By X. Anktos. University of Alabama. 2019.

Physical exercise improves learning by modulating hippocampal mossy fiber sprouting and related gene expression in a developmental rat model of penicillin-induced recurrent epilepticus buy discount cytoxan 50 mg line. Physical activity purchase cytoxan paypal, quality of life buy cytoxan 50mg amex, and burnout among physician trainees: the effect of a team-based, incentivized exercise program. The relationships of change in physical activity with change in depression, anxiety, and burnout: a longitudinal study of Swedish healthcare workers. Obesity in older adults: a systematic review of the evidence for diagnosis and treatment. Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement. Change in mental health after smoking cessation: systematic review and meta-analysis. Classical mindfulness: an introduction to its theory and practice for clinical application. Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Relaxation response induces temporal transcriptome changes in energy metabolism, insulin secretion and inflammatory pathways. Meditation effects within the hippocampal complex revealed by voxel-based morphometry and cytoarchitectonic probabilistic mapping. Impact of mindfulness-based stress reduction training on intrinsic brain connectivity. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. Risk management programs complement quality improvement programs in minimizing liability exposure while maximizing quality of patient care. Quality improvement programs focus on improving the structure, process, and outcome of care. The patient-plaintiff must prove that the anesthesiologist 284 owed the patient a duty and failed to fulfill this duty, that the anesthesiologist’s actions caused an injury, and that the injury resulted from a breach in the standard of anesthesia care. Chronic pain management is the source of an increasing number of malpractice claims against anesthesiologists. In anesthesia, as in other areas of life, everything does not always go as planned. An anesthesia risk management program can work in conjunction with a program for quality improvement to minimize the liability risk of practice. In addition, there has been a move toward linking reimbursement to performance measurement and reporting. The legal aspects of American medical practice are important to the anesthesia community as the public turns to the courts for economic redress when their expectations of medical treatment are not met. The chapter provides background for the practitioner concerning the role of risk management activity in minimizing and managing liability exposure. Also described are the medical legal system, the most frequent causes of lawsuits for anesthesiologists, and appropriate actions for physicians to take in the event of a malpractice suit. Anesthesia Risk Mortality and Major Morbidity Related to Anesthesia Estimates of anesthesia-related morbidity and mortality are difficult to quantify. Not only are there difficulties obtaining data on complications, but also different methods yield different estimates of anesthesia risk. Studies differ in their definitions of complications, in length of follow-up, and especially in approaches to evaluation of the contribution of anesthesia care to patient outcomes. A comprehensive review of anesthesia complications is beyond the scope of this chapter. A sampling of studies of anesthesia mortality and morbidity will be presented to provide historical 285 perspective plus a limited overview of relatively recent findings. Early studies estimated the anesthesia-related mortality rate as 1 per 1,560 anesthetics. More recent studies use data from the 1990s, and later estimate1 the anesthesia-related death rate in the United States to be lower than 1 per 10,000 anesthetics. This lends support to the generally accepted belief that anesthesia8 safety has improved over the past 50+ years. Lower-extremity neuropathy following surgery in27 the lithotomy position was observed in 151 per 10,000 patients. Permanent28 neurologic injury following neuraxial anesthesia was estimated at 0 to 4. Among these include use of a Wilson surgical bed61 frame, obesity, and long anesthetic durations. All can contribute to increased venous congestion in the optic canal and potentially reduce optic nerve perfusion pressure. There was insufficient evidence to conclude that intraoperative anemia or transient periods of hypotension were causative factors. There is some evidence that the incidence of postoperative visual loss has been decreasing in the United States. Dental injury complaints are usually resolved by a hospital risk management department. Dental injuries after general endotracheal anesthesia were observed in approximately 1 per 2,000 to 3,000 patients in the United States. It is difficult to sort out the potential contributions of surgery, anesthesia, and illness on neurocognitive function. Cognitive dysfunction, usually short term, has been observed in many adult patients after major surgery, and it has been hypothesized that the elderly may be at more significant risk for long-term cognitive problems. While the role of anesthesia in postoperative cognitive62 dysfunction has not been definitively determined, recent evidence based on twin studies suggests that major surgery with anesthesia results in a negligible effect on cognitive function in middle-aged and elderly patients. For up-to-date research findings and a consensus64 statement from a diverse group of experts on the use of anesthetic drugs in infants and toddlers, see the web site for SmartTots at smarttots. Risk Management Conceptual Introduction Risk management and quality improvement programs work hand in hand to minimize liability exposure while maximizing quality of patient care. Although the functions of these programs vary from one institution to another, they overlap in their focus on patient safety. A hospital risk management program is broadly oriented toward reducing the liability exposure of the organization. This includes not only professional liability (and therefore patient safety) but also contracts, employee safety, public safety, and any other liability exposure of the institution. Quality improvement programs have as their main goal the continuous maintenance and improvement of the quality of patient care. These programs may be broader in their patient safety focus than strictly risk management.

Aminoesters are hydrolyzed by plasma cholinesterases and aminoamides are transformed by hepatic carboxylesterases and cytochrome P450 enzymes buy 50 mg cytoxan visa. Severe liver disease may slow the clearance of aminoamide local anesthetics and significant drug levels may therefore accumulate effective cytoxan 50 mg. Bupivacaine is a more lipid-soluble and more potent agent with less systemic absorption over time purchase cytoxan 50 mg with visa. Nonetheless, pharmacokinetics are difficult to predict in any given circumstance because both physical and pathophysiologic characteristics will affect the individual pharmacokinetics. There is some evidence for increased systemic plasma levels of local anesthetics in the very young and in the elderly owing to decreased clearance and increased absorption ; however, the correlation of systemic blood levels between the84 dose of local anesthetic and weight is often inconsistent (Fig. Effects85 of gender on clinical pharmacokinetics of local anesthetics have not been well defined, although pregnancy may decrease clearance. Pathophysiologic86 87 states such as cardiac and hepatic disease will alter expected pharmacokinetic parameters (Table 22-10), and lower doses of local anesthetics should be used for these patients. As expected, renal disease has little effect on pharmacokinetic parameters of local anesthetics (Table 22-10). All of these factors should be considered when using local anesthetics and minimizing systemic toxicity, the commonly accepted maximal dosages (Table 22-9) notwithstanding. Arterial and pulmonary concentrations of the enantiomers of bupivacaine after epidural injection in elderly patients. They all take advantage of their ability to attenuate or block pain and other noxious stimuli. When applied topically to the skin, a eutectic mixture of lidocaine and prilocaine reduces the sharp, painful sensation associated with needle insertion and intravenous catheter placement, particularly in the pediatric population. In the awake patient, aerosolized benzocaine and viscous lidocaine directed at the mucosal surface can help blunt the protective reflex responses associated with airway instrumentation (see Chapter 28). In addition, lidocaine can be given intravenously to decrease the incidence and the severity of pain associated with propofol administration (see Chapters 19, 31). Likewise, intravenous lidocaine may also help to reduce the hemodynamic response to tracheal intubation and extubation. For a wider and greater area of coverage, a regional anatomic approach to anesthesia and analgesia can be used. This can be accomplished either by intravenous administration of local anesthetics to a limb under pneumatic compression (Bier block) or by direct application of local anesthetics to individual peripheral nerves (nerve blocks). Local anesthetics can be deposited centrally near the nerve roots, either intrathecally in the lumbar cistern or epidurally in the thoracic, lumbar, and caudal regions of the spine (see Chapter 35). Alternatively, injections can be made peripherally at the plexus, such as at the brachial or lumbar plexus block or on the nerve fibers (see Chapter 36). The duration of the anesthesia and analgesia is dependent on the type of local anesthetics 1456 used, though it can be extended with continuous infusion through an indwelling catheter. Surveys from France and the United States of over 280,000 cases involving regional anesthesia show an incidence of seizures of approximately 1/10,000 with epidural injections and 1457 7/10,000 with peripheral nerve blocks. Nonetheless, in an analysis of closed malpractice claims in the United States from 1980 to 1999, epidural anesthesia (primarily obstetrical) constituted all of the cases of death or brain damage resulting from unintentional intravenous injection of local anesthetic. However, although all local anesthetics can cause hypotension, dysrhythmias, and myocardial depression, more potent agents (bupivacaine, ropivacaine, and levobupivacaine) are predisposed to devastating outcomes, such as fatal cardiovascular collapse and complete heart block (Fig. In animal models, both ropivacaine and levobupivacaine appear to exhibit 30% to 40% less cardiovascular toxicity than bupivacaine on a milligram-to-milligram basis (Fig. Although local anesthetics can directly cause major disturbances to the heart, their effects on other components of cardiovascular systems may be just as important. Disruption to the arterial baroreflex in the brainstem by bupivacaine can lead to attenuation of the heart rhythm response to changes in blood pressure. In the periphery, vasoconstriction occurs at subclinical doses and vasodilation at higher doses. Figure 22-12 Success of resuscitation of dogs after cardiovascular collapse from intravenous infusions of lidocaine, bupivacaine, levobupivacaine (L-bupiv), and ropivacaine. Success rates were greater for lidocaine (100%) compared to ropivacaine (90%), levobupivacaine (70%), and bupivacaine (50%). Required doses to induce cardiovascular collapse were greater for lidocaine (127 mg/kg) compared to ropivacaine (42 mg/kg), levobupivacaine (27 mg/kg), and bupivacaine (22 mg/kg). Cardiac resuscitation after incremental overdosage with lidocaine, bupivacaine, levobupivacaine, and ropivacaine in anesthetized dogs. Both levobupivacaine and ropivacaine required significantly greater serum concentrations than bupivacaine. Systemic toxicity of levobupivacaine, bupivacaine, and ropivacaine during continuous intravenous infusion to nonpregnant and pregnant ewes. The central nervous system and cardiovascular effects of levobupivacaine and ropivacaine in healthy volunteers. First, bupivacaine has an inherently greater affinity for binding resting and inactivated sodium channels than lidocaine. This slow rate of dissociation prevents a complete recovery of the channels at the end of each cardiac cycle (at the physiologic heart rate of 60 to 80 beats/min), thereby leading to an accumulation and worsening of the conduction defect. In contrast, lidocaine fully dissociates from sodium channels during diastole and little accumulation of conduction delay occurs (Fig. It is widely accepted that local anesthetics bind and disrupt the normal function of the heart-specific voltage- gated sodium channel, Na 1. Local anesthetics have been shown to antagonize the currents of other cations, primarily calcium and potassium. Lastly, individuals and experimental animal models with L-carnitine deficiency exhibit an increased susceptibility to local anesthetic–associated cardiac toxicity, suggesting that local anesthetics can affect mitochondrial function and fatty acid metabolism. Sodium channels are predominantly in the resting form during diastole, open transiently during the action potential upstroke, and are in the inactive form during the 1461 action potential plateau. Block of sodium channels by bupivacaine accumulates during the action potential (systole), with recovery occurring during diastole. Recovery of sodium channels results from dissociation of bupivacaine and is time-dependent. Recovery during each diastolic interval is incomplete and results in accumulation of sodium channel block with successive heartbeats. Mechanisms for bupivacaine depression of cardiac conduction: fast block of sodium channels during the action potential with slow recovery from block during diastole. Mechanisms for bupivacaine depression of cardiac conduction: Fast block of sodium channels during the action potential with slow recovery from block during diastole. Elevated plasma levels of local anesthetics can occur by inadvertent intravascular injections or systemic absorption. The risk for intravascular injections can be reduced by using a local anesthetic test dose (about 3 mL), frequently aspirating the injectate for signs of blood return, and dividing the dose of the local anesthetics. Heart rate and rhythm, blood pressure, and oxygenation should be monitored at all times.

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In the event of bowel perforation cheap cytoxan 50 mg with amex, the affected intestinal seg- ment is rapidly resected generic cytoxan 50 mg without a prescription, followed by mesenteric revascularization cytoxan 50 mg free shipping, leaving the reconstruction of the intestinal tract until second-look laparotomy after 18–36 h. While temporary skin-only closure may be a good option in some patients, full open abdomen to optimize visceral circulation may be necessary in others. This wire is snared in the aorta using a snare passed through a femoral access and then brought out, creating through-and-through access. In one center, a temporary stoma is created, followed by administration of parenteral nutrition until the surgical recovery phase is over [38]. In patients undergoing extensive bowel resections, proximal resection of the jejunum, or multiple resections, bowel anastomosis after effective intes- tinal revascularization may be benefcial in avoiding high output stoma, short bowel syndrome, and the increased mortality associated with intestinal failure [39]. Take-Home Messages • Recognition and timely management of abdominal compartment syn- drome after repair of ruptured abdominal aortic aneurysm is crucial for improvement of survival. Is the evolving management of intra-abdominal hypertension and abdominal compartment syndrome improving survival? Damage control: an approach for improved survival in exsanguinat- ing penetrating abdominal injury. Abdominal compartment syn- drome associated with endovascular and open repair of ruptured abdominal aortic aneurysms. A systematic review and meta-analysis of abdominal compartment syndrome after endovascular repair of ruptured abdominal aortic aneurysms. Massive transfusion: red blood cell to plasma and platelet unit ratios for resuscitation of massive hemorrhage. Management of the tense abdomen or diffcult abdominal closure after operation for ruptured abdominal aortic aneurysms. Editor’s choice: abdominal compart- ment syndrome after surgery for abdominal aortic aneurysm: a nationwide population based study. Damage control in the man- agement of ruptured abdominal aortic aneurysm: preliminary results. Damage-control laparotomy in non-trauma patients: review of indications and outcomes. Colonic ischaemia and intra-abdominal hypertension following open repair of ruptured abdominal aortic aneurysm. Systematic review and meta-analysis of long-term survival after elective infrarenal abdominal aortic aneu- rysm repair 1969–2011: 5 year survival remains poor despite advances in medical care and treatment strategies. Temporary abdominal closure after abdominal aortic aneu- rysm repair: a systematic review of contemporary observational studies. Open abdo- men treatment after aortic aneurysm repair with vacuum-assisted wound closure and mesh- mediated fascial traction. Early results after treatment of open abdomen after aortic surgery with mesh traction and vacuum-assisted wound closure. Vacuum-assisted wound closure and mesh-mediated fascial traction – a novel technique for late closure of the open abdomen. Vacuum-pack tem- porary abdominal wound management with delayed-closure for the management of ruptured abdominal aortic aneurysm and other abdominal vascular catastrophes: absence of graft infec- tion in long-term survivors. Delayed abdominal closure in the man- agement of ruptured abdominal aortic aneurysm. Kirkpatrick A, Roberts D, De Waele J, Jaeschke R, Malbrain M, De Keulenaer B, Pediatric Guidelines Sub-Committee for the World Society of the Abdominal Compartment Syndrome, et al. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus defnitions and clinical practice guidelines from the World Society of Abdominal Compartment Syndrome. Management of the open abdomen using vacuum-assisted wound closure and mesh-mediated fascial traction. Vacuum and mesh-mediated fascial traction for pri- mary closure of the open abdomen in critically ill surgical patients. One hundred percent fascial approximation with sequential abdominal closure of the open abdomen. Multicentre prospective study of fascial closure rate after open abdomen with vacuum and mesh-mediated fascial traction. Evaluation of the open abdomen clas- sifcation system: a validity and reliability analysis. Revascularization of the superior mesenteric artery after acute thromboembolic occlusion. Outcomes of damage- control celiotomy in elderly non-trauma patients with intra-abdominal catastrophes. European Society of Vascular Surgery Guidelines on the management of diseases of the mesenteric arter- ies and veins. Transcatheter thrombolysis combined with damage control surgery for treatment of acute mesenteric venous thrombosis associated with bowel necrosis: a retrospective study. Retrograde mesenteric stenting during laparotomy for acute occlusive mesenteric ischemia. High risk of fstula formation in vacuum-asisted closure therapy in patients with open abdomen due to secondary peritonitis – a retrospective analysis. Systematic review and meta-analysis of the open abdo- men and temporary abdominal closure techniques in non-trauma patients. Revascularization of acute mesenteric ischemia after creation of a dedicated multidisciplinary center. Endovascular and open surgery for acute occlusion of the superior mesenteric artery. The techniques reported in the literature have the advantage of being diverse and appli- cable in all the countries. Some techniques are easy to apply and cheaper and could be used also in countries with a lower economic status. However in our era, the attention to a spending review meant that even these countries researched cheaper but equally effective devices [1, 2]. The most important difference between devices and techniques is to apply or not a negative pressure therapy. The recent tech- niques develop a system with a negative pressure to reduce fuids in the abdomen through aspiration drainages or aspiration continuous or intermittent pump. The other important point to take into consideration is the pathology underlying the choice of the open abdomen management. A different technique could be used in young trauma patients compared to septic elderly patients or to severe acute pancreatitis patients. In fact different pathophysiological mechanisms underlie these clinical conditions, and a different approach can be used. However a best device that can achieve a good fascial closure preserving the abdominal wall domain of the intra-abdominal organs is not found yet. They consist in closing the skin only by making the edges closer using towel clips (Fig.

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Fiane Chapter 28 Techniques for Driveline Positioning – 281 Christina Feldmann generic cytoxan 50 mg fast delivery, Jasmin S purchase cytoxan overnight. Schmitto Chapter 29 Percutaneous Devices: Options – 287 Melody Sherwood and Shelley A purchase cytoxan cheap online. Adamson Chapter 34 Pump Removal After Myocardial Recovery During Left Ventricular Assist Device Support – 349 E. Schima In this chapter, general considerations and blood pump assembly comprises infow and the operation principle of rotary blood pumps outfow cannulas for its connection to the will be frst presented with particular focus cardiovascular system and a fexible driveline for on the pressure-fow-speed characteristics, on connection to electric power supply and to a what infuences the pump fow rate, and on control unit (. Finally current state-of- Rotary blood pumps can be classifed the-art about hemodynamic monitoring and according to fve main factors: geometry, bearing control of these pumps will be presented. If the angle between blood infow and Rotary blood pumps are used in the treatment of blood outfow is 90° (blood exits the pump in a heart failure. Common indication for the direction orthogonal to the blood infow), one implantation of these devices is end-stage heart speaks of a centrifugal-fow pump. A pump with a low lef ventricular ejection fraction characterized by angles between these two (<25%), elevated pulmonary pressures, reduced extreme cases is called a mixed-fow pump. Rotary blood pumps can bearing type relies on the low friction coefcient be used to bridge the patient until heart of the bearing material (ceramic, ruby), the transplantation becomes possible, or they can second on magnetic forces, and the third on even be implanted for lifetime. Tis latter is hydrodynamic forces to obtain levitation of the described as destination therapy and is considered impeller and contactless rotation. Concerning when there is a contraindication for cardiac trans- implantability, one can distinguish between plantation, such as irreversible pulmonary implantable devices, where the pump housing hypertension, active systemic infection, active and cannulas are placed into the body with power malignancy or history of malignancy with pro- supply and driving unit being still extracorporeal, bability of recurrence, or inability to comply with and external devices, where the only implantable 14 complex medical regimen. In a few cases, these components are the pump infow and outfow devices can be used as bridges to recovery, such as cannulas. Te duration of use constitutes another in case of acute cardiac failure following cardiac factor to distinguish devices: one can have short- surgery or acute myocarditis infections. As a result of cannulation to the lef atrium is sometimes also the impeller action, the blood leaves the impeller used. Te outlet cannula is commonly sutured to at a higher pressure and velocity than at its the ascending aorta, but the descending aorta or entrance. Te infow is 5 Guarantee continuous operation without cannulated to the lef ventricle and outfow to the maintenance for years (5–10 years). Rotary blood pumps are small in size, which 5 Be small to reduce surgical trauma and allows minimally invasive implantation. Schima operation, which is important for patient quality depends on the interaction between the residual of life. Tey sufer however from a lack of ventricular function, the overall hemodynamics adaptation to changing hemodynamics, which and the pump speed setting. Generally one leads, for example, to pump fow rate decrease in distinguishes between partial support and full response to an increasing arterial pressure or to support. Trombus formation, strokes and toward the aorta, and the aortic valve stays bleeding still remain an issue with these devices, permanently closed (see. In both support types, the fow rate still challenging for coagulation and hemostasis generated by the rotary pump is related to the [3, 4]. Further complications include infections of ventricular and aortic pressures as well as to the the percutaneous driveline. In case of 167 14 Engineering and Clinical Considerations in Rotary Blood Pumps Q, and it is measured in liters per minute (l/min). In this paragraph, a simplifed and which the impeller rotates is referred to as pump graphical analysis of the infuence of these factors speed. It is symbolized by the letter N, and it is on the pump fow rate will be presented. Considering the diferent head will lead, via the pump characteristic for a speeds, one speaks of the pressure-fow-speed given rotational speed, to a pulsatile pattern of the characteristics. For a more unloading of the ventricle since blood is technical description of hydraulic characteristics continuously pumped through the heart cycle and design concepts of centrifugal- and axial-fow (the fow rate is >0). In the rightmost panel (c), the time course diference during systole (Hs) and diastole (Hd) is shown. It is preload and aferload is therefore strictly valid in therefore incorrect to name rotary blood pumps the short time afer the speed change; the later as “nonpulsatile” assist devices. Only in the rare changes can be investigated in a similar manner, case of ventricular fbrillation (no residual however, as it is presented next. Instead Doppler ultrasound can diastolic one, leading to a reduction of the Hs and be used to detect fow in the radial artery when an almost constant Hd (. Also this assumption is strictly valid in three abovementioned variables is considered the short time afer the preload change, and a here; when a decrease occurs, the opposite further analysis can be performed considering changes will take place. Te increase of AoP leads to an increase of and diastolic pressure head are constant too. Te analysis is however similar and Thrombogenicity with just one relevant diference. In this case, the trauma and triggering platelet activation and systolic pump fow rate will have a rather constant coagulation of thrombi. Te In the early developments, spinning disks systolic fow rate will be indeed the intercept of were preferably used to avoid high shear stress the pump characteristic with the x-axis (e. Monitoring using an implantable pump fow Terefore, an ultrashort exposure to high shear rate sensor has been reported in patients [16]. Patient be destroyed per passage) is difcult to measure, monitoring that relies only on available pump and short exposure times at well-defned shear data seems very promising, particularly because would require new test setups, which are not additional sensors are ofen afected by drifs and available yet. Several hemodynamic decades of research, numerical models of blood indices and methods were developed based on trauma are limited in reliability and accuracy available pump signals: a ventricular contractility [11]. A method to evaluate heart rate roughness, and long residence times in stagnation and arrhythmic events (e. To provide thrombogenicity tests for tachycardia or atrial fbrillation) as well as heart pumps and specifc blood pathways, several rate variability [27] and methods to detect in vitro setups have been developed [13, 14]. All these most critical parts in design, due to their shear methods and indices use either pump fow rate gradient, the generated friction heat, and critical waveform, which can be either measured or location in the center of the rotor in usually low- estimated from pump motor current and speed fow areas. As a potential solution to this issue, [30], or directly the motor current/speed pumps with either actively controlled magnetic waveforms. Tese and successfully implemented in commercially methods take advantage of the pulsatility in the available devices. In this setting, the pump can be understood as a “turbo A detailed knowledge of the hemodynamic discharger” of the ventricle, which – simply interaction of the pump and the cardiovascular speaking – facilitates ventricular output by system allows one to predict hemodynamic providing pressure work. If the ventricle has some behavior depending on the pump fow rate remaining contractile force or recovers afer waveform and therefore perform patient implant, it can overtake some physiological monitoring using pump data. Tis is especially adaptation by the Starling mechanism still important in rotary blood pumps because of their working against a lower output pressure. Only in patients with completely divided in those which make use of external dysfunctional ventricle such adaptation is sensors and those that rely on assist device motor difcult, with circadian hemodynamic changes parameters to estimate hemodynamic variables that may lead to suction during night and 171 14 Engineering and Clinical Considerations in Rotary Blood Pumps Q Heart rhythm Aortic valve Contractility Pump flow-rate estimated from Relaxation motor current and speed Time Suction.

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