By G. Mojok. School for International Training. 2018.

Optimal Diagnostic Criteria aurogra 100 mg online impotence ring, Investigations aurogra 100 mg with visa erectile dysfunction doctor in kuwait, treatment & referral criteria *Situation1: At secondary Hospital/ Non-Metro situations: Optimal standards of treatment in situations where technology & resources are limited. Symptoms and signs in the absence of fever, which mandate a comprehensive search for infection and aggressive, immediate empirical therapy: Unexplained hypotension, tachycardia, tachypnea, confusion, rigors, skin lesions, respiratory manifestations, oliguria, lactic acidosis, leukocytosis, leukopenia, immature neutrophils (i. A detailed medication history, line manipulation, blood transfusion, appearance of new rash, diarrhea, or any new procedure performed should be enquired b. Focused physical examination should be performed looking for any source of sepsis or non-infectious cause of fever. New fever, purulent secretion, bronchial breathing Central line sepsis-Line in place for more than 48 hours Erythema, purulent discharge at central line site. Urinary catheter related infection – Catheter more than 48 hours in place,suprapubic tenderness cloudy urine Surgical site infection – purulent discharge from wound site Sinusitis- Nasogastric or nasotracheal tube, purulent nasal discharge 59 Parotitis- poor oral hygiene, unilateral tender parotid swelling A calculus cholecystitis- abdominal tenderness, intolerance of feed d. Non specific treatment with antipyretic should be instituted in patients with central nervous system disorder, extremes of age, poor cardiac reserve. Referral Criteria: If higher diagnostic tests and imaging techniques are not available and the patient is not improving, transfer to well equipped centres should be undertaken. Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America. Clinical practice guidelines for the diagnosis and management of intravascular catheter- related infection: 2009 Update by the Infectious Diseases Society of America. Attention to technical details correct interpretation of data, and its application in selecting therapy should be individualized within the clinical context. In addition, presence of arterial catheter enables frequent sampling of arterial blood without arterial punctures in critically ill patients. Set up of the pressure tranducing system o The pressure transducing assembly consists of a coupling system, pressure transducer, amplifier and signal conditioner, analog to digital converter, microprocessor which convert the signal received from the vein or artery into a waveform on the a bedside monitor o The flushing system – is set up using a 500 ml saline bottle encased in a bag 65 pressurized to 300 mm Hg. At this pressure the catheter will be flushed with 3 ml saline per hour and help keep the catheter patent. Heparinised saline is no longer routinely used  The reference point is usually at the level of the heart where the transducer is zeroed. Other veins that may be used are the arm veins (basilic, cephalic), external jugular and femoral veins. The fluid challenge is performed in 4 steps: o Select the type of fluid: usually normal saline or a colloid o Infuse rapidly. Rate of infusion: 500ml of crystalloid or 200 ml of colloid over 20-30 minutes o Target the Desired therapeutic response: the parameters are set empirically by the physician. This brought the catheter out of the domain of radiologists and at the bedside of the patients in intensive care. An SvO2 below 65% implies low oxygen delivery, while a value below 60% indicates that there is a serious risk of tissue hypoxia if corrective measures are not taken. In some disease states, cells in some tissues are unable to assimilate and/or process the needed oxygen. Indications  Management of complicated myocardial infarction • Hypovolemia vs cardiogenic shock • Severe left ventricular failure  Assessment of type of shock  Septic shock  Assessment of therapy • Afterload reduction • Vasopressors • Beta blockers • Intra-aortic balloon counterpulsation  Assessment of fluid requirement in critically ill patients • Hemorrhage • Sepsis • Acute renal failure • Burns  Management of postoperative open heart surgical patients Methods of monitoring cardiac output  Thermodilution (intermittent or continuous) using the pulmonary artery catheter has been the classical method of cardiac output monitoring. A central venous catheter, special thermistor tipped femoral artery catheter and monitor are required. The additional advantages are the values of extravascular lung water, global end-diastolic volume and the stroke volume variation (a dynamic measure of preload). They are not reliable in patients ventilated with low tidal volume and in patients with increased intraabdominal pressure  In these cases Passive leg raising is an alternative choice. Line 70 0 70 Saline, syringes 400 200 200 Total Initial Set up 11,470 12750 9770 Cost (Does not Add Presep include capital cost of continuous hemodynamic ScvO2 catheter monitors) 8000 Total: 17700 Daily monitoring cost 4500-5000 4500-5500 3500-4000 (based on an average of 3 days monitoring, 6000-7000 does not include including professional fees) Presep Further reading: 1. Minimally invasive hemodynamic monitoring for the intensivist: Current and emerging technology Crit Care Med 2002; 30:2338 –2345 6. Equipment review: New techniques for cardiac output measurement – oesophageal Doppler, Fick principle using carbon dioxide, and pulse contour analysis. Hemodynamic monitoring in shock and implications for management International Consensus Conference, Paris, France, 27–28 April 2006. It should be suspected anytime there is hypotension accompanied by an elevated central venous pressure (or neck vein distension), which is not otherwise explained by acute myocardial infarction, tension pneumothorax, pericardial tamponade, or a new arrhythmia. The concern about radiation is overcome by the hazard of missing a potentially fatal diagnosis or exposing the mother and fetus to unnecessary anticoagulant treatment.

Positive feedback: a regulatory mechanism in which the inputs and outputs in control system continue to enhance each other so that the variable moves further from steady state value 100 mg aurogra sale bph causes erectile dysfunction. Purkinje fibers: Small terminal fibers that extend from the bundle of it is and rapidly transmit an action potential throughout the ventricular myocardium purchase 100mg aurogra with visa erectile dysfunction miracle. Refractory period: Period when an activated membrane is refractory to further stimulation preventing action potential from spreading backward. Right atrium: the heart chamber that receive venous blood from the systemic circulation. Right Ventricle: the heart chamber that pumps blood in to the pulmonary circulation. Saltatory condition: propagation of action potential in a myelinated fiber with the impulse jumping from one node of Ranvier to another. Sarcoplasmic reticulum: reservoir of ionic calcium Second messenger: an intracellular chemical messenger activated by extracellular chemical that triggers preprogramed biochemical events, resulting in control of cellular activity. Signal transduction: The sequence of events, which carry signals from first chemical messenger conveyed to the cell. Vasoconstriction: the narrowing of a blood vessel lumen as a result of contraction of the vascular circular smooth muscle. Vasodilatation: the enlargement of a blood vessel lumen as a result of relaxation of the vascular circular smooth muscle. Venous return: the volume of blood returned to each atrium per minute from the veins. After this chapter the student is expected to: • relate the structural organization of the respiratory system to its function • describe the functional importance of the intraplueral fluid , the parietal and visceral pleura • know the structural and functional features that distinguish the respiratory zone of the airways from the conducting zone • define and describe the alveolar-capillary unit • know the definitions fractional concentrations (of dry gas) and partial pressure of gases • know the normal values of partial pressure of oxygen and carbondioxide in arterial and mixed venous blood • know how exchange of gases occur between the blood and tissues • know the control mechanisms involved in respiration Introduction The major functions of the respiratory system can be divided in two categories: respiratory and non-respiratory. The respiratory system must obtain oxygen from the environment and must eliminate carbondioxide produced by cellular metabolism. These processes must be coordinated so that the demand for oxygen is met and so that the carbondioxide that is produced is eliminated. The respiratory system is well designed to carry out gas exchange in an expeditious manner. It participates in + maintaining acid-base balance, since increase in Co2 in the body lead to increased H the lungs also metabolize naturally occurring compounds such as angiotensin I, 229 prostaglandins and epinephrine. Functional anatomy of the respiratory system Functionally, the respiratory air passages are divided into two zones: a conductive zone and a respiratory zone. The airway tree consists of a series of highly branched hollow tubes thatdecrease in diameter and become more numerous at each branching. Trachea, the main airwayin turn branches into two bronchi, one of which enters each lung. Within each lung, these bronchi branch many times into progressively smaller bronchi, which in turn branch into terminal bronchioles analogous to twigs of a tree. The terminal bronchioles redivide to form respiratory bronchioles, which end as alveoli, analogous to leaves on a tree. The conducting zone includes all of the anatomical structures through which air passes before reaching the respiratory zone. The conducting zone of the respiratory system, in summary consists of the following parts: Mouth→ nose→ pharynx→ larynx→ trachea→ primary bronchi→ all successive branches of bronchioles including terminal bronchioles. This ensures that a constant internal body temperature will be maintained and that delicate lung tissue will be protected from desiccation. Filtration and cleaning: Mucous secreted by the cells of the conducting zone serves to trap small particles in the inspired air and thereby performs a filtration function. This mucus is moved along at a rate of 1-2cm/min by cilia projecting from the tops of the epithelial cells that line the Conducting zone. There are about 300 cilia per cell that bend in a coordinated fashion to move mucus toward the pharynx, where it can either be swallowed or expectorated. As a result of this filtration function, particles larger than about 6μm do not enter the respiratory zone of the lungs. The importance of this disease is evidenced by the disease called black lung, which occurs in miners who inhale too much carbon dust and therefore develop pulmonary fibrosis. The cleansing action of cilia and macrophages in the lungs is diminished by cigarette smoke. Respiratory zone The respiratory zone includes the respiratory bronchioles (because they contain separate out pouching of alveoli) and the alveoli.

The main principles for such examinations are: • Selection of a diluting fluid that not only will dilute the cells to manageable levels but will either identify them in some fashion or destroy contaminant cellular elements discount aurogra 100 mg on-line erectile dysfunction muse. Counting Chambers The hemocytometer is a thick glass slide with inscribed platforms of known area and precisely controlled depth under the coverslip generic aurogra 100 mg amex impotence and diabetes 2. In the center of the upper surface 87 Hematology there are ruled areas separated by moats/channels from the rest of the slide and two raised transverse bars one of which is present on each side of the ruled area. The ruled portion may be in the center of the chamber (single chamber) or there may be an upper and lower ruled portion (double chamber). When an optically plane cover glass is rested on the raised bars there is a predetermined gap or chamber formed between its lower surface and the ruled area (fig. The ruled area itself is divided by microscopic lines into a pattern that varies again with the type of the chamber. The counting chamber recommended for cell counts is a metallized surface (Bright-line) double cell Improved Neubauer ruled chamber. Each side is, therefore, divided into 20 equal divisions (the width of 16 small squares and 4 sets of triple lines). The Improved Neubauer Counting Chamber The depth between the lower surface of the cover glass which is on the raised bars and the ruled area is 0. The central square of these nine is divided by engraved lines into 400 tiny squares of arranged in 25 groups of 16 by triple boundary lines. Fuchs-Rosenthal counting chamber This chamber was originally designed for counting cells in cerebrospinal fluid, but as such a relatively large area is covered, it is preferred by some workers for counting leucocytes. Another type of Fuchs-Rosenthal chamber is now available, 91 Hematology which has the same depth as the one described, but is ruled over 9mm2 only. Burker ruled counting chamber Like the Neubauer counting chamber, this has a ruled area of 9mm2 and a depth of 0. To count white cells using Burker Chamber, the four large corner squares are used (4mm2) and the same calculation as describe for the Improved Neubauer ruled chamber is used. Dilution of the Sample Dilution of sample is accomplished by using either a thomma pipette or the tube dilution method. With tubes larger volumes of blood and diluting fluid are used and the greater will be the accuracy as compared with the smaller volumes used in the thomma pipette techniques. Thomma pipettes are small calibrated diluting pipettes designed for either white cell or red cell count. Counting and Calculation The diluted cells are introduced into the counting chamber and allowed to settle. Cells lying on or touching the upper or left boundary lines are included in the count while those on the lower and right boundary lines are disregarded. Principle Whole blood is diluted 1 in 20 an acid reagent which hemolyzes the red cells (not the nucleus of nucleated red cells), leaving the whit cells to be counted. Diluting Fluid Turk’s solution - 2% aqueous solution of acetic acid 95 Hematology colored pale violet with gentian violet or pale blue with methylene blue. The glacial acetic acid causes erythrocyte lysis while the gentian violet lightly stains the leucocytes permitting easier enumeration. Once the pipette accurately filled to the mark, the rubber suction (or mouth piece) is carefully removed, with the pipette held horizontally and only one finger sealing the tip. Both ends of the pipette may then be sealed with special small rubber sealing caps or with the middle finger on the tip and the thumb on the other end. The cover glass is placed on the chamber and a slight pressure applied to the ends of the cover glass until a 96 Hematology “rain bow” or Newton’s diffraction rings are revealed on either side. Once the diluted blood in the pipette has been thoroughly mixed, a few drops are expelled to discard the cell-free diluting fluid in the long stem of the pipette. With the index finger forming a controlled seal over the end of the pipette, which is held at an angle of 450 , the tip of the pipette is brought up to the edge of the cover glass and by gentle release of index finger pressure, fluid is allowed to run out slowly until the counting platform is covered. If blood is diluted with the tube technique (in which 20µl of blood is taken with a sahli pipette and mixed with 0. The chamber is placed in position on the microscope stage and is allowed to stand for 2 or 3 minutes so that the cells will settle. Pipettes (thomma and sahli) should be washed well with a sequence of water and acetone (filled with 97 Hematology each fluid three or four times) and air drawn after the acetone until the inside of the pipette is thoroughly dry.

Goldhaber-Fiebert (she’ll probably have you call her “Sara”) for her dedication to developing and improving the cognitive aids you’ll see in this book and in the laminated cards you’ll receive cheap aurogra 100 mg fast delivery impotence 40 years. Macario buy 100 mg aurogra with mastercard erectile dysfunction pills over the counter, Residency Program Director, who will be one of the first attendings to know all of you by your first names. Acquiring the fundamental knowledge, as well as cognitive and technical skills necessary to provide safe anesthesia, are essential early on in your training. Understand the proper use of laboratory testing and how abnormalities could impact overall anesthetic management. Exam ple Traces • Time delay exists due to length and volume of sample tube as wellas samplingrate (50-500 A. Ph iladelph ia:L ippincottW illiams& W ilkins, correlationwith tympanicandesoph agealtemperatures 2003. A nesth esiology 74:489, 1991 6 M inim um A lveolarC oncentration A lveolarconcentrationofagas atwh ich 50% of subjsubjecectts do ns do notrotrespesponondd ttoo sursurgigiccaalliinncciisisionon M A C & A w areness Im portantPoints • R emarkably consistentacross species. F actors Decreasing M A C A w areness • Drugs decreasingcentralcatech olamines: – Reserpine,-meth yldopa • Very rare – Ch ronicamph etamine abuse • M ostcommonsensationis h earingvoices •• O tO thh ererdrdrugugs:s: – O pioids,benz odiaz epines,barbiturates,2-agonists(clonidine, • M ostly occurs duringinductionoremergence dexmedetomidine),ketamine,lidocaine,lith ium,verapamil,h ydroxyz ine. Cellularandmolecularmech anismsof • Talk to th e patientafterth e case to assess ifth ey h ad any anesth esia. O pioids O pioids M orph ine – Slow peak time (~80% effectat15 minutes,butpeak analgesic F entanyl efefffececttiis ats at~9090 miminnututes)es). The strategies presented here are simply 60 suggestions, something to get you thinking rationally Fentanyl about how and when you use opioids for analgesia. S trategies forO pioid U se R eferences • M eperidine is usually reserved fortreatment/prevention • F ukuda K. Intraoperative H ypertension Treatm entofH ypertension • “L igh t”anesth esia • Temporiz e with fast-onset,sh ort-actingdrugs,but • Pain ultimately diagnose and treatth e underlyingcause. A utonomicnervous system: • DirectandindirectadrenergicstimulationviaN E release ph ysiology and ph armacology. A minosteroids = “-oniums” jjununccttiiononalalrrh yth yth mh m,orarorarrrestest;al;always giways givve 2e 2nd dosedose wiwitthh 00. DifficultIntubation – H istoryofpriordifficulty – H istoryofpriordifficulty DifficultA irw ay A lgorith m – F acialh air – Underlyingpath ology (e. W h enI meth im inppreopp,I was relieved th ath e because I was gettinggastriccontents (you always say th is),th e sursurggeonceoncompompllaiainns abs aboutouta pa pereriiodiodicwh icwh iffffofofa fa fouloulodor Wodor. Post-renal(post-renalobstruction) Parkland F ormula – F oleykinked,clogged,displaced,ordisconnected – Surgicalmanipulationofkidneys,ureters,bladder,orureth ra 3. DurD iing massiivettransfusif ionwhenh fifibrb iinogenllevellnottavaiilbllable HctHct((ststarartt)) <1year 80 4. Hypotherm ia • Diagnosisof ex clusion:firstR /O sepsis,volum eoverload,and • Bloodproductsarestoredcold-useafluidwarmer! Itis a signth atth ey,too,h ave been Duringth e middle ofa straigh tforward case I was sprayed with eith erPropofolorK efz olwh ile tryingto draw ddrawiingupmy ddrugs ffortthh e nexttcase. C entralC ontrol • G eneralanesth esia inh ibits th ermoregulationand • Th ermalinputsare “preprocessed”atnumerouslevelswith inth e spinalcord increases th e interth resh old range ~20-fold,to ~4°C. EfferentR esponses • Beh avioralresponses(sh elter,cloth ing,voluntarymovement,etc)are most importantandare determinedbyskintemperature. C onsequences ofH ypoth erm ia W arm ing S trategies Preventionofh ypoth erm iais m ore effective th antreatm ent! Prom eth az ine,Proch lorperaz ine) – Serotoninreceptorantagonist – Dopamine antagonist – M ore effective atpreventingemesisth annausea – Cancause sedationandextrapramidalside effects – A llagentsequallyeffective – Ph energan12. Scopolam ine) Steroids – Centrallyacting – Ch eapandeffective – Transdermaladministrationrequires2-4 h oursforonset. A factorialtrialofsixinterventionsforth e preventionof • U se propofolforinductionand maintenance of postoperative nauseaandvomiting. H ow much are patientswillingtopaytoavoid • A void N O and/orvolatile anesth etics postoperative nauseaandvomiting?

Statistical heterogeneity in a meta-analysis of four trials 121 (73 percent of patients reporting this outcome) that favored intranasal corticosteroid was low buy aurogra 100mg with visa erectile dysfunction drug. The fourth trial reported a treatment effect of unknown size favoring nasal antihistamine generic aurogra 100 mg on-line erectile dysfunction treatment houston, but this trial represented 5 percent of patients reporting this outcome. Of four trials not included in the meta-analysis, one showed a treatment effect in the opposite direction (favoring nasal antihistamine) but did not report the magnitude of effect. Because this trial represented 5 percent of patients reporting this outcome, the reduction in the pooled estimate if this trial were included in the meta-analysis 117 likely would be minimal, unless the treatment effect was unexpectedly large. One trial (12 percent of patients reporting this outcome) showed a treatment effect (0. Change in the pooled estimate likely would be minimal if this trial 116, 119 116 119 were included in the meta-analysis. To determine 116, 119 the impact of these two trials on the pooled estimate, we added both to the meta-analysis with assumed standard deviations equal to half the mean change in score in each treatment group. The body of evidence in support of a conclusion of equivalence of intranasal corticosteroid and nasal antihistamine for this outcome is therefore considered precise. A meta-analysis of four good quality trials (N=1791; 75 percent of patients reporting this outcome) yielded a statistically significant pooled effect of 0. Of three trials not included in the meta-analysis, two 119 117 reported treatment effects of 0. Eighty-eight percent of patients reporting this outcome were in good quality trials. Treatment effects consistently favored intranasal corticosteroid in all trials, and statistical heterogeneity of a meta-analysis of four 115, 121 trials (75 percent of patients reporting this outcome) was low. Of three trials not included in the meta-analysis, one did not report the magnitude of the treatment effect, but this trial represented 5 percent of 117 patients reporting this outcome. One trial (13 percent of patients reporting this outcome) 80 showed a treatment effect (0. The third 119 trial (7 percent of patients reporting this outcome) showed a treatment effect of 0. To determine the impact of this trial on the pooled estimate, we added it to the meta-analysis with an assumed standard deviation equal to half the mean change in score in each treatment group. The body of evidence in support of a conclusion of equivalence of intranasal corticosteroid and nasal antihistamine for this outcome is therefore considered precise. Five reported treatment effects favoring intranasal corticosteroid, and two reported treatment effects favoring nasal antihistamine. A meta-analysis of five good quality trials 121 (N=2097; 93 percent of patients reporting this outcome) yielded a statistically significant pooled effect estimate of 0. Two trials not included in the meta-analysis reported treatment effects favoring nasal antihistamine. Treatment effects consistently favored intranasal corticosteroid in 93 percent of patients reporting this outcome. The two trials not included in the meta-analysis did not report treatment effect magnitudes, but both favored nasal antihistamine. If these trials were included in the meta- analysis, the pooled effect would decrease. The body of evidence in support of a conclusion of equivalence of intranasal corticosteroid and nasal antihistamine for this outcome is therefore considered precise. Individual nasal symptoms of congestion, rhinorrhea, and sneezing were assessed at 3 weeks 116 and 4 weeks in one trial (N=50). For rhinorrhea and sneezing, treatment differences were zero at both 3 weeks and 4 weeks. This trial was rated poor quality due to noncomparable groups at baseline, inadequate blinding, and inappropriate analysis of results (unadjusted for baseline group differences). The evidence was therefore insufficient to support the use of one treatment over the other for these outcomes. This trial was rated poor quality due to noncomparable groups at baseline and inappropriate analysis of results (unadjusted for baseline group differences). The evidence was therefore insufficient to support the use of one treatment over the other for this outcome. Eye Symptoms 115, 117, 118 Five of nine trials (N=2128 of 2473 patients) assessed eye symptoms at 2 weeks.