By V. Fedor. North Central College. 2019.
Most of the cytokine molecules secreted by a particular cell react with near by well-bound Enzyme-linked Immunospot Assay anticytokine antibodies buy discount levitra with dapoxetine 40/60 mg on line. The colored prod- the number of the cells in a population that ucts precipitate and form a spot only on the are producing antibodies specific for given areas of the well where cytokine-producing antigen or an antigen for which one has spe- cells are deposited generic levitra with dapoxetine 40/60mg otc. For example buy levitra with dapoxetine 40/60 mg otc, individual B cells of colored spots buy discount levitra with dapoxetine 40/60 mg, it is possible to determine producing specific antibody or individual T the number of cytokine-producing cells. It is an inhibition-type assay, the concentration of antigen is inversely proportional to the color produced. Biotin/Avidin Enhanced Immunoassay avidin (a protein component of egg white), In many situations, the sensitivity of these as- which binds biotin with extreme high affinity says can be further enhanced by using addi- and specificity (Figs 6. Most commonly din enhanced immunoassays allows for anti- this is done by the use of secondary antibod- gen detection using extremely small sample. The separated proteins are then trans- ferred (blotted) to cellulose filter paper. Next, Chemiluminescence serum from the individual is added to the Measurement of light produced by chemilu- blot. When an enzyme sub- miluminescence, a luxogenic (light generat- strate is added, colored bands appear on the ing) substrate takes the place of chromogenic paper. Immune Blotting Western Blot Test Flow Cytometry and Fluorescence Western blotting technique is used for iden- The fluorescent antibody techniques are ex- tification of a specific protein in a complex tremely valuable qualitative tools, but they mixture of proteins. The binding of avidine is monitored by the conversion of the substrate (S) to a colored product (P). Explain the effects of excess of antigen Immunoelectron Microscopic Test and antibody on precipitation reaction. When viral particles mixed with specific an- Discuss the agglutination reactions with tisera are observed under the electron mi- their applications. In the example shown, a mixed cell population is stained with two antibodies, one specific for surface antigen A and the other specific for surface antigen B. The anti-A antibodies are labeled with fluorescein (blue) and the anti-B antibodies with rhodamine (brown). The cells are expelled, one at a time, from a small vibrating nozzle that generates microdroplets, each containing not more than a single cell. As it leaves the nozzle, each droplet receives a small electrical charge and the computer that controls the flow cytometer can detect exactly, when a drop generated by the nozzle passes through the beam of laser light that excites the fluorochrome. The intensity of the fluorescence emitted by each droplet that contains a cell is monitored by a detector and displayed on a computer screen. Because the computer tracks the position of cache droplet, it is possible to determine when a particular droplet will arrive between the deflection plates. By applying a momentary charge to the deflection plates when a droplet is passing between them, it is possible to deflect the path of a particular droplet into one or another collecting vessel. This allows the sorting of a population of cells into subpopulations having differ- ent profiles of surface markers. Complement System 7 The complement system includes serum and activate or inhibit reactions in the cascade. Up to C5, activation involves prote- The term ‘complement’ refers to the ability of olytic cleavage, liberating smaller fragments these proteins, to complement (augment) the from C2 through C5 except for C2, where for effects of other components of the immune historical reasons the larger fragment that re- system (e. Complement has sev- mains bound to the complex is termed C2a, eral main effects: the smaller fragments are by the letter ‘a’ 1. Production of peptide fragments that system can be initiated, either by antigen- participate in inflammation and attract antibody complexes or by a variety of non- phagocytes. Opsonization of organisms and immune vation of complement components occurs complexes for clearance by phagocyto- via three main pathways. Further more the complement goes to work, as soon Only, immunoglobulin M (IgM) and immu- as an invading microbe is detected; the noglobulin G (IgG) (IgG1, IgG2, IgG3 not system makes up an effective host im- IgG4) activate or fix complement via the clas- mune defense long before specific host sical pathway. C1 in A cascade is a set of reactions that amplify serum is a macromolecular complex consist- some effects, i. One molecule 2 so far identified in the complement system, of IgM or two molecules of IgG can initiate 13 participate in the cascade itself, seven the process. C1q binding in the presence 78 Textbook of Immunology of Escherichia coli, Salmonella of low viru- lence), viruses (parainfluenza virus, human immunodeficiency virus) and even apoptotic cells interact with C1q directly, causing C1 activation and there by classical pathway. Alternative pathway (properdin pathway) The alternative pathway does not involve im- mune complex. Many unrelated substances such as bacterial endotoxin, IgA and IgD an- tibodies, cobra venom factor, nephritic factor (protein present in the serum of glomerulo- nephritis) initiate alternative pathway. The additional C3b binds of calcium ions, leads to sequential activation to the C3 convertase to form C3bBbC3b, of C1r and C1s. C3b forms complex with C4bC2a pro- mannan-binding lectin pathway ducing a new enzyme called C5 convertase Lectins are proteins that bind to specific car- (C4bC2aC3b). C5a is an anaphylatoxin or mannan-binding lectin is an acute phase and chemotactic factor. The C5b component protein, which binds sugar residues like man- is extremely labile and becomes inactive nose, found on microbial surface (e. Listeria within 2 minutes, unless C6 binds to it and species, Salmonella species, Candida albi- stabilizes its activity. Loss of membrane integrity Regulation of the results in the unregulated flow of electrolytes Complement System and causes lysis and death of cell. Following the activation of the complement, Non-immunological classical pathway acti- its components and split products are capa- vators: Certain bacteria (e. Factor ‘P’ (properdin) protects C3b and stabilizes this C3 convertases of the al- ternative pathway. Anaphylatoxin inactivator is an alpha globulin that enzymatically degrades C3a, C4a and C5a, which are anaphyla- Fig. The Complement Activation activation of complement system is regulated at different stages. Complement plays an important role in hu- moral immunity by amplifying the response Regulation Before Assembly and converting into an effective defense of Convertase Activity mechanism to destroy invading pathogens. Inhibitor-bound 4b is cleaved by factor I of the interactions of complement fragments to form bound 4d and soluble 4c. Inhibitor-bound C3b is cleaved by fac- ity by binding, biologically active comple- tor I to form iC3b and soluble C3f frag- ment components and degrading them into ment. The complement receptors I releases C3c and leaves C3dg bound and their primary ligands, which include to the membrane. Increased capillary permeability: C2 kinins are vasoactive amines, which in- creases capillary permeability. Virus neutralization: May require par- ticipation of ‘C’ for neutralization of herpes virus by IgM antibody. Immune adherence: ‘C’ bound to im- mune complex adhere to erythrocytes or to non-primate platelets. The immune adherence (C3 and C4) contributes to defense against pathogenic microorgan- isms, since such adherent particles are rapidly phagocytosed. Opsonization: Cells, immune complex- Deficiency in the complement system affects es are easily phagocytosed much more both innate and acquired immunity. A num- efficiently in the presence of C3b recep- ber of gene defects involving complement tors in most of the cells. Chemotaxis: C3a and C5a stimulate the to susceptibility to infections or risk to auto- movement of neutrophils. Although the two pathways are initiated in different ways, they combine to activate the complement system; B. The action of C3b is critical for opsonization and along with C5b for formation of membrane attack complexes. Synthesis of Complement C3 deficiency results in serious problems Complements are synthesized by liver, with recurrent infections and with immune spleen and phagocytic cells. Explain in detail nents (C5, C6, C7, C8 and C9) involved in about complement pathway. Cells and Tissues of the Immune System 8 The cells, which take part in immune reac- ing separated by connective tissue trabecu- tions are organized into tissue and organs in lae. Lymphocytes (thymocytes) are placed order to perform their functions most effec- more densely towards the periphery of each tively.
Almost all the techniques must be performed at inter- The skin of the dorsum of the hand generic 40/60mg levitra with dapoxetine fast delivery, very movable and vals of 2 weeks generic levitra with dapoxetine 40/60 mg on line, for about 4–5 applications order 40/60mg levitra with dapoxetine, and subse- delicate levitra with dapoxetine 40/60 mg generic, becomes thin and irregularly pigmented with aging, quently at intervals of 3 and then 4 weeks depending on the with dark ﬂecks caused by actinic or seborrheic keratosis. Brunelli Lipoﬁlling has also been used to correct the “skeletal” aspect of the hand and the excessive thinning of the skin. The opera- tion consists of harvesting a small amount of fat from the ﬂanks and the abdomen, as during a micro-liposuction, and injecting the collected material into the dorsum of the hand. Local anes- thesia is obviously requested and, even though the result is soon visible, more than one treatment may be necessary. According to published clinical studies, 25 % of patients require a new injection about 1 year after the ﬁrst treatment. Over the period of approximately 1 year, repeated fat injections may be required to achieve a deﬁnitive result. In any event it must be borne in mind that there is no clini- cal study documenting the results of these treatments over a sufﬁciently long period, owing to their recent deployment in clinical practice. Peelings and lipoﬁlling, like laser and cryotherapy, are simple techniques that are easy to perform. Nevertheless, lasers and chemical peelings have led to severe complica- tions, with late healing and, in some cases, retracting scars. Today, body fat can be used as a permanent ﬁller to correct numerous defects, but there are some limitations due to both the absolute amount of injectable fat and the type of ana- F i g. The aging process leads to the necessity of a treatment The application of peeling is progressively increasing in which operates on a dual level, considering the color and the the light of new technological advances made in the dermal- consistency of the hand tissue on the basis of the patient’s cosmetology approach to aging. According to the to overcome different problems related to skin aging of the principle of selective photothermolysis, the light energy dorsum of the hand. Regarding peels, both glycolic acid and beam is converted to thermal energy only in the presence of Retin-A have been demonstrated to reduce pigmentation melanin (contained into the freckle). More aggressive peels such us phenol and the are selectively destroyed in a few sessions and the surround- pyruvic acid may be theoretically used for their efﬁcacy, but ing tissue is not damaged. Moreover, the heat generated by the pulsed light will 5 Authors’ Technique also lead to a modest cutaneous compactness, owing to the induction of the naturally occurring repair processes (Figs. Despite aesthetic face correction, Another problem requiring a more elaborate solution con- true age will always be revealed by the hands, showing sists in the progressive loss of substance of the hand skin imperfections in graphic detail. With aging, the skin of the hand becomes so thin of the hand is a delicate part of the body, with regard to both that the vessels, nerves, and bone become evident on each continuous stimulation due to muscle activity and its con- movement. The material is implanted by injection using a threading technique in a criss-cross fashion, thus treating successfully whole atrophic area. The thick dermis is the natural consequence not so much of the ﬁlling action but rather of the new collagen proliferation. The deﬁnitive results last longer than those obtained with other materials, and in fact the effect lasts up to 18 months. Today it is pos- sible to treat the hand aging not by palliative techniques but via superﬁcial and deep rejuvenation techniques. Even though hand rejuvenation is not the most requested treatment in aesthetic surgery, it is desirable for some people who consider such a body part important from a professional and social point of view. The rejuvenation techniques that have been developed aim to correct aging defects, thus giv- ing the hand a healthy aspect complying with a body in healthy condition. Initially this therapy, consisting of subcu- taneous and cutaneous injection of gaseous carbon dioxide, was used in aesthetic medicine for cellulite treatment. Carboxytherapy improves the blood circulation and the cel- lular metabolism by causing vasodilatation and reactivation of the microcirculation, thus increasing tissue oxygenation. Radiofrequency acts at level of the collagen ﬁbers • Treatment of cellulite by emitting, in a controlled manner, heat in the deep dermis. This (medium venous insufﬁciency) in angiology process induces the natural alignment of ﬁbers and supports • Treatment of arthrorheumathic pathologies and periar- the new collagen production. The pressure of gas emission depends on the skin and If the patient desires an immediate visible result, the aesthetic defect type and the ﬁnal depth the treatment must approach consists of injection of absorbable materials or achieve. The fat for this type of • Arterial vasodilatation ﬁlling is harvested from the patient him-/herself, under local • Circulation improvement anesthesia, from hidden body areas. The ﬁlling effect is • Tissue oxygenation immediately visible, and within weeks hands appear more smoothed and the visibility of veins, bone, and nerves is The treatment is performed in ambulation, without reduced. Its use is indicated when very thin needles , at variable doses, in different points the carpus bones are visible through the hand skin. Treatment generally requires one session per week and Since the hand is continuously subject to movements, it about 12–15 sessions in total. The treatment lasts on average needs not so much a simple “ﬁller” but rather a constant “tis- of 15–20 min, and the return to daily activities is sue stimulator. Brunelli coagulation dysfunctions, active herpes, and dermatologic autoimmune pathologies. Radiofrequency can lead to complications such as ery- thema, edema, and sensibility alterations. The most frequent complications occurring with the use of laser are intensive erythema, transient edema, and, in the more severe cases, superﬁcial burns, which rarely develop evident scars. Carboxytherapy can be responsible for ecchymosis and transient tumefaction of the tissue, disappearing after some hours. Peeling and lipoﬁlling, laser therapy, and cryotherapy are extremely simple techniques that are easy to perform. Laser and peeling applied on the dorsum of the hand can lead to severe complications, demonstrating extremely delayed healing processes and retracting scars in some cases. Plast Reconstr Surg 85:387–389 ments such us pulsed light, lasers, chemical peels, and other 9. In these cases, Plast Surg 24(2):347–367 carboxytherapy can also optimize the other treatment effects 10. Guerrerosantos J (2000) Long-term outcome of autologous fat persistent erythema, which can last for 48–72 h. Salus effects such as allergic reactions, granulomas, and hemato- Internazionale, Rome mas. Aesthetic Plast Surg 34(2):239–243 Medial Dermolipectomy of the Thigh Flavio Saccomanno 1 Introduction tion. Care was taken to avoid the femoral vessels in the groin and damage to the saphenous vein. In 1964, Pitanguy  Flaccidity of the medial region of the thighs, with or without included the inguinocrural area in the trochanteric region by lipodystrophy, causes considerable inconvenience for those harvesting a single ﬂap whose superoposterior rotation cor- women affected by it. This aesthetic defect almost exclu- rected the trochanteric lipodystrophy in addition to the ﬂac- sively affects women and is uncommon in men except in cidity of the anterior and medial areas of the thigh. In rhizomelic obe- Ducourtioux , stressing the importance of gynecological sity of the lower limbs, functionality is the main problem, positioning during surgery, indicated a skin-fat excess in a where the thighs rub together at the proximal portion. In vertical direction that could be corrected by horizontal exci- extreme cases this can lead to signiﬁcant skin lesions, con- sion, and a skin excess in an anteroposterior direction that siderably limiting the patient’s quality of life. Increased could be corrected by circumferential excision (vertical focus on the problem of obesity by national health organiza- scar). I should also cite Vilain and Dardour  who, in their tions has increased the demand for the correction of excess work of 1975, despite not having made a substantial contri- skin resulting from signiﬁcant weight loss. They described a “subcutaneous” bined with liposuction when, in addition to ﬂaccidity, lipo- fat, which varies with diet, and another, non-localized fat, dystrophy is also present, especially in cases of obesity of the “not different from the point of view of the pathologist,” superomedial region of the lower limbs (Fig. The correction of these abnormalities has never been They described the use of the curette for the correction of viewed with enthusiasm by surgeons because of difﬁculties lipodystrophy of the knees. Therefore, Vilain and Dardour arising from the awkward position taken by the surgeon dur- can be placed between the precursors of liposuction and the ing the procedure in addition to the high risk of complica- study of what is now considered “system fat. Hoffman and Simon , in classifying patients presenting The medical literature and research publications regard- indications for the thigh lift into ﬁve types, were the ﬁrst to ing this issue are scarce. In 1957, Lewis [1 ] ﬁrst conceived focus attention on the complications and their frequency in correction of “ptosis of the thighs,” describing the “thigh this type of intervention: from asymmetry to depression, up lift,” whereby he proposed the excision of a large ellipse of to scar retraction with distortion of the labia majora, and pain skin and subcutaneous tissue from the anterior inguinocrural when sitting, even after a period of 3 years. The fol- The introduction of liposuction in 1980 by Illouz  made lowing are some works grouped according to the type of ﬂap major contributions to the correction of localized adiposity. In ﬁxing and chronology: cases of moderate ﬂaccidity associated with lipodystrophy, with Medial Dermolipectomy of the Thigh 455 the superﬁcial liposuction proposed in 1989 by Gasperoni et al.
In cases of autologous or biological materials buy 40/60 mg levitra with dapoxetine overnight delivery, if the sling cannot be clearly identified buy discount levitra with dapoxetine 40/60mg on line, then formal transvaginal urethrolysis (see in the following text) should be performed discount levitra with dapoxetine 40/60 mg with mastercard. Unlike autologous and biological slings generic levitra with dapoxetine 40/60 mg without a prescription, it is imperative to identify the sling and cut it. Conversion to urethrolysis without specifically cutting the sling may fail to relieve obstruction. Usually, the sling is easily found, and identification can be aided by palpation of the sling. However, sometimes this can be quite difficult, especially in cases where the sling has migrated proximally or has rolled onto itself and created a tight narrow band. The cut ends can be grasped with clamps and dissection proceeds hugging the sling to minimize injury to underlying tissue. If sling incision is not successful in relieving obstruction, formal urethrolysis may be carried out. A right-angle clamp may be placed between the sling and the periurethral fascia to avoid injury to the urethra. The approach chosen depends on several factors that include patient presentation, type of initial anti-incontinence surgery, history of prior urethrolysis, and surgeon and patient preference. In general, proceeding from the less morbid transvaginal approach and reserving the retropubic approach for failures is prudent. However, exceptions exist that would favor a retropubic approach as the primary initial procedure such as inadequate vaginal access precluding a transvaginal approach, in cases where the original anti-incontinence surgery was performed transabdominally or associated with bladder perforation, fistula, or other operative complication, after a Burch resuspension, or associated with intravesical mesh exposure, which must be removed. This was felt secondary to the inability to reach proximal most sutures transvaginally. Transvaginal Urethrolysis In 1984, Leach and Raz described the transvaginal technique of urethrolysis, and though variations have been published since, it is still the most commonly used today . A midline or inverted U incision approximately 3 cm long is made in the anterior vaginal wall extending from the level of the midurethra to 1–2 cm proximal to the bladder neck. Dissection proceeds laterally along the glistening surface of the periurethral fascia to the pubic bone. The retropubic space is entered sharply by perforating the attachment of the endopelvic fascia to the obturator fascia (Figure 79. The urethra is dissected bluntly and sharply off the undersurface of the pubic bone and completely freed proximally to the bladder neck. Some separation of the urethra from the pubis is done blindly with the Metzenbaum scissors (Figure 79. Care should be taken to stay as close to the underside of the pubis as possible, and manual palpation of this plane along with an awareness of the location of the urethral catheter provides a proprioceptive map in this hard-to-visualize space. If an inadvertent injury to the urethra or anterior bladder wall near the bladder neck is caused, primary repair should be attempted and completion of the procedure should be entertained as further bladder or urethral wall damage can occur. Fistula formation is minor as the area of perforation is well away from the vaginal incision. Once sufficient space is developed in this plane, the remaining adhesions and scar can be swept down bluntly with an index finger. If suspension sutures are felt, a clamp can be used to bring it into view so it can be cut safely. After this initial mobilization, a right-angle clamp can be placed between the pubic bone and the urethra, and a Penrose drain is placed around the urethra. Downward traction is applied on the Penrose drain to aid visualization and all remaining retropubic attachments are dissected free (Figure 79. At this point, the urethra should be freely mobile in all planes, and this can be tested with movement of an intraurethral sound or cystoscope. Cystoscopy should be performed to rule out urethral and/or bladder injury prior to vaginal closure. It is also good practice to assess ureteral integrity by giving intravenous indigo carmine or methylene blue to assure efflux. The endopelvic fascia, periurethral fascia, and vaginal wall are retracted medially to expose the urethra in the retropubic space. With tension on the upper edge, the perineal membrane is perforated and all attachments, scar, and sutures between the pubic bone and urethra are incised sharply with scissors. An index finger can be followed along the underside of the pubis into the retropubic space. With a sweeping motion directed laterally and posteriorly, obstructing bands can be identified and either bluntly or sharply freed. The arms of the sling or suspending sutures are encountered with lateral dissection and should be divided sharply. Once done, urethral mobility is assessed and if adequate, cystoscopy is performed to rule out inadvertent injury prior to vaginal incision closure . A Penrose drain has been placed around the urethra, isolating it from the pubic bone. Resuspension poses the risk of persistent obstruction and if symptoms do not resolve, it is difficult to determine whether this situation resulted from inadequate urethrolysis or resulted from the secondary resuspension. Retropubic Urethrolysis The patient is placed supine on the operating table with the legs slightly spread apart to allow for manual vaginal access. The rectus fascia and muscle are opened in the midline to the level of the pubic symphysis. Any visible and palpable suspension sutures are cut and all attachments and scar between the urethra and pubis are incised sharply. Complications can be minimized by keeping the tips of the scissors up against the pubic symphysis during sharp dissection. Careful attention is paid to the location of the Foley catheter to avoid inadvertent bladder or urethral injury. If bladder injury occurs, prior to repairing it, it may be helpful to leave the bladder open until the dissection is complete to give a constant sense of where the bladder is, with respect to the scar tissue. The index finger of the surgeon’s nondominant hand placed into the vagina helps identify the boundaries of the vagina in relation to the urethra and urethrovesical junction. At the end of the dissection, the urethra, bladder neck, and anterior vaginal wall should be mobile and free from the overlying pubic bone. It should be possible to pass fingers through the abdominal wound, under the pubis, and see your fingers pushing the vaginal skin out in the distal vagina. In cases of severe scarring, it may be necessary to mobilize laterally as far as the ischial tuberosities, creating a paravaginal defect. This defect should be repaired by reapproximating the paravaginal fascia to the fascia of the obturator internus along the arcus tendineus. An omental flap can be brought down and fixed between the pubis and urethra so that recurrent 1220 scarring is minimized . Cystoscopy is performed to rule out urethral injury and confirm efflux of indigo carmine from the ureteral orifices. Recurrent obstruction may result from periurethral fibrosis and scarring, or intrinsic damage to the urethra that has occurred as a consequence of the urethrolysis surgery. Both transvaginal and retropubic approaches were chosen depending on the clinical situation. Obstruction was cured in 96%, but storage symptoms completely resolved in only 12% and were improved and required medication in 69%. In another series, repeat urethrolysis resulted in cure of obstructive symptoms in 72% and storage symptoms in 59% . These data clearly support aggressive repeat urethrolysis in the face of initial failure, at least for retention and incomplete emptying. In general, if an aggressive transvaginal urethrolysis fails, then a retropubic approach may be considered. In cases where the aggressiveness of the initial transvaginal procedure is unknown, or if only a sling incision was performed, then a repeat transvaginal approach may be appropriate. Consideration should also be given to the use of a Martius labial fat pad flap as an interposition layer to decrease recurrent fibrosis and provide some urethral support. The flap is divided midway along its longitudinal axis to allow for circumferential coverage of the urethra, effectively supporting the undersurface and retropubic surface of the urethra . In the 75% of patients that responded, 100% were able to stop all antimuscarinics . However, if there is any concern for residual obstruction or inadequate initial urethrolysis, then a repeat urethrolysis should be considered. The treatment algorithm flowchart summarizes the diagnosis and treatment approach (Figure 79. While keeping in mind the patient’s symptoms and goals, the physician must use careful decision making when assessing, diagnosing, and treating obstruction.
As opposed to an anterior colporrhaphy in which the vaginal epithelium and muscularis are split for plication levitra with dapoxetine 40/60mg online, the mesh is placed underneath the muscularis to maintain a thickened vascularized epithelium in order to minimize mesh exposure or erosion order levitra with dapoxetine 40/60 mg mastercard. To enter this potential space order levitra with dapoxetine 40/60mg on line, the surgeon injects a dilute vasopressin solution or 0 levitra with dapoxetine 40/60 mg for sale. Irrigation may help during the dissection, as the defect is a glistening white line. A sagittal colpotomy incision is made between the Allis clamps long enough to admit two fingers comfortably. Next, countertraction along the entire incision line is achieved with either the serial Allis clamps or a self-retaining retractor. The vaginal epithelium and full-thickness muscularis are dissected away from the bladder defect. Sharp and blunt dissection of the bladder is then performed while keeping the muscularis and epithelium on the vaginal flaps. A number of different trocar types are available including helical-shaped trocars similar to those for transobturator slings and flexible straight trocars. Cutaneous incisions that are 4–7 mm in length are made over the appropriate locations for the obturator 1258 foramen and/or gluteus trocars. When placing multiple mesh arms through the transobturator space, the superior and inferior puncture sites should be at least 3 cm apart so the mesh can lay flat. Two fingers placed into the vagina can retract the colon, elevate the bladder, and minimize deviation of the trocar tip with direct palpation. If the surgeon conserves the uterus, then permanent sutures can be placed into the cervical stroma to stabilize the mesh. Cystoscopic and rectal examinations before, during, and after each portion of the surgery can be helpful. Once adequate hemostasis is obtained, the vaginal epithelium is closed with a continuous nonlocking stitch of delayed absorbable suture. Placing a lubricated vaginal pack may minimize bleeding and keep the mesh flat during healing. After desired tensioning, all ends of the mesh arms should be trimmed below the surface of the skin and the incisions closed. Concurrent procedures, such as a midurethral sling, should be done through a separate vaginal incision at this time. Nontrocar Mesh Kits The nontrocar or “single-incision” mesh kits have become increasingly popular and largely replaced trocar-based kits. The products avoid the potential complications associated with blind trocar passage through the transobturator space and ischiorectal fossa and allow mesh fixation via direct visualization. Additionally, most currently available nontrocar kits provide apical fixation to the sacrospinous ligaments bilaterally as well as anterior vaginal support. The technique for the nontrocar kits begins similarly to the technique for trocar-guided kit placement. For apical fixation, the surgeon palpates the location of interest then identifies the sacrospinous ligament at least 2 cm medial to the ischial spine. The mesh arms are slowly and individually adjusted to a loose tension, and then the mesh is sutured flat. Cystoscopy with visualization of ureteral flow is performed to ensure integrity of the bladder and ureters. Retropubic surgeries such as the Burch colposuspension are discussed in Chapter __. The preparation for vaginal paravaginal repair begins as for an anterior colporrhaphy. Marking sutures are placed on the anterior vaginal wall on each side of the urethrovesical junction, identified by the location of the Foley balloon after gentle traction is placed on the catheter (Figure 82. In patients who have had a hysterectomy, marking sutures are also placed at the vaginal apex. If a culdeplasty or apical suspension procedure is being performed, the stitches are placed but not tied until completion of the paravaginal repair and closure of the anterior vaginal wall. As for anterior colporrhaphy, vaginal flaps are developed by incising the vagina in the midline and dissecting the vaginal muscularis laterally. The dissection is performed bilaterally until a space is developed between the vaginal wall and retropubic space. Blunt dissection using the surgeon’s index finger is used to extend the space anteriorly along the ischiopubic rami, medially to the pubic symphysis, and laterally toward the ischial spine. If the defect is present and dissection is occurring in the appropriate plane, one should easily enter the retropubic space, visualizing retropubic, and paravaginal adipose tissue. After dissection is complete, midline plication of the bladder adventitia can be performed, either at this point or after placement and tying of the paravaginal sutures (Figure 82. Retraction of the bladder and urethra medially is best accomplished with the Breisky–Navratil retractor, and posterior retraction could be provided with a lighted right-angle retractor. If the white line is detached from the pelvic sidewall or clinically not felt to be durable, then the attachment should be to the fascia overlying the obturator internus muscle. The placement of subsequent sutures is aided by placing tension on the first suture. A series of three to six stitches are placed and held, working anteriorly along the white line from the ischial spine to the level of the urethrovesical junction (Figure 82. Starting with the most anterior stitch, the surgeon picks up the edge of the periurethral tissue (vaginal muscularis or pubocervical fascia) at the level of the urethrovesical junction and then tissue from the undersurface of the vaginal flap at the previously marked sites. Subsequent stitches move posteriorly until the last stitch closest to the ischial spine is attached to the vagina nearest the apex, again using the previously placed marking sutures for guidance. Stitches in the vaginal wall must be placed carefully to allow adequate tissue for subsequent midline vaginal closure. After all the stitches are placed on one side, the same procedure is carried out on the other side. The stitches are then tied in order from the urethra to the apex, alternating from one side to the other. The vaginal flaps are trimmed and closed with a running subcuticular or interlocking delayed absorbable suture. Cystoscopy Cystoscopy with visualization of ureteral flow is usually performed after cystocele repair, especially if slings or apical suspension procedures are also being performed. The purpose is to ensure that no sutures or mesh have been placed in the bladder and to verify patency of both ureters. Intraoperative release of the offending sutures almost always releases the obstruction without further sequelae. Few studies have addressed the long-term success of surgical treatments for anterior vaginal prolapse. While the majority of studies evaluating anterior vaginal prolapse repairs are uncontrolled series, an increasing number of randomized surgical trials have been done in recent years. Success rates vary considerably depending upon the outcome measure used to define success. Historically, most studies evaluating the treatment of pelvic organ prolapse have focused exclusively on anatomic success without considering other important areas such as symptoms, vaginal compliance, quality of life, or socioeconomic outcomes. For an individual patient, the most important outcome of a surgical procedure is the relief of her symptoms and improvement in her quality of life, yet until recently these areas have largely been ignored. Reported success rates for native-tissue anterior colporrhaphy range from 37% to 100% with most cohorts reporting success rates greater than 80%. Standard anterior colporrhaphy resulted in 30% of patients with an optimal or satisfactory anatomic result; anterior colporrhaphy with polyglactin 910 mesh overlay had 42% optimal or satisfactory result and ultralateral plication under tension a 46% optimal or satisfactory result. No difference was seen in anatomic or functional outcomes and most patients reported satisfaction with their symptom improvement. The low success rates found in the trial are used as evidence that anterior colporrhaphy should be augmented by either synthetic mesh or another approach used (e. Long-term results of anterior colporrhaphy are largely unknown, although Gotthart et al. No randomized trials have been performed evaluating the efficacy of paravaginal defect repair for the treatment of anterior vaginal prolapse. Single-center uncontrolled case series suggest good anatomic results for both open retropubic (success rate 75%–97%) and vaginal (success rate 67%–100%) approaches [33,34]. However, the vaginal approach appears to be associated with high risk of hemorrhage, with one series reporting a 21% blood transfusion rate . Few data are available on the efficacy or safety of the laparoscopic or robotic paravaginal defect repair.
The best instrument for this is either a hook or better a fat electrical spatula that will “slice” the gallbladder from the liver bed purchase levitra with dapoxetine 40/60mg with visa. Opening of the gallbladder is an inelegant technical mishap effective 40/60mg levitra with dapoxetine, but studies have shown that it does not affect the outcome for the patient if all the bile is aspirated 40/60 mg levitra with dapoxetine fast delivery, the area is irrigated purchase levitra with dapoxetine 40/60 mg with visa, and all the spilled stones are removed. In many instances an opening in the gallbladder occurs at the unperitonized area next to the liver bed. It is possible to grasp the gallbladder with the left grasper and apply a rotating motion on the opening exactly as one would do with a can-opener (the “spaghetti technique”), which will usually control the bile leak through a small opening. If the tear is large, the only solution is to grab it and insert an Endoloop (Fig. If neither the spaghetti technique nor insertion of an Endoloop closes the opening, the only resource will be to suck out the contents of the gallbladder, limiting the spillage of stones, and fnally introduce a bag to retrieve the gallbladder. Spillage of stones can be managed by irrigating the area to allow the stones to foat on the surface. Removal of the stones will then be easier by sucking them using a 10 mm specifc suction cannula. Unfortunately the stones can easily obstruct the tubing, in which case the only option is to pick the stones up one by one and insert them in a bag. Abscesses forming around stones have been described, and the author considers it crucial to remove them all whenever possible, and to irrigate and aspirate the bile. The patient will then not suffer any complications from an incident that usually looks messy but rarely affects the postoperative course. Acute In acute gangrenous cholecystitis, removal of the infammatory adhesions from the fun- Gangrenous dus of the gallbladder is the frst step. This is accomplished by applying high-pressure Cholecystitis hydro-irrigation through the irrigation suction cannula to the edge of the gallbladder to open up planes, which are then further dissected using a grasper and scissors with cau- tery, staying away from the duodenum at all times. An additional 5 mm trocar for an irrigation suction device is routinely inserted at the left midclavicular line by the author (trocar E, Fig. When the fundus of the gallbladder has been identifed, it is possible Impacted Stone (Hydrops, Empyema, Early Mirizzi) 29 to make a small opening using electrical scissors and insert an irrigation suction device into the fundus to aspirate the contents of the gallbladder. This will ease the tension of the gallbladder and enable it to be grasped using graspers with tiny teeth. If this is not possible secondary to infammation in the porta hepatis, then a cholangiogram should be attempted through the neck of the gallbladder to visualize the anatomy. However, if this also is not feasible, and the cystic duct and the neck of the gallbladder have been clearly identifed, then one can proceed with the cho- lecystectomy. As a rule of thumb the aim should be to recognize the elements of the triangle of Calot within 45 min of beginning the dissection. If after that period of time the anatomy is still not clear, conversion should be the rule. As the gallbladder is being removed from the liver bed some bleeding may occur from the liver parenchyma, owing to diffculty in fnding the best plane of dissection. Compression should be applied using a 2 × 2 gauze, and a collagen hemostatic pad should be left in place on the liver bed. In some cases of gangrenous gallbladder there may not be an obvious plane of dissection. In the case of a stone impacted in the neck of the gallbladder with an empyema or Impacted Stone hydrops of the gallbladder (Fig. An incision is then made in the neck of the gallbladder, approximately two to Mirizzi) three centimeters above the junction of the cystic duct and the neck. This incision should be generous to allow for exteriorization of the stone, almost like an “enucleation” of a mass (Fig. The junction between the neck of the gallbladder and the hepatic duct is also shortened and dangerous for dissection. We recommend in this case completing the opening of the gall- bladder, and obtaining a mushroom shape of Hartmann’s pouch that will be closed using a running suture after the removal of the rest of the gallbladder (subtotal cholecystec- tomy), (Fig. The fat present at the hepatic duct does not allow for perfect visualization of the cystic duct. Both cases pres- ent themselves in an identical manner on the screen to the eye of the surgeon who has a two dimensional vision lacking the perception of depth. A clip is placed at what is consid- ered to be the neck of the gallbladder, and an incision is made for a possible cholangio- gram. In the frst example, the clip is placed across the neck of the gallbladder, and the a b Fig. In our opinion, these fgures indicate the need for a very thorough dissection of the neck of the gallbladder, the junction between the cystic duct and neck of the gallbladder, and the junction between the cystic duct and the hepatic duct (visual cholangiogram). Color coding illustrates the illusion created by the short cystic duct Adhesions Due to Previous Upper Midline Laparotomy 35 If hemorrhage occurs from the liver bed, the spatula used to dissect the gallbladder can con- Controlling veniently be used to attempt hemostasis, with an increase in voltage from the cautery unit. If Bleeding in there is severe bleeding in the liver bed, it is possible to introduce a piece of 2 × 2 radiopaque the Liver Bed gauze and apply compression. The steps of managing hemorrhage from the liver bed are: Avoid obscuring the video laparoscope with blood, pull the camera back, leaving the tip in the port to still provide adequate visualization. Introduce an irrigation/suction device to dry the site of bleeding with the left hand. Care is taken to check that the tip of the cautery does not injure a peripheral bile duct (Duct of Lushka). Application of clips is usually a waste of time as it is rarely effcient in controlling oozing in the liver bed. If these actions do not initially take care of the bleeding the compression should be continued. If the bleeding is due to a major tear in the liver, and hepatic or portal venous branches are involved, and if all possibilities are exhausted, the only recourse is conver- sion using a mini-laparotomy. This has very rarely been the case in the author’s experi- ence, but it may occur more frequently in cirrhotic patients. There is no need for a large subcostal incision and usually a 5 cm mini-laparotomy will suffce. In the case of a supra-umbilical incision with severe midline adhesions that obscure the Adhesions Due view, one can place a 5 mm trocar along the left midclavicular line to take those adhe- to Previous sions down using harmonic shears (Fig. Another trick is to insert the camera to the Upper Midline right and superior to the umbilicus, closer to the gallbladder. The patient is tilted to the Laparotomy left, possibly on a bean bag; this will allow for a different angle of visualization and a safe cholecystectomy. Trocars for the right and left hand are also placed a little more to the right of the patient (Fig. E additional trocar used to take down adhesions; C insertion of the frst camera port using a Hasson technique to the right of the umbilicus; A subxyphoid port; B midclavicular port; D retractor for gallbladder fundus. Arch Surg 144(10):979 Selected Baraka A, Jabbour S, Hammoud R et al (1994) End carbon dioxide tension during lapa- Further roscopic cholecystectomy, Correlation with the baseline value prior to carbon dioxide Reading insuffation. Am J Surg 168(1):54–56 Cushieri A, Dubois F, Mouiel J et al (1991) The European experience with laparoscopic cholecystectomy. Ann Surg 222(1):36–42 Fabiani P, Iovine L, Katkhouda N, Gugenheim J, Mouiel J (1993) Dissection of the triangle of Calot during laparoscopic cholecystectomy. Am J Surg 169(5):533–538 Fredman B, Jedeikin R, Olsfanger D, Flor P, Gruzman A (1994) Residual pneumoperito- neum: a cause of postoperative pain after laparoscopic cholecystecomy. Ann Surg 221(3):214–219 Gold-Deutch R, Mashiach R, Boldur I et al (1996) How does infected bile affect the post operative course of patients undergoing laparoscopic cholecystectomy? Br J Surg 81(8): 1202–1206 Halevy A, Gold-Deutch R, Negri M et al (1994) Are elevated liver enzymes and bilirubin levels signifcant after laparoscopic cholecystectomy in the absence of bile duct injury? Arch Surg 131(5):540–544 Korman J, Cosgrove I, Furman M, Nathan I, Cohen J (1996) The role of endoscopic retro- grade cholangiopancreatography and cholangiography in the laparoscopic era. Ann Surg 223(2):212–216 Kubota K, Bandai Y, Sano K, Teruya M, Ishizaki Y, Makuuchi M (1995) Appraisal of intraop- erative ultrasonography during laparoscopic cholecystectomy. Br J Surg 81(6):799–810 Pertsemlidis D (2009) Fluorescent indocyanine green for imaging of bile ducts during laparoscopic cholecystectomy. Am J Surg 167(1):42–50 The Southern Surgeons Club (1991) A prospective analysis of 1518 laparoscopic chole- cystectomies. Arch Surg 143(9):847–851 Yamaguchi K, Chijiiwa K, Ichimiya H et al (1996) Gallbladder carcinoma in the era of laparoscopic cholecystectomy.
Red blood cells safe levitra with dapoxetine 40/60 mg, hemoglobin or myoglobin in urine generic 40/60 mg levitra with dapoxetine amex, are chemically detected by the pseudoperoxidase activity shown by the heme moiety of hemoglobin or myoglobin cheap 40/60mg levitra with dapoxetine with mastercard. Red blood cells or hemoglobin in urine might stem from prerenal levitra with dapoxetine 40/60mg without a prescription, renal, or postrenal disease or hemolysis. Myoglobin in urine can be detected in cases of muscle necrosis, rhabdomyolysis, or myositis. A positive dipstick reading of red blood cells merits further microscopic examination to confirm or refute the diagnosis of asymptomatic microscopic hematuria. Proteins in urine are a mixture of high- and low-molecular-weight proteins from plasma, kidney proteins such as Tamm–Horsfall protein, and proteins from the urinary and genital tract. Mucoproteins and low-molecular-weight proteins are less sensitively detected and Bence–Jones proteins are not detected. Albumin concentrations less than 20 mg/L, termed “low-grade albuminuria,” may be suspicious for early glomerular damage. In order to screen for proteinuria resembling kidney damage in spot urine samples, the protein/creatinine ratio test has been designed. In morning urine samples, this technique compares favorably with 24 hours urine protein excretion with a threshold of 0. Glucose is found in urine when the volume of glucose filtered out of the blood stream by the glomerulus is greater than that that can be reabsorbed by the proximal renal tubule. The differentials for this include diabetes mellitus, pregnancy, Cushing’s syndrome, hepatobiliary, and pancreatic diseases. Ketone bodies measured in the urine are acetoacetate and acetone and, to a lesser extent, β- hydroxybutyrate. Ketone bodies are elevated during diabetic hyperglycemia and ketosis, as well as after (overnight) fasting and inflammatory diseases of the bowel. Specific gravity is measured using a chemical test and assesses the osmolality of urine compared to that of water. For example, in renal tubular acidosis or uric acid stone disease, urinary pH is constantly elevated or decreased, respectively. Bacteria metabolizing urea to ammonia, such as Proteus mirabilis, increase urine pH to 8. Particle Analysis Particle analysis is the detailed assessment of urinary components either manually, mostly under a microscope, or via automated microscopy and flow cytometry . It can be performed in unprocessed urine or using staining and can be performed in both centrifuged and noncentrifuged samples. There is a consensus that for most cases of routine examination, centrifugation is not necessary. Leukocytes Granulocytes are the most frequent leukocytes detected in the urine and are mainly observed as a response to urinary tract infection. In asymptomatic bacteriuria, granulocytes may also be seen, and their presence does not preclude the diagnosis of asymptomatic bacteriuria. Macrophages also commonly appear in the urine of patients with urinary tract infection. In glomerulonephritis, interstitial nephritis, or interstitial cystitis, the major immune cellular components seen are granulocytes. Lymphocytes in urine are more associated with viral diseases and renal transplant rejection. Red Blood Cells Red blood cells in urine, and their morphology, may reflect the origin of bleeding. Dysmorphic red blood cells are of an abnormal size or shape (erythrocytes usually have a diameter of 4–7 mm) and suggest renal disease, whereas normal morphology usually suggests the source to be the lower urinary tract. Accordingly, they can determine whether the subsequent diagnostic workup should be urological or nephrological. Other Cells Urothelial cells derive from the multilayered epithelium lining the urinary tract. The appearance of squamous epithelial cells is a marker of contamination by poor collection technique. During pregnancy, epithelial cells in urine are increased regardless of quality of the collection technique. Casts Casts are particles formed in the distal tubules and collecting ducts and usually reflect the presence of renal disease. Within casts, plasma proteins, lipids, different types of cells, microorganisms, pigments, or crystals may be found. Bacteria 5 Bacteria are detected at concentrations above 10 colony-forming units/mL (cfu) and centrifugation does not increase diagnostic accuracy. Applying Gram staining to centrifuged urine can increase diagnostic accuracy, but this is dependent on bacterial density. Urine Cytology Urine cytology is an important form of particle analysis used to investigate patients who are at risk or under surveillance for urothelial carcinoma. Several classification systems for urine cytology have evolved over the years [16–20]. General cytomorphological features suggesting malignant cells include nuclear hyperchromasia, irregular nuclear contours, abnormal chromatin texture, prominent nucleoli, eccentric nuclear location, nuclear indentations, increased nucleus-to-cytoplasm ratios, and high cellularity (Figure 40. Urine cytology has a high sensitivity and specificity for high-grade urothelial lesions, such as carcinoma in situ, but low sensitivity and low negative predictive value in patients with low-grade urothelial tumors. Additional methods include fluorescence in situ hybridization techniques and various molecular approaches that are under evaluation currently. Urine Culture The aims of urine culture are to identify pathogens of urinary tract infection and estimate the concentration of bacteria and susceptibility to antimicrobials. The most commonly implicated bacteria in urinary tract infections are enterobacteria, such as E. However, in acute 3 uncomplicated cystitis, colony concentrations of midstream urine samples are at concentrations of ≤10 cfu/mL, so must be detected by additional tests such as plating on agar mediums, such as cystine lactose electrolyte deficient agar plates. Despite the presence of large numbers of bacteria, false-negative results may be obtained if patients have already commenced on antimicrobials. Special tests, such as the Bacillus subtilis test, help to detect antimicrobials in these circumstances. There are several standardized methods available, such as disc diffusion, dilution, and epsilometer testing . Susceptibility testing is performed according to international standards (Clinical and Laboratory Standards Institute or European Committee on Antimicrobial Susceptibility Testing). Susceptibility testing using automated systems has also been available for several years in most microbiological laboratories. Three commonest fastidious organisms involved in chronic urinary tract infections are Ureaplasma urealyticum, Mycoplasma hominis, and Chlamydia. These organisms are more difficult to culture as they have complex nutritional requirements. To assess for fastidious organisms, laboratories must carry out either polymerase chain reaction testing or utilize culture mediums that enrich for a wider range of species and culture this for a longer than the usual duration of 7 days [23,24]. Due to the cost and time implications, most laboratories do not routinely screen for fastidious organisms. A single 3-month empirical course of a low-dose quinolone or tetracycline antibiotics can effectively treat 82% of fastidious organisms and a second 3-month course can treat 96% . In view of the prevalence of these organisms in patients with chronic refractory lower urinary tract symptoms, it is important that fastidious organisms are considered and appropriate investigations conducted or empirical treatment initiated. Novel Techniques New “point-of-care” microbiology assessments are being developed that might enable susceptibility analyses of urine samples within 4–6 hours. This technology could avoid empirical broad-spectrum antibiotic usage and allow a more targeted approach. Although most commonly used to confirm the presence of infection, it has the ability to assess multiple other important diseases or concerns. To clean or not to clean: Effect on contamination rates in midstream urine collections in toilet-trained children. Effect of urogenital cleaning with paper soap on bacterial contamination rate while collecting midstream urine specimens. Protein-to-creatinine ratio in spot urine samples as a predictor of quantitation of proteinuria. Review of the state of the art and recommendations of the Papanicolaou Society 16. Mycoplasma and ureaplasma colonisation in women with lower urinary tract symptoms. Spectrum of bacterial colonization associated with urothelial cells from patients with chronic lower urinary tract symptoms.
Intraoperative Management Use of axillary roll with lateral decubitus position decreases the risk of brachial plexus injury discount levitra with dapoxetine 40/60mg. Consultation with a neurologist may be indicated for nerve conduction and electromyography testing generic levitra with dapoxetine 40/60 mg amex. Before discharge buy 40/60 mg levitra with dapoxetine with mastercard, the patient notes she has numbness in her left leg and has difficulty walking order 40/60mg levitra with dapoxetine with mastercard. Common peroneal nerve The common peroneal nerve is the most commonly injured nerve in the lower extremity because of the super- ficial course it takes around the fibular head. The patient was placed in stirrups for the procedure, which likely caused compression of the nerve. Her vital signs on admission are heart rate, 47 beats/min; blood pres- sure, 80/50 mm Hg; respiratory rate, 18 breaths/min; oxygen saturation, 97%; and temperature, 36. Phenylephrine would increase her blood pressure but may exacerbate her slow heart rate by causing reflex bradycardia. Of course, the pulse rate can always be determined by palpation of peripheral arteries or auscultation of heart sounds. Treatment: If the patient is stable with normal mentation, blood pressure, and oxygen saturation, then obser- vation is appropriate. Note that hypoglycemia no longer included in Hs but nonetheless should still be included in the differential diagnosis. Better outcomes are associated with early chest compressions, quality of chest compressions (sternal depression of 1½–2 in (4–5 cm) in adults or 1–1½ in (2–4 cm) in children and then allowing for full reexpansion of the chest wall) and decreased time between intervals in chest compres- sions. If the provider is alone, he or she should give 30 compressions for every 2 breaths. If an advanced airway or bag-mask is used with another rescuer assisting, respirations should target 10 to 12 breaths/min. A pulse check and analysis of rhythm should be performed after 5 cycles of 30:2 compressions to breaths. The resulting rhythm and presence or absence of pulse will determine the next step in care. After the defibrillator pads are attached to the chest, the initial shock (120–200 J) is given. This cycle is repeated until another rhythm is identified or efforts have been exhausted. During the code, the Hs and Ts should be discussed, and treatment should be instituted (e. Clinical manifestations: Rapid heart rate with or without hemodynamic instability. Rate-related signs and symptoms can occur at many rates but infrequently at less than 150 beats/min. His postoperative pain is being treated with hydromorphone patient-controlled analgesia. At shift change, the nursing staff finds him unresponsive without a pulse, and a code is called. Because this has already been started, the next intervention should be to defibrillate. The airway can be secured after the initial shock because time to defibrillation is an important predictor of survival. Emergence from General Anesthesia Problems such as airway obstruction, shivering, agitation, delirium, pain, nausea and vomiting, hypother- mia, and autonomic labiality are frequently encountered. Delayed emergence The most frequent cause of delayed emergence (when the patient fails to regain consciousness 30–60 min after general anesthesia) is residual anesthetic, sedative, and analgesic drug effect. Nerve stimulator used to exclude significant neuromuscular blockade in patients on a mechanical ventila- tor who have inadequate spontaneous tidal volumes. Less common causes of delayed emergence include hypothermia, marked metabolic disturbances, and perioperative stroke. Supplemental oxygen should be administered during transport to patients at risk for hypoxemia. Rescue single-shot, continuous nerve blocks, or continuous epidural analgesia are used when moderate to severe postoperative pain is present or oral analgesia is not possible. Differential diagnosis of postoperative agitation includes serious systemic disturbances (e. Transdermal scopolamine is effective but associated with side effects such as sedation, dysphoria, blurred vision, dry mouth, urinary retention, and exacerbation of glaucoma, particularly in elderly patients. Shivering and Hypothermia The most important cause of hypothermia is a redistribution of heat from the body core to the peripheral compartments. Differential diagnosis for shivering includes nonspecific neurologic signs (posturing, clonus, or Babinski sign), bacteremia, sepsis, drug allergy, or transfusion reaction. These 2 physiological effects are poorly tolerated by patients with preexisting cardiac or pulmonary impairment. Hypothermia has been associated with an increased incidence of myocardial ischemia, arrhythmias, increased transfusion requirements caused by coagulopathy, and increased duration of muscle relaxant effects. Patients should have been observed for respiratory depression for at least 20 to 30 minutes after the last dose of parenteral opioid. Minimum discharge criteria for patients recovering from general anesthesia include: Easy arousability Full orientation The ability to maintain and protect the airway Stable vital signs for at least 15 to 30 minutes The ability to call for help if necessary No obvious surgical complications (such as active bleeding). Postanesthetic Aldrete Recovery Score Ideally, the patient should be discharged when the total score is 10, but a minimum of 9 is required. Treatment includes jaw-thrust maneuvers, small dose of succinylcholine (10–20 mg) and temporary positive-pressure ventilation with 100% oxygen to prevent severe hypoxemia or negative-pressure pulmonary edema. Glottic edema after airway instrumentation is an important cause of airway obstruction in infants and young children. Treatment Obtundation, circulatory depression, and severe acidosis (arterial blood pH <7. Large doses of naloxone in sudden pain and marked increase in sympathetic tone, which can precipitate a hypertensive crisis, pulmonary edema, and myocardial ischemia or infarction. Hypoxemia Most common cause of hypoxemia after general anesthesia: Increased intrapulmonary shunting from a decreased functional residual capacity relative to closing capacity Treatment: Oxygen therapy with or without positive airway pressure is the cornerstone of treatment. Routine administration of 30% to 60% oxygen is usually enough to prevent hypoxemia with even moder- ate hypoventilation and hypercapnia. Significant hypotension, defined as a 20% to 30% reduction of blood pressure below the patient’s baseline level, requires correction. Treatment Increase in blood pressure after a fluid bolus (250–500 mL crystalloid or 100–250 mL colloid) confirms hypovolemia. Hypertension Most commonly caused by noxious stimulation from incisional pain, endotracheal intubation, or bladder distention Marked hypertension can precipitate postoperative bleeding, myocardial ischemia, heart failure, or intracranial hemorrhage. Elevations in blood pressure greater than 20% to 30% of the patient’s baseline and those associated with adverse effects such as myocardial ischemia, heart failure, or bleeding should be treated. Hydralazine and sublingual nifedipine may cause reflex tachycardia and have been associated with myocardial isch- emia and infarction. Bradycardia often represents the residual effects of cholinesterase inhibitors, opioids, or β-adrenergic blockers. Premature atrial and ventricular beats often represent hypokalemia, hypomagnesemia, increased sympa- thetic tone, or (less commonly) myocardial ischemia. The body of the mask functions as both a reservoir for oxygen and expired carbon dioxide; therefore, a minimum oxygen flow of 5 L/min is required to avoid rebreathing. The basic difference is the reservoir being filled “partially” with the patient’s expired tidal volume versus a nonrebreather, which uses a flap-type valve between the bag and the reservoir. Oxygen hoods cover the entire head while allowing ongoing access to the patient’s body. The most popular mixture is 79% helium and 21% oxygen, which has a density that is 40% of pure oxygen. Patients with upper airway obstruction (subglottic edema, subglot- tic stenosis, foreign bodies, or tracheal tumors) and those with lower airway obstruction (asthma) can experience improved oxygen delivery to the alveoli. In lower airway obstruction, Heliox does appear to improve delivery of needed therapies such as bronchodilatory agents (albuterol nebulization).