabdominal organs (urinary tract infection, ovarian disease, abdominal wall pain). Often, if simply asked whether he or she is hungry, a child will respond in the affirmative. Vomiting may be a sign of increased intracranial pressure, which may or may not be accompanied by associated headache or vital sign changes (bradycardia, hypertension, irregular respirations), a bulging fontanel, an altered level of consciousness, or neurologic findings (3rd or 6th cranial nerve palsies). Care should be taken to determine whether the pain occurs before or after the onset of the vomiting. With acute surgical lesions (those caused by intestinal obstruction, acute appendicitis, acute cholecystitis), the pain usually occurs before or during the vomiting. If the vomiting occurred before the onset of pain, the clinician should suspect gastroenteritis or another nonspecific problem. Dark brown or frankly bloody material indicates gastritis, prolapse gastropathy, or peptic ulcer disease as the source of pain. Diarrhea occurs commonly in intestinal diseases of viral, parasitic, or bacterial origin. The stool volume is large, and defecation is usually preceded by cramping pain that is alleviated by the passage of the diarrheal stool. Diarrhea may also occur in the presence of acute appendicitis or other pelvic infections (such as those resulting from pelvic inflammatory disease, tubo-ovarian abscess); in these cases, diarrhea is caused by inflammation and irritation of an area of colon adjacent to an inflammatory mass. Diarrhea may also occur in lesions that cause partial obstruction of the bowel, such as strictures, adhesions, and Hirschsprung disease. Constipation alone can cause acute abdominal pain and may also indicate other gastrointestinal dysfunction. Some constipated children present with a picture very similar to that seen in acute appendicitis but have a large amount of stool filling the entire colon. It is therefore important to obtain a good history of not only bowel movement frequency but also consistency as well (see Chapter 16). The history and exam is sufficient to make the diagnosis of constipation, and imaging is usually not necessary. Once the diagnosis is made, appropriate treatment should start with a proper clean-out followed by maintenance therapy. The clinician should not be fooled by the symptom of tenesmus, where the patient has a feeling of constantly needing to pass stools despite having an presence or absence of anorexia and nausea than do direct questions about appetite or nausea. Vomiting associated with acute pain is usually related to intestinal disease, such as ileus, gastroenteritis, or acute problems of the gastrointestinal tract that warrant surgery. The three general localizations of midline "visceral" abdominal pain are epigastric (1), periumbilical (2), and hypogastric (3). The child who seems only mildly ill but moves with great care, if at all, is assumed to have an inflammatory process until it is proven otherwise. Older children should be asked to get onto the examination table with as little assistance as possible. If the child does this easily, the probability of an acute intraabdominal inflammatory process is quite low. Outer bulky clothing should be removed to allow good exposure of the abdomen without the child having to feel vulnerable. The examination must be performed in a relaxed, friendly manner with attention fully focused on the child. A conversation with the child about family, friends, pets, school, sports, music, or other specific interests of that child diverts attention (distraction) from the examination and increases cooperation. The absence of fever does not exclude the diagnosis of acute appendicitis or other problems necessitating surgical intervention. Tachycardia may reflect anxiety or may be caused by dehydration, shock, fever, or pain. Tachypnea suggests a metabolic acidosis (shock, diabetes mellitus, or toxic ingestion), an intrapulmonary process, sepsis, or fever. The vital signs must be viewed in context but may be the first clue to a serious illness. Examination of the head, neck, chest, and extremities may precede the abdominal examination. In children too young to describe the location of the pain, a careful examination of the ears is important, but can be performed at the end of the examination. Streptococcal pharyngitis or mononucleosis is sometimes accompanied by severe abdominal pain. Affected children will present with fever, appear ill, and have tender cervical adenopathy and an obvious tonsillitis, pharyngitis, or both. Decreased breath sounds and/or rales in a lower-lung lobe, especially on the right side, may indicate pneumonia. Children with lower lobe bacterial pneumonia present with severe abdominal pain, high fever, tachypnea, and, on occasion, vomiting. This presentation could mimic that of a child with peritonitis; however, the abdominal findings are not consistent with the diagnosis of an acute intraabdominal process, and examination of the lungs should demonstrate the pneumonia. The abdominal examination should be performed systematically and with the child as comfortable as possible. Inguinal and femoral hernias are often overlooked but a common cause of abdominal pain. Next, the child should be asked to indicate with one finger the point of greatest pain. The point may be a vague circle in the area of the umbilicus, but if the child specifies a defined spot, the examiner should avoid that area until the remainder of the abdomen has been palpated. The examiner must warm both hands and the stethoscope before touching the patient. Auscultation of the chest can simply be extended to the abdomen, with the examiner assuring the child that the stethoscope did not hurt on the chest. Tenesmus can be seen in the setting of proctocolitis or inflammatory bowel disease and is often misinterpreted by the patient as constipation. The presence of headache, sore throat, and other generalized aches and pains moves the examiner away from a diagnosis of an acute problem warranting surgery and strongly suggests a viral flu-like illness. Asking the child to point to the area of worst pain sometimes results in the child pointing to the head or throat. The examiner must be careful to remember the whole child and not to focus on the abdomen just because that is the area of the presenting complaint. Many systemic diseases directly or indirectly produce abdominal pain and must be considered in the differential diagnosis (Table 10. Certain systemic and inherited diseases, such as sickle cell anemia, diabetes mellitus, celiac disease, spherocytosis, familial Mediterranean fever, and porphyria, are associated with episodes of abdominal pain. A strong family history of migraine headaches in a child with several previous episodes of intense abdominal pain that have resolved, who presents with a new "attack," suggests the possibility of abdominal migraine.

The nomenclature treatment xdr tb guidelines buy kytril 1mg with amex, definition and classification of cardiac structure in the setting of heterotaxy treatment 101 kytril 1 mg for sale. Controversies symptoms blood clot leg 1mg kytril, genetics inoar hair treatment discount 2mg kytril, diagnostic assessment medicine 6 year cheap kytril 2 mg on-line, and outcomes relating to the heterotaxy syndrome symptoms 3 weeks pregnant cheap kytril 1 mg free shipping. Close clinical assessment is needed when feeding neonates with ductal-dependent congenital heart disease. Complexity of congenital heart defect and time of intubation are two predictors of postoperative feeding dysfunction. There are noticeable variations in strategies for preoperative feeding management between providers. Clinicians practicing outside the United States are eight times more likely to enterally feed ductal-dependent neonates than clinicians practicing in the United States. Clinical assessment, arterial blood gas assessment, blood lactate level, diastolic blood pressure, echocardiogram, abdominal x-ray, and abdominal near-infrared spectroscopy may be helpful in making this decision. Enteral feeding in neonates with prostaglandin-dependent congenital cardiac disease: international survey on current trends and variations in practice. What congenital heart lesions are treated with placement of a shunt in the newborn period? The modified Blalock­Taussig shunt is a Gore-Tex interposition shunt placed between the subclavian artery (right or left) and the right or left pulmonary artery. Examples include lesions with a hypoplastic pulmonary annulus, atretic pulmonary valve annulus, or severely hypoplastic main and branch pulmonary arteries. The modified Blalock­Taussig, the bidirectional Glenn procedure, and the Sano modification of the Norwood operation are the most common types of shunts used today. What is a Glenn procedure, and in what kinds of congenital heart disease is it used? A bidirectional Glenn anastomosis is a connection from the right superior vena cava to the right pulmonary artery, or the left superior vena cava to the left pulmonary artery, or both (bicaval bidirectional Glenn anastomosis). The pulmonary arteries are in continuity, so a right bidirectional Glenn anastomosis connection will send blood flow into the right and the left pulmonary arteries. In neonates coarctation of the aorta is generally approached through a left thoracotomy. The three standard surgical approaches involve resection and end-to-end anastamosis (most common), subclavian flap repair (ligation of distal subclavian artery to use the proximal portion to overlay patch the coarctation segment), or patching with foreign material (Dacron). The Jatene procedure (arterial switch) is performed for d-transposition of the great arteries. The coronary arteries are removed from the aorta and re-implanted into the pulmonary artery, which becomes the new aorta. Left ventricular dysfunction, supraventricular arrhythmias, and supravalvar aortic and pulmonary stenosis are all potential complications. Both left ventricular dysfunction and arrhythmias may be a sign of coronary insufficiency. The presence of ventricular arrhythmias should also elicit questions regarding the adequacy of the ventricular function and coronary re-implantation. What is the Norwood procedure (or modified Norwood, stage I), and what are the two additional procedures for neonates with single-ventricle physiology? Stage 1 (alternate approach): In some centers a Norwood­Sano operation is performed as a first stage. Tachycardia, decrease in oxygen saturation, increase in cardiac filling pressures, abrupt decrease in chest tube drainage, increasing cardiac size on chest x-ray, and poor perfusion are all warning signs of postoperative cardiac tamponade. Abrupt resolution of postoperative bleeding should prompt consideration for development of a pericardial effusion. Pulsus paradoxus may not be evident in mechanically ventilated patients unless they are spontaneously breathing. What are some of the concerns in a neonate with an "open chest" after heart surgery? Lung tidal volume should be adjusted appropriately so that the lung does not herniate. When the chest is eventually closed, all of the intravascular pressures will increase, airway compliance will increase, and tidal volume should be adjusted downward. Why is junctional ectopic tachycardia important to recognize in the postoperative period? If the infant cannot be taken off cardiopulmonary bypass after surgery, what are the options? What are the principles of preoperative management in the neonate with critical congenital heart disease? In critical congenital heart lesions the ultimate outcome depends on timely and accurate assessment of the structural anomaly and on evaluation and resuscitation of secondary organ damage. This drug should be administered using a continuous intravenous drip, preferentially through an umbilical venous line, or a well-functioning intravenous line. Abdominal ultrasound should be considered if there is any association of known renal, splenic, or situs concerns. Laboratory studies including renal and hepatic function should be evaluated to look for end-organ dysfunction. A head ultrasound or other central nervous system imaging modality may be considered, especially if there were any in utero concerns. During the care of postoperative patients, it is important to assess the patient, not just the laboratory values and the numbers. What information is needed to care for the neonate with congenital heart disease after cardiothoracic surgery? What are the most common noncardiac causes of respiratory compromise after cardiothoracic surgery? Chylothorax is a rare complication of cardiac surgery with an incidence of approximately 0. Second, it may occur with thrombosis of the superior vena cava, leading to increased hydrostatic pressure in the superior vena cava and thoracic duct. Most common surgeries that are complicated by chylothoraces are tetralogy of Fallot, Glenn and Fontan palliation, and orthotopic heart transplantation. Placement of a chest tube with the initiation of a medium-chain triglyceride diet is the initial management. Total parenteral nutrition with enteric rest (nothing by mouth) may be needed if conservative management fails. Adjuvant therapy includes diuretics, albumin infusions, immunoglobulin replacement, electrolyte replacement, and fresh frozen plasma and antithrombin replacement. Octreotide infusion followed by thoracic duct ligation may be needed in cases not amenable to other measures. Caution should be used with octreotide, and it is generally recommended that the patient receive nothing by mouth during octreotide infusion. Increased risk adjusted congenital heart surgery score, prolonged intubation time, low birth weight, and neurological co-morbidities. What consideration should be given to the neonate after surgery for oral or nasogastric feeding? Although there is no correct answer, the clinician should consider whether the infant was fed before surgery, length of bypass and circulatory arrest times, adequacy of the cardiac output, presence of bowel sounds, minimization of vasoconstrictive agents, and the absence of lactic acidosis. Preoperative and postoperative care of the infant with critical congenital heart disease. Near-infrared spectroscopy: what we know and we need to know-a systematic review of congenital heart disease literature. Most rejection episodes in the era of cyclosporine immunosuppression are relatively asymptomatic, especially in the older child. The neonatal recipient, however, can often have the nonspecific findings of fever, irritability, tachycardia, loss of appetite, and an S3 gallop on physical examination. What are major long-term complications that can occur after heart transplantation? Rejection, infection, coronary artery disease, hypertension, renal dysfunction, and tumors may occur. During cardiac transplantation all nerves to the heart are severed so that there is no direct sympathetic or parasympathetic control of heart rate. Concomitantly, during the first few postoperative days the stroke volume of the transplanted heart is relatively fixed, and the contractility of the heart is diminished secondary to the ischemia that occurred during harvest and implantation. Cardiac output is directly proportional to changes in the heart rate in the early postoperative period. Therefore many surgeons try to maintain cardiac output by pacing the heart with temporary pacing wires. Are neonates at an advantage compared with older children with regard to heart transplantation? Some evidence suggests that infants who receive transplants when younger than 6 months of age have improved survival 10 years after the transplant compared with older children. Newborn infants do not have a mature complement system and do not produce a typical isohemagglutinin response to blood groups. Heart transplantation in neonates: achievements, challenges, and controversies for the future. After cardiac catheterization in a neonate, it is crucial to assess vital signs, femoral and dorsalis pedis pulses, and hematocrit levels. Which kinds of congenital heart disease may benefit from a cardiac catheterization interventional procedure? Which anomaly of the systemic veins may prevent access to the right side of the heart from the femoral veins? An interrupted inferior vena cava prevents access to the right side of the heart from the femoral veins. Therefore the umbilical vein remains an alternative way to gain access to the right side of the heart. Although originally developed using fluoroscopy, a balloon atrial septostomy may be performed at the bedside using transthoracic echocardiography guidance. What is characteristic of a full-term normal newborn electrocardiographic reading? The normal electrocardiogram in a newborn shows a preponderance of right ventricular forces because the right and left ventricles are of equal mass at birth. What is the definition and differential diagnosis of sinus tachycardia in a newborn? The differential diagnoses should include fever, infection, anemia, pain, hypovolemia, hyperthyroidsim, myocarditis, and drug interaction. What is the definition and differential diagnosis of sinus bradycardia in a newborn? Sinus bracycardia is defined as sinus rhythm with a heart rate (awake) below the lower normal limit (91 bpm first week of life and 107 bpm first month of life). Blocked premature atrial beats are common, often having a pause that may average out the heart rate on the monitor to a lower than clinically relevant number, but rarely cause symptoms. What are the electrocardiographic signs of abnormal right ventricular hypertrophy in a newborn? What are the electrocardiographic abnormalities observed in infants with hyperkalemia? What are the electrocardiographic abnormalities observed in infants with hypokalemia? Toxic effects of digoxin are usually seen in the formation and conduction of the impulse. This finding is associated with a Wolff­Parkinson­White pattern on the electrocardiogram. Sinus rhythm with ventricular preexcitation (Wolff­ Parkinson­White) pattern ("delta wave" arrow). Are there certain congenital heart lesions that may be seen with Wolff­ Parkinson­White syndrome? All patients with a Wolff­Parkinson­White pattern on their electrocardiograms should have an echocardiogram to rule out structural heart disease. Associated lesions include the following: n Ebstein anomaly of the tricuspid valve n Ventricular inversion (congenitally corrected transpositions; levo-transposition of the great arteries [l-tga]) n Hypertrophic cardiomyopathy n Cardiac tumors 153. Maternal connective tissue diseases (systemic lupus erythematosus and Sjцgren syndrome) can cause complete congenital heart block or dilated cardiomyopathy (or both) in the fetus and infant. What are congenital anatomic and nonanatomic causes of congenital complete heart block in the fetus? Blocked premature atrial contractions often cause what appears to be a pause on the monitoring strips, and they occur when the ventricle is refractory and not conducted. Premature beats account for 80% to 90% of fetal arrhythmias but are generally benign. Re-entrant supraventricular tachyarrhythmias account for 5% of fetal arrhythmias, complete heart block 2. There is a 1:1 atrioventricular relationship at a heart rate of 257 beats per minute. Most (60% to 90%) of infants with Wolff­Parkinson­White syndrome undergo spontaneous resolution by 1 year of age. All three of these drugs have potential pro-arrhythmic side effects and institution of such antiarrhythmics should occur in a hospital (monitor/telemetry) setting. Presenting symptoms typically occur within the first 2 days of life, and there does not tend to be an association with structural heart defects. Direct cardioversion or overdrive esophageal atrial pacing therapies are effective in more than half of the cases.

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