Keila E. Torres, MD, PhD
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Pharmacology note: Because sodium reabsorption in the proximal tubule is indirectly coupled to bicarbonate reabsorption arrhythmia young buy calan 80 mg otc, carbonic anhydrase inhibitors such as acetazolamide exert a diuretic effect by blunting sodium reabsorption. The loss of bicarbonate can cause acidosis (normal anion gap type) when carbonic anhydrase inhibitors are used as diuretics. In fact, clinically, carbonic anhydrase inhibitors are used much more often for their ability to increase bicarbonate excretion and thus treat a metabolic alkalosis. The result is an accumulation of acid in the plasma, leading to the metabolic acidosis that is characteristic of advanced renal failure. Renal causes include early acute renal failure, distal renal tubular acidosis (type 1), proximal renal tubular acidosis (type 2), and hyporeninemic hypoaldosteronemic renal tubular acidosis (type 4). Caused by inability of kidneys to excrete an appropriate amount of acid; this is caused by too few functional nephrons rather than a specific acid secretory defect. Renal failure can result in an anion gap metabolic acidosis as well as a normal anion gap acidosis if due to renal tubular acidosis. Renal hypoperfusion resulted in a low glomerular filtration rate, which reduced the acid excretory capacity of the kidneys. In these conditions, not only is there excess production of lactic acid but conversion of lactic acid to glucose by the liver is also decreased because of reduced hepatic blood flow. In the absence of insulin, "runaway" lipolysis occurs in the adipose tissue, and b-oxidation occurs in the liver. This acidosis is further exacerbated by the hyperglycemia, because the hyperglycemia causes an osmotic diuresis which results in volume depletion. Salicylic acid toxicity can cause tinnitus, vertigo, and nausea and in severe cases can cause seizures and death; in children and adolescents, it can also cause Reye syndrome. In terms of acid-base disturbances, salicylic acid toxicity can cause a respiratory alkalosis by stimulating the medullary respiratory center, causing hyperventilation, and a metabolic acidosis by inhibiting oxidative metabolism. The toxic effects of the metabolites of methanol can be prevented by competitively inhibiting the enzyme alcohol dehydrogenase with ethanol or fomepizole. If the delta-delta were less than 1, we would have a superimposed normal gap metabolic acidosis, perhaps from the diarrhea. If the delta-delta were greater than 2, we would have a superimposed metabolic alkalosis, perhaps from the vomiting.
When attempting to obtain a diagnostic-quality image and the image is underpenetrated blood pressure 3rd trimester cheap calan 240 mg fast delivery, and given the choice between increasing the total number of X-rays (mA) or the penetrability of the X-rays already present (kVp) to improve the image, the kVp should be increased initially as this will not increase the radiation output [11]. Collimating the image to the minimum size necessary for performing the work will reduce the amount of unnecessary radiation to which the patient and anyone else in the room is exposed. Radiation entering the patient is absorbed, scattered, or transmitted as a function of the density of the tissue it encounters. The contribution from tube leakage, and scatter from machine components and from the patient comprises the secondary radiation field and this is of the most concern to persons in the room during fluoroscopic imaging. Radiation "spreads out" in a three-dimensional space with a discrete or fixed number of photons spreading out in to successively larger spaces. As a result, the area geometrically increases as a function of distance from the source. Increasing the distance from the source is one of the least expensive and most dramatic ways to reduce the dose of radiation to which operating personnel are exposed. By doubling the distance from the source, the radiation is reduced to one-fourth of its original intensity because the same number of photons is in a space that is four times larger. Similarly, by tripling the Ultrasound versus fluoroscopy-guided access (see also Chapter 12) the advantages of ultrasound- over fluoroscopy-guided access in to the collecting system include reduction of exposure to radiation for the urologist and operating room personnel. In pregnancy and in patients with transplanted, horseshoe, or ectopic kidneys, ultrasound represents the modality of choice [16, 17]. Another advantage is proper localization of the adjacent organs for prevention of injury. The application of several technical modifications provides adequate information for preoperative planning and postoperative assessment [30]. Each of these new technologies offers several potential advantages over the traditional percutaneous approach under fluoroscopic control. It should, however, be stated that all of these technologies are in a nascent stage of development. For that reason it is necessary to reinforce the basic concepts governing the realization of a conventional procedural approach to the kidney under fluoroscopic control. While this conventional approach is appealing, only a small percentage of urologists are familiar with it [4], and various training models are essential for consolidating the use of this surgery [31, 32]. The performance of puncture with ultrasound guidance and without use of fluoroscopy has also been reported [19]. While ultrasound can be a useful complement to access the kidney, it should be emphasized that fluoroscopy is an indispensable component of safe percutaneous surgery.
Other primitive reflexes should be checked for blood pressure xanax 80 mg calan mastercard, including the rooting reflex and the startle reflex. The parents should be given a brief summary of the findings and any follow-up required, with appropriate reassurance and explanation. Valid consent must be obtained prior to starting the procedure; to do otherwise is an assault on the woman. In law, a competent adult retains the right to make decisions and refuse treatment, even if these decisions appear unwise. Ideally, her consent will be recorded in written form, with a record of all the risks and benefits that have been discussed with her. Her informed consent to the procedure is still valid, however, even if not in written form. If the woman withholds her consent to a procedure that is thought to be in her best interests by the obstetric team, then she should be fully counselled regarding the risks of not proceeding. If she still refuses to undergo the procedure, her decision should be respected and all discussions fully documented. Although time may be critical, she should have information regarding the risks and benefits to enable her to come to an informed choice. After consenting to the procedure she retains the right to change her mind and withdraw consent at any time. She describes having a mucus show the previous night, but denies any history of preterm rupture of membranes. Objective structured clinical examination questions 77 3 Antenatal care A thirty-year-old woman attends a routine booking clinic. Her last pregnancy ended in a miscarriage at 18 weeks after she was admitted with backache. You are asked to counsel this lady as to the possible options that are available for her management. What are three possible maternal complications of this disease if it remains untreated The maternal blood pressure was 140/75 mmHg, the temperature was 370C and the pulse rate was 80 beats per minute. Objective structured clinical examination questions 79 c) With regard to women delivering after preterm rupture of the fetal membranes, what post-natal complications are important Objective structured clinical examination questions 81 17 Psychiatric disorders in pregnancy and the puerperium A twenty seven-year-old mother is seen by the community midwife 5 weeks after having a Caesarean section for failure to progress in the first stage of labour. Associated with these changes are decreases in the maternal mean arterial pressure and in the peripheral vascular resistance. However, it does not promote lactation during this time as its function is antagonized by oestrogen.
Intravenous alkalinization is more effective than the oral route; urinary pH is elevated more quickly arteria sacralis mediana buy generic calan 80 mg on line, to a higher degree, and more reliably. This technique, however, is typically reserved for hospitalized patients with acute episodes of renal colic and obstruction. One-sixth molar lactate solution has been demonstrated to dissolve uric acid stones even when they are causing ureteral obstruction [27]. Cardiac and hypertensive patients must be monitored for the large sodium load in these solutions. Several other oral therapies have been suggested to facilitate dissolution therapy. Caution must be taken when prescribing acetazolamide because it can be poorly tolerated and can induce calcium phosphate stone formation. A dose of 250 or 500 mg is taken at bedtime to maintain urine alkalinity during sleep. In cases of hyperuricosemia and hyperuricosuria, allopurinol should be added to inhibit the production of uric acid through inhibition of the enzyme xanthine oxidase. Secondary dissolution may be useful in patients with residual fragments after some other primary therapy. In this context, chemolysis may render the patient stone free, thus reducing the potential for recurrences or more invasive interventions. For effective chemolysis, the irrigant must have several important characteristics: (1) be compatible with biologic tissue and of limited toxicity; (2) have minimal systemic absorption in order to limit potential toxicity; (3) dissolve calculi and their fragments quickly to reduce treatment burden for the patient; and (4) do not precipitate causing secondary stone formation. Additionally, an ideal irrigation system must provide for free flow of irrigant to a targeted area, while maintaining low renal pelvic pressures to prevent bacteria from entering the bloodstream and avoiding renal damage [17]. Some stones may require long treatment periods, which may necessitate prolonged hospital admission and patient discomfort. For example, uric acid and struvite amorphous minerals dissolve much faster than highly crystalline salts such as calcium oxalate. Large stones will dissolve more slowly than the same volume of smaller stones as the surface area is greater in the latter [19, 20]. These variables can make it difficult to predict the necessary length of treatment a priori. In addition, the choice of chemolytic agent will depend on stone type and stone composition must be determined prior to chemolysis. Uric acid stones Almost all individuals who form uric acid stones have persistently low urinary pH (<5.
Diseases
However blood pressure zantac calan 240 mg order online, with attention given to anatomic considerations, supracostal access to the upper pole can be obtained safely and efficiently to contribute to successful percutaneous renal surgery. Approaches to the superior calyx: Renal displacement technique and review of options. Prospective evaluation of safety and efficacy of the supracostal approach for percutaneous nephrolithotomy. Safety and efficacy of supracostal access in tubeless percutaneous nephrolithotomy. Risks, advantages and complications of intercostal vs subcostal approach for percutaneous nephrolithotripsy. Splenic injury: rare complication of percutaneous nephrolithotomy: report of two cases with review of literature. Using and choosing a nephrostomy tube after percutaneous nephrolithotomy for large or complex stone disease: a treatment strategy. Use of lower pole nephrostomy drainage following endorenal surgery through an upper pole access. Nephrostomy tube after percutaneous nephrolithotomy: Large-bore or pigtail catheter Tubeless and stentless percutaneous nephrolithotomy in patients requiring supracostal access. The rapid dissemination of image-guided techniques in urology and interventional radiology has contributed to the innovation of percutaneous renal procedures. Simple drainage has evolved in to percutaneous treatments for stone disease, upper tract and renal cancers, and urinary diversion/drainage, amongst others. The advancement of endourologic techniques has led urology in to the minimally invasive era. This rapid innovation has forced urologists to become proficient in percutaneous renal procedures, offering optimal treatment for the expanding number of pathologies amenable to percutaneous treatment. On rare occasions, access to various imaging modalities may be unavailable, or proficiency with image-guided percutaneous nephrostomy placement may be lacking. Anatomy (see also Chapter 6) the retroperitoneal location of the kidney allows for relatively safe percutaneous access via a posterior approach. Nephrostomy placement without image guidance is completed utilizing anatomic landmarks, assuming normal renal anatomy. A thorough understanding of renal anatomy and relations is essential to avoid complications and gain access to the collecting system [8]. The kidney is a mobile organ and its position can vary depending on patient position and phase of respiration.
For females hypertension 130100 order 120 mg calan mastercard, we typically will use a shorter ureteral access sheath at 35 cm, and for males, a 55-cm ureteral access sheath. There are several lengths available for the access sheath, but these work for most of the patients we encounter. The ureteral access sheath is advanced over the "working" super-stiff wire under fluoroscopic guidance, making sure not to allow buckling of the access sheath or wire within the bladder. A flexible ureteroscope is advanced in to the renal pelvis through the access sheath. In patients with the infundibulum of the desired calyx obstructed by a large calculus or stone debris, ureteroscopic holmium laser lithotripsy is performed to allow the ureteroscope to be advanced in to the desired calyx. A transverse skin incision of about 5 mm is made to penetrate the dermis over the target calyx. An 18G percutaneous, conical-tip, trocar needle is advanced toward the tip of the ureteroscope residing in the desired calyx, which provides a definitive radio-opaque target. The advancement of the needle is monitored fluoroscopically to position the needle hub over the tip, over the target calyx, and endoscopically to monitor the entry of the tip of the needle in to the calyx with the ureteroscope. The insertion of the trocar needle in to the collecting system is simultaneously monitored by both fluoroscopy and direct ureteroscopic visualization. The advancement of the needle as it punctures the calyx is monitored to ensure that the needle traverses the fornix of a posterior calyx and is not inadvertently advanced too deeply. If the nitinol guidewire is passed down the ureteral access sheath, it can be delivered out through the urethral end of the access sheath. The nitinol wire can then be exchanged for a 260-cm Bentson exchange wire using a standard 5F open-ended ureteral catheter or a Kumpe catheter. The long exchange wire allows the maintenance of access along the entire access tract from the urethra to the percutaneous puncture, and can act as the safety wire for both the renal access and the retrograde access. If the long exchange wire is in place, the ureteral access sheath can be withdrawn and passed again over a super-stiff guidewire. If the nitinol wire is passed along the side of the ureteral access sheath, an attempt is made to pass it in to the bladder. In this fashion, all subsequent coaxial maneuvers on the wire will be safely passed along the natural lumen of the urinary tract. Lastly, if the nitinol wire is curled in the renal pelvis, an attempt can be made to grasp it with a stone basket or grasper via the ureteroscope and bring it out through the urethral end of the access sheath [3].
Their utility is limited to settings where high urine flow is required to prevent intratubular precipitation blood pressure up and down discount 80 mg calan with mastercard, such as with intravascular hemolysis, hyperuricemia and myoglobinuria. Dopamine at low doses causes renal vasodilatation and may induce a modest natriuresis and diuresis. Hence, its use for prevention or treatment of acute tubular necrosis is not recommended. The role of other medications, including fenoldopam, atrial natriuretic peptide, calcium channel blockers and other medications is investigational. Severe acidosis is treated by administration of sodium bicarbonate, and, if persistent, dialysis. Factors that aggravate hyperkalemia are acidosis, which causes potassium to shift from the intracellular compart ment, infection, hemolysis and tissue damage. Symptoms of hypertensive encephalopathy are related to the rapidity of rise rather than the absolute value of blood pressure. Since the half-life of this drug is in minutes, it may be stopped if there is a precipitous fall in blood pressure. Maintenance oral therapy is instituted using a calcium channel blocker (nifedipine, amlodepine), beta-adrenergic blocker (atenolol), or vasodilator (prazosin) alone or in combination. Hypertonic saline must be used cautiously because of complications of fluid overload and hypertension. Infections, including respiratory and urinary tract, peritonitis and septicemia, are important causes of death. The purpose of dialysis is to remove endogenous and exogenous toxins and maintain fluid, electrolyte and acid base balance until renal function recovers. Dialysis should begin early to prevent these complications, especially in hypercatabolic states. The choice of dialysis modality is influenced by several factors, including goals of dialysis, the advantages and disadvantages of each modality and institutional resources. Peritoneal dialysis does not require vascular access and sophisticated equipment and is easy to perform even in neonates. It is often the initial renal replacement therapy of choice in sick and unstable infants. Peritoneal access is obtained using a stiff catheter and trocar, or a soft silastic catheter. Commercially available dialysates are lactate based and with a dextrose concentration of 1. Potassium is not added in the first 5-10 cycles, to enable correction of hyperkalemia. Patients who are sick and have severe lactic acidosis are dialyzed using a bicarbonate dialysate.
To achieve their recycling functions arrhythmia uk generic 120 mg calan otc, the kidneys receive a substantial fraction (20% to 25%) of the cardiac output despite comprising less than 2% of body weight. The basic functional unit of the kidney is the nephron, where blood is filtered; there are approximately 1 million nephrons per kidney. Each glomerulus is an expansion of an afferent arteriole in to a diffuse capillary bed, the glomerular capillaries, which have an extensive surface area for filtration; these capillaries are surrounded by an expansion of the renal tubular system. The ultrafiltrate of plasma created in the glomerulus flows in to the tubular system, where selective reabsorption and secretion of solutes and water occurs along the various segments of the nephron. Inner medullary collecting duct (thick ascending limb) Macula densa Juxtaglomerular cells Afferent glomerular arteriole Extraglomerular mesangial cells Mesangial region Interglomerular mesangial cells Distal tubule Efferent glomerular arteriole 6-3: Anatomy of the glomerulus. Pathology note: In a condition known as minimal change disease (lipoid nephrosis), the negative charges on the glomerular filtration barrier are lost for unknown reasons. This attenuation is due to intrinsic autoregulatory mechanisms in the kidneys, which maintain relatively constant renal perfusion despite fluctuations in systemic arterial pressure (see later discussion and. Regulation of glomerular hydrostatic pressure: primarily depends on afferent and efferent arteriolar resistances Etiology of renal artery stenosis: fibromuscular hyperplasia in young women, atherosclerotic disease in older adults Clinical note: Narrowing of the renal arteries (renal artery stenosis) most commonly occurs as a result of atherosclerosis or fibromuscular hyperplasia. When both renal arteries are affected (bilateral renal artery stenosis), renal blood flow may become so compromised that the kidneys are unable to perform their normal recycling functions, resulting in the toxic accumulation of metabolic byproducts. At very high or very low arterial blood pressures, autoregulatory mechanisms fail, and renal blood flow parallels changes in systemic arterial pressure. At extremes of blood pressure, systemic arterial pressure and renal blood flow are in Autoregulation occurs through the myogenic mechanism and tubuloglomerular feedback, as discussed below. This mechanism is dependent on the presence of a specialized structure termed the macula densa, which is located at the end of the thick ascending limb and abuts the glomerulus adjacent to the afferent arteriole. The macula densa and the specialized cells within the glomerulus and the walls of the afferent arteriole are referred to as the juxtaglomerular apparatus. When filtration increases, through an unclear mechanism the increased NaCl delivery to the macula densa triggers vasoconstriction of the afferent arteriole. The term renal function is used to refer to the rate at which the kidneys remove toxins from the circulation. The main mechanism of toxin removal is filtration of toxin-laden plasma through the glomerulus, leaving the toxins behind in the tubule and reabsorbing 99% of the filtrate. Clearance is the volume of plasma from which a substance has been completely cleared by the kidneys per unit of time.
Temmy, 36 years: Nevertheless, arterial pulsations are not always readily identifiable endoscopically during surgery, mainly because patients may be hypotensive due to anesthesia [31]. Crossing ureteric strictures: microcatheters to the rescue when conventional methods fail. We are currently conducting a study on the efficacy of arthroscopically assisted direct injection of Botox in to the superior head of the lateral pterygoid at the pterygoid shadow.
Mirzo, 35 years: In either case, the C-arm remains fixed, and the needle is advanced until the point of coincidence between the calyx and the needle tip is reached. Since the half-life of this drug is in minutes, it may be stopped if there is a precipitous fall in blood pressure. At this stage in the operation, the assistant manipulates the condyle in a seated position in a reciprocal fashion, together with the surgeon.
Eusebio, 47 years: If tissue loss is important, autotransplantation (especially in younger patients) or ileum interposition may Partial ureteral avulsion Partial ureteral avulsion is a rare complication which causes less severe sequelae than ureteral avulsion. Women who are found to be non-immune should be advised to avoid infectious contacts. Effectiveness of totally tubeless percutaneous nephrolithotomy in selected patients: a prospective randomized study.
Karrypto, 57 years: Reducing the amount of time spent in the vicinity of the device also decreases the amount of radiation exposure for those performing and assisting in the procedure. Role of ureteral stenting after uncomplicated ureteroscopy for distal ureteral stones: a randomized, controlled trial. The remainder of the tract is then manually dilated under direct vision using grasping forceps.
Vigo, 43 years: Frequently, the greatest concavity of the glenoid fossa is less evident, whereas the condyle becomes difficult to palpate, particularly if the lateral pole is degenerated or absent. Chapter 2 How to Protect Patients and Personnel from Radiation 17 Shielding Once time and distance have been optimized, the next level of protection is shielding, in particular for those persons who are required to be within the region of exposure. This approach is preferable to continuing with the initial intervention, which carries an increased risk of ureteral lesion.
Brontobb, 33 years: Also patients of advanced age or poor nutritional status, with diabetes, obesity, significant kidney or liver diseases, and female patients have a higher risk [6]. On occasion the space between ribs is very narrow and the sheath is sandwiched so tightly that maneuverability is significantly hampered. Under experimental conditions with an electrohydraulic lithotripter, the maximum disintegration was seen at a distance of 12 cm from the expected peak power region [24].
Esiel, 54 years: The functional lung capacity is reduced, however, and the diaphragm may be splinted by the gravid uterus. Perirenal coverings the kidney surface is enclosed in a continuous covering of fibrous tissue, the renal capsule ("true renal capsule"). There are also 3D video projectors available which will alternatively display left and right eye images on a large video screen.
Pedar, 60 years: Optimal dosing and instillation schedules have not yet been established, but some trials have demonstrated that a reduced dosing regimen (onethird dose) may be as effective as standard dosing but with fewer side effects [8284]. A guidewire is then passed through one ureteral end, through-and-through to the other lumen, using a combination of fluoroscopy and direct visual control. First a guidewire is inserted under X-ray control, and then the access sheath is inserted over the guidewire.
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