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Rhinoplasty (Nose Surgery)\nRhinoplasty — commonly known as a nose job — is the surgical reshaping of a patient's nose. Cosmetic nose surgery is also performed in cases of trauma, disease or congenital malformation. This procedure may be performed for aesthetic or medical reasons. Patients may feel that their nose is too large, too small, too wide or too narrow. Some patients may dislike the hump on their nose, their nose may be crooked or their nostrils may be too large or too small. Regarded as one of the best surgeons in Gainesville, FL, Dr. Poser has the goal of taking a patient’s visible insecurities and transforming them into features which restore self-confidence and self-esteem. Schedule a consultation for cosmetic face surgery today.\nTypes Of Rhinoplasty Procedures\nNose surgery may either add tissue to the nose — augmentation rhinoplasty — or remove tissue from the nose — reduction rhinoplasty. Before the plastic surgery nose procedure begins, general anesthesia is administered to patients. Dr. Poser will then perform either an open procedure or a closed procedure to reshape the patient's nose. The exact surgery procedure may vary as each patient has different nasal anatomy, the purpose for surgery (cosmetic or functional), and desired nasal structure. During a closed procedure, the surgeon operates from within the patient's nose. In an open procedure, the surgeon makes an incision through the columella, the flesh that separates one nostril from another. A septoplasty may also be required to treat a deviated septum during the surgery.\nWho Is A Candidate For Rhinoplasty?\nThe most accurate and effective way to determine rhinoplasty candidacy is through a consultation with our Dr. Poser. Important information, such as medical history, nasal concerns, and aesthetic goals will be discussed during the consultation. To create an optimal treatment plan, preoperative planning is necessary. With the aid of digital manipulation, Dr. Poser will work with patients to develop an exact plan that addresses nasal features and outlines the exact degree of correction necessary to give patients a desired aesthetic. Once candidacy is confirmed, patients may schedule the appointment for rhinoplasty in Gainesville, FL — contact Poser Plastic Surgery Center.\nHow To Prepare For Rhinoplasty\nThe team at Poser Plastic Surgery Center will thoroughly assist each patient in preparing for their procedure. Before the surgery, the patient should be free of any respiratory problems, which includes the common cold. Patients should stop taking medications that cause the blood to thin, such as aspirin. Patients must also restrict themselves from eating or drinking beginning at midnight before the rhinoplasty procedure, so as to avoid complications while under general anesthesia during surgery. Additionally, patients must ensure reliable transportation to and from the plastic surgery center due to the effects of general anesthesia and to ensure proper recovery thereafter.\nWhat To Expect After Rhinoplasty Surgery\nUsing the preoperative planning completed during the consultation, Dr. Poser will reconstruct or sculpt nasal bones and cartilage to create the desired nasal appearance. Once the nose plastic surgery is completed, patients will have a nasal splint applied for at least a week. The nostrils will also be packed with gauze. The gauze must remain inside of the nose for one day or more — patients may begin to gently clean the edges of the nostrils using peroxide after a few days. After nasal surgery, mild swelling and bruising are expected. Patients may typically resume daily activities within one week. |
Jaw Support Device During Third Molar Extractions Trial\n“Assessing a New Jaw Support Device During Third Molar Extractions”\nDuring mandibular 3rd molar (wisdom tooth) extractions, when a downward force is placed on the patient's jaw, the patient must tense his/her jaw muscles to oppose it. Patients under moderate/deep sedation or general anesthesia cannot tense their muscles to counter this downward force to prevent injury to the jaw including the temporomandibular joint (TMJ). Bite blocks hold the patient's mouth open but do not counter this downward force on the mandible. Currently, oral and maxillofacial surgeons (OMSs) when surgically removing 3rd molars (wisdom teeth) with moderate/deep sedation or general anesthesia have a dental assistant that stands behind the chair and places their hands on both sides of the jaw to support it and oppose the downward force on the patient's jaw during the extractions. It is hard for the dental assistant to maintain support while anticipating the direction and amount of force placed by the OMS on the patient's jaw during the surgical removal. This may explain the finding that almost a quarter of new onset TMD cases in young adults is associated with 3rd molar removal. This study will look at the use of a jaw support device to provide a stable counterforce to downward forces on the jaw, thus preventing jaw hyperextension and injury to the jaw.\nDevice - The Restful Jaw Device\nThe Restful Jaw Device is used to support the jaw during dental procedures including surgical removal of 3rd molars (wisdom teeth) with sedation. The device is designed to counter the downward forces placed on the mandible by clinicians during dental procedures and prevent jaw hyperextension (opening too wide) while providing a secure, stable jaw position. When 3rd molar teeth are surgically removed with sedation, a dental assistant stands behind the dental chair and supports the patient's jaw w ...read more on ClinicalTrials.org\nThe Restful Jaw Device: A New Way to Support and Protect the Jaw During Third Molar Extractions |
||Planning of operation in hand surgery\nback to top\nAs a rule, a diagnosis is posed after the use of the previously described possible diagnostic techniques and\nthen it is decided if conservative or surgical treatment is appropriate. In some cases, no treatment is\nnecessary (e.g. small benign tumors, minor malformations, or marginal restriction of function).\nAn indication as to whether non-surgical or surgical treatment is necessary is based on the diagnosis,\nthe level of discomfort of the patient, and the overall medical condition of the patient.\nIn addition, the possibility of an out-patient procedure versus a hospital stay should be discussed with\nthe patient or, if necessary, the patient's guardians.\n- Planning of the operation - Appointments\nConsiderations should include:\n- School vacation and school schedule of children\n- Employment situation\n- Post-operative care of older patients by family\n- Post-operative placement of patients in need of additional care by relatives or professional care providers\n- Explanation by the surgeon of:\n- The operation\n- The risks related to the operations\n- The eventual necessity for third/party care or treatment.\n- The type and duration of post-operative treatment.\n- The duration of the inability to work (probability of losing one's job)\n- Explanation by the anesthesiologist of:\n- The type of anesthesia to be used during the operation\n- The risks associated with the anesthesia\n- The sequence of events of the anesthesia during the operation\n- Post-operative treatment by the anesthesiologist\n- Patient conduct when returing home after an out-patient surgery |
Having undesirable fat in various areas of your body can have a substantial impact on your health and self-confidence. While conventional weight-loss through workout and diet plan is a terrific way to lose weight overall, even the very best workouts cannot target issue locations like the belly, inner thighs, arms, and butts. Liposuction is a time tested treatment that is used to eliminate excess fat from particular areas of the body, allowing an individual to shape and contour their body to their taste. Is liposuction right for you? Find out now.\nPros of Liposuction\nThere are many advantages to this cosmetic procedure, including:• Right away obvious changes. Unlike standard weight loss, liposuction develops changes that are immediately visible in the body. Some difference is noticeable right away, and the preferred results are generally achieved in simply a few days.\n• Proven and safe. This cosmetic treatment has been carried out by knowledgeable cosmetic surgeons all over the world for years and the method has been improved over and once again to be safe and reliable.\n• Healing time is generally fast. The downtime needed after having this type of procedure is normally much less than what is needed for other types of cosmetic procedures, consisting of abdominoplasty, breast reduction, and more. Individuals who have had the procedure can often go back to work a lot more rapidly than they anticipated and can get back to living a healthy, active lifestyle.\n• Weight reduction can be permanent. With the ideal maintenance methods, the fat that was gotten rid of throughout the liposuction procedure will not return.\n• Complete control over your body. With liposuction, a person can have complete control over how they wish to look, beyond exactly what traditional diet plan and exercise can offer. Offering people this power over their bodies increases self-esteem and assistance people feel their best.\nWhile there are numerous advantages to liposuction, there are naturally a few caveats that need to be considered prior to making the final decision to move forward with the treatment.\nCons of Liposuction\nPrior to having actually liposuction done, it is very important to examine the prospective disadvantages of the treatment and figure out if the benefits outweigh the risks in your certain case. Your cosmetic surgeon can assist you find out more about the threats related to the procedure and can help you decide if moving on is the ideal thing for you.\n• Complications with basic anesthesia. Because liposuction is carried out under general anesthesia, the treatment carries the exact same dangers as other kind of surgery where general anesthesia is used. Underlying medical conditions might enhance these risks.\n• Adverse reactions. Bruising, bleeding, and pain are all to be anticipated, nevertheless, in uncommon cases can cause more considerable complications.\n• The prospective to gain the weight back. After having liposuction done, it is important to maintain a healthy diet and exercise effectively as advised by your doctor. Failure to do so might cause getting back the weight that was lost or possibly much more.\nAlthough there are dangers related to liposuction, for many individuals, the advantages far outweigh them. Educate yourself about the procedure by having in-depth discussions with your cosmetic surgeon and consider how liposuction has the prospective to affect you as an unique individual. Only you and your surgeon can figure out if liposuction will supply you with the outcomes you are looking for within your expectations.\nLaser Liposuction procedure is a new non invasive procedure to loose unwanted bodyfat in Winterville NC\nLaser liposuction is a newer, minimally intrusive treatment that includes heating the fat cells to melting point and eliminating the melted fat through a small cannula. The treatment is normally done right in your doctor's workplace and is an exceptional option for individuals who have less than 500 ml of fat to remove from any one location. Laser liposuction can be a safe, complementary procedure to weight loss in order to shape the body you've constantly desired.\nContact a Surgeon in your Winterville NC today.\nIf you're thinking about liposuction as a weight-loss option, it's important that you discuss your desires with a certified plastic surgeon in your location. Your surgeon will carry out a complete test and health history questionnaire to determine if liposuction can benefit you and help you reach your physical and psychological goals. Call today for an assessment and find out more about how liposuction can help you achieve the body of your dreams. |
As the patients we evaluate for surgery get ever sicker, we are always searching for better ways to assess a patient's health. Of course there are all sorts of expensive tests we can order to give us hard numbers and reassure us of our anesthetic plans. However in this age of cost cutting and insurance oversight, perhaps there are cheaper tests that will give us equivalent results.\nA few years ago I wrote about an article in the ASA Newsletter that described a couple of bedside techniques to help decide if a patient is safe to undergo surgery. They both have the advantage of requiring nothing more than a blood pressure and a pulse. Nothing simpler or cheaper than that.\nNow there is another simple test that can be performed quickly and cheaply in preop. Written up in the Wells blog of the New York Times, this new test was developed in Norway and rapidly assesses the oxygen delivery capacity of a patient. Oxygen delivery is one way of determining a patient's cardiovascular health and physiologic age. The researchers were able to whittle all the different physiologic measurements of their 5,000 test subjects down to a test with only seven questions that can reliably decide oxygen delivery. Three of the questions ask about the exercise habits of the subject. Other questions include sex of the person, age, waist size, and baseline pulse rate. After trying out this test, it seems that the quantity and quality of exercise made very little difference in my calculated physiologic age. Whether I worked out less than or greater than thirty minutes each time made no change in the final calculation. But varying my waist size or pulse rate made much more meaningful changes. This makes sense since most people can achieve a smaller waist size or slower heart rate by exercising regularly.\nSo next time you see a patient in preop who you want to delay a case to get one more test prior to clearance, try some of these simple and noninvasive methods. This may save the patient from another expense and prevent your reputation from taking a hit as the anesthesiologist who likes to cancel cases. |
FORT ATKINSON – Fort HealthCare’s Internal Medicine & Pediatrics clinic, with offices in Fort Atkinson and Whitewater, is pleased to welcome internal medicine specialist Maysa Hussain, MD to their medical group practice.\nHussain received her bachelors’ degrees in medicine and surgery from the University of Baghdad in 1995. She attended the University of Al-Mustansiriyah in Baghdad where she completed a residency in anesthesia. In 2006, she attended the University of Wisconsin Medical School, and completed a residency in internal medicine. She also completed an internship at Aurora Health Care Sinai & St. Luke’s Medical Center, Milwaukee.\nA United States citizen, Hussain is a member of the American College of Physicians, and is fluent in English and Arabic. She has a special interest in Endocrinology. As an educator at heart, she has won numerous teaching awards and works to help her patients understand their medical conditions and treatments.\n“My medical philosophy revolves around getting to know my patients very well, understanding their backgrounds and life styles, and developing individualized care plans best suited to their circumstances”, said Hussain. “I feel it is important that my patients trust me as a partner in maintaining their quality of life, so I also take time to educate them on preventive health measures.”\nIn her spare time, she enjoys spending time with her family, especially outdoors. |
Anesthesia for Patients Too Sick for Anesthesia, an Issue of Anesthesiology Clinics (eBook)\n|File type:||EPUB DRM|\nAvailable for immediate download\nTo download this eBook, simply 'Add to basket' and pay at the Checkout as normal. Don't forget to download Digital Editions too, if you don't already have it.\nOne of the anesthesiologist's greatest challenges is managing high-risk patients with acute or severe conditions. This issue brings the anesthesiologist up to date on the most important and latest approaches to management of the sickest of patients. Topics covered include managing the patient with sepsis or septic shock; anesthetic considerations for patients in respiratory failure; anesthetic concerns in patients presenting with renal failure; perioperative management of patients with liver failure; management of acute coronary syndrome in the OR; intraoperative concerns in patients presenting with sever aortic stenosis, aortic insufficiency, mitral regurgitation, or mitral stenosis; intraoperative management of patients with cardiac tamponade; anesthetic concerns in trauma victims requiring operative intervention; patients presenting with acute toxin indigestion; anesthetic concerns in patients with known neurologic insufficiency; management of endocrine insufficiency in the OR; and management of patients with mediastinal mass or tracheal stenosis. |
Health care is undergoing major transformation with a shift from fee-for-service care to fee-for-value. The advent of new care delivery and payment models is serving as a driver for value-based care. Hospitals, payors, and patients increasingly expect physicians and healthcare systems to improve outcomes and manage costs. The impact of the coronavirus disease 2019 (COVID-19) pandemic on surgical and procedural practices further highlights the urgency and need for anesthesiologists to expand their roles in perioperative care, and to impact system improvement. While there have been substantial advances in anesthesia care, perioperative complications and mortality after surgery remain a key concern. Anesthesiologists are in a unique position to impact perioperative health care through their multitude of interactions and influences on various aspects of the perioperative domain, by using the surgical experience as the first touchpoint to reengage the patient in their own health care. Among the key interventions that are being effectively instituted by anesthesiologists include proactive engagement in preoperative optimization of patients’ health; personalization and standardization of care delivery by segmenting patients based upon their complexity and risk; and implementation of best practices that are data-driven and evidence-based and provide structure that allow the patient to return to their optimal state of functional, cognitive, and psychologic health. Through collaborative relationships with other perioperative stakeholders, anesthesiologists can consolidate their role as clinical leaders driving value-based care and healthcare transformation in the best interests of patients.\nHealth care is in the midst of historic change, and anesthesiologists need to incorporate strategies that align with a value-based framework.1 This change has been further accelerated by the coronavirus disease 2019 (COVID-19) pandemic and the near collapse of the healthcare system and financial model for healthcare delivery. While the return of essential surgical care to previous levels remains dependent upon the control of the pandemic, there is an increased recognition among all healthcare practices that financial viability and sustainability will require cost of care to be further controlled in the face of decreasing reimbursements, and there will be continued transition to risk- and value-based payment models. Anesthesiologists have made enormous gains through the years in reducing intraoperative risk, and their continued engagement with patients and various stakeholders across the continuum of surgical care will lead to long-term improvements in health care. Given their primary focus on safe, episodic hospital-based care, anesthesiologists have a unique opportunity to demonstrate what it means to redesign perioperative care to improve clinical outcomes and efficiency. Patients and insurance payors will benefit from improved outcomes with an associated cost avoidance secondary to reduced complications and discharge disposition, while hospital administrators will appreciate improved efficiency and coordination of care.\nThis concept is hardly new and has been developed on the heels of other individuals who have shaped the field of anesthesiology. In 2005, Mark Warner, M.D., broached the thought that in a healthcare environment already changing at that time, we, as a field, should no longer be simply confined to the operating room; we should expand our horizons into other areas where our expertise would be valuable including genomics, pharmaceutical avenues, and management.2 In his 2009 Rovenstine Lecture, Ronald Miller, M.D., further expounded on the “parade of challenges…to address,” including other technologies or medical personnel doing the traditional operating room management.3 He asked our specialty to address how we will respond to this issue and still pursue excellence, and suggested that the solution is to think beyond the box of the operating theatre. In 2011, Patricia Kapur, M.D., asked us the hard question to which she already had the answer: “…are we leveraging our costly knowledge and skills to the greatest extent, to provide components of the patient care process for which our education and training are necessary?”4 Shortly thereafter, the American Society of Anesthesiologists (Schaumburg, Illinois) developed the concept of perioperative surgical home,5,6 and had a series of editorials on “how anesthesiologists can participate in and lead the transformation of health care with focus on patient value throughout the episode of care.”7 The ability for the anesthesiologist to work in concert with our surgical and medical colleagues to practice population health is even more valid today than it was in the past.8\nYou may be asking, “In the natural progression of our specialty, we have been able to adapt. So why the urgency?” Imagine two scenarios where the operating room anesthesiologist becomes obsolete or not needed. The first: The entire world practices preventative and personalized medicine through the ability to target genes causing disease. Operations and disease, even in underdeveloped countries, are no longer required with our current world’s frequency. This is futuristic and bordering on fantasy. The second: Hospitals no longer allow surgical teams to provide nonurgent or even potentially urgent operations because of a disaster during which (1) operating rooms are required to treat the critically ill; and (2) one operation will exponentially heighten the casualties and create a vicious cycle perpetuating the disaster. Sound vaguely familiar?\nAs many hospitals, administrators, and physicians continued to focus on the fee-for-service model, reinforcing volume (vs. value), COVID-19 instantaneously laid waste to the hospitals’ primary revenue generator: the operating room. The subsequent, swift collapse of the financial model for healthcare delivery exposed the vulnerabilities of not only our hospitals and hospital systems, but of our specialty. Because there has been an estimated 19.5% reduction in inpatient volumes and 34.5% reduction in outpatient volumes, it is estimated that hospitals lost $202.6 billion between March 2020 and June 2020 because of low patient volumes, and hospitals are estimated to lose an additional minimum of $120.5 billion from July to December 2020, for a total of a $320.5 billion loss.9 If a surge continues, losses will be even greater. Total relief dollars available for hospitals and providers by the Coronavirus Aid, Relief, and Economic Security Act in the United States are estimated to be $175 billion, only half of the total losses.9,10 What happens to the operating room fee-for-service model when these services are suspended? Will it be strategically sustainable for the anesthesiologists to practice only in the operating room? During the COVID-19 public health emergency, a great deal of nonemergent care was not performed, and it is unclear if it will return to baseline levels after the public health emergency.\nThe call to action before was well received, but there was no impetus to change. Fee-for-service has been the standard. The financial model seemed reliable. Because anesthesiologists were secured in the reliability of the operating room, some felt we would never experience a shortage in patients, and the premise of diversifying our field was seen as a luxury, not a must. In January 2020, health care in the United States stood on the cliff of such a model. COVID-19 seemed to push us over that cliff. Alongside the tsunami of sweeping regulatory and economic changes in health care, it is in this space that anesthesiologists can and must innovate in and create further value.\nRationale for Value-based Care\nIn 2019, U.S. healthcare spending reached $3.81 trillion, approximately $11,559 per person.11 This healthcare spending is projected to nearly double during the next 10 yr, to more than $6.2 trillion (fig. 1A). The percentage of U.S. gross domestic product that will be attributed to health care during the next decade will rise by nearly 2%, from 17.8% in 2018 to at least 19.4% in 202711 (fig. 1B). However, this does not necessarily mean that health and health care has improved. Life expectancy (a key metric in the assessment of population health) in the United States remains low compared to the other countries who are part of the Organisation for Economic Co-operative Development (Paris, France), in spite of the higher healthcare spending.12–17 The Institute of Medicine’s (now the National Academy of Medicine, Washington, D.C.) 1999 report estimated that 98,000 deaths occurred each year in the U.S. healthcare systems due to preventable harm. Health outcomes after surgical care demonstrate significant variability across different hospitals and providers, with a high incidence of postoperative complications and mortality after surgery.18,19 Additionally, many surgical procedures may not be associated with improved quality or quantity in life-years and therefore are of low or no value.20\nWhy is there a disparity between so much expenditure for potentially so little gain? The reasons for this apparent disparity are complex and multifactorial1,21,22 for several reasons. (1) There is no requirement for new drugs/devices to be more effective or less costly than current and approved treatments; thus, expensive new therapies are adapted without good evidence that outcomes are improved over other drugs/devices, and patients may have little to gain from them.23 For example, survival after myocardial infarction is similar between the United States and Canada, but invasive testing, procedures, and surgery were 5 to 10 times higher in the United States than Canada.24 (2) There is significant variation in prices paid by private insurers, which is not secondary to quality of care, but bargains struck with health systems or private physicians. Medicare uses an adjusted cost model based on multiple factors including geographic region and medical education. (3) Delivery of surgical care is frequently marred by avoidable and costly events—patients do not receive the right care, procedures/tests are performed with questionable benefit, and complications lead to prolonged hospital stays, or worse, unnecessary readmissions and reinterventions. The focus should shift from quantity of life (lifespan) to quality of life (health span). Value-based care has been advocated as a healthcare delivery model in which providers (hospitals and physicians) are reimbursed for their services based on improved patient health outcomes delivered at the same or decreased cost. As a provision of value-based care, providers are rewarded for helping patients improve their health and live healthier lives in an evidence-based manner.\nIndeed, in health care, “Value” is defined as “Quality (or Outcomes) ÷ Cost,” although a more nuanced description of quality includes the six key domains identified by Institute of Medicine: safety, effectiveness, patient-centered, efficiency, timeliness, and equity.25\nDrivers of Value-based Care\nThere are multiple drivers and initiatives of value-based health care that have been developed to help improve health outcomes and reduce spending (fig. 2; table 1). While fee-for-service is a significant component of current practices, the drivers for change in U.S. health care continue to move the delivery systems to payment models with increased value-based care, alternative payment, and risk-based models in nearly every U.S. market.\nIf anything, COVID-19 has further established the need for acceleration of value-based care. A recent (October 2020) report from the Centers for Medicare and Medicaid Services (Baltimore, Maryland) has provided guidance that Medicare, Medicaid, and private insurance payers should coordinate with one another, and also calls on the state healthcare services to advance value-based care payment models.26 To provide some context, 34% of total U.S. healthcare payments were tied to alternative payment models in 2017, a steady increase from 23% 2 yr ago. The Centers for Medicare and Medicaid Services have a goal of all payments by 2025 being associated with value-based care.27 The move to value-based payment has bipartisan support, and therefore, the change in administration will not change the goals. Thus, during the next 5 yr, every healthcare organization in the country will face changes in their Medicare reimbursement.\nMost commercial health insurance providers are also participating in value-based care models and are accelerating the trend for providers/healthcare practices to assume greater risk. For instance, Humana (Louisville, Kentucky) reported decreased costs for its members/patients in its 2020 Value-based Care Report.28 Humana Medicare Advantage members would have incurred an estimated $4 billion in plan-covered medical expenses if they had been under the original fee-for-service model, instead of in value-based agreements.\nThe value-based programs reward healthcare providers with incentivized payments for the improved quality of care they provide to patients. This is an opportunity for anesthesiologists to partner with their surgical/medical colleagues and the hospital in realizing these incentives/savings. The anesthesiologist should become familiar with such value-based programs and whether their hospital/practice successfully participates in them (fig. 2; table 1). For instance, large employers have driven the creation of Centers of Excellence, a multidisciplinary and comprehensive program, that utilizes an institution’s expertise and resources to provide patients care in a very focused area of medical practice.29,30 This involves integrated practice and in some cases involves an integrated delivery and financial system. While benefits of participation in such multidisciplinary programs exist, in some specialties, such as bariatric surgery, the outcomes for patients who undergo surgery at Centers of Excellence sites may be no better than undergoing surgery at non–Centers of Excellence sites.31 Further disadvantages cited in the literature include decreased access to care (bariatric/orthopedic surgery) despite no difference in outcomes and the need for continued validation of Centers of Excellence criteria.32,33 A key issue is that the definition of Centers of Excellence can vary significantly, and this variability may affect the ability to judge quality.34 Another value-based care delivery model promoted by the Centers for Medicare and Medicaid Services, accountable care organizations, is comprised of a group of physicians, hospitals, and other healthcare providers, joining together to coordinate care among Medicare patients. The accountable care organizations are meant to ensure that patients receive appropriate care at the appropriate time, streamline communication, reduce medical errors, reduce duplication of services35 and, potentially, reduce mortality.36 But an accountable care organization does not guarantee success. A recent (2019) study of patients after spine surgeries failed to demonstrate a reduction in 90-day morbidity and mortality for patients who received care at an accountable care organization versus a non–accountable care organization.37 Further, the capital required to set up the information technology infrastructure for an accountable care organization and potential unequal sharing of costs between providers may be prohibitive. Regional care organizations have similar advantages and disadvantages when compared to accountable care organizations, except that they offer the services to Medicaid patients, and there is a much greater shared financial risk between provider and the organization.\nMany insurers (payors) have specialty programs such as bundled payments, shared cost savings, population-based payments, and pay-for-performance. The bundled payment model was introduced by the Centers for Medicare and Medicaid Services in 2009 under the Acute Care Episode. Results from the Acute Care Episode program focusing on orthopedic total hip and knee arthroplasties have shown overall hospital cost-savings, largely through reduction of supply costs including implants, improvements in staffing models, and reduction of length of stay.38 The Centers for Medicare and Medicaid Services have championed bundled payment incentives through their Bundled Payments for Care Improvement initiative, which linked payments for the multiple services beneficiaries received during an episode of care. Under the initiative, organizations entered into payment arrangements that included financial and performance accountability for episodes of care. Some of the pay-for-performance programs have been controversial and, indeed, some studies indicated that not only did pay-for-performance not improve quality or reduce cost, but it penalized physicians for caring for the poorest and sickest patients.39 Finally, universal health care has been proposed as an answer to population health, and indeed, in theory, this sounds like a perfect solution: All patients, everywhere, can receive diagnosis of and treatment for disease states. But as measured in a study from The Lancet in 2016, the issue is far more complex than all patients receiving “some kind of health care.” Indeed, the study states, “the pursuit of universal healthcare coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view and subsequent provision of quality health care for all populations.”40\nMany hospitals, administrators, and physicians continue to be focused on the fee-for-service model, which reinforces volume (vs. value), reinforces siloed work, and provides little incentive for real integration. In fact, some believe that it incentivizes futile surgery, waste, and low-value care. The COVID-19 pandemic is the stimulus for change to a more value-based marketplace. During the pandemic, there was a tectonic shift to telemedicine with delay in both nonurgent surgery and treatment of many medical conditions. Accountable care organizations offer the opportunity for health systems to preserve income during a potential resurgence of COVID-19 or a future pandemic.41 It would also allow innovation in care delivery like telemedicine or automatic hovering without concerns for fraud and abuse from inappropriate use in a fee-for-service environment. Similarly, bundles focused on conditions (e.g., back pain) rather than procedures will allow clinicians to determine the most cost-effective and patient-centered care rather than care dictated by the ability to send a bill or meet some insurer conditions of participation, and the potential development of such bundles was signaled by discussions at the 2019 Healthcare Learning and Action Network meeting (Washington, D.C.). At the time of the writing of this article, many of the regulations remain suspended, and the final decision on telehealth and the status of waivers could change future directions leading to an increased efficiency with the utilization of telemedicine.42,43\nIf value-based payments, shared savings, and global/bundled payments are the way of the future, this would require resources and better integration between the anesthesiology and surgical services. Anesthesiology requires innovation and strategies that pave the way for the future healthcare paradigm: to be paid not just for the quantity of services provided but for how well those services are delivered according to accepted outcome metrics that are patient-centered and team-based.\nPerioperative Care Transformation\nWorldwide, the two leading causes of mortality are attributed to heart disease and stroke, which, when combined, account for more than 25% (15 million) of mortal events.43 The third leading cause is 30-day postoperative mortality, which lays claim to 7.7% of all global deaths (4.2 million people).44 Previous literature in the United States established that 30-day postoperative mortality is third behind heart disease and cancer.45 Improving health outcomes after surgery is an opportunity for innovation and for creating greater value. In that regard, anesthesiologists can make significant impact through a few key approaches in the pre-, intra-, and postoperative periods. First, instead of using the preoperative encounter to only gather information to prevent same day delay or cancellation, we can use that sentinel surgical experience as a touchpoint for proactively improving population health as opposed to reactive medicine. Second, segmenting patients based upon their risk for low versus high variance procedures will not only help the hospital maintain efficiency but also help personalize care and garner significant societal benefits (figs. 3 and 4). Finally, for the patient to receive the best recovery possible, an evidence-based and data-guided approach to the standardization of processes for routine care and design of in-hospital and value-based perioperative pathways should be implemented. This will likely include greater patient engagement in their own care and “steerage” toward best postoperative care delivery such as the best rehabilitation programs.\nSurgical Event: Proactive and Preventative Medicine versus Reactive Medicine\nIn perioperative care, as in all businesses, the needs of the patient (customer), not the characteristics of the provider, define value. Thus, the entire surgical and concurrent medical pathway for the patient, not simply a component, should define the metrics used to measure success for all patients.46 For example, care delivery algorithms, such as enhanced recovery protocols, are not defined by only multimodal analgesia or early ambulation, but by compliance with the majority of measures in the pathway itself.47 The longitudinal cycle of care on the order of weeks to months, which encompasses the patient’s responsibility toward their health through the distant postoperative future and continued engagement to stay healthy, is far more important than the operative episode of only a few hours or days. Focusing only on the “inputs and outputs” of the system on these short episodic levels obscures the true relationship from a patient perspective, making the shorter cycle of care far less important than the longer cycle of care.46,48 This includes the decision to perform the surgery or procedure itself. In more direct terms: Once the decision for surgery is made, the use of sevoflurane versus isoflurane during an operative episode of care may not matter nearly as much as the patient’s reduction in body mass index, which may reduce the risk of diabetes, malnutrition, stroke, cardiovascular disease, and polypharmacy—all of which keep the patient from requiring the next, more invasive, procedure. Reactive medicine (the ability to help manage the patient from one episode to another) then becomes preventative medicine, and the surgical encounter, in many cases, becomes the first touchpoint for a patient to engage in and improve upon their own medical care.\nThis may not require hospital administration to invest in new resources for an anesthesiology department but may be accomplished through a reapplication of current resources. While at one time, our core function in the preoperative period was to gather and summarize all available and relevant information to help patients for their procedure, and to optimize throughput in the operating room, we should focus on utilizing intensive clinical databases to stratify risk, coordinate the entire perioperative process, and reduce silo-driven care. In many ways, this may even start before the final decision to undergo surgery, and we must be able to provide the patient with resources to understand the perioperative journey from best case to worse case.49 Only by understanding the patient’s goals, needs, values, and lifestyle can we make their health care work within that framework, and while many elements of perioperative medicine have been implemented at different institutions, few centers, if any, have successfully implemented the complete package of perioperative care.\nSeveral anesthesiology departments across the country have established comprehensive preoperative care centers to achieve these goals. Duke University (Durham, North Carolina) has a series of preoperative clinics designed to treat many modifiable risk factors before surgery including malnutrition, anemia, diabetes, and pain, while coordinating care throughout the perioperative period.50 Duke also provides a specific pathway for geriatric patients, who may be at increased risk of adverse outcomes postoperatively.50 Brigham and Women’s Hospital (Boston, Massachusetts) has established a Center for Perioperative Management and Medical Informatics, as well as a Center for Perioperative Research, analyzing short- and long-term patient outcomes, improvement of patient safety, and increasing efficiency, while facilitating pilot research projects designed to test strategies to promote high-quality perioperative care.51 Further, given the mounting evidence of postoperative delirium and cognitive dysfunction, they have also engaged in a robust program for the assessment and identification of risks to the brain postprocedure.52–55 At University of Pittsburgh Medical Center (Pittsburgh, Pennsylvania), the Center for Perioperative Care, which exists as series of outpatient clinics and an inpatient service, focuses not only on a cardiopulmonary assessment of patients but also on a holistic view of the patient, looking to modify risk and lifestyle and re-engage the patient in their community care.56 Utilizing machine-learning predictive algorithms and protocol-driven care, the program’s main goals are to (1) identify patients who are at high-risk for short- and long-term poor surgical outcomes, encouraging a “surgical pause” for the opportunity to mitigate risk; (2) design a program that provides a comprehensive menu of services aimed at improving both physiologic and psychosocial conditions that contribute to vulnerability of high risk, before their nonurgent or even urgent surgical procedure (e.g., comprehensive medical assessment, measurement of frailty and cognitive status, nutrition and weight management, cardiopulmonary rehabilitation, chronic pain and opioid management, drug and alcohol use, mental health evaluation, assessment for delirium and potential for postoperative cognitive decline, and supportive care [finances, transportation, and postoperative planning]); (3) provide at-risk patients with a supportive “surgery coach,” specifically trained in surgical preparation, who mentors patients, readying them for their surgical experience; and (4) engage an anesthesiologist-directed multidisciplinary team comprised of surgeons, primary care providers, and physician specialists all working in concert with the patient in a shared decision-making approach.\nImplementation of this clinic can be challenging within a fee-for-service system. Physicians and hospital administration must be convinced of several points: (1) healthier patients undergoing surgery will result in cost avoidance and reduced readmission; (2) healthy patients will always require surgery; and (3) focusing on cost avoidance and doing the right thing for the patient may reduce revenue, but will substantially increase profit margins. At the same time, it has been our experience that, in the past, many surgeons receive referrals for which they feel the only option is surgery, even though they are aware that the patients are not reasonable surgical candidates. Many times, they may feel “pushed into” the surgery by the patients and/or patient families because the medical personnel (internists, oncologists, cardiologists, and so forth) do not understand the postoperative course of an ill individual and assume that the patient will return to a normal quality of life. Additionally, this is how the surgical teams build their referral base. We, as anesthesiologists, are accustomed to the serious complications that can occur intra- and postoperatively. Because we know this well, we should see ourselves—and be seen—as vital to resetting the expectations of patients for their postoperative care in collaboration with the surgeons. In this way, we can present a united team with the surgeons in reducing mortality and complications, which ultimately results in cost avoidance and increased profit margins to both insurance payors and healthcare services.\nWe recognize smaller private practices might not be in the best position to implement some of these programs because those practices may not have the same resources and structures that already exist for large, multispecialty practices. Notwithstanding, their participation in cross-disciplinary programs such as enhanced recovery after surgery, perioperative surgical home, operating room cost reduction initiatives, and so forth, will enhance their role in improving healthcare delivery. Indeed, one of the best methods to become involved may be to establish a perioperative surgical home or participate in an accountable care organization.\nManaging Risk and Personalizing Care: Intraoperatively and Perioperatively\nSegmenting patients based on risk and complexity is important. While many of the care processes for patients seeking routine care can be implemented with a Focused Factory Model (standardization and established protocols), some patients and processes demonstrate significant complexity that requires management through a complex adaptive system approach.57 Hospitals are generally arranged as networks designed for interaction within multiple specialties/individuals/groups.57 A program should make use of a team of experts to develop protocols and decision logic, based upon current evidence, that can be executed with large swaths of patients, without requiring intensive resource utilization, of which the American College of Cardiology (Washington, D.C.)/American Heart Association (Dallas, Texas) Approach to Perioperative Cardiac Assessment for Coronary Artery Disease is a prime example.58 Patient risk and required assessment are categorized depending on severity of illness and procedure. Linear processes can drive standardized care for patients who are not complex. However, more complex patients require multiple interactions, nuanced in a tailored approach as in an adaptive system.57 The standardized or factory approach consists of low-complexity surgeries, which have lower risk, occur in higher volumes, and have less variance in procedure, where potential gains are related to high efficiency, care coordination, and discharge planning. Higher-complexity procedures are ones in which the population may have a higher variance and incidence of postoperative complications, where improved clinical outcomes are brought forth by a network of experts. For example, orthopedic procedures, such as total joint replacements, occur in high volumes and are lower-risk. Although many older elective orthopedic surgical patients most likely have some degree of preoperative cognitive impairment, such impairment is associated with development of delirium postoperatively, longer hospital stay, less likelihood of going home upon hospital discharge,53 and delayed return to cognitive health. This at-risk subset requires a more adaptive approach. This approach can also be used to determine the optimal location of care. These patients can be stratified preoperatively, but the innovation in intraoperative care is extremely important for their postoperative recovery.\nThree terrific examples have been reported. The Mayo Clinic (Rochester, Minnesota) implemented a focused-factory model for cardiac surgery in five stages: identification and segmentation of the population; creation of clinical pathways and protocols for all areas of care; design, building, and adoption of health information technology systems for communication and decision support; empowerment of bedside providers to advance (de-escalate) care by such protocols, when appropriate; and locating similar patients with similar complexity near each other.59 They found significant decreases in mortality across their population and significant improvement in complication rates for sepsis, pneumonia, and renal failure.\nAnother report describes patients requiring transaortic valve replacement being segmented based on underlying risk into distinct intraoperative conscious sedation and general anesthesia care and postoperative clinical care pathways, in an attempt to reduce cost and improve outcomes.60 They reported that conscious sedation for transaortic valve replacement was safe and could significantly reduce cost and improve outcomes (reduced length of stay and intensive care unit time) if the patient parameters were favorable, which included a transfemoral approach, no perfusion or operating room nurses on standby, and a surgeon in house but not scrubbed, with a fast-track recovery plan. This enables personnel to be available for other cases, as necessary.\nFinally, Anesthesiology published a study regarding value of patient segmentation for improving intra/perioperative care delivery and operating room throughput in orthopedic surgery.61 This study showed that with appropriately selected patients, spinal anesthesia for arthroplasties and parallel processing using induction rooms can result in patient out-of-room time of only 14 min and increase the number of cases per operating room per day. This style of operating room management can achieve high efficiency because of patient selection/segmentation. The selection criteria for more facile patients included those undergoing a primary joint replacement, an anticipated easy spinal anesthetic without contraindication, and patient willingness. Patients who did not meet these criteria had to have their care in regular operating rooms with more personalized care.\nThese examples are only a small subset of all surgeries that occur, and risk assessment is required in all specialties. It requires significant information technology, design, building, and testing in order to establish such a risk assessment algorithm that can accurately predict postoperative mortality and complications with anesthesia and surgery. Recent reports suggest successful development of such risk models using various machine-learning approaches. Several anesthesiology and perioperative care groups have developed adaptive models through “deep learning” to predict 30-day mortality.62,63 However, few have reported the results from implementation of these models in changing care delivery or clinical practice at the current time. With the ability to diagnose complications in the operating room well before they happen would come revolutionized intraoperative care, prevention of significant events, and further enhancement of postoperative recovery.\nWhile patients are risk-stratified, educated, given realistic expectations, and empowered to understand that they are the most important person in their care and recovery, this is only the beginning of the clinical pathway, and challenges remain in both the intra- and postoperative arenas. Requirements include integrating care outside of the hospital before and after surgery, standardizing intraoperative care, and effective use of in-hospital resources in the postoperative period. This brings about the concept of vertical and horizontal integration of pathways.64 Each surgical service line has a pathway by which they care for their patients. But there are disease states and treatment methodologies that will cross all surgical service lines, guided by the same tenets. The patient with hyperglycemia or diabetes still requires glucose control. The patient with congestive heart failure still requires specific care whether or not they have a total joint replacement or a Whipple procedure. Patients will still have discomfort and requiring pain management regardless of their procedure.\nEnhanced recovery protocols are a good example of innovation within the intraoperative and postoperative realm.65–75 Based on five major tenets of limiting preoperative fasting, minimally invasive surgical procedures, multimodal analgesia, early feeding, and early ambulation, these cross multiple surgeries. At the Kaiser Permanente (Oakland, California) integrated healthcare delivery system, two populations—colorectal and orthopedic surgery—saw the controlled and prospective implementation of the enhanced recovery protocol clinical pathway, with certain minor differences based upon the type of surgery. They found significantly reduced length of stay, reduced mortality, and reduced postoperative complications.76 At the University of Pittsburgh Medical Center, utilization of an enhanced recovery protocol across eight service lines in approximately 6,000 patients was significantly associated with improved discharge disposition and a reduction in mortality at 30 days and 1 and 2 yr, and compliance with only five or more elements of the enhanced recovery protocol was associated with better outcomes.77\nClinical pathways are important not only for patients and hospital systems but also for the significant value added for society in general. More than 100 million Americans experience chronic pain, and the treatments are upwards of $635 billion, which is more than the amount spent on heart disease and cancer combined ($552 billion).78 In 2014, 21.5 million American patients were diagnosed with a substance use disorder, and 10% of those involved prescription pain medications.79 There are 259 million opioid prescriptions written annually, more than enough to give every American adult their own bottle of pills.79 Drug overdose has been listed as the leading cause of accidental death in the United States, and the opioid epidemic is, in part, caused by these prescription opioids, many of which are given postsurgery.80 As anesthesiologists, we can have a direct impact on this epidemic, by coordinating perioperative pain medicine within the preoperative arena, partnering with surgical teams to coordinating team treatments, offering opioid-sparing/-free analgesia through our regional anesthesia teams, and developing a postsurgical and postdischarge pain plan for them. Two excellent examples from the literature show that anesthesiology-led acute and chronic pain services as part of a perioperative surgical home/comprehensive program have a significant role in improving outcomes and improving the opioid epidemic.81,82 Acute postoperative pain is usually well controlled in those institutions that have an anesthesia pain management service. The addition of multimodal analgesia and complimentary regional anesthesia has transformed perioperative care and can reduce the use of opioids for postoperative pain.83 Importantly, pain is frequently less well-controlled on general medical wards, even in institutions with an anesthesia pain management service, since the service usually focuses on management of epidural analgesia and peripheral nerve catheters. Improving the process of pain assessment and treatment in all hospitalized patients presents a significant opportunity for anesthesiologists to improve patient outcomes and decrease the overall cost of health care, thus improving value. Finally, we can add value by establishing pathways for who is discharged with opioids and how much they should have when they go home. Anesthesiologists can also be trained in palliative care and would be able to offer a more diverse repertoire of treatments to patients undergoing palliative procedures. Overall, increased training in perioperative medicine and critical care is essential for anesthesiologists to effectively participate in many such initiatives that can bring healthcare change for the surgical patients. All of these taken together create significant value for healthcare systems and for all of society.\nGap between Intention and Reality: Data and Variability\nCritical to successful implementation of these integrative pathways is the ability to garner reliable and meaningful data to inform us to continue on a current path or to help us fail quickly. The transition to an electronic record promised free-flowing data for rapid transformation of health care. The current dystopic state of somewhat poorly recorded and difficult-to-access medical record information creates a major barrier to defining success metrics. Healthcare data analytics and information technology are required platforms for any performance improvement initiative that is sustainable, and the data gathered should be used as an advantage and strength to help a department and organization compete more effectively. Anesthesiologists with direct knowledge of complications, perioperative mortality, and other metrics that impact performance can affect a hospital system’s and insurance payor’s ability to compete in a value-based system.\nIn that regard, anesthesiology departments can use their perioperative domain knowledge to help build or partner with the hospitals’ information technology groups in creating scalable and validated clinical and financial data marts and dashboards to implement value-based care initiatives.84 It can also help identify clinical comorbidities that can be used to help risk-adjust their value-based payments.\nWith continued growth of digital technology and software applications for improving health, several programs have implemented clinical decision support systems in their clinical practices, either as tools built within the institutions’ electronic health record or as standalone applications that interface with electronic health records. Digital health solutions can enable implementation of the clinical pathways and monitoring of compliance, all of which can help positively affect the course of patient success. As an example, clinical decision support was used to calculate a patient’s risk for postoperative nausea and vomiting based upon the information in the electronic health record.85 After institution, there was a clear reduction in postoperative nausea and vomiting with high compliance for the pathway. A reality in several critical care units,86 we can develop intraoperative clinical decision support by utilizing machine learning to predict adverse hemodynamic events and other crises in patients intraoperatively, leading to the practice of proactive, instead of reactive, perioperative medicine.87\nAnesthesiology and perioperative care are also beset with variability and lack of standardization in many of the routine clinical practices, which has been shown to negatively impact both outcomes and costs.88–93 For example, anesthesiologists demonstrate a lack of consensus on how much crystalloid to give during abdominal surgery. A two-center retrospective analysis of total crystalloid administration in nearly 6,000 patients during abdominal surgery revealed a widely variable range of administration anywhere between 2.3 ml · kg–1 · h–1 and 14 ml · kg–1 · h–1.92 Another example comes from a study describing significant interinstitutional difference in failure to rescue from complications after surgery. Among the majority of U.S. hospitals, while types and rates of postsurgical complications were similar (24 to 26%), mortality rates ranged from 12.5 to 21.4% depending upon how effective the failure-to-rescue processes were established in a given hospital.94 There are other barriers to practice that may account for such variability. Amalberti et al. discuss said barriers to change within the medical field, comparing safety profiles of surgical procedures and anesthesia to other unrelated medical fields. For example, cardiac surgery in American Society of Anesthesiology physical class III to V is only slightly safer than Himalayan mountaineering above 8,000 meters, but it is less safe than traveling by planes, trains, and automobiles, and is more than 1,000-fold less safe than the nuclear industry.95 Thus, an important role for anesthesiologists will be in trying to address the variability in perioperative practices and partnering with the other stakeholders in reducing the overall risk for the patients. As our focus expands from the operating theater to the continuum of care, we have a great opportunity to impact preventable harm and fully participate in population health goals of returning our patients to better physical, cognitive, and psychologic health. Relatively new tools of improvement science, safety science, implementation, and system safety science should be accelerators of change and integrate into evidence-based pathways of care for medical and surgical conditions.\nFinally, it is important to highlight that currently, while there are not a great deal of data to advocate for the programs that we have discussed, data are not generated without studies and deep dives into the issues surrounding patient care. Indeed, perhaps one of the most important contributions we can make as anesthesiologists is to directly involve ourselves in the research to assess and develop evidence-based approaches.\nAnesthesiologists have much to contribute to the advancement of value-based care through their multitude of interactions and influences on various aspects of surgical care. Perioperative medicine is not as much an expansion of our current roles as a rediscovery of our value to the healthcare community at large, whether it be patient or provider. It doesn’t imply abdication of our excellence in providing care in the operating rooms. Not all anesthesiologists, however, will be able or willing to play a role in these new activities, but a subset will need to do so, and should be supported by their colleagues in their efforts. Nonetheless, the time has come for us to increase our value, to work as an integrated unit with hospital and surgeon leadership, and to become leaders ourselves, realizing that our goals are the same: providing better care at decreased cost, increasing standardization, establishing clinical pathways and quality metrics, utilizing data and clinical decision support along the way for iterative improvement, and sharing of results with other institutions for our continued improvement across the nation and world.\nSupport was provided solely from institutional and/or departmental sources.\nDr. Mahajan is Founder of Sensydia, Inc. (activity not related to the subject matter of the manuscript); and received a stipend from the National Institutes of Health (Bethesda, Maryland) as a National Institutes of Health Study Section Reviewer (activity not related to the subject matter of the manuscript). The other authors declare no competing interests. |
Macs 20 Multi-Parameter ECG MonitorPrice on estimate\nMonitor for patients, multi-parameter\nMacs 20 offers monitoring capability and functionality in an intuitive way. It responds to the unique pace and needs of intensive care for adults, children and newborns. It is designed for anesthesia and perioperative care, as well as cardiac care settings.\nWarranty 1 year parts and labor\ntechnical sheet (contact us)\nRef : MON / M20 |
Envision Physician Services is seeking a Site Medical Director in Washington, PA\nMust be Board Certified in Emergency Medicine or Board Certified in Primary Care with Emergency Department and administrative experienceFACILITY INFORMATION\nSince 1897, Washington Hospital has been dedicated to providing the highest quality care to patients in southwestern Pennsylvania. The Washington Hospital is a voluntary, not-for-profit community hospital. Features include a 239-bed hospital with a 17-bed Transitional Care Unit, a 16-bassinet Nursery and an 8-bed residential hospice. Washington utilizes the most advanced medical technology in its state-of-the-art facilities. Washington is part of the Pittsburgh metro area and 30 minutes from the heart of Pittsburgh.\nWashington, Pennsylvania is a suburb of Pittsburgh and has a population of almost 14,000 residents. Specialized transit services allow for easy access to downtown Pittsburgh. Washington Park is 255 acres of beautiful woodland and is perfect for outdoor sports and walking trails. Other points of interest include The Bradford House, The LeMoyne House, Washington and Jefferson College and the Tanger Outlets.\nBENEFITS AND COMPENSATION\nEnvision Physician Services is a dynamic physician- and clinician-led medical group that has been offering exceptional career opportunities for more than 60 years. With more than 25,000 affiliated clinicians coast-to-coast, Envision Physician Services is nationally recognized for delivering clinical excellence supported by innovation, integration and exceptional leadership.\nCandidates considering becoming a teammate at Envision Physician Services will find full-time, part-time and independent contractor opportunities available in a variety of community types, from rural and underserved communities to major metropolitan areas; practice settings, from small hospitals to academic health systems; and job levels, from entry level to senior management. Envision teammates also benefit from the following resources:\n*Benefits vary by division, clinical specialty and employment status.COMPANY INFORMATION\nEnvision Physician Services is a leading national medical group, delivering care when and where it's needed most. Our team of 25,000 clinicians specializes in anesthesiology, emergency medicine, hospital medicine, radiology, surgery and women's and children's care. Together, we care for more than 32 million patients a year and support healthcare partners across 45 states and the District of Columbia\nAs a part of Envision Healthcare, we are making a meaningful difference in patients' lives and driving innovations that improve the delivery of care and the health of communities in every corner of America. We treat more than 15 percent of the country's emergency department visits, deliver more than 120,000 babies, conduct more than 10 million radiology reads and provide more than 2.6 million anesthesia cases each year.\nWe are focused on protecting and empowering clinicians so they can focus on what matters most – caring for patients. We do this by providing mental health and well-being resources, administrative support, clinical best practices, clinical research opportunities, leadership coaching and more. Our unique structure enables us to develop local practices that support clinicians with regionally-based clinical leaders and operational expertise from our expansive nationwide network.\nEach Envision partner facility or health system has its own unique culture, but all of our sites recruit and hire clinicians who share the group's core values of being patient-focused, team-oriented and caregiver-inspired.\nEnvision Physician Services values the diverse perspectives and experiences of our teams. We recognize that through our collective expertise, we can improve the delivery of care for patients and clinicians. Learn more about our commitment to diversity, equity and inclusion here and how we are supporting clinician wellness here. We are proud to be an EOE/AA employer.\nContact InformationShow Contact Details\nDate Posted: 6/4/2021\nJob Id: 2092126\nEnvision Physician Services (www.envisionphysicianservices.com) is America’s leading national medical group, providing anesthesiology, emergency medicine, hospital medicine, radiology, surgical services, and women’s and children’s health services to more than 1,800 clinical departments in 45 states and D.C.. As a part of Envision Healthcare, we lead the delivery of care and treat more than 35 million patients every year.\nWe are focused on what matters most—our patients. By protecting and empowering our team of more than 25,000 clinicians through wellness resources, administrative support, clinical best practices, clinical research, leadership opportunities and more, we deliver the best care to patients when and where they need us most.\nEnvision Physician Services is built for your career in medicine — wherever it takes you. You’ll find an opportunity that fits your needs, schedule and goals at any stage of your journey.\nSign up to receive job postings that match your search criteria —\ndelivered to your inbox daily! |
A chin implant is used to give more projection to an under-projecting chin. There can be a number of types of under-projection, and it is important to make the proper diagnosis, as a chin implant alone is only used in a situation where the occlusion (the way the teeth fit together) is normal. If the chin retrusion is severe enough, a bony advancement may be needed rather than a chin implant. Houston plastic surgeon, Dr. Wiener, will guide you through the process of deciding whether a chin surgery in Houston is the answer to improve your facial aesthetics. Dr. Wiener serves chin surgery patients from all over Houston including Pearland and League City, Texas. Chin implant patients choose Dr. Wiener for his extensive chin surgery knowledge and cutting edge techniques.\nWhat types of Chin Implants does Dr. Wiener use?\nDr. Wiener prefers the silicone implant due to ease of placement and also easier removal, if necessary. There are a number of other types of chin implant materials available, but these don’t have a significant advantage over the silicone implant. For most men in Houston, an extended implant is often used to give more fullness to the sides of the chin. For women in League City or Pearland, a standard chin implant is frequently used in order to avoid an overly masculine appearance.\nHow is Chin Implant surgery in Houston done?\nDr. Wiener places most chin implants using intravenous anesthesia along with local anesthetic nerve blocks. The local anesthetic gives prolonged postoperative pain control. Most implants in Dr. Wiener’s practice are placed through a submental incision (an incision just underneath the chin) near the chin crease. The advantage of this is typically a good scar, less chance of infection compared to the incision inside the mouth, and no restrictions on food after surgery in Houston. A small pocket is made underneath the chin tissues, on top of the jawbone at the chin, and the implant is placed in the pocket. The tissues are closed with absorbable sutures.\nHow will I look and feel after surgery?\nThere will be some swelling that will be most noticeable the first week after surgery, and all swelling may take 2-3 months to fully resolve. There may also be some initial bruising, but Dr. Wiener will give you a medication to help minimize bruising. Numbness will occur initially due to the nerve blocks, but all numbness from the surgery itself may take a week or more to go away, and in rare instances, numbness can be prolonged. There may be some lower lip dysfunction for a week or two, and rarely longer. The surgery is typically not overly painful, but there is a sensation of pressure over the chin for a few days.\nAre there restrictions after a Chin Implant surgery?\nYou will be at somewhat restricted activity for a few weeks. No strenuous exercise for 3 weeks, and avoidance of bumping the chin for 3-4 weeks to minimize the chance of displacement of the implant.\nWhat are the benefits of a Chin Implant?\nA chin implant can help balance the facial harmony and restore adequate projection to the chin, and it may also help improve mild skin excess of the neck. A more refined profile can boost self-esteem, and give someone the self-confidence that they have been searching for. Dr. Wiener performs chin implant surgery to patients in Houston and the surrounding areas like Missouri City or Sugar Land. His office is conveniently located 11 miles South of Pasadena, TX, in Clear Lake. If you are considering chin implant surgery, call our office today to schedule a one-on-one consultation with Dr. Wiener. During the consultation, he will go over your reasons for wanting chin implant surgery and what type of incision would be right to achieve the results you are looking for.\nimagine the change\nDr. Thomas Wiener, MD, FACS is a board-certified plastic surgeon specializing in Breast Augmentation, Breast Revision, Liposuction,\nand Mommy Makeover.Dr. Wiener has serves Houston, Clear Lake, and Pearland, Texas.\nAll Rights Reserved.\nHouston Online Marketing & Web Design by Studio III |
#Cheek Augmentation/ #Facial Rejuvenation\nI appreciate your question.\nCost varies by geographic location, surgeon expertise, OR time, anesthesia, length of procedure etc. I would recommend that you go to The American Society of Plastic Surgery website and look for a list of board certified plastic surgeons in your area. You can call their offices in advance and ask for quotes prior to scheduling consultations.\nThe best way to assess and give true advice would be an in-person exam.\nPlease see a board-certified plastic surgeon that specializes in aesthetic and restorative plastic surgery.\nBest of luck!\nBoard Certified Plastic Surgeon\nDirector-Beverly Hills Breast and Body Institute\nCheek augmentation with implants\nCheek augmentation with implants includes facility fee, anesthesia fee and surgeon's fee. If done in local anesthesia with sedation the cost is in the range of $4500-6500 in South Florida. Recovery is associated with minimal discomfort and minimal/moderate swelling for up to 2 weeks. You can go back to your job in 2-3 weeks in full capacity.Cheek augmentation can also be achieved with fat grafting or soft tissue fillers, or any combination of these three modalities as needed.You should consult a board certified plastic surgeon with good reputation in facial rejuvenation (in particular facial implants) for detailed evaluation and discuss your options. Good luck.\nCost of a cheek implant procedure\nThe cost of a cheek implant procedure is directly determined by actual cost of the implants, cost of anesthesia, cost of the operating room, and the cost for the surgeon who placed the implants and all the postoperative follow-up appointments. For more information and chin implant before and afters, in addition to our price list, please see the link and video below\nTotal cost for cheek augmentation?\nHi, non smiling photos of your face from the front and side would help with the evaluation. I have performed many facial shaping procedures using dermal fillers, facial implants (cheek, chin), liposuction and/or facelifts for over 30 years. Following the beauty principles outlined in my book on face and body beauty, women look the most feminine, youthful and attractive with heart shaped faces. Heart shaped faces have cheeks that are full and round in the front. Cheek augmentation with a dermal filler or using cheek implants for a permanent enhancement will create full, round cheeks that will feminize the entire face. Conversely, men look chiseled and handsome with angularity in the cheeks, chin and mandibular angles. Cheek augmentation, with cheek implants, would require you to avoid strenuous activity for 3-4 weeks after the procedure. If you can do that, it might be best to use a dermal filler to shape the cheeks.Hope this helps.\nThe amount of filler needed to augment your cheeks depends on how much volume you have lost and need to be filled. There is no one answer for you especially without knowing your facial anatomy and which filler you are interested in. Please consult an expert. Voluma is my favorite product for this area. Best, Dr. Green |
The aim of this study was to evaluate the current practice of acute\npostoperative pain management in the 3 major referral hospitals\nof Asmara, Eritrea.\nMethods: Cross sectional survey of 50 (out 70) medical professionals\nwho care for postoperative patients by means of a questionnaire.\nThe questionnaire included 16 questions in the following\ncategories: availability of analgesic drugs, pain assessment, prescribing\npattern of analgesics for post operative pain management,\ntools, equipment, techniques, judgment about adequacy of analgesia,\ncauses of inadequacy, documentation of pain and consequent\ntreatment and continuing medical education regarding pain management.\nThe 50 postoperative care providers were 12 surgeons,\n13 nurse anaesthetist, 5 nurses and 20 health assistants.\nResults: None of the participants reported the use of regional analgesia,\ntransdermal patches or multimodal approach. The majority\n(75%) of the participants preferred NSAI as a sole analgesic (Diclofenac\ni.m.) followed by Pethidine i.m. Analgesia was reported\nto be inadequate by majority (52%). Poor documentation was observed\nas eighty percent of nurses and health assistants don’t document\nany patient complaints and/or consequent interventions.\nThe major constraint reported was lack of continuing medical education\nafter graduation (92%). Other problems were unavailability\nof analgesic drugs (68%), improper prescription of the analgesia\n(58%) and underutilization of Physician service to manage pain\nJournal of Trauma and Orthopedic Nursing received 4 citations as per Google Scholar report |
Mrs./Ms. Abigail L Thomas specializes in certified registered nurse anesthetist in Green Bay, WI and has over 4 years of experience in the field of medicine. She graduated from her medical school with her medical degree in 2017. She is affiliated with numerous hospitals in Wisconsin and more, including Aurora Baycare Medical Ctr. Mrs./Ms. Abigail L Thomas is licensed to practice by the state board in Wisconsin (153064).\nMrs./Ms. Abigail L Thomas also practices at 2845 Greenbrier Road, Green Bay, WI. She is accepting new patients at her medical office, and available for appointments, preventative care, medical care as well as ongoing patient care.\nCheck Mrs./Ms. Abigail L Thomas's office address in Green Bay, WI and make an appointment.\nLet us know if this doctor no longer has an office or not practice in Green Bay, WI, report a correction and it's FREE!\nPrimary specialty: Certified Registered Nurse Anesthetist\nWith more than 4 years of experience, Mrs./Ms. Abigail L Thomas has been identified as specializing in certified registered nurse anesthetist specialist.\nDoctors can have one or more medical licenses for different specialities in Wisconsin or different states. Related medical licenses for Mrs./Ms. Abigail L Thomas are as mentioned below:\nWhat is Nurse Anesthetist, Certified Registered?\n(1) A licensed registered nurse with advanced specialty education in anesthesia who, in collaboration with appropriate health care professionals, provides preoperative, intraoperative, and postoperative care to patients and assists in management and resus... [View more]\nShe was educated at the following institutions:\nAn affiliated hospital is a hospital where a doctor can practice and admit patients. Affiliation usually means doctors can admit patients to a hospital. Mrs./Ms. Abigail L Thomas is professionally affiliated with the following hospitals in Green Bay area and more:\nThis doctor has multiple office locations in Wisconsin and more. See office information for details.\nMrs./Ms. Abigail L Thomas does not have any insurances listed.\nIf your insurance plan is accepted and have any questions regarding your insurance, please visit the office location or contact to get information about insurances provided by this doctor.\nThere are currently no reviews for Abigail in Green Bay, Wisconsin.\nTell us about your experience by posting a comment about Abigail in Green Bay, Wisconsin to help others decide which doctor is right for them. |
CHAPTER 15 Hospital Dental Services for Children and the Use of General Anesthesia\nDentists can provide essential services to patients within an operating room setting in addition to providing consultative and emergency services. Staff membership is necessary. National commissions such as the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]) issue the standards for hospital governance for all hospital services.\nIn recent years, with the increasing number of general practice residencies and postdoctoral specialty programs, the qualified dentist finds that hospital staff privileges are a necessity. Active involvement in hospital dentistry has added a rewarding component to the practice of many dentists. Many hospitals have incorporated not only dental specialties but also general dental services, providing a comprehensive health care facility in which to serve the community.\nAdditional requirements may have to be met to obtain staff privileges. Many hospitals ask staff members to sign a “Delineation of Privileges” form indicating the procedures that staff members are qualified to perform and that are accepted by the governing body of the hospital. In addition, the applicant must show proof of professional liability insurance, and membership in the American Dental Association is desirable.\nIn a children’s hospital, dentists might be required to have adequate advanced training to treat and manage children in the hospital. The requirements may include a dental residency of 1 to 4 years in a teaching hospital in which the dentist (1) gains experience in recording and evaluating the medical history and current medical status of children; (2) receives instruction in physical examination techniques and in recognition of conditions that may influence dental treatment decisions; (3) learns to initiate appropriate medical consultations when a problem arises during treatment; (4) learns the procedure for admitting, monitoring, and discharging children; and (5) develops proficiency in operating room protocol. A rotation in which the dental resident was actively involved in administering general anesthetics to children is highly desirable. Current certification in basic cardiopulmonary resuscitation should be maintained by all members of the hospital’s professional staff, including dentists.\nAs active members of the hospital staff, dentists should be aware of the hospital’s bylaws, rules, regulations, and meetings. A copy of the bylaws should be obtained for easy reference. Fully understanding the responsibilities of staff membership will enable dentists to treat their patients within the established protocol of the institution. Most important, dentists should endeavor to provide the highest quality care within the specialty area for which they are trained. The American Academy of Pediatric Dentistry encourages the participation of pediatric dentistry practitioners on hospital medical-dental staffs, recognizes the American Dental Association as a corporate member of the Joint Commission, and encourages hospital member pediatric dentists to maintain strict adherence to the rules and regulations of the policies of the hospital medical staff.\nThe use of general anesthesia for dental care in children is sometimes necessary to provide safe, efficient, and effective care. Depending on the patient, this will be done in an ambulatory care setting or inpatient hospital setting. It should be only one component of the dentist’s overall treatment regimen. Oral hygiene and preventive care must be implemented at the onset of treatment with parents or guardians and patients to eliminate the cause of the dental problem.\nThe safety of the patient and practitioner, as well as the need to diagnose and treat, must justify the use of general anesthesia. All available management techniques, including acceptable restraints and sedation, should be considered before the decision is made to use a general anesthetic. Crespi and Friedman cite several authors who agree in recommending that at least one or two attempts be made using conventional behavior management techniques or conscious sedation before general anesthesia is considered.1\nParental or guardian written consent must be obtained before the use of general anesthesia. Documentation regarding dental treatment needs, unmanageability in the dental setting, and contributory medical problems must be included in the patient’s hospital record. Records must be clearly written so others are able to read and understand them. Review organizations examine dental admissions for proper documentation in the hospital chart for insurance payment and quality assurance purposes.\nIf the benefits of the procedure outweigh the risk of anesthesia, there are few if any contraindications to general anesthesia. However, when a concern about the medical condition exists, an anesthesia consult would be desirable. Patients for whom general anesthesia is usually contraindicated include those with a medical contraindication to general anesthesia and healthy and cooperative patients with minimal dental needs.\nHospitalization is a frequent source of anxiety for children. According to King and Nielson, 20% to 50% of children demonstrate some degree of behavioral change after hospitalization.2 Separation of the child from the parent appears to be a significant factor in post-hospitalization anxiety, although other causes are also documented. Allowing the parent to stay with the child during the hospitalization, and especially to be present when the child leaves for and returns from surgery, can reduce anxiety for the child and parent alike.\nAccording to Camm and colleagues, postoperative behavioral changes reported by mothers in a limited sample of children who received dental treatment with general anesthesia in a hospital were similar to those observed in children who received treatment under conscious sedation in a dental clinic.3 Mothers of children receiving dental treatment with general anesthesia in a hospital setting were found to experience more stress during the procedure. Ways to decrease these stresses include the following: providing a prior tour of the operating room facility, informing the parents of the status of the child during the procedure, and letting them know that “everything is all right.” Seventy-five percent of the children receiving general anesthesia exhibited some type of behavioral change. Positive changes included less fuss about eating, fewer temper tantrums, and better appetite. Negative changes included biting the fingernails, becoming upset when left alone, being more cautious or avoiding new things, staying with the parent more, needing more attention, and being afraid of the dark. Ways to minimize negative changes include (1) involving the child in the operating room tour, (2) allowing the child to bring along a favorite doll or toy, (3) giving preinduction sedation, (4) providing a nonthreatening environment, (5) giving postprocedure sedation as needed, and (6) allowing parents to rejoin their children as early as possible in the recovery area.\nTo limit the severity and duration of psychologic disturbances, the dentist should strive to reduce parental apprehension concerning the operative procedure. Because children often sense apprehension in their parents, effectively reducing the parents’ anxiety will put the child more at ease. Thoroughly explaining the procedure, describing the normal postanesthetic side effects, and familiarizing the child and parents with the hospital can reduce postoperative anxiety.\nPeretz and colleagues concluded that children treated for early childhood caries under general anesthesia or under conscious sedation at a very young age behaved similarly or better in a follow-up examination approximately 14 months after treatment than at their pretreatment visit, as measured by the Frankl scale and by the “sitting pattern.”4\nFuhrer and colleagues found children were more likely to exhibit positive behavior at their 6-month recall appointment following dental treatment for childhood caries under general anesthesia versus those treated under oral conscious sedation.5\nDuring the past 30 years, the popularity of outpatient anesthesia and surgery has continually increased. Currently more than 70% of all pediatric surgical and diagnostic procedures are performed on an outpatient basis. The criteria for and advantages of ambulatory general anesthesia procedures are well recognized. The increasing cost of inpatient hospital care, advances in anesthetic management, and quality assessment of patient care have led to changes in preoperative and postoperative management of many surgical procedures done under general anesthesia that were previously assumed to be possible only on an inpatient basis. Ambulatory care is more expeditious, better tolerated both by family and hospital teams, and less traumatic for the patient. Development of freestanding ambulatory care surgical centers (i.e., same-day surgery centers) and hospital ambulatory surgical care areas has cut health care costs for consumers and third-party providers. The advances in perioperative anesthesia care are related to the wider availability of more highly qualified anesthesia care providers (board-certified anesthesiologists with subspecialty training) and the availability of modern, safer short-acting anesthetic and adjuvant drugs and monitoring equipment. A number of studies have reported a significant decrease in anesthesia-related morbidity and mortality in children over the past 2 decades.\nGood patient selection is an important criterion of a successful outpatient surgery program. A young child or adolescent who requires a general anesthetic and is free of any significant medical disorders (i.e., is categorized as class I or II on the American Society of Anesthesiologists (ASA) physical status classification—see Box 14-1) can be considered a candidate for outpatient surgery. Certain patients with well-controlled chronic systemic diseases such as asthma, diabetes, and congenital heart disease can also be considered for outpatient anesthesia following prior consultation with an anesthesiologist.\nWhen the outpatient surgery is planned, the child undergoes a complete preoperative evaluation, including a comprehensive medical history and physical examination, anesthesia assessment, and limited hematologic evaluation. Many medical facilities allow this preadmission preparation to be performed outside of the medical outpatient treatment facility. Biery and associates suggest that routine laboratory tests, such as urinalysis and complete blood count with indices and electrolyte levels, are not cost effective nor are they necessary for patients categorized as ASA class I in whom the prior complete medical history and physical examination was unremarkable.6\nAs an outpatient, the child should be brought by the parents to the hospital at least 1½ hours before the dental surgery. The nursing staff will verify that all preoperative instructions have been followed and that the appropriate laboratory tests have been performed. Several hours after the procedure is completed, the patient is released to the parent or guardian. Postoperative instructions are given, and a follow-up appointment is scheduled.\nThe dentist will be more responsible for team communication, physical assessment, management, and postoperative evaluation for outpatient procedures under general anesthesia than for inpatient procedures. Ferretti reported that pediatric outpatient general anesthesia patients must have reliable parents or guardians to qualify for treatment.7 For example, the parents must have transportation available to return the child to the hospital in case postoperative complications develop at home.\nThe child should be treated as an inpatient if a medical condition exists that requires close follow-up, if the child lives outside the general area of the hospital, or if the parents demonstrate questionable ability to comply with preoperative or postoperative instructions. In many instances, medically or developmentally disabled patients with multiple problems requiring lengthy dental treatment are not good candidates for ambulatory care using general anesthesia. However, even some of these patients can be managed in an ambulatory setting when they are properly assessed and when no postoperative complications are anticipated.\nOnce the decision has been made that a general anesthetic would be preferable for a pediatric patient, the dentist should evaluate the child’s medical history, the current medical status, and the possibility of complications resulting from the procedure. This risk assessment process is discussed in Chapter 14, and the patientclassification categories are shown in Box 14-1. The parents should be told of any potential complications, and their informed consent must be obtained (Fig. 15-1).474\nIntraoperative medical complications of dental patients with and without disabilities undergoing general anesthesia have been reported at 0% to 1.4%. In a survey of 200 pediatric dental general anesthesia cases, Enger and Mourino indicated that the most common postoperative complications following general anesthesia in children younger than the age of 5 years were vomiting, fever, and sore throat.8 Treatment of complications consisted of administration of antiemetic medications for nausea with vomiting, ice chips for sore throat, and acetaminophen (Tylenol) for fever postoperatively. Bradley and Lynch found that no significant long-term complications resulting from anesthesia or operative procedures were observed in 100 disabled and nondisabled patients.9\nThe Joint Commission requires that all patients admitted to a hospital or treated under general anesthesia as an outpatient have a physical examination performed by a physician or qualified dentist. The child’s physician must therefore be consulted for the completion of a comprehensive medical history and physical examination (Box 15-1). If the physician is not a member of the hospital staff, a staff physician should complete the medical history and physical examination before admission. The dentist should perform a thorough intraoral examination and submit a record of the findings together with a summary of the child’s dental history and the reason for admission (Box 15-2). The hospital must be notified to reserve an appropriate surgical suite and a bed for the child. Two weeks before admission or an outpatient dental surgery appointment, a letter containing general instructions concerning the procedure, results of the dental examination, and pertinent dates and times should be mailed to the parents. |
October 23, 2008\nSelf-made billionaire offers $75-million motivator to curb pet overpopulation\nAward goes to the scientist who invents non-surgical, safe means to sterilize dogs, cats\nBy: Jennifer Fiala\nFor The VIN News Service\nA wealthy, retired orthopedic surgeon is dangling a $75-million carrot in front of anyone who can curb pet overpopulation by inventing a non-surgical and safe means to sterilize animals.\nRetired orthopedic surgeon Gary Michelson made his initial fortune by inventing spinal implants and now holds 185 patents, earning him a spot on Forbe’s 2007 list of world billionaires. According to reports, he donated $10 million last year to saving unwanted animals in Los Angeles.\nNow the 59-year-old animal lover has launched the Michelson Prize in Reproductive Biology to see if researchers can solve pet overpopulation. The international competition involves granting $25 million to the first person or group to invent a safe, one-time non-surgical means to sterilize companion animals. An additional $50 million is being offered to support the research of those who present reasonable approaches.\n“We’re killing millions of pets annually in the U.S. for the simple lack of a home, and sterilization programs are the only viable solution,” Michelson says. “Animal-welfare experts have long recognized sterilization as the most important component in the fight against pet overpopulation.”\nHe speculates that a lack of funding has stood in the way of researchers on the verge of discovering pet contraceptives and non-surgical sterilants. Surgical spay and neuter is not ideal, he says, because it requires anesthesia and adequately equipped facilities, both of which create cost obstacles for those who rescue homeless pets.\nVIN News Service commentaries are opinion pieces presenting insights, personal experiences and/or perspectives on topical issues by members of the veterinary community. To submit a commentary for consideration, email [email protected]. |
|Year : 2020 | Volume\n| Issue : 12 | Page : 1018-1024\nA randomised controlled comparison of serratus anterior plane, pectoral nerves and intercostal nerve block for post-thoracotomy analgesia in adult cardiac surgery\nRohan Magoon1, Brajesh Kaushal1, Sandeep Chauhan1, Debesh Bhoi2, Akshay K Bisoi3, Maroof A Khan4\n1 Department of Cardiac Anaesthesia, Cardio and Neurosciences Center, New Delhi, India\n2 Department of Anaesthesiology, Pain Medicine and Critical Care, New Delhi, India\n3 Department of Cardiothoracic and Vascular Surgery, Cardio and Neurosciences Center, New Delhi, India\n4 Department of Biostatistics, AIIMS, New Delhi, India\n|Date of Submission||17-May-2020|\n|Date of Decision||01-Jul-2020|\n|Date of Acceptance||26-Aug-2020|\n|Date of Web Publication||12-Dec-2020|\nDr. Brajesh Kaushal\nDepartment of Anaesthesia, Gandhi Medical College and Hamidia Hospital, Bhopal - 462 001, Madhya Pradesh\nSource of Support: None, Conflict of Interest: None\nBackground and Aims: Enhanced recovery after cardiac surgery is centred around multimodal analgesia which is becoming increasingly feasible with the advent of safer regional analgesic techniques such as fascial plane blocks. We designed this prospective, single-blind, randomised controlled study to compare the efficacy of serratus anterior plane block (SAPB), pectoral nerves (Pecs) II block, and intercostal nerve block (ICNB) for post-thoracotomy analgesia in cardiac surgery. Methods: 100 adults posted for cardiac surgery through a thoracotomy were randomly allocated to one of the three groups: SAPB, Pecs II or, ICNB wherein the patients received 2.5 mg/kg of 0.5% ropivacaine for ultrasound-guided block after completion of surgery. Postoperatively, intravenous (IV) paracetamol was used for multimodal and fentanyl was employed as rescue analgesia. Visual analogue scale (VAS) was evaluated at 2, 4, 6, 8, 10 and 12 hours post-extubation. Results: The early mean VAS scores at 2, 4 and 6 hours were comparable in the 3 groups. The late mean VAS (8, 10 and 12 hours) was significantly lower in the SAPB and Pecs II group compared with that of the ICNB group (P value <0.05). The cumulative rescue fentanyl dose was significantly higher in ICNB group compared to SAPB and Pecs II group (P value <0.001). The SAPB group had the highest time to 1st rescue analgesic requirement in contrast to the other groups. Conclusion: SAPB and Pecs II blocks are simple single-shot effective alternatives to ICNB with a prolonged analgesic duration following thoracotomy and can potentially enhance pain-free recovery after cardiac surgery.\nKeywords: Adult cardiac surgery, intercostal nerve block, pectoral nerve block, postoperative pain, serratus anterior plane block, thoracotomy\n|How to cite this article:|\nMagoon R, Kaushal B, Chauhan S, Bhoi D, Bisoi AK, Khan MA. A randomised controlled comparison of serratus anterior plane, pectoral nerves and intercostal nerve block for post-thoracotomy analgesia in adult cardiac surgery. Indian J Anaesth 2020;64:1018-24\n|How to cite this URL:|\nMagoon R, Kaushal B, Chauhan S, Bhoi D, Bisoi AK, Khan MA. A randomised controlled comparison of serratus anterior plane, pectoral nerves and intercostal nerve block for post-thoracotomy analgesia in adult cardiac surgery. Indian J Anaesth [serial online] 2020 [cited 2021 Feb 26];64:1018-24. Available from: https://www.ijaweb.org/text.asp?2020/64/12/1018/303239\n| Introduction|| |\nA conventional cardiac surgical setting presents peculiar impediments to an unabated incorporation of regional analgesic modalities considering the technical difficulties, risks associated with haemodynamic perturbations and epidural haematoma against the background of the requirement of systemic heparinisation., Nevertheless, an augmented embracement of the modern safer regional analgesic techniques increasingly motivates the cardiac anaesthesiologists to formulate effective regional-centric multimodal analgesic schemes, particularly pertinent to the present era of opioid sparing.,,,\nDespite the advent of minimally invasive cardiac surgery (contemplating alternative surgical approach such as an anterolateral thoracotomy compared to the traditional midline sternotomy), postoperative pain, respiratory compromise and consequential pulmonary morbidity present significant management concerns. In addition, a conglomeration of factors ranging from surgical incision, chest wall retraction and muscle layer splitting to postoperative insertion of the chest drain collectively contribute to the nociceptive-pathway stimulation culminating as post-thoracotomy pain (PTP). PTP adversely affects the depth of breathing and the ability to cough leading to hypoxemia, atelectasis and other post-operative respiratory impediments to an early recovery.,\nThe aforementioned elucidation of the importance of ensuring effective post-thoracotomy analgesia in conjunction with an early recovery continues to evoke interest in the regional analgesic approach to PTP management. While the intercostal nerve block (ICNB) has been extensively studied and employed for post-thoracotomy analgesia, the literature on improved analgesia with fascial plane blocks such as serratus anterior plane block (SAPB) and pectoral nerves (Pecs II) block is promising., Nevertheless, the dearth of comparative evaluation of the existing and upcoming regional analgesic modalities, particularly in the setting of thoracotomy for adult cardiac surgery prompted this index study staging a randomised controlled comparison of post-thoracotomy analgesic efficacy of SAPB, Pecs II and ICNB.\n| Methods|| |\nThis prospective, single-blind, randomised comparative trial was conducted at a tertiary care cardiothoracic center and was duly approved by the institutional ethical committee (IECPG-284/7.09.2017, RT-37/28.09.2017) and registered at ctri.nic.in (CTRI/2018/01/011610). The study complied with the CONSORT 2010 randomised controlled trial (RCT) statement guidelines [Figure 1].\nThe index study included 100 American Society of Anesthesiologists (ASA) physical status II-III participants in 15–40 years age group scheduled for an elective cardiac surgery through a thoracotomy incision in the time period from February 2018 to September 2019. The patients were excluded if they were unable to perform the visual analogue scale (VAS), or had previous thoracic surgeries. An emergency surgical setting, known ropivacaine allergy; infection at the injection site; or derangement in the coagulation parameters (platelet count <100 × 103/μL, prothrombin and activated partial thromboplastin time >1.5 times of the normal, or an international normalised ratio >1.5) constituted additional study exclusions.\nA written informed consent was obtained from all the study participants. The preoperative cardiac medications were continued and premedication was administered in the form of (0.1 mg/kg morphine and 0.5 mg/kg promethazine) intramuscularly. After wheeling into the operating room, standard ASA monitoring was initiated including: 5-lead electrocardiogram, non-invasive blood pressure and pulse oximetry following which a peripheral intravenous (IV) and an arterial line were secured. General anaesthesia was induced and maintained alongside capnography and bispectral index monitoring as per standard institutional protocol. The hemodynamic parameters were maintained within 20% of the baseline. A posterolateral incision in the 4th or 5th intercostal space was performed. In the patients requiring extracorporeal support for assisting a surgical correction, cardiopulmonary bypass (CPB) was instituted under adequate heparinisation. Following the successful CPB weaning, the anticoagulant effect of heparin was adequately reversed with injection protamine in order to achieve baseline activated clotting time.\nAfter completion of surgery, one of the 3 regional nerve blocks (SAPB, Pecs II, or ICNB) was performed under ultrasound-guidance wherein the group allocation was assisted by a computer-generated random number table and concealed with the help of coded, opaque and sealed envelopes. The blocks were performed under aseptic precautions using a Philips – L 12–3 linear array transducer (Philips Inc, USA) in a sterile cover with jelly and a 21-gauge 100 mm Stimuplex A sterile block needle (B. Braun, Melsungen, Germany).\nSAPB was performed in a lateral decubitus position with the ultrasound probe oriented in a sagittal plane over the mid-clavicular thoracic region. The fifth rib and the overlying muscles such as latissimus dorsi, teres major and serratus anterior were identified in the mid-axillary line. The needle was introduced into the plane deep to the serratus anterior muscle and 2.5 mg/kg of 0.5% ropivacaine was injected in this plane under ultrasound-guidance [Figure 2]a.\n|Figure 2: Depiction of the SAPB sonoanatomy with the needle directed (at the level of the fifth rib) toward the optimal plane for local anaesthetic deposition below the serratus anterior muscle (a); Ultra-sonographic image outlining the Pectoralis major and minor muscles (b); Pecs II block with the needle drug injection hydro-dissecting the plane between the pectoral muscles (c); Sonoanatomy of the intercostal musculature and adjacent ribs for administering ICNB (d). LA: Local anaesthetic; LD: Latissimus dorsi; TM: Teres Major; P Major: Pectoralis major; P Minor: Pectoralis minor|\nClick here to view\nPecs II block was performed in a supine position with the ultrasound probe oriented inferolaterally in the mid-clavicular region. The pectoralis major and minor muscles were outlined [Figure 2]b. The needle was introduced at the level corresponding to the 4th rib, heading, from medial to lateral direction toward the anterior axillary line. Thereby the needle was advanced until the rib and then it was withdrawn so as to position the tip in the plane between serratus anterior and pectoralis minor muscle. A total of 1.25 mg/kg of 0.5% ropivacaine (half the total dose) was injected after confirming a negative aspiration. Following the initial drug injection, the needle was meticulously withdrawn so that the tip lay between the two pectoral muscles, and 1.25 mg/kg of 0.5% ropivacaine (rest of the dose) was injected after careful aspiration [Figure 2]c.\nICNB was performed in a lateral decubitus position with the ultrasound probe oriented longitudinally and the cranial aspect (of the probe) slightly laterally rotated at the posterior angulation of the concerned rib. The three layers of intercostal muscle (innermost, internal and external) were outlined in the space between the adjacent ribs. Subsequently, the needle was introduced and advanced carefully into the innermost intercostal muscle layer, and 0.5% ropivacaine was administered (after negative aspiration for air or blood) in divided doses at the incisional level and two spaces below and above the incision. The total drug administered amounted to 2.5 mg/kg, in congruence with other two study groups [Figure 2]d.\nFollowing the administration of the block, the patients were shifted to the intensive care unit (ICU). The study participants were extubated on meeting the following criteria (conscious, haemodynamic stability, peak inspiratory pressure <20 cmH2O, no residual neuromuscular blockade and satisfactory arterial blood gas analysis). The patients requiring postoperative ventilation for more than three hours were excluded from the analysis. VAS score was assessed at 2, 4, 6, 8, 10 and 12 h post-extubation. The mean computed scores were classified as early (2, 4 and 6 h) and late (8, 10 and 12 h) VAS. All the patients received IV paracetamol, 15 mg/kg, 8 hourly. Rescue analgesia was provided in the form 0.5–1 μg/kg IV fentanyl so as to maintain the post-extubation VAS score ≤4 premised on the assessment of the observer anaesthesiologist who was blinded to the group allocation. The intraoperative and 12-h postoperative fentanyl consumption was recorded. The time to first rescue analgesic requirement was estimated as the duration elapsed following the block administration. Participants were discharged from the ICU once the haemodynamic parameters were stable (on minimal inotropic/vasopressor support), satisfactory respiratory status (extubated with acceptable arterial blood gases and airway patency), oxygen requirement no more than an FiO2 of 60%, neurologic stability and no other significant post-operative complications such as vomiting which could preclude oral acceptance.\nA sample size of 90 adults was estimated based on the finding of a pilot study evaluating the mean post-extubation VAS amongst the SAPB, Pecs II and ICNB groups (2.9 ± 0.47, 3.22 ± 0.51 and 3.75 ± 0.56, respectively) to ensure 90% power at α = 0.05. Hence, 100 adults were included considering the possibility of dropouts.\nThe statistical analysis was performed using The Stata software, Version 14 (StataCorp LP, College Station, TX). The continuous data was expressed as mean and standard deviation, whereas the qualitative data were expressed as frequencies and percentages. The association between qualitative variables was examined using the Chi-square test/Fisher's exact test. One-way analysis of variance followed by Bonferroni correction was performed for comparison among the groups. A P value <0.05 was considered to be statistically significant.\n| Results|| |\nA total of 100 patients undergoing cardiac surgery through a thoracotomy incision were initially recruited. After exclusion of 9 patients (3 patients excluded due to intraoperative conversion to sternotomy prior to randomisation and 6 patients excluded after randomisation due to prolonged intubation >3 h postoperatively) the data of 91 participants (30 in SAPB group, 31 in Pecs II group and 30 in ICNB group) was analysed [Figure 1]. The demographic profile, baseline characteristics and the extubation time were comparable in the three groups [Table 1].\n|Table 1: Demographic profile and peri-operative characteristics of the study participants|\nClick here to view\nThe trend of the post-extubation mean VAS scores is depicted in [Figure 3], wherein the early VAS scores (2, 4, 6 h, post-extubation) were comparable in the SAPB, Pecs II and ICNB group. However, the late VAS scores (8, 10 and 12 h, post-extubation) were significantly lower in the SAPB group in contrast to the ICNB group (P value <0.001). The Pecs II group also demonstrated significantly lower VAS score as compared to the ICNB group at 10 hours (P < 0.001) and 8, 12 h post extubation (P < 0.05). With regards to the comparison within the fascial plane blocks, there was no significant difference between the SAPB and Pecs II groups except the mean post-extubation VAS score at 12 h which was significantly lower in SAPB (3.23 ± 0.50) compared to the Pecs II group (3.71 ± 0.69) (P value <0.05) [Table 2].\n|Figure 3: VAS trends upto 12 h post-extubation (a); Number of patients demonstrating a VAS >4 in the three groups at different time points (b)|\nClick here to view\n|Table 2: Mean VAS in the three groups throughout the first 12 h post extubation|\nClick here to view\nThe cumulative postoperative rescue fentanyl consumption was greatest in the ICNB group (0.67 ± 0.16 μg/Kg) and was considerably higher than the SAPB (0.21 ± 0.04 μg/Kg) and Pecs II groups (0.23 ± 0.06 μg/Kg) (P value <0.001). The mean time to rescue analgesic requirement was highest in the SAPB group (11.7 ± 0.29 h) signifying a prolonged analgesic duration in contrast to other blocks (Pecs II: 11.44 ± 0.34 h; ICNB: 10.92 ± 0.61 h). The length of stay in the ICU was significantly lower in the fascial plane groups (SAPB, Pecs II) as opposed to the ICNB group [Table 3].\nNo noteworthy complication related to the block performance, such as an intravascular injection, haematoma formation or neural injury was observed in any of the study participants. Other postoperative adverse effects: nausea, vomiting, bradycardia, hypotension, pruritus and respiratory depression, were comparable among the three groups.\n| Discussion|| |\nThe study demonstrates a satisfactory efficacy of the fascial plane blocks and ICNB in the early PTP management (within 6 h of extubation) while a superior efficacy of the fascial plane blocks in the late postoperative period (6–12 h following extubation) is outlined by the significantly lower mean VAS scores in the fascial plane block groups compared to the ICNB group [Table 2].\nThe liaison between minimising invasion in cardiac surgery (such as thoracotomy approach) and an effective PTP can prove instrumental to attain fast-tracking in cardiac surgery., While the PTP management can be particularly challenging owing to the richly innervated thorax (necessitating the administration of systemic opioids and other non-opioid analgesics precluding an early recovery), safe and effective regional thoracic analgesic techniques can potentially provide a viable solution.\nIn this context, ultrasound-guided fascial plane blocks are receiving increased attention closely backed up by a refined comprehension of the sonoanatomy of these blocks. Originally described in the setting of breast surgery by Blanco et al.,, the initial literature accumulating on the role of these innovative blocks in post-thoracotomy analgesia is encouraging. However, the majority of the available research focuses on SAPB in thoracotomy with only scarce literature pertaining to the application of Pecs II in thoracotomy. A three-armed RCT by Saad and colleagues evaluated the efficacy of pre-incisional SAPB, thoracic paravertebral block (TPVB) in comparison to systemic analgesic approach following thoracotomy in 90 patients. They revealed lower VAS scores in the SAPB and TPVB groups compared to systemic analgesia up to 9 postoperative hours. However, the pain scores beyond 12 h were lower for the TPVB group in contrast to the SAPB group although the haemodynamics were better maintained in the patients receiving SAPB. There are a few case series depicting reduced pain following thoracic trauma with the contemplation of Pecs II block., Kumar et al. delineated the analgesic and opioid-sparing benefits of Pecs II block in their case series of 10 patients undergoing video-assisted thoracoscopic surgery.\nThe demonstration of a superior analgesic profile of SAPB and Pecs II compared to ICNB in this index study [Figure 3] is the extension of our previous experience with the pre-incisional administration of blocks in a RCT in paediatric thoracotomies for congenital cardiac surgery. However, we performed a post-operative block in the present study given the highly variable surgical duration in adult cardiac surgery (incorporating relatively smaller procedures like patent ductus arteriosus ligation to more time consuming valve replacement surgeries). Similar finding elucidating the superiority of postoperative SAPB over ICNB has also been discovered in a retrospective cohort study involving 42 post-thoracotomy patients by Öksüz et al. Moreover, the duration of analgesic cover provided by SAPB in the present study (11.7 ± 0.29 h) is in congruence with the previous literature.\nTo the best of our knowledge, this was the first trial comparing SAPB, Pecs II and ICNB for acute post-operative PTP management in adult cardiac surgical subset. The prolonged analgesic duration of SAPB and Pecs II blocks explain the much lower, almost one-third post-operative rescue fentanyl requirement in the former groups compared to the ICNB group [Table 3]., This can be attributed to the elevated systemic absorption and rapid clearance of the drug from the highly vascular intercostal bed, whereas the deposition of the local anaesthetic (LA) drug in a myofascial plane of interest is expected to more selectively block the higher-order ramifications of the branches of the intercostal nerves.,,, In addition, other analgesics such as non-steroidal anti-inflammatory drugs were avoided in all the study participants, particularly given a cardiac surgical setting where the former can potentially predispose to postoperative bleeding and/or acute-kidney injury. Moreover, ropivacaine constitutes a safer LA option in cardiac patients considering a lower cardiotoxicity potential.\nThere were a few limitations in our study. First, inclusion of a control group could have substantiated the methodological credibility of the RCT furthermore. Second, the lack of assessment of VAS beyond 12 h post extubation limits the conclusiveness of interesting study observations such as lower VAS in the SAPB compared to the Pecs II group at the 12th h after extubation. Third, patient controlled rescue analgesia could have been incorporated. Lastly, the addition of other adjuvants and/or continuous catheters constituted additional feasible options to prolong postoperative analgesia.\n| Conclusion|| |\nThe study concludes that the fascial plane blocks like SAPB and Pecs II block are simple, single-shot and effective alternatives to ICNB with a longer postoperative analgesic duration, thereby representing a promising inclusion to the regional analgesic repertoire for PTP management in cardiac surgical arena. The increasing recognition and incorporation of such novel analgesic modalities as the major component of multimodal analgesic scheme can potentially minimise the opioid requirement and augment an enhanced postoperative recovery after cardiac surgery.\nDeclaration of patient consent\nThe authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.\nFinancial support and sponsorship\nConflicts of interest\nThere are no conflicts of interest.\n| References|| |\nMittnacht AJC, Shariat A, Weiner MM, Malhotra A, Miller MA, Mahajan A, et al\n. Regional techniques for cardiac and cardiac-related procedures. J Cardiothorac Vasc Anesth 2019;33:532-46.\nChoudhury A, Magoon R, Sahoo S, Sehgal L. Opioid free cardiac surgery: Opportunities and obstacles. J Cardiothorac Vasc Anesth 2020;34:567-8.\nMagoon R, Makhija N, Sarkar S. Erector spinae plane block and cardiac surgery: “A closer look'. J Clin Anesthesia 2020;60:8.\nMagoon R, Choudhury A. Opioid free anesthesia. Is it too early to bid adieu? Can J Anesth 2019;66:1268-9.\nKaushal B, Chauhan S, Saini K, Bhoi D, Bisoi AK, Sangdup S, et al\n. Comparison of the efficacy of ultrasound-guided serratus anterior plane block, pectoral nerves ii block, and intercostal nerve block for the management of postoperative thoracotomy pain after pediatric cardiac surgery. J Cardiothorac Vasc Anesth 2019;33:418-25.\nKavanagh BP, Katz J, Sandler AN. Pain control after thoracic surgery. A review of current techniques. Anesthesiology 1994;81:737-59.\nWurnig PN, Lackner H, Teiner C, Hollaus PH, Pospisil M. Fohsl-Grande B. Is intercostal block for pain management in thoracic surgery more successful than epidural anaesthesia? Eur J Cardiothorac Surg 2002;21:1115-9.\nJack JM, McLellan E, Versyck B, Englesakis MF, Chin KJ. The role of serratus anterior plane and pectoral nerves blocks in cardiac surgery, thoracic surgery and trauma: A qualitative systematic review [published online ahead of print, 2020 Feb 16]. Anaesthesia. 2020;10.1111/anae.15000. doi: 10.1111/anae.15000.\nKelsheimer B, Williams C, Kelsheimer C. New emerging modalities to treat post-thoracotomy pain syndrome: A review. Mo Med 2019;116:41-4.\nChin KJ, Pawa A, Forero M, Adhikary S. Ultrasound-guided fascial plane blocks of the thorax: Pectoral I and II, serratus anterior plane, and erector spinae plane blocks. Adv Anesth 2019;37:187-205.\nBlanco R, Parras T, McDonnell JG, Galino AP. Serratus plane block: A novel Ultrasound-guided thoracic wall nerve block. Anaesthesia 2013;68:1107-13.\nBlanco R, Fajardo M, Parras Maldonado T. Ultrasound description of Pecs II (modified Pecs I): A novel approach to breast surgery. Rev Esp Anestesiol Reanim 2012;59:470-5.\nSaad FS, El Baradie SY, Aliem M, Ali MM, Kotb TAM. Ultrasound-guided serratus anterior plane block versus thoracic paravertebral block for perioperative analgesia in thoracotomy. Saudi J Anaesth 2018;12:565-70.\nKumar V, Gaber M, Moore F, Castresana M. Ultrasound guided pectoral nerve block (PEC 1 and 2) as an alternative for pain management in patients with multiple rib fractures. In: Spring 2016 Abstract Titles: ASRA 41st\nAnnual Regional Anesthesiology and Acute Pain Medicine Meeting March 31 – April 2, 2016, New Orleans, LA. Reg Anesth Pain Med 2016;41:651.\nJoyce A, Ivie R, Ketchandji D. Use of subpectoral interfascial plane blocks to reduce ventilatory requirements following cardiopulmonary resuscitation: A case series. Pain Med (United States) 2019;20:609-10.\nKumar V, Gaber M, Moore F, Castresana MR. Pectoral blocks as an alternative for pain management after video assisted thoracoscopic surgeries and its potential role in enhancing postoperative recovery. Anesth Analg 2016;122(Suppl 3):S325.\nÖksüz G, Sayan M, Arslan M, Urfalioğlu A, Öksüz H, Bilal B, et al\n. The comparison of serratus anterior plane block versus intercostal block for postoperative analgesia following thoracotomy surgery. Anestezi Dergisi 2018;26:223-8.\nÖkmen K, Ökmen BM. The efficacy of serratus anterior plane block in analgesia for thoracotomy: A retrospective study. J Anesth 2017;31:579-85.\nKumar S, Goel D, Sharma SK, Ahmad S, Dwivedi P, Deo N, et al\n. A randomised controlled study of the postoperative analgesic efficacy of ultrasound-guided pectoral nerve block in the first 24 h after modified radical mastectomy. Indian J Anaesth 2018;62:436-42.\n] [Full text]\nKhemka R, Chakraborty A. Ultrasound-guided modified serratus anterior plane block for perioperative analgesia in breast oncoplastic surgery: A case series. Indian J Anaesth 2019;63:231-4.\n] [Full text]\nLuo M, Liu X, Ning L, Sun Y, Cai Y, Shen S. Comparison of ultrasonography-guided bilateral intercostal nerve blocks and conventional patient-controlled intravenous analgesia for pain control after the Nuss procedure in children: A prospective randomized study. Clin J Pain 2017;33:604-10.\nMoore DC, Bush WH, Scurlock JE. Intercostal nerve block: A roentgenographic anatomic study of technique and absorption in humans. Anesth Analg 1980;59:815-25.\nSakamoto H, Akita K, Sato T. An anatomical analysis of the relationships between the intercostal nerves and the thoracic and abdominal muscles in man. I. Ramification of the intercostal nerves. Acta Anat (Basel) 1996;156:132-42.\nAbdallah FW, Cil T, MacLean D, Madjdpour C, Escallon J, Semple J, et al\n. Too Deep or Not Too Deep? A propensity-matched comparison of the analgesic effects of a superficial versus deep serratus fascial plane block for ambulatory breast cancer surgery. Reg Anesth Pain Med 2018;43:1-8.\nGarg R. Regional block: Walking away from central to peripheral nerves and planes for local anaesthetic drug deposition. Indian J Anaesth 2019;63:517-9.\n] [Full text]\nKuthiala G, Chaudhary G. Ropivacaine: A review of its pharmacology and clinical use. Indian J Anaesth 2011;55:104-10.\n] [Full text]\n[Figure 1], [Figure 2], [Figure 3]\n[Table 1], [Table 2], [Table 3] |
Spinal fusion is a surgical procedure used to correct problems with the bones (vertebrae) of the back (spine). The spine is stabilized by fusing together two or more vertebrae, using bone grafts and metal rods and screws.\nSpinal fusion is used to treat:\nSpinal fusion eliminates motion between vertebral segments, which can be a significant source of pain in some patients. The surgery also stops the progress of spinal deformity, such as scoliosis.\nSpinal fusion will take away some spinal flexibility. But most spinal fusions involve only small segments of the spine and thus do not limit motion very much.\nCross-section of a normal spine (inset left) and cross-section of a protruding disk (inset right).\nMore than 325,000 spinal fusions were performed in 2003. About 137,000 procedures involved the upper (cervical) spine. About 162,000 involved the lower (lumbar) spine.\nBone is the most commonly used material to help promote fusion of the vertebrae. Generally, small pieces of bone are placed into the space between the vertebrae to be fused. Sometimes larger solid pieces are used to provide immediate structural support.\nThe bone is either supplied by the patient (autogenous bone) or harvested from other individuals (allograft bone).\nAutogenous bone is generally better at promoting fusion, but it requires extra surgery to remove bone from the patient’s hip. Allograft bone, on the other hand, is readily available from bone banks. Bone-graft substitutes are being developed, but have yet to be proven as cost-effective substitutes for autogenous bone graft for general use.\nAfter bone grafting, the vertebrae are held together to allow fusion to progress. The bones are held immobile with metal rods and screws. External bracing or casting may also be used. Both forms of immobilization may be necessary in some patients.\nIf you have persistent back pain or pain in your thigh, buttock, or leg; numbness or tingling in your leg; and/or weakness in your leg, and it does not respond to conservative, nonsurgical treatment, your family doctor can refer you to an orthopaedic surgeon for an evaluation.\nYou and your orthopaedic surgeon will determine whether you would benefit from low back surgery that relieves pressure on the nerves in the spinal cord and/or stabilizes the spine.\nThe orthopaedic evaluation consists of four components:\nYou may be asked to stop taking certain medicine or to stop smoking to prepare for surgery. Depending on your age and general medical fitness, you may be asked to undergo a general medical checkup by your family doctor.\nSome medicines may interfere with or affect the results of your surgery. They may cause bleeding or may interfere with the effects of your anesthesia. These medications include aspirin and nonsteroidal anti-inflammatory drugs. Your doctor may ask you to stop taking the medication before your surgery.\nDonating blood usually is not necessary for most low back surgery that does not include fusing vertebrae together. However, there is always a chance that some blood loss will occur during surgery. Your doctor will discuss the advantages and disadvantages of donating your own blood compared with using someone else’s blood. If you decide to donate your own blood, your doctor may prescribe an iron supplement to help build up your blood before surgery.\nYou will be able to walk after surgery, but you may need to arrange for some help with washing, dressing, and household activities, such as cleaning, laundry, and shopping, for a few days after your return home. Your orthopaedic surgeon will probably recommend that you do not drive a car for a period of time after surgery. You will need to arrange for transportation to and from your hospital appointments and to other places that you need to go during this time. You should consult your doctor before taking car trips.\nThe incidence of complications after low back surgery is low. Risks for any surgery include bleeding and infection. For spinal fusion surgery, complications include difficulties with urination (retention) and temporary decreased or absent intestinal function. Major complications that can occur include, but are not limited to:\nAlthough rare, new nerve damage can occur as a result of this surgery. These complications may result in pain and prolonged recovery time.\nPatients usually are admitted to the hospital on the day of surgery. After admission, you will be taken to the preoperative preparation area where you will be interviewed by a doctor from the anesthesia department, who will review your medical history and physical examination reports. You and your doctor will discuss the type of anesthesia to be used. (Sometimes this is done during an outpatient visit up to 7 days before your surgery.) The most common types of anesthesia used for low back surgery are general (you are asleep for the entire operation) or spinal (you may be awake but have no feeling from your waist down).\nThe surgical procedure usually takes from 1 to 3 hours, depending on your problem. Your orthopaedic surgeon will remove a portion of bone and ligament overlying the nerve roots and will remove displaced disk material to relieve pressure on the nerve roots. Fusion is sometimes done at the same time, if an instability (spondylolisthesis) is present.\nWhen your surgery is completed, you will be moved to the recovery room, where you will be observed and monitored by a nurse until you awake from your anesthesia. You will have an intravenous (IV) line inserted into a vein in your arm. You also may have a catheter inserted into your bladder to make urination easier.\nWhen you are fully awake and alert, you will be taken to your hospital room. Your IV line and catheter will be removed soon after.\nThere is usually pain for the first few days after surgery. Pain medication will be given regularly, perhaps by a patient-controlled analgesia. You will probably require a urinary catheter.\nThe fused spine must be kept in proper alignment. You will be taught how to move properly, reposition, sit, stand, and walk.\nWhile in bed, you will be instructed to turn frequently using a “log rolling” technique. This maneuver allows your entire body to move as a unit, avoiding twisting of the spine.\nYou may be discharged from the hospital with a back brace or cast. Your family will be taught how to provide care at home.\nAfter your discharge from the hospital, you will need to follow your doctor’s orders exactly to ensure a successful recovery. You should arrange for transportation home that will allow you to ride in a leaning back or lying down position. You may do as much for yourself as you can as long as you maintain a balanced position of your spine. You should not stay in bed during the day. Do not hesitate to ask for help from your family members or friends if it is needed. If necessary, arrangements can be made for a home health aide.\nYour wound may be closed with stitches (sutures) or staples, which will be removed approximately 2 weeks after surgery. If the wound is clean and dry, no bandage is needed. If drainage continues after you are home, the wound should be covered with a bandage and a call made to your surgeon.\nSome loss of appetite is common. Eating well-balanced meals and drinking plenty of fluids are important. Your doctor may recommend an iron supplement or vitamins before and after your surgery.\nLoss of energy is frequently experienced after major surgery, but this improves over time. An exercise program designed to gradually increase your strength and stamina may be prescribed. Initially, your doctor will recommend that you should only participate in walking. Later, your doctor will encourage you to swim or use an exercise bike or treadmill to improve your general physical condition.\nIt is important that you carefully follow any instructions from your doctor relating to warning signs of blood clots and infection. These complications are most likely to occur during the first few weeks after surgery.\nWarning signs of possible blood clots include the following:\nOccasionally, a blood clot will travel through the blood stream and may settle in your lungs. If this happens, you may experience a sudden chest pain and shortness of breath or cough. If you experience any of these symptoms, you should notify your doctor immediately. If you cannot reach your doctor, someone should take you to the hospital emergency room or call 911.\nInfection following spine surgery occurs very rarely. Warning signs of infection include:\nIf any of these symptoms occur, you should contact your doctor or go to the nearest emergency room immediately.\nAfter you have recovered from your low back surgery, you may continue to have some achy pain in your lower back; this may be persistent. You can reduce the pain by staying in good physical condition. If you are overweight, you should enroll in a program to help you lose weight and keep it off.\nYour doctor will evaluate you after your surgery to make sure that your recovery is progressing as expected.\nLast reviewed and updated: September 2007\nAAOS does not review or endorse accuracy or effectiveness of materials, treatments or physicians. |
Fernandes CR, Ruiz Neto PP -O Sistema Respiratório e o Idoso: Implicações Anestésicas\nJustificativa e Objetivos -As complicações respiratórias são responsáveis por grande parte dos óbitos após procedimentos c i r ú r g i c o s q u e o c o r r e m n a p o p u l a ç ã o g e r i á t r i c\nConteúdo -São apresentadas as alterações respiratórias fisiológicas do envelhecimento. São enfatizadas as alterações de volume e capacidades pulmonares, da mecânica respiratória e de trocas gasosas proporcionadas pela a n e s t e s i a . S ã o a b o r d a d o s a s p e c t o s r e l a t i v o s à morbimortalidade pulmonar pós-operatória em geriatria\nMorbid obesity has a profound effect on respiratory mechanics and gas exchange. However, most studies were performed in morbidly obese patients before or after anesthesia. We tested the hypothesis that anesthesia and abdominal opening could modify the elastic and resistive properties of the respiratory system. Eleven morbidly obese and eight normal-weight patients scheduled for gastric binding and cancer treatment, respectively, under laparotomy were studied. Respiratory mechanics, partitioned into its lung and chest wall components, were investigated during surgery by means of the end-inspiratory inflation occlusion method and esophageal balloon at five time points. Static respiratory and lung compliance were markedly reduced in obese patients; on the contrary, static compliance of chest wall presented comparable values in both groups. Obese patients also presented higher resistances of the total respiratory system, lung and chest wall, as well as "additional" lung resistance. Mainly in obese patients, laparotomy provoked a significant increase in lung compliance and decrease in "additional" lung resistance 1 h after the peritoneum was opened, which returned to original values after the peritoneum had been closed (P < 0.005). In obese patients, low respiratory compliance and higher airway resistance were mainly determined by the lung component.\nThe esophageal balloon is the most common method to obtain indirect pleural pressure. In sedated or anesthetized patients without major respiratory compliance changes, esophageal pressure variation corresponds to pleural pressure variation when PEEP is applied.\nIt has been suggested that malignant hyperthermia and exercise-induced rhabdomyolysis are closely related syndromes. Patient died before any specific investigation of malignant hyperthermia, but it is important to look for susceptibility for this syndrome within the family to avoid potentially life-threatening anesthetic events.\nResearch was conducted in multiple database (MEDLINE from 1965 to 2011, Cochrane Library, and LILACS), and in crossed references with the surveyed material aiming the identification of articles with the best methodological design. Following the findings, critical evaluation of the contents and classification according to the strenght of evidence were performed. The research was conducted between December 2010 and April 2011. For PubMed, were used the following strategies:\nThis study aims to evaluate the viability of a clinical model of remote ischemic preconditioning (RIPC) and its analgesic effects. It is a prospective study with twenty (20) patients randomly divided into two groups: control group and RIPC group. The opioid analgesics consumption in the postoperative period, the presence of secondary mechanical hyperalgesia, the scores of postoperative pain by visual analog scale, and the plasma levels interleukins (IL-6) were evaluated. The tourniquet applying after spinal anesthetic block was safe, producing no pain for all patients in the tourniquet group. The total dose of morphine consumption in 24 hours was significantly lower in RIPC group than in the control group (p = 0.0156). The intensity analysis of rest pain, pain during coughing and pain in deep breathing, showed that visual analogue scale (VAS) scores were significantly lower in RIPC group compared to the control group: p = 0.0087, 0.0119, and 0.0015, respectively. There were no differences between groups in the analysis of presence or absence of mechanical hyperalgesia (p = 0.0704) and in the serum levels of IL-6 dosage over time (p < 0.0001). This clinical model of remote ischemic preconditioning promoted satisfactory analgesia in patients undergoing conventional cholecystectomy, without changing serum levels of IL-6.\nBackgroundPreoperative anxiety and distress can produce significant psychological impacts on children undergoing oncologic care or investigation. Adjuvant therapy is used for pain management in children; however, pre-analgesia options are restricted because they can cause undesirable outcomes.ObjectivesOur study aimed to investigate the use of gabapentin in procedural sedation as adjuvant therapy in children undergoing oncologic treatment.MethodsWe performed a double-blinded, randomized, clinical trial at Albert Sabin Infant’s Hospital in Fortaleza, Brazil. Children aged 1 - 6 years who had myelogram or lumbar puncture (associated or not with intrathecal chemotherapy) received placebo or gabapentin syrups (15 mg/kg and 30 mg/kg) one to two hours before the procedure. Preoperative anxiety was evaluated by the Yale preoperative anxiety scale modified (m-YPAS scale). The pediatric anesthesia emergence delirium (PAED) and children and infants postoperative pain scale (CHIPP) scales were used for emergence delirium and pain intensity measurement, respectively.ResultsWe evaluated 135 patients. We observed that the gabapentin groups presented lower m-YPAS scores than the placebo group at separation and induction times. Postoperatively, the gabapentin groups had lower PAED and CHIPP scores than the placebo group; however, only had PAED scores clinical relevance. No significant differences were found between the gabapentin groups. Furthermore, children with less than three prior similar procedures were more likely to benefit from gabapentin. Postoperative vomiting was prevented by 30 mg/kg gabapentin.ConclusionsAlthough gabapentin has little preoperative effects, it ameliorates anxiety before induction, improves anesthetic induction, and reduces the occurrence of emergence delirium and postoperative vomiting up to eight hours after the procedure. Thus, we indicate gabapentin as adjuvant therapy for procedural sedation.\nscite is a Brooklyn-based startup that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health. |
Anesthesia and Sedation for Dentistry\nPhysicians have been performing diagnostic and surgical procedures using some form of sedation for many years. Many minor procedures involving the knee, wrist, nose, ears and feet are often preformed while the patient is comfortably sedated. Such care not only makes the patient more comfortable but can also provide protection to the patient should the stress associated with the procedure cause undesirable physiological symptoms like an increase in heart rate or blood pressure.\nIf the dental procedure has the potential to make the patient uncomfortable, there are several anesthesia and sedation options available that can make the dental procedure more comfortable. A number of factors will be considered, including the patient's overall health, the nature of the procedure, and the patient's anxiety level before deciding which option is most appropriate for the situation.\nLocal anesthesia is the medication used to numb the area in which dental treatment is to take place. A gel form of the medication can be placed on the surface of the mucosa to numb it prior to delivery of the local anesthetic. The local anesthetic will take several minutes to completely numb the area to be treated and will last a couple of hours following the appointment.\nNitrous Oxide (Laughing Gas)\nNitrous oxide is an inhaled gas that is delivered through a small mask that fits over the nose. It is mixed with oxygen and helps patients relax during their treatment. The gas's effect appear quickly and end quickly once the gas delivery is stopped. For this reason, patients are usually able to resume their regular daily activity, including driving, following their appointment. Nitrous oxide is considered a light form of sedation and some patients will not respond to its effects. Local anesthesia must be used in combination with nitrous oxide to prevent the patient from feeling pain.\nOral sedatives are administered in either liquid or pill form and are drugs similar to Valium®. The medication may be prescribed to take the night before the appointment to obtain a restful night sleep or within an hour of the appointment. These medications are frequently combined with nitrous oxide and offer a deeper level of sedation than nitrous oxide alone. Because they take time to absorb into the system, oral sedatives cannot be adjusted once they are given and therefore their dosages must be kept conservative to prevent the patient from becoming over sedated. Patients receiving oral sedation must have a responsible adult accompany them and drive them home following their appointment.\nIntravenous (IV) Sedation\nIntravenous (IV) sedation delivers the sedative medicine directly into the blood stream and produces its sedative effects within minutes. The level of sedation is deeper and more safely adjusted than either nitrous oxide or oral sedation. IV sedation usually has profound amnesic effects and the patient will likely not remember having the treatment completed. Like other types of sedation, the patient must have a responsible adult accompany them and drive them home following their appointment.\nUnlike oral and IV sedation, in which the patient retains some level of responsiveness, general anesthesia renders the patient completely asleep and totally unaware of their dental procedure. General anesthesia is frequently used when the patient cannot cooperate at all as in patients with developmental disabilities or other special health care needs. When general anesthesia is used a board certified anesthesiologist is present to administer the medication and monitor the patient during the procedure. Like the other types of sedation, patients receiving general anesthesia must have a responsible adult accompany them to drive them home. |
Most people will gravitate towards non-surgical treatments that will help them get rid of the fine lines and wrinkles because there’s little to no downtime, and it’s the most convenient. The two FDA-approved fillers you should educate yourself on are Dysport and Botox. Both fillers have the same functions blocking the nerve signals, relaxing the muscles temporarily, diminishing the appearance of wrinkles, and softening deep lines. Comparing the benefits of each filler will help you decide which one is most suitable for you.\nWhat Are The Benefits Of Dysport and Botox?\nThis easy and successful injectable can smooth wrinkles and facial lines. This procedure can give you a fresh and youthful appearance without having surgery. The treatment takes only 15 minutes and is without pain medication or anesthesia. There’s no recovery time to get back to your regular daily routine.\nWhich Filler Is The Easier?\nWhile both filters have the same result, one can be considerably easier than the other. Dysport spreads easily compared to Botox during the treatment. When it comes to large muscle groups like the forehead or armpit, your specialist may want to use Dysport because it will allow them to use fewer injections. You will experience minor discomfort, bruising, and swelling when you have fewer injections.\nWhat’s The Takeaway?\nBoth fillers are non-surgical and will smooth wrinkles and fine lines. A specialist in a medical office will do the treatments, and you can return to your original schedule after each appointment. Within two weeks, you will start to see the filler results last four to six months. Your fine lines and wrinkles will become smooth and you will love your new appearance!\nIf you are interested in fillers, contact Chatham Plastic Surgery today! Call us at 912-446-1985 to schedule a consultation with Dr. Pearl and check out our Instagram account. Our practice serves Savannah, GA, and surrounding areas. |
Become Yourself Again – Mona Lisa Touch\nGynecological health is an important part of a woman’s well-being at all ages and during times of illness, treatment with chemotherapy; radiation therapy and postmenopausal changes which commonly occur. When estrogen levels decline due to changes in life significant changes in gynecological health occur.\nMona Lisa Touch allows women to restore vaginal health without taking medications, undergoing surgery or using topical creams and lotions.\nMona Lisa Touch is the only treatment of its kind using laser light to rejuvenate and restore vaginal and labial integrity.\n- Millions of women are experiencing changes in their gynecological health.\n- Virtually every woman can benefit from Mona Lisa Touch therapy.\n- Non-surgical approach to gynecological health.\n- Clinically proven to bring lasting relief.\n- Mona Lisa Touch is life changing for most patients.\n- Mona Lisa Touch therapy is simple and safe. Mona Lisa Touch difference matters.\n- Three treatments of less than ten minutes each.\n- In office procedure.\n- Requires no anesthesia.\n- Thousands of women successfully treated since 2012.\nHow does Mona Lisa Touch create such impressive results?\n- A virtually painless procedure in which a speculum like device which administers fractional C02 Laser DOC’s apply therapeutic light energy scattered over the vaginal mucosa providing the stimulation necessary to restore vaginal mucosa and to stimulate the development of collagen.\n- No anesthesia required. Virtually painless treatment procedure.\nThis safe effective treatment is demonstrated in a video for our patients at YouTube: Mona Lisa Touch at Sollay Laser Center in Baltimore, Maryland.\nThe therapy requires three treatments lasting five to ten minutes in order to accurately apply the appropriate treatment dose. The procedure is done in the doctor’s office at Sollay Laser Center. The best part is no downtime and virtually no pain or side effects.\nMost women being treated for their gynecological health experience an improvement in their health overall. The patients quality of life is reported by over 85% of patients as being positively improved. Mona Lisa Touch has been successfully treating women since 2012 for improvement in gynecological health including vaginal dryness; vaginal laxity; vaginal irritation and inflammation; vaginal pain; vaginal hypersensitivity; recurrent vaginal infections; recurrent vaginal inflammation; and side effects/complications of medications patients may be consuming that were prescribed to treat other medical conditions but resulting in vaginal dysfunction.\nClinically proven to bring lasting results. In a recent study, 84% of patients showed significant improvement in their physical and mental quality of life scores over baseline and were satisfied with the treatment. An additional 8% of patients reported improvement of life scores over baseline and were satisfied with the treatment when provided a fourth treatment. Mona Lisa Touch therapy has proven immediate and lasting results which provide a high degree of patient satisfaction. The Mona Lisa Touch treatment system provides the opportunity for women to receive life changing treatments of their gynecological health without downtime and without any significant inconvenience. Literally, Mona Lisa Touch therapy can be performed during a patient’s lunch hour. It is important for the patient and the doctor to achieve life changing results without significant side effects, complications, reactions or additional costs.\nMona Lisa Touch is cutting-edge one of a kind life changing technology.\nCall today to schedule your free consultation, 410-644-7655. |
Shelby, NC, United States\nJob ID: 19422\nJob Family: Anesthesia Services (CRNAs)\nStatus: Part Time\nDetailed Shift and Schedule: Variable shifts, 8hrs, 10hrs, 12hrs, 16hrs, 24hrs\nJob Type: Regular\nDepartment Name: 16011004930168-CRNA Anesthesia Services - Surgical\nIf it’s possible, you will find it at Atrium Health—the leading community-focused academic healthcare system serving North Carolina and South Carolina. We invite you to discover all that we can do when we bring healing hearts, inquisitive minds, and progressive visionaries together in our Anesthesia team at Atrium Health Cleveland in Shelby, North Carolina.\nJob SummaryAdministers intravenous, inhaled, regional, or other anesthetics to render patients insensible to pain during medical or surgical procedures. Maintains anesthetics at required levels and supports life functions during the administration of anesthesia, under the supervision of a licensed anesthesiologist.\nRequires frequent walking and standing. Must be able to assist in moving, by pushing, pulling or lifting, patients greater than 100 pounds. Requires frequent stooping, kneeling, bending and reaching. Able to use both hands and perform fine manipulations with the fingers. Near visual acuity, depth perception and color perception are required. Clear speech and the ability to hear is mandatory. Occasional exposure to noise and the hazards resulting from inhalation agents occur.\nEducation, Experience and Certifications\nNC RN licensure required. Graduate of an accredited School of Nurse Anesthesia required. CRNA licensure required. BLS and ACLS HCP from AHA required.\nWhen you join Atrium Health, you will be welcomed into an inclusive culture that celebrates and respects the contributions a diverse team can make together. Practice where your voice is valued, your passion for advancing medicine is rewarded, and you get the resources and support you need to thrive personally and professionally. In our nationally renowned integrated health system, you can work alongside the most advanced minds in medicine to improve medicine, elevate hope and advanced healing. |
Ultrasound-guided parasternal Pecs block: a new and useful supplement to Pecs I and serratus anterior plane blocks 0 comment(s)\nDr Christian Kruse Hansen, Dr Mette Dam, Dr Troels Dirch Poulsen, Dr Per-Arne Lönnqvist, Dr Thomas Fichtner Bendtsen, Dr Jens Børglum\nAnaphylaxis after Albumin Infusion in a Patient with both IgA and anti-IgA antibodies. 0 comment(s)\nDr Ryo Okabe, Dr Mai Sakashita, Dr Takamitsu Hamada, Dr Asao Mimura, Dr Yuhei Saitoh, Dr Keishi Hashimoto\nSafe tubeless anaesthesia for laryngeal surgery in a patient with a known difficult airway 0 comment(s)\nDr Sahra Lantz-Dretnik, Dr Richard Gande, Mr Tahwinder Singh\nCombined spinal-epidural ultrasound-guided caudal block in an infant 0 comment(s)\nDr Hugo Trindade, Dr Ronald Silva, Dr Teresa Rocha\nThe use of Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) to facilitate Tracheostomy under sedation 0 comment(s)\nDr Lasitha Abeysundara, Dr Helen Parker, Dr Anna Fowler, Dr Anil Patel\n- AAGBI Award to Innovative Anaesthetist\n- Comments invited from members on new draft guideline AAGBI: use of blood components and alternatives 2016\n- ‘Never Events’ in surgery occur at random and are not related to hospital performance\n- AAGBI statement to BMA Junior Doctors' ballot outcome\n- AAGBI statement on today's Department of Health junior doctors' contract offer\n- Lipid emulsion for intoxication by local anaesthetic: sunken sink?\n- Hypertension: is it a peri-operative or a public health problem?\n- Interscalene catheters - should we give them the cold shoulder?\n- An analysis of 1505 consecutive patients receiving continuous interscalene analgesia at home: a multicentre prospective safety study\n- Heart attacks prevent chocolate. Or, the differences between correlation and causation |
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If you are considering facet joint injections, be sure to discuss the risks and benefits with your doctor.\nThe role played by the anesthesiologist and pain management experts:\nFacet joint injections are a type of pain management treatment that can be used to relieve pain in the spine. The facet joints are the joints between the vertebrae, and they can become inflamed or damaged, causing pain. Facet joint injections involve injecting a local anesthetic and steroid into the facet joint, which numbs the pain and reduces inflammation.\nThe injections can be performed by either pain management experts or anesthesiologists. 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Pancuronium bromide is a chemical compound, used in medicine with the brand name PavulonŽ (Organon Pharmaceuticals).\nIt is a nondepolarizing medium-term muscle relaxant and works by curarimimetic action - the competitive antagonism with acetylcholine of the autonomic cholinergic receptors. With the correct intravenous dosage the effects last around 45 minutes and it is used with general anaesthesia in surgery for muscle relaxation and as an aid to intubation or ventilation. It does not have sedative or analgesic effects.\nSide effects include moderately raised heart rate and thereby arterial pressure and cardiac output, excessive salivation, apnea and respiratory depression, rashes, flushing and sweating. The muscular relaxation can be dangerous in the seriously ill and it can accumulate leading to extended weakness.\nIts empirical formula is:\n- C35H60Br2N2O 4 |
|Year : 2013 | Volume\n| Issue : 2 | Page : 241-243\nSevere autonomic dysreflexia induced cardiac arrest under isoflurane anesthesia in a patient with lower thoracic spine injury\nAmit Jain, Babita Ghai, Kajal Jain, Jeetinder K Makkar, Kishore Mangal, Supriya Sampley\nDepartment of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India\n|Date of Web Publication||13-May-2013|\nDepartment of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh\nSource of Support: None, Conflict of Interest: None\nWe present a case of severe autonomic dysreflexia (AD) progressing to cardiac arrest and death under isoflurane anesthesia. Though AD in chronic cervical spine injury is a common entity, occurrence of such an event in the stage of flaccid paralysis in lower dorsal spinal cord injury is rare, especially under general anesthesia. Manipulation of urinary bladder catheter under light plane of isoflurane anesthesia might be the precipitating factor. Increasing concentration of isoflurane failed to abort the episode or might have aggravated it. High level of suspicion and vigilance is necessary to prevent, diagnose and treat such a condition.\nKeywords: Autonomic dysreflexia, cardiac arrest, spinal cord injury\n|How to cite this article:|\nJain A, Ghai B, Jain K, Makkar JK, Mangal K, Sampley S. Severe autonomic dysreflexia induced cardiac arrest under isoflurane anesthesia in a patient with lower thoracic spine injury. J Anaesthesiol Clin Pharmacol 2013;29:241-3\n|How to cite this URL:|\nJain A, Ghai B, Jain K, Makkar JK, Mangal K, Sampley S. Severe autonomic dysreflexia induced cardiac arrest under isoflurane anesthesia in a patient with lower thoracic spine injury. J Anaesthesiol Clin Pharmacol [serial online] 2013 [cited 2019 Oct 23];29:241-3. Available from: http://www.joacp.org/text.asp?2013/29/2/241/111652\n| Introduction|| |\nAutonomic dysreflexia (AD) is a potentially life-threatening condition in which noxious visceral or cutaneous stimuli cause a sudden, massive, uninhibited reflex sympathetic discharge in individuals with high-level spinal cord injury (SCI). While AD is well recognized in chronic stage of SCI, it has only been rarely documented in the acute phase (1 month) after SCI, especially below T6. If not recognized as a medical emergency and promptly treated, acute AD may result in devastating complications. We present a rare case of severe intractable early onset AD, in a patient with complete SCI below T9, progressing to asystole under isoflurane anesthesia.\n| Case Report|| |\nA 25-year-old man sustained fracture dislocation at T7-T8 vertebrae following a road traffic accident. He was scheduled for pedicle screw fixation of T7-T8 vertebrae two weeks after injury. On pre-anesthetic evaluation, patient presented with complaints of inability to move his lower limbs and numbness in lower half of body. Clinical examination revealed a conscious, well oriented, afebrile patient with pulse rate of 76 beats per minute and blood pressure of 110/70 mmHg. Central nervous examination revealed complete bilateral flaccid paralysis (paraplegia) and loss of all sensations below T9 dermatome with areflexia. There was no voluntary contraction of the anal sphincter with absence of sensation around the anus. Magnetic resonance imaging showed complete transaction of spinal cord at T10 level. All routine investigations were within normal limits.\nWhile applying standard monitoring in the operating room, it was found that patient's urinary bladder was distended up to the umbilicus though a bladder was in situ. It was decided to induce anesthesia and thereafter change of blocked urinary catheter and place central venous pressure and intra-arterial pressure monitoring lines. After adequate preloading, general anesthesia was induced with fentanyl 100 mcg and thiopentone 250 mg intravenous (IV). Tracheal intubation was done after adequate relaxation with 6 mg vecuronium. Anesthesia was maintained with isoflurane in mixture of oxygen and nitrous oxide. Post-induction vitals were stable with 100% saturation and end-tidal carbon dioxide of 36 mmHg. Blocked urinary catheter was removed and re-catheterization done. 1500 ml of urine was drained. Subsequent to bladder catheterization and decompression, patient developed polymorphic premature ventricular contractions with hypertension. Isoflurane concentration was increased, but it was followed by severe bradycardia (38 beats per minute) with malignant hypertension (220 mmHg/100 mmHg). Sodium nitroprusside was started at a rate of 1 mcg/kg/min. As bradycardia was refractory, atropine 1 mg IV was administered. Despite this, patient developed asystole. Cardiopulmonary resuscitation (CPR) was started with 100% oxygen. Sodium nitroprusside was stopped immediately and repeat dose of atropine 1 mg IV was given. Advanced cardiac life support was continued for 30 min with no return of spontaneous circulation. Autopsy revealed mildly dilated heart with a weight of 350 g. All three major coronary arteries were normal and histological examination showed no infarction.\n| Discussion|| |\nAD is a life-threatening complication of SCI that results in an uncontrolled sympathetic response secondary to a precipitant. Suspicion of AD is high with SCI at T6 or above. Usually, patients with SCI at T6 or above have normal systolic blood pressure of 90-110 mmHg. A sudden 20 to 40 mmHg increase of systolic blood pressure over baseline may indicate AD. Tachycardia and reflex bradycardia are most commonly observed in this setting, and are attributed to heightened noradrenergic sympathetic activity and reflex vagal responses, respectively. Other electrocardiographic abnormalities that have been observed during an attack of autonomic hyperreflexia include premature atrial and ventricular contractions, alterations in T-wave and U-wave amplitudes, atrial fibrillation, bigeminy and conduction block. However, the arrhythmias associated with AD have seldom been recognized as a cause of cardiac arrest in individuals with traumatic spinal cord injury. A report of AD-induced recurrent ventricular fibrillation in a patient with C6 tetraplegia by Cholachis et al. was one of such a rare description available in the literature. Contrary to the successful outcome of CPR observed by these authors, no return of spontaneous circulation was obtained in our patient. This could possibly be due to inherently poor survival rate associated with asystole (about 7% to 24%) as compared to a shockable rhythm (25% to 34%). Moreover, there is possibility of delayed diagnosis and treatment of AD as blood pressure monitoring was non-invasive and continual, but not continuous; thus, no real-time blood pressure was available at the time of removal of the blocked urinary catheter. Hypertension was evident during the period of bladder decompression. The use of atropine for asystole was futile in the present case. \nClassical signs and symptoms of AD include pounding headache, profuse sweating above the level of the lesion, piloerection or goose bumps, flushing of the skin, blurred vision, spots in the visual field, nasal congestion and anxiety. AD patients may have one or more of these symptoms, which may be minimal. Most of these diagnostic features can be appreciated only in conscious patients and might have been obscured by general anesthesia in our patient. This possibly resulted in further delay in diagnosis. Some of the serious consequences of AD include retinal, cerebral or subarachnoid hemorrhage. \nSeveral factors that trigger AD have been described in the literature. Irritation of the urinary bladder and gastrointestinal tract are among the most common causes of this condition. , Catheterization and manipulation of an indwelling catheter, urinary tract infection, detrusor sphincter dyssynergia and bladder percussion are all well-known precipitating factors. The onset of AD in a tetraplegic patient following the removal of blocked urinary catheter and while the external urethral meatus was being cleaned with chlorhexidine prior to catheterization has been described. Afferent impulses are transmitted through pelvic, pudendal and hypogastric nerves to the isolated spinal cord and cause massive sympathetic response from adrenal medulla and sympathetic nervous system which is no longer under central hypothalamic control. Vasoconstriction occurs below the level of the lesion causing hypertension. This may stimulate baroreceptor reflex producing bradycardia, heart block, ventricular arrhythmias and even cardiac arrest. Compensatory vasodilatation above the level of the injury results in headache, flushing and nasal congestion.\nResearchers believed that orthostatic hypotension was confined to the acute phase of SCI and AD to the chronic phase of SCI. However, the presence of AD in the early phases of SCI has been reported recently. A retrospective analysis demonstrated 5.7% (3 of 58) incidence of early AD in patients with acute SCI above T6. All the three individuals who developed evidence of early AD had complete cervical tetraplegia. Though, the occurrence of severe AD is rare in early stages, especially in patients with low SCI, our patient developed severe intractable AD leading to cardiac arrest following sudden decompression of bladder. It could possibly be due to a lighter plane of anesthesia during the removal of blocked catheter as well as during re-catheterization of bladder. The occurrence of such a severe AD in the phase of flaccid paralysis, especially in SCI below T6, has not been reported in the literature. Our patient, with complete spinal cord lesion at T10, developed severe AD under general anesthesia with isoflurane that was refractory to the vasodilator therapy, and ultimately led to cardiac arrest and death.\nWhen AD occurs during surgery, if possible, management should begin with the removal of precipitant stimulus. Most episodes appear to be brief and self-limited and in most cases no specific treatment is required. Blocked urinary catheter or impacted fecal matter must be attended to. Dysreflexia occurring under general anesthesia is best managed by increasing anesthetic depth in the first instance. Nonetheless, high incidence of AD and associated dysrhythmias has been reported during halothane anesthesia and the use of a myocardial depressant in patients with increased systemic vascular resistance has been questioned. Upright positioning may produce a desirable fall in blood pressure. Further, a wide range of vasodilators has been used to abort the episodes of AD.\n| Conclusion|| |\nWe present a rare case of severe AD resulting in asystole and death in a patient with SCI below T6 segment, in the absence of prior symptoms. The precipitating event was sudden decompression of bladder under general anesthesia. Such an event during isoflurane anaesthesia has not been reported previously.\n| References|| |\n|1.||Kewalramani LS. Autonomic dysreflexia in traumatic myelopathy. Am J Phys Med 1980;59:1-21. |\n|2.||Cilberti BJ, Goldefein J, Rovenstine EA. Hypertension during anaesthesia in patients with spinal cord injuries. Anesthesiology 1954;15:273-9. |\n|3.||Karlsson AK. Autonomic dysreflexia. Spinal Cord 1999;37:383-91. |\n|4.||Krassioukov AV, Karlsson AK, Wecht JM, Wuermser LA, Mathias CJ, Marino RJ, et al. Assessment of autonomic dysfunction following spinal cord injury: Rationale for additions to International Standards for Neurological Assessment. J Rehabil Res Dev 2007;44:103-12. |\n|5.||Colachis SC, Clinchot DM. Autonomic hyperreflexia associated with recurrent cardiac arrest: Case report. Spinal Cord 1997;35:256-7. |\n|6.||Guttmann L, Frankel HL, Paeslack V. Cardiac irregularities during labor in paraplegic women. Paraplegia 1965;3:141-51. |\n|7.||Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, et al. Part 8: Adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122:S729-67. |\n|8.||Teasell R, Arnold AP, Krassioukov AV, Delaney GA. Cardiovascular consequences of loss of supraspinal control of the sympathetic nervous system after spinal cord injury. Arch Phys Med Rehabil 2000;81:506-16. |\n|9.||Eltorai L, Kim R, Vulpe M, Kasravi H, Ho W. Fatal cerebral hemorrhage due to autonomic dysreflexia in a tetraplegic patient. Case report and review. Paraplegia 1992;30:355-60. |\n|10.||Kursh ED, Freehafer A, Presky L. Complications of autonomic dysreflexia. J Urol (Paris) 1977;118:70-2. |\n|11.||Vaidyanathan S, Soni B, Oo T, Hughes P, Singh G, Pulya K. Autonomic dysreflexia in a tetrplegic patient due to blocked urethral catheter: Spinal cord injury patients with lesions above T-6 require prompt treatment of an obstructed urinary catheter to prevent life-threatening complications of autonomic dysreflexia. Int J Emerg Med 2012;5:6. |\n|12.||Prakash M, Raxwal V, Froelicher VF, Kalisetti D, Vieira A, O'Mara G, et al. Electrocardiographic findings in patients with chronic spinal cord injury. Am J Phys Med Rehabil 2002;81:601-8. |\n|13.||Krassioukov AV, Furlan JC, Fehlings MG. Autonomic dysreflexia in acute spinal cord injury: An under-recognized clinical entity. J Neurotrauma 2003;20:707-16. |\n|14.||Hambly PR, Martin B. Anaesthesia for chronic spinal cord lesions. Anaesthesia 1998;53:273-89. |\n|15.||Greene ES, Seltzer JL. Autonomic hyperreflexia during upper extremity surgery. Can Anaesth Soc J 1981;28:268-71. | |
Shock Wave Lithotripsy\nExtracorporeal (outside of the body) Shock Wave Lithotripsy (stone crushing) or ESWL uses shockwaves to break the kidney stone into smaller pieces so they can more easily travel through the urinary tract and pass from the body\n- The surgery is usually an outpatient procedure performed under general anesthesia and lasts between 45 and 60 minutes.\n- After you are placed under general anesthesia, the surgeon uses x-rays to precisely locate the stone. High-energy sound waves travel through skin and other internal organs and disintegrate the kidney stone into fine sand-like particles that can be passed through the urinary tract.\n- In some cases a stent (a plastic tube) may be used to bypass a stone, relieve obstruction or to keep the ureter from swelling shut after the procedure. This is done more commonly for stones greater than 1cm in size.\nAfter the procedure stone fragments usually pass in the urine for a few days and can cause mild pain. Approximately 85% of patients are stone free following the initial procedure. Complications with ESWL occur rarely. You may be advised to undergo inversion therapy after the procedure to help maximize the clearance of stone fragments.\nPossible Complications include:\n• About 15% of patients have residual fragments of stones which may require additional treatment.\n• Discomfort caused by the passage of stone fragments.\n• Blocked urine flow as a result of stone fragments becoming stuck in the urinary tract requiring an emergency procedure to relieve the blockage.\n• Urinary Tract Infection.\n• Bleeding around the kidneys.\nPlease observe the following Pre-Operative Guidelines:\n• You should stop the following medications one week prior to surgery: aspirin (ASA), NSAIDs (Motrin, Advil, ibuprofen), Coumadin, Lovenox, Celebrex, and Plavix. Please contact us if you are unsure about which medications to stop, and do not stop any medication without contacting your prescribing physician\n• It is very important that your last urine culture show no bacteria before the procedure.\n• The day before your surgery start the pre-operative bowel prep: 2 bottles of Magnesium Citrate (AM, PM), 2 fleet enemas (AM, PM). Both medications are available over-the-counter at your pharmacy.\n• Have nothing by mouth after midnight the night prior to your procedure unless otherwise instructed by the anesthesiologist.\nAfter the procedure:\n• Although the procedure is minimally invasive it may be physically taxing, you should allow for a day or two of restful recovery time.\n• Most patients experience some degree of discomfort/pain for a day or two after the ESWL procedure. The pain will lessen over the following days. It is normal to see blood in the urine for up to several weeks after the procedure.\n• Please contact us if you pain continues to increase, you observe large amounts of blood or blood clots in your urine, nausea, vomiting or diarrhea, notice swelling in your calf or thigh, or if you have a fever above 101°F. All these may be indicators of an injury or serious infection.\n• It is also necessary to schedule follow-up visits between one and two weeks after the procedure to assess progress. |
Jean and Shawn learned that their daughter, Maia was not going to be the perfectly formed baby that they hoped for when an ultrasound taken during the sixth month of her pregnancy showed that the baby’s mouth was broken. Jean blamed herself and was certain that her baby’s facial malformation was the result of not taking vitamins early enough in her pregnancy. Jean cried every day until Maia was born and even when she saw her daughter she still had great difficulty in accepting her. Shawn was a pillar of support for Jean and encouraged her to accept their first child. Jean felt some relief when she learned from her doctor that surgery to repair Maia’s lip was possible as soon as she reached six months of age. A few days later her uncle told her about Operation Smile and that teams of doctors and nurses came regularly to the Philippines to help children like Maia.\nIn November 2012, an international team with volunteers from eleven different countries arrived in Cavite for a medical mission celebrating Operation Smile’s 30th Anniversary. When Shawn, Jean and Maia arrived at the hospital they realised that there were many other children and even adults like Maia and they were grateful that Maia’s cleft was very small in comparison to those of others they saw.\nThe family and all their neighbours were overjoyed when they learned that Maia was cleared and scheduled for surgery.\nAs Jean handed Maia over to her daughter’s anesthesiologist she really wanted to accompany her into the operating room but was told that she could not. Jean and Shawn spent an anxious time until Jean was called in the Recovery Room to hold her daughter as she woke up to her new world with a beautiful smile. |
Posted by Dr. Julian De Silva | June 5th, 2015\nThis patient underwent Asian Blepharoplasty under Sedation/ Twilight Anaesthesia with Dr. Julian De Silva, this is her personal account and experience.\nI had disliked my upper eyelids ever since my teens, and had always been conscious of the expression they gave to my face. My lids were quite hooded and had a look of puffiness, and even though I did have half a natural crease, this was hidden by the heaviness of my eyelids. The hoodedness made my eyes look small. I had wanted to have Asian blepharoplasty for many years to make my eyes look more open but, being quite nervous of surgery, hadn’t ever plucked the courage to go through with it. It wasn’t until around a year ago, when I started looking into it again, that I realised that techniques had moved on since my teens and recovery was easier.\nI knew that finding the right surgeon for me would be integral to my final decision, so I made a long list. I googled ‘best London cosmetic surgeon’ and received a list of names, shorter than I had actually expected, and researched each one. I focused on past patients’ reviews, as I wanted to cut through the marketing, understand the surgeon’s surgical methods and approach to patients, and get a sense of his success rate. I found a website that shows patient reviews, googled for more reviews for each surgeon, and also looked at their facilities and location. Throughout my research, Dr. De Silva came out as a front runner, with excellent reviews. I read through his website several times and was struck by the level of detail and by his combined emphasis on the aesthetic and on modern techniques – both very important. I had consulted one other surgeon previously and hadn’t been as impressed by the level of information or reassurance given. So I made my first appointment with Dr. De Silva.\nI went armed with dozens of questions and quizzed Dr. De Silva on many fine details about the surgery, recovery period and expected results. I received all the information I needed and by the end of the consultation, felt confident enough to seriously consider surgery. After mulling it over for a couple more weeks, I decided to book.\nMy surgery was scheduled for around 8 weeks after my first consultation, and I was booked in for a pre-surgery appointment around 2 weeks before. There, we went over the procedure again and the kind of results I was looking for. I tried to be as specific as possible about how I wanted to look, though also understanding that the exact results can’t be guaranteed. It helped to show Dr. De Silva photos of someone whose eyelids I liked, and I was quite specific about how much higher I hoped my eyelid crease would be. At the consultation also I received my prescription for medications, which included antibiotics, anti-swelling medicines, antibiotic ointment, Vitamin C, arnica and painkillers. I made myself a timetable for the 8-9 days around surgery so that I would know day-to-day exactly what I needed to take and when, as the prescriptions varied quite significantly. A few meds, like antibiotics, need to be started a day or so before the actual procedure.\nPre-surgery, I also prepared small bags of frozen peas to reduce swelling, gathered as many pillows as possible (because I had to sleep upright and propped up on them, post-surgery), and generally prepared to be homebound for 7-10 days after surgery.\nThe night before I was both very nervous and somewhat in denial! I aimed to get a good night’s sleep, and was careful not to eat or drink past the permitted time. I had opted to have twilight sedation in my surgery, so I had a few rules to observe.\nIn the morning, I took an antibiotic pill with a sip of water, but had nothing else. On arrival, I was led to the surgical facilities downstairs, where Dr. De Silva first ran through a few procedural matters. I was given a fetching blue gown, slippers and cap to wear, and had to remove all metal (jewelry, underwired bra etc.). I then met the anaesthetist, who talked me through what I could expect with the sedation, then gave me an IV paracetamol drip because the sedation drugs might otherwise smart when introduced. The anaesthetist explained that I would be in a state of half-sleeping, half-wakefulness but would probably not remember much or anything of the procedure. I might drop in and out of a light sleep, and could signal to the anaesthetist if I was feeling too awake at any time. Throughout, I would be on painkillers, so even if I felt more awake than I wanted, I would not be able to feel anything. Although everyone reacts differently to sedation, I joked that my ideal would be to be knocked out completely and not remember a thing!\nLast before surgery, Dr. De Silva came in to markup my eyelids. He spent a fair amount of time measuring the right proportions and getting the lines right.\nMark up done, I went into the theatre, lay on the table with my head propped in a soft disc, and had a metal patch attached to the cauterizing equipment stuck on to my leg (this is to earth the system). The anaesthetist fed the sedation medications into my drip, and no sooner had I commented on being able to feel them flow lightly up my arm, did I switch off spontaneously! I was out like a light and only came to when the surgery was over and I had a bag of ice over my eyes. I didn’t remember anything of the surgery (and still don’t now), and felt comfortable and reasonably alert when I woke up.\nA friend was waiting to take me home, and though I felt a little woozy, I was pretty much fine. I took my medications as prescribed for the rest of the day, slept a little and took it easy. I had mostly no pain, apart from needing to take a painkiller in the evening for a little discomfort. I had a line of stitches in each eyelid but no dressing. There were two types of stitches – one permanent and the other dissolvable. They were not visible apart from the small knots in places.\nThe first week, I stayed at home and didn’t venture out. I spent the days taking my meds, applying antibiotic ointment on the wounds, and applying the frozen pea bags to my eyelids every 15 mins. I took it easy but was able to do everything for myself. My main focus was to follow Dr. De Silva’s instructions to the letter! My eyelids were quite swollen but the wound was already obviously within the crease, so I was confident that, when the swelling went down, the scar lines would not be visible. I had no pain throughout my recovery and no bleeding or seepage. I had a little discolouration at the corner of my right eye and above my let, but apart from that, virtually no bruising.\nI took care to remain upright at all times, so slept propped up on pillows. The swelling went down quite rapidly between the 4th and 7th days, and the wound began to settle into the crease.\nAt day 7, I had my permanent stitches taken out, which I was so glad for as they had been feeling tight for a day or two. My eyelids had healed so well that apparently the skin had healed over the stitches in a couple of places, but the stitches were not difficult to take out. There were a few twinges and sharp pulls but the stitches came out easily. The dissolvable ones were left in.\nI went back to work on day 9, and by then the swelling was coming under control. My eyes looked a little puffy as if I had just woken up, but I don’t think anyone really noticed. I used eye drops regularly as my eyes were a little dry, but otherwise all was as good as normal. I made the decision not to cover up the scar with concealer, as I didn’t feel comfortable with applying chemicals over healing skin, and to be honest, the scar has formed into my crease so well now that I don’t think anyone can see it unless I close my eyes.\nAt week 4\nWell, now I am at week 4, and very happy! The swelling has almost all gone down, the skin has healed well, and I no longer need eye drops. Though I still have a red line across my eyelid, I’m fine with that. My dissolvable stitches disappeared just after 2 weeks. I have no real lingering effects of the surgery, apart from my lids feeling numb where the fat has been taken out. The results of the surgery look very natural and my eyes are more open, to a subtle, conservative degree but just enough to change the overall expression of my face. I look forward to further scar healing, when the line turns lighter, and I am already beginning to lightly use eyeshadow on my lids. Overall, I am very pleased with my results, and so happy that I took the plunge! This has been well worth it! |
Partnered Programs – NaV1.7 Inhibitor for the Treatment of Pain\nBased on our discovery of NaV1.7 deficiency underlying the rare human disease called congenital indifference to pain, or CIP, where individuals with CIP are unable to feel pain, we believe that NaV1.7 is a highly-validated target for the treatment of pain.\nFlexion Therapeutics acquired the global rights to develop and commercialize XEN402, a Nav1.7 inhibitor also known as funapide. Flexion’s FX301 consists of XEN402 formulated for extended release from a thermosensitive hydrogel. The initial development of FX301 is intended to support administration as a peripheral nerve block for control of post-operative pain.\nOn March 31, 2021, Flexion announced the treatment of the first patient in a Phase 1b proof-of-concept trial evaluating the safety and tolerability of FX301 administered as a single-dose, popliteal fossa block (a commonly used nerve block in foot and ankle-related surgeries) in patients undergoing bunionectomy.\nFlexion anticipates data from the Phase 1b trial of FX301 in late 2021. Pursuant to the terms of the agreement, Xenon is eligible to receive certain clinical, regulatory, and commercial milestone payments, as well as future sales royalties. |
Get the facts about seasonal allergies, including the different types, symptoms, and doctors who treat it.\n- Facelift Facts about facelifts, including the different types of procedures.\n- Home Allergies Facts about indoor allergies, including symptoms & common allergens.\n- Seasonal Allergies Facts about seasonal allergies, the different types and the symptoms.\n- View All Care Guides Prepare for your next visit with our extensive library of Care Guides\nAbout Dr. Leal G Segura\nDr. Leal G Segura, MD is a Doctor primarily located in Rochester, MN. She has 16 years of experience. Her specialties include Pediatric Anesthesiology, Anesthesiology and Otolaryngology. Dr. Segura is affiliated with Olmsted Medical Center, Mayo Clinic Hospital Methodist Campus and Essentia Health St Marys Medical Center. She speaks English.\nDr. Leal G Segura has the following 3 specialties\n- Pediatric Anesthesiology\nAnesthesiologists are physicians who are trained to administer anesthetics, which are medicines used to block nerve sensation. Anesthesia can be either local to one specific part of a body, like a tooth, or regional to block feeling to a larger portion of the body, such as during an epidural for child birth. It can also be more general to block sensation to the entire body, resulting in unconsciousness.\nAnesthesiologists assist in surgery by determining how much anesthesia is necessary and by monitoring the patient's level of responsiveness and vital signs throughout the procedure. The anesthesia specialist will also bring the patient out of anesthesia and then continue to monitor his or her vital signs post-operation.\nBesides assisting in surgeries, anesthesiologists may also treat patients suffering from chronic pain.\nAn otolaryngologist is more commonly referred to as an ENT, someone that can treat medical issues you may be having with you ears, nose, or throat. This is a physician who is specially trained to diagnose and treat conditions of the ear, nose, sinuses, larynx (voice box), mouth, throat, head, and neck. These doctors treat patients through both medical and surgical means. For instance, an otolaryngologist may treat an obstruction of the nasal passage, caused by malformation of the nose, through rhinoplasty.\nDr. Leal G Segura has the following 1 expertise\nDr. Leal G Segura is Board Certified in 2 specialties\nSee the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.\nDr. Segura is affiliated (can practice and admit patients) with the following hospital(s).\n16 Years Experience\nMount Sinai School Of Medicine Of New York University\nGraduated in 2002\nDr. Leal G Segura accepts the following insurance providers.\n- Aetna Choice POS II\n- Aetna Managed Choice POS Open Access\n- Aetna Signature Administrators PPO\n- Multiplan PPO\n- PHCS PPO\n- UHC Choice Plus POS\n- UHC Medica Choice\n- UHC Options PPO\nLocations & DirectionsMayo Clinic, 200 1st St SW, Rochester, MN\nDr. Leal G Segura is similar to the following 3 Doctors near Rochester, MN. |
If you are an emergency case requiring immediate attention, please call (+555) 959-595-959 or the nurse at (+555) 959-595-959. We will give you instructions and directions. If you know the Medical Centre’ s address, please come as quick as possible. If you need transfer by us, please let us know by phone.\nWhat can I expect at an appointment?\nWhen you arrive at the Medical Centre, the staff will greet you and seat you at the waiting room. We will examine you as quick as possible – average waiting time is 15 minutes.\nWhat happens if I am a new patient?\nYou may have referred yourself, have been referred by another specialist or by Medical Insurance. We will discuss your problem and ask about your medical history. A thorough examination will then follow. We may request examinations and tests to assist and support our diagnosis.\nX-rays, blood / urine analysis, ultrasonography, MRI, endoscopy can all be performed with no delay in the same building. If you have previous examinations and tests related to your current condition, please bring those along to the consultation. Also bring any copies of letters from other doctors or recent medication. It will help us to help you.\nWe will discuss with you the results of your examinations and we will recommend the proper treatment. Some conditions may be faced immediately by conservative or surgical treatment. In case you need surgery requiring general anesthesia, we arrange routine or urgent transfer by quick boat, state or private air ambulance to Athens or to your preferred destination (subject to stable medical condition). In special cases a patient can be escorted.\nOtherwise, depending on the results of your examinations, the nature of the medical problem and your holiday plan, we will discharge you from our clinic, refer you on to another health professional or book you for surgery. If follow-up consultation or further consultations are required, we will indicate this and the staff will let you know the date and time of your next appointment.\nDo you have Imaging (x-rays, ultrasonography, CT-scan) facilities?\nOrdinary x-rays, panoramic mouth views, ultrasonography , endoscopy, CT-scan, bone mass density scanner or laser imager ( digital developer ) can be performed on location.\nDo you examine children at your clinic?\nA Pediatrician is immediately available if needed.\nWhat happens if I need an intramuscular or intravenous injection?\nCertain cases require injections for quick and full recovery. These can include antibiotics, anti-inflammators, local anesthesia or steroids.\nSteroids and local anesthesia injections are administered by Doctors and anti-inflammators / antibiotics by an experienced nurse under our supervision.\nWhat if I need Anesthetic?\nWe can undertake only small or minor procedures in our Medical Centre, using local anesthesia or superficial sedation.\nAll other procedures requiring general anesthesia are transferred to Athens or back to patient’s destination, to be admitted at a General Hospital.\nWhat happens if I need a prescription?\nWe may prescribe for example analgesia treatment for your condition. Please let us know in case you have any allergy or other medical condition.\nIf you have already been taking drugs prescribed by your home doctor, please bring them with you for clarification or possible drug interactions and correlations with the new condition.\nInsurance and Billing\nDo you accept my insurance?\nOur Medical Centre accepts most of the internationally recognized Insurance companies with affiliate.\nIf this is not your case, or if you have no insurance coverage then you will be expected to pay the bill in cash or credit card at the end of consultation. The original receipt, the signed copy of the credit card bill, the medical report in English and the results of tests performed are given to you in order to be delivered to your private or state insurance for reimbursement.\nAn estimate of consultation fees and costs, investigations or surgery are available on request.\nDo I need referral?\nIf you have private insurance with an affiliate, the referral can be sent from your insurance company to us by fax or e-mail. We suggest that you contact your insurance in order to obtain this referral before your visit to our offices.\nIf you don’t have an insurance coverage, feel free to come to our Medical Centre. The billing procedure is as explained above.\nDo you have parking facilities?\nFree Parking is available in front and around the Medical Centre.\nQuesto sito utilizza i cookies per migliorare la tua esperienza di navigazione. Non raccogliamo troppi dati, tuttavia, utilizzando questo sito, accetti implicitamente l'utilizzo dei cookies stessi. AccettoLeggi Tutto\nPrivacy & Cookies\nNecessary cookies are absolutely essential for the website to function properly. This category only includes cookies that ensures basic functionalities and security features of the website. These cookies do not store any personal information.\nAny cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. It is mandatory to procure user consent prior to running these cookies on your website. |
Physical medicine and rehabilitation is often referred to as physiatry. Physiatry is the branch of medicine emphasizing the prevention, diagnosis, treatment and rehabilitation of disorders, particularly those of the neuromusculoskeletal, cardiovascular and pulmonary systems, which may produce temporary or permanent impairment.\nReducing pain and improving function\nOur physiatrists are nerve, muscle, spine and brain experts who treat injury or illness without surgery to decrease pain and restore function. The role of the physiatrist is to provide medical care to patients with pain, weakness, numbness and loss of function, so that they can maximize their physical, psychological, social and vocational potential.\nTheir broad expertise and training enable them to treat a wide range of illnesses and injuries—from diagnosis to treatment and rehabilitation—throughout your lifetime. Physical rehabilitation doctors treat you, not just your symptoms. They take the time to understand your ailments and explain treatments you can do for yourself and with medical specialists.\nServices and treatments\nOur physiatrists provide the following services and treatments:\n- Treatment for muscular and skeletal problems\n- Ultrasound-assisted joint injections and nerve blocks\n- Diagnosing and treating acute and chronic pain\n- Therapeutic exercise training\n- Prescribing assistive devices such as braces or artificial limbs\n- Care for neurological and orthopedic conditions\n- Imaging and nerve conduction studies\n- Pain prevention strategies\n- Treatment coordination |
Ketorolac in Breast Cancer Trial\nLocation: Cliniques Saint-Luc, Brussels, Belgium\nCollaboration: Dr Patrice Forget\nThere has been recent interest in the possible impact of the perioperative period on cancer outcomes. Several observations suggest that physiological changes induced by surgery and anesthesia may have an impact on the growth of tumor cells in breast cancer. It is well documented that anesthesia and surgery induce a change in immunity and an inflammatory response. Local inflammation and angiogenesis required for wound healing may also influence roles in the process. Though cancer surgery is key in the management of many types of cancer, research on the perioperative period and possible consequences on cancer outcomes is scarce.\nRecently, Patrice Forget et al. evaluated all drugs used during anesthesia and surgery of breast cancer in women treated with removal of the whole breast (mastectomy) performed at the Cliniques Saint-Luc in Brussels. They found that cancer patients who received ketorolac, a non-steroidal anti-inflammatory drug, during surgery had a lower risk of breast cancer recurrence. Ketorolac is sometimes used by anesthesiologists to prevent postoperative pain. Other anesthesiologists use other drugs instead of ketorolac to demonstrate preferences. The link between injection of ketorolac during surgery and lower risk of breast cancer recurrence suggests important factors to affect the risk of recurrence. The same finding was observed in another center in Belgium (although not statistically significant due to a low number of recurrences). Within the Cliniques Saint-Luc, the same phenomenon was observed in patients operated for lung cancer, but not in patients operated for prostate cancer.\nIn order to verify if an injection of ketorolac is responsible of the risk reduction of breast cancer recurrence, this hypothesis must be tested in a randomized clinical trial. The Anticancer Fund decided to support this breast cancer clinical trial that started in February 2013 at the Cliniques Saint-Luc in Brussels. The study will involve 4 additional Belgian centers, and ultimately include 200 women diagnosed with breast cancer. These cancer patients must have a moderate to high risk of cancer recurrence and will be randomized in 2 arms: ketorolac or placebo. Cancer patients and doctors will not know whether placebo or ketorolac had been administered. Recruitment is planned over 2 years and results should be available by the end of 2016. Dr Patrice FORGET is the principal investigator, in collaboration with Prof Marc DE KOCK, Prof Martine BERLIERE, Prof Jean-Pascal MACHIELS, Dr François DUHOUX, Prof Pierre COULIE and Dr Aline VANMAANEN.\nYou can send an email to Alain Dekleermaker, study coordinator, at kbctrial@gmail [dot] com for more information.\nMore details about this study (NCT01806259) at www.clinicaltrials.gov. |
Pre existing disease and anaesthesia\nStoelting coexisting disease 7th edition pdf\nThere are limited clinical data suggesting that the success of peripheral nerve blockade supraclavicular brachial plexus may be higher in diabetic patients independent of other predictors of success eg, body mass index compared to nondiabetic patients. Pregnancy is frequently associated with a decrease in disease relapse, whereas the postpartum period is often associated with an increased risk of relapse. Ultimately, the decision to perform regional anesthesia should be made on an individual basis after a thorough discussion with the patient regarding the potential risks and benefits. This injury can produce acute uncontrolled hypertension with the introduction of a noxious stimulus below the level of the lesion, leading to a peripheral sympathetic response producing vasoconstriction below the injured level. Compston A, Coles A: Multiple sclerosis. Kuczkowski KM: Labor analgesia for the parturient with neurological disease: what does an obstetrician need to know? Suppression of the immune response with prolonged high-dose corticosteroids or intravenous immunoglobulin is the current treatment of choice. She completed a residency in anesthesia and critical care at the University of California, Davis in\nClin Neurophysiol. The following year was spent in mixed animal practice in Seattle, WA before moving on to advanced specialty training in anesthesiology. Risk factors or potential triggers for PSIN include malignancy, diabetes mellitus, tobacco use, systemic infection, volatile anesthetic use, and recent blood transfusion.\nPeripheral nervous system disorders comprise neurological disease states that involve the cell body, axon, neuromuscular junction, and myelin sheath.\nPreexisting pathology has long been reported to play a role in the development of postoperative neurologic dysfunction.\nStoeltings anesthesia and coexisting disease 7th edition pdf free\nIn contrast to peripheral nerve blockade, the potential risk of new or progressive neurologic deficits in MS patients after spinal anesthesia was first described in However, the avoidance of regional anesthesia within this patient population may also be due to physician and patient biases or potential medicolegal concerns. The goal of treatment is to sufficiently blunt the inflammatory response to allow for axonal regeneration. Williams BA, Murinson BB: Diabetes mellitus and subclinical neuropathy: a call for new paths in peripheral nerve block research. There is pathophysiologic evidence of abnormalities in both large and small neural blood vessels, ultimately contributing to multifocal fiber loss. Vocational implications of post-polio syndrome. In both cases, the use of higher local anesthetic concentrations may have contributed to the delayed recovery. Initial symptoms include hyperesthesia in the ulnar nerve distribution, elbow pain, and paresthesias in the ring and small fingers. These symptoms are often intermit-tent and may progress over the course of months to years. Postpolio syndrome is the most prevalent motor neuron disease in North America. Acta Neurol Psychiatr Belg ;—\nAs a result, diabetic peripheral nerves may be more susceptible to subsequent injury from local anesthetic toxicity or ischemic insults. Lastly, there is a correlation of low vitamin D levels with MS.\nPre existing disease and anaesthesia\nAnother potential application of ultrasound technology is the ability to use the cross-sectional area of a peripheral nerve to identify a clinical or subclinical peripheral neuropathy: a diagnosis that historically would have required complex nerve conduction studies. A potentially dangerous condition that may develop in the month s after the resolution of acute spinal shock is autonomic dysreflexia AD. Toward a potential paradigm shift for the clinical care of diabetic patients requiring perineural analgesia: strategies for using the diabetic rodent model. She has since been working in private specialty practice and is a co-editor of and author of several chapters in the book, Pain Management in Veterinary Practice. Despite this evidence, the overall incidence and clinical relevance of this underlying peripheral neuropathy remains undefined in the setting of performing peripheral nerve blockade in patients with MS. In summary, patients with DPN likely have neural elements that are more sensitive to the effects of local anesthetic. Amyotrophic lateral sclerosis is a rapidly progressive disease with progressive degeneration of motor neurons that causes muscular weakness, atrophy, fasciculations, spasticity, and hyperreflexia.\nCurr Opin Anaesthesiol. The degree of neurotoxicity depends on the agent used, the duration of administration, and the cumulative dose received. However, given the potential for worsening respiratory failure following general anesthesia due to the use of muscle relaxants and opioid medications, the ability to avoid airway manipulation may be considered a benefit within this high-risk patient population.\nPregnancy in Multiple Sclerosis Group. Most of this information is universal although, as a North American text, it is inevitable that some management protocols will differ from those in Europe and it is interesting to see references to drugs such as methoxyflurane, methohexital, and phenobarbital.\nbased on 104 review |
Online Dictionary: translate word or phrase from Indonesian to English or vice versa, and also from english to english on-line.\nHasil cari dari kata atau frase: epidural(0.01335 detik)\nFound 1 items, similar to epidural.\nEnglish → English (WordNet)\nn : regional anesthesia resulting from injection of an\nanesthetic into the epidural space of the spinal cord;\nsensation is lost in the abdominal and genital and pelvic\nareas; used in childbirth and gynecological surgery [syn:\nepidural anesthesia, epidural anaesthesia]\nadj : on or outside the dura mater [syn: extradural] |
Both propofol and volatile anesthetics have been reported to interact with the endocannabinoid system. The purpose of this study was to evaluate the effect of selective agonists for cannabinoid receptor types 1 and 2 on etomidate-induced sedation.\nA controlled, blinded, experimental study was performed in 20 mice that received intraperitoneal injections of etomidate, the cannabinoid1 receptor agonist arachidonyl-2-chloroethylamide (ACEA), the cannabinoid2 receptor agonist JWH 133 alone, and both ACEA and JWH 133 combined with etomidate. The cannabinoid1 receptor antagonist AM 251 and the cannabinoid2 receptor antagonist AM 630 were administered 10 min before the delivery of ACEA and JWH 133, respectively. Each drug combination was applied to 6-8 mice of these 20 study animals. Sedation was monitored by a Rota-Rod (Ugo Basile, Comerio, Italy). Isobolographic analysis was used for evaluation of pharmacologic interaction.\nSingle drug administration of etomidate and ACEA produced dose- and time-dependent decreased time on the Rota-Rod (P < 0.05). No sedative effect was seen after JWH 133. Etomidate-induced sedation was significantly increased and prolonged with ACEA (P < 0.05), but not with JWH 133. Isobolographic analysis revealed an additive interaction between ACEA and etomidate that was antagonized by the cannabinoid1 receptor antagonist AM 251. The cannabinoid1 receptor antagonist had no effect on etomidate alone.\nEtomidate-induced sedation was increased and prolonged by activation of the cannabinoid1 receptor, but not of the cannabinoid2 receptor, in mice. However, this interaction was only additive.\nENDOCANNABINOIDS have been demonstrated to play an important role in the physiologic control of sleep, sedation, anxiety, pain processing, and emesis, suggesting a possible role as adjuvants during anesthesia.1The endocannabinoid system includes two identified cannabinoid receptors: type 1, which mainly exists in the central nervous system, and type 2, which is absent from the brain but is enriched in peripheral neuronal and immune tissues.2It has recently been proposed that the anesthetic drug propofol induces an increase in the brain content of the endocannabinoid anandamide and that this may contribute to the sedative effects of propofol.3Furthermore, volatile anesthetic–evoked sleep duration has been reported to be prolonged by different exogenously administered cannabinoids.4\nEtomidate (R -(+)ethyl-1-(1-phenylethyl)-1H-imidazole-5-carboxylate) is a widely used potent hypnotic drug whose major advantage has been described as hemodynamic stability. This pharmacologic profile renders etomidate particularly suitable for induction of anesthesia in critically ill patients and patients with cardiovascular disease.5The anesthetic effect is thought to be mediated primarily through an action on γ-aminobutyric acid receptors.6In addition, interactions of etomidate with α2adrenoreceptors7and the nitric oxide metabolism8have been suggested.\nTo elucidate the role of cannabinoid receptors in the anesthetic action of etomidate, we studied the interaction of etomidate with selective agonists and antagonists for cannabinoid1/2receptors in vivo in mice. We hypothesized that the activation of the cannabinoid1receptor increases etomidate-induced sedation, but not activation of the cannabinoid2receptor.\nMaterials and Methods\nThis project was approved by the Animal Investigation Committee of the University Schleswig-Holstein, Campus Kiel, Germany, and the animals were managed in accordance with institutional guidelines. This was a controlled, blinded, randomized, experimental study in 20 mice (129S2/SVHsd) of either sex, weighing 25–35 g. Mice were housed 4 animals per cage and maintained on a 12-h light–dark cycle with free access to water and food. All experiments were conducted between 08:00 and 18:00 h.\nA total of 20 mice were used in this study. Each following drug combination was applied to 6–8 mice of these 20 study animals. Thus, each animal was repeatedly exposed to different drug combinations. To avoid any interference with drug remnants from the previous regimen, a washout period of at least 20 days was chosen.\nLipid emulsion (Lipofundin® 20%; B. Braun, Melsungen, Germany) was used as the solvent for etomidate (Etomidate®-Lipuro; B. Braun) and as an inactive control. Arachidonyl-2-chloroethylamide (ACEA) and JWH 133 (Tocris Bioscience, Ellisville, MO) are cannabinoid1and cannabinoid2receptor agonists with 1,400-fold9and 200-fold10selectivity for binding to the cannabinoid1and cannabinoid2receptor in vitro , respectively. AM 251 and AM 630 (Tocris Bioscience) are cannabinoid1and cannabinoid2receptor antagonists with 306-fold11and 165-fold12selectivity for binding to the cannabinoid1and cannabinoid2receptors in vitro , respectively. ACEA, JWH 133, AM 251, and AM 630 were dissolved in ethanol, Cremophor (Sigma-Chemie, Deisenhofen, Germany), and saline in a 1:1:18 ratio. Solvents were also used as vehicle control for cannabinoid1/2receptor agonists and antagonists, respectively. All drugs were administered intraperitoneally in a volume of 10 ml/kg body weight, and animals were weighed on the day of the experiment for calculation.\nSedation was determined by placing mice on a rotating wheel (Rota-Rod; Ugo Basile, Comerio, Italy), and measuring the duration of time they remained on the rod as described previously.7Mice were initially trained until they could stay on the Rota-Rod for at least 60 s at a speed of 28 revolutions per minute. Time on the Rota-Rod was recorded 1, 2.5, 5, 7.5, 10, 15, 20, 30, 45, 60, 75, and 90 min after drug administration. The observer was blinded with respect to the drugs applied.\nAgonists and Etomidate\nFor evaluation of the single drug dose response of the sedative action of the cannabinoid1receptor agonist (ACEA, 2.5, 3, 4, 5, 6, 8, 10, and 15 mg/kg), cannabinoid2receptor agonist (JWH 133, 2.5, 5, 10, and 15 mg/kg), and hypnotic drug (etomidate, 0.5, 1, 2, 4, 5, 6, 8, and 10 mg/kg), each agent was intraperitoneally administered. ED50values of ACEA and etomidate were separately calculated representing the effective dose that produced a reduction in time on the Rota-Rod to an average of 30 s in the six to eight mice tested. Injection time of each single drug experiment was defined as t = 0.\nRole of Cannabinoid Receptor Subtypes\nTo further determine whether the effects of ACEA and JWH 133 were mediated through certain subtypes of cannabinoid receptors, the cannabinoid1receptor antagonist (AM 251, 5 mg/kg) and cannabinoid2receptor antagonist (AM 630, 5 mg/kg) were administered 10 min before the delivery of ACEA (ED50) and JWH 133 (5 mg/kg), respectively. Then, we investigated the drug combination of 5 mg/kg AM 251, ED50ACEA, and ED50etomidate. Furthermore, we evaluated the role of the endocannabinoid system in etomidate-induced sedation. Therefore, we examined the effect of the cannabinoid1/2receptor antagonists (AM 251, 5 mg/kg; and AM 630, 5 mg/kg) combined with both lipid emulsion (0.2 mg/kg) and etomidate (ED50) on Rota-Rod performance, respectively.\nAn isobolographic analysis13was used to determine the nature of pharmacologic interaction between ACEA and etomidate. This method is based on comparisons of doses that are determined to be equieffective. First, each ED50value was determined from the single drug dose–response curves. Next, ACEA was coadministered with etomidate or 0.2 mg/kg lipid emulsion (t = 0) in a fixed 1:1 ratio of their respective agonist ED50values (0.1, 0.25, 0.33, 0.4, 0.5, 0.6, and 1.0). From the dose–response curve of the combined drugs, the ED50value of the mixture was calculated. The isobologram was constructed by plotting the ED50values of the single agents on the x- and y-axes, respectively. The theoretical additive dose combination was calculated.\nStatistics were performed using commercially available statistics software (GraphPad Prism version 4.03 for Windows; GraphPad Software, San Diego, CA). A Kolmogorov-Smirnov test was used to test for gaussian distribution. Data were analyzed using two-way repeated-measures analysis of variance factoring for time and drug effects with post hoc Bonferroni correction. Data are expressed as mean ± SEM. The dose–response lines were fitted using least-squares linear regression and ED50. Drug combinations were analyzed for additive interactions using a “fixed ratio design” isobologram whereby combinations of two drugs in known ratios were administered as fractions of their respective ED50, as outlined above.13The isobologram consists of an additivity line that connects the ED50of ACEA on the vertical axis to the ED50of etomidate on the horizontal axis. The theoretical dose required for a purely additive interaction (Zadd= (f)ED50, drug A+ (1 − f)ED50, drug B, where f is the fraction of drug A used) was calculated and compared via an unpaired Student t test to the actual dose (Zmix, determined from the ED50of the combination dose–response curve) required to achieve the same effect experimentally. Statistical significance was considered at a two-sided P value of less than 0.05.\nSingle drug administration of etomidate and ACEA to conscious mice produced dose- and time-dependent decreased time on the Rota-Rod (figs. 1A and B; P < 0.05). JWH 133 in different dosages from 2.5 to 15 mg/kg did not affect ability to remain on the Rota-Rod. Rota-Rod values at the time points at which the greatest sedative responses were observed for each respective drug were used to plot the agonist log dose–response curves displayed in figure 1C. The mean ED50values (±SEM) of etomidate and ACEA were 4.84 (±0.35) and 6.23 (±0.40) mg/kg, respectively. Comparison of curve fits revealed that a sigmoidal dose–response model with variable slope provided the best fit for etomidate (goodness of fit, R 2= 0.7034) and ACEA (R 2= 0.7779).\nDose- and time-dependent sedative effects of the cannabinoid1receptor agonist ACEA combined with etomidate are shown in figure 2A, and combinations were of equal fractions (0.1, 0.25, 0.33, 0.4, 0.5, 0.6, and 1.0) of each paired drug’s respective ED50value coadministered in a fixed 1:1 ratio of the ED50of ACEA:ED50of etomidate. Rota-Rod values at the time points at which the greatest sedative responses were observed for each respective combination were used to plot the dose– response curve shown in figure 2B. Paired combinations of ACEA and etomidate produced a dose-dependent decrease of time on the Rota-Rod (P < 0.05). Dose fraction (an arbitrary value) ED50values were determined and converted to absolute dose values for isobolographic analysis. The ED50value (±SEM) of the fixed-ratio combination ACEA and etomidate was 0.47 (±0.04). Comparison of curve fits revealed that a sigmoidal dose–response model with variable slope provided the best fit for the combination of ACEA and etomidate (R 2= 0.7467). The cannabinoid2receptor agonist JWH 133 combined with ED50etomidate did not change time on the Rota-Rod compared with ED50etomidate alone.\nAccordingly, isobolographic analysis revealed an additive interaction between intraperitoneal ACEA and etomidate. The experimental ED50value (A) did not significantly differ from the theoretical ED50value (B) (P = 0.5787; fig. 3). Experimentally obtained (Zmix) and theoretical (Zadd) additive doses of ED50, ED30, ED25, and ED20are presented in table 1.\nThe cannabinoid1receptor antagonist AM 251 reversed the sedative effect of single drug administration of ED50ACEA (P < 0.01), and the sedative component of ACEA when ED50ACEA was combined with ED50etomidate (P < 0.01; fig. 4A). In contrast, the cannabinoid1/2receptor antagonists AM 251 and AM 630 combined with ED50etomidate did not significantly differ from ED50etomidate alone. Further, AM 251 and AM 630 combined with 0.2 mg/kg lipid emulsion did not affect baseline Rota-Rod performance (fig. 4B).\nEtomidate is widely used for induction of anesthesia, particularly in critically ill patients, because of its beneficial properties, including rapid, predictable onset of action, cardiovascular stability, and short half-life.5In agreement with previous experimental studies,14,15intraperitoneal injection of etomidate reduced time on the Rota-Rod, an index of the sedative action of general anesthetics in mice, in a dose-dependent manner.\nMain findings of our experimental study in mice are as follows. First, etomidate and the cannabinoid1receptor agonist ACEA alone reduced time on the Rota-Rod in a dose-dependent manner, indicating increased sedation, whereas the cannabinoid2receptor agonist JWH 133 had no effect, irrespective of the dosage used. Second, etomidate-induced sedation was significantly increased and prolonged with ACEA, but not with JWH 133. However, isobolographic analysis revealed that this interaction is based on simple additivity. Third, the anesthetic action of etomidate is not mediated via cannabinoid receptors.\nWith regard to natural cannabinoids, their analgesic and sedative properties have historically been used during surgical procedures more than three centuries ago.16In our experimental study, the synthetic cannabinoid1receptor agonist ACEA altered the Rota-Rod performance by decreasing time on the Rota-Rod in a dose-dependent manner, whereas the cannabinoid2receptor agonist JWH 133 had no effect. Cannabinoid1receptors are located throughout the central nervous system, including the neocortex, hippocampus, basal ganglia, and brainstem,17regions that have been associated with sedation.18In this respect, sleep duration of volatile anesthetics such as halothane or isoflurane has been reported to be prolonged when combined with both nonselective and selective cannabinoid1receptor agonists.4Delta-9-Tetrahydrocannabinol enhanced thiopental-induced loss of righting reflex, too.19In addition, propofol-evoked loss of righting reflex was increased by coadministration of a nonselective cannabinoid1receptor agonist.3These authors have further suggested that propofol induces an inhibition of the anandamide-degrading enzyme, the fatty acid amide hydrolase that leads to elevated concentration of anandamide, an endogenous nonselective cannabinoid1/2receptor ligand, which in turn may contribute to the sedative effects of propofol. More recently, even a reduced anandamide concentration has been reported after etomidate administration in patients, suggesting counteracting effects of etomidate and fatty acid amide hydrolase.20\nThe current study indicates that activation of the cannabinoid1receptor by ACEA increased and prolonged significantly etomidate-induced sedation, suggesting a potentially anesthetic-sparing effect. Furthermore, isobolographic analysis of this study revealed that our results for the combination of ACEA and etomidate represent a simple additive interaction, suggesting that activation of both cannabinoid receptors and γ-aminobutyric acid receptors cause sedation by independent mechanisms or sites of action. However, the fact that lower doses of sedative drugs may be administered in combination to cause effective sedation may have potential clinical benefit. Additive drug combinations may enhance the pharmacodynamic safety margin because the lower clinical dose requirements for each agent will minimize drug-specific adverse effects.21In addition, as etomidate is not used for repetitive administration and long-term sedation because of its detrimental effect on adrenal function,22enhanced and prolonged sedative effects after a single etomidate injection might be advantageous under special circumstances.\nWith respect to an appropriate effect size for the difference between the actually measured additive dose, Zmix, and the theoretical one, Zadd, we considered a difference of 10% or greater between the observed and expected absolute dose in mg/kg of etomidate or ACEA to be clinically meaningful. At none of the four different fractional ED50levels did we obtain any such difference. Hence, not only did the Student t test give a nonsignificant result, but also the mean data differed by less than the clinically relevant effect size. Therefore, it can reasonably concluded that the interaction is simply additive.\nFurthermore, a pharmacokinetic alteration of the endocannabinoid system by etomidate3is unlikely because an inhibition of fatty acid amide hydrolase by etomidate has not yet been demonstrated, and ACEA metabolism is independent of fatty acid amide hydrolase.23Moreover, an interaction between ACEA and the lipid solvent contained in the etomidate emulsion also seems highly improbable, because the combination of both drugs did not affect Rota-Rod performance. In addition, although etomidate is indeed known as an inhibitor of cytochrome P450 3A4, ACEA has, to the best of our knowledge, not been reported as a substrate, inhibitor, or inducer of any CYP isoenzyme including CYP3A4. Hence, CYP-mediated drug–drug interactions are also unlikely. However, it remains speculative whether other interactions between ACEA and etomidate, especially given by the intraperitoneal route, may have influenced the results obtained.\nIn terms of pretreatment of mice with the cannabinoid1receptor antagonist AM 251 that did not significantly change etomidate-induced sedation, sedative properties of etomidate may not depend on activation of cannabinoid1/2receptors by endocannabinoids per se , whereas an endogenous cannabinoid tone mediated by cannabinoid1receptors has been suggested to contribute to sedative–hypnotic effects of propofol.3To further determine whether the effects of cannabinoids were mediated through certain subtypes of cannabinoid receptors, the cannabinoid1receptor antagonist AM 251 and cannabinoid2receptor antagonist AM 630 were administered 10 min before the delivery of ACEA and JWH 133, respectively. Therefore, AM 251 reversed the sedative component of ACEA when ACEA was administered both alone and in combination with etomidate. In contrast to cannabinoid1receptor activation, the cannabinoid2receptor agonist JWH 133 did not affect etomidate-induced Rota-Rod performance. This difference is not astonishing, because cannabinoid2receptors have been demonstrated to be predominantly expressed in peripheral neuronal tissue and in the immune system,2and single cannabinoid2receptor activation did not induce impairment in motor coordination in our study.\nSeveral limitations to this study should be noted. First, the use of the intraperitoneal route enables hepatic metabolism, and we did not determine serum concentration or brain content of the drugs applied and their active metabolites. Second, we did not perform any ligand-binding studies to elucidate a direct activation of cannabinoid1receptors by etomidate. Third, effects of drugs given throughout the study on systemic hemodynamic and respiratory variables were not evaluated. Further, both the timing and the dose of the cannabinoid1receptor antagonist used may be responsible for the negative effect on etomidate-induced sedation. However, 5 mg/kg AM 251 reversed the sedative effect of single drug administration of ACEA completely. Therefore, the dose range of AM 251 used in our study may provide sufficient antagonistic properties at the cannabinoid1receptor when combined with etomidate. With respect to effect site concentrations, in the clinical context, dosing of anesthetic drugs is usually accomplished irrespective of plasma concentrations. Hence, our results are particularly meaningful because they translate from dose to response as opposed to concentration to response. Finally, data from animals should be extrapolated to humans with caution.\nIn conclusion, activation of the cannabinoid1receptor, but not of the cannabinoid2receptor, resulted in increased and prolonged etomidate-evoked sedation based on an additive interaction. Therefore, these data suggest that selective cannabinoid1receptor agonists could be novel targets for anesthetic drug development. |
Patient Safety Tool: APIC's MRSA Elimination Guide\nThe Association for Professionals in Infection Control and Epidemiology offers a free guide to eliminating methicillin-resistant Staphylococcus aureus.\nThis second edition of the guide, which was published in 2010, includes practice guidance to eliminate MRSA transmission in hospital settings. The guide addresses MRSA risk assessment, surveillance, antimicrobial stewardship, decolonization and other issues. A recent study on MRSA decolonization also provides insight into preventing this infection.\nDownload the MRSA elimination guide for use in your own facility.\nNote: View our database providing more than 400 reports that link to free downloadable and adaptable tools for use in surgery centers, hospitals and other organizations by clicking here.\nMore Articles on MRSA:\n© Copyright ASC COMMUNICATIONS 2016. Interested in LINKING to or REPRINTING this content? View our policies by clicking here.\n- Innovation in GI: Advances in gastroenterology technology & technique\n- A game changer for GI — Dr. Anthony Starpoli on how the TIF procedure can control regurgitation\n- How to create a strategic partnership with a hospital\n- 9 states with the highest & lowest physician salaries\n- Frenetic consolidation: The anesthesia market today & where ASCs fit in |
Unfortunately, youthful good looks don’t last forever. The face and neck are exceptionally vulnerable areas that are easily affected by sun damage, thinning skin, smoking, and stress. While wearing sunscreen and leading a healthy lifestyle will make a difference, if you’re already unhappy with certain changes in your face, you’ll see the most dramatic improvement with cosmetic surgery. A Board-certified plastic surgeon like Dr. Ver Halen can overcome the common signs of aging—or even get ahead of them—with a custom facelift that gives you a natural look.\nA facelift, or rhytidectomy, is a surgical procedure that can repair the following:\n- Relaxed skin that causes sagging in your face\n- Deepened fold lines between the nose and corner of the mouth\n- Fat that has fallen or disappeared\n- Jowls in your cheeks or jaw\n- Loose skin and excess fat in your neck area that creates a double chin or “turkey neck”\nWho’s Eligible for a Facelift?\nFacelift surgery is a highly individualized procedure. You should do it for only yourself, not to satisfy someone else’s desires or to try to fit any particular image. Dr. Ver Halen will do a full evaluation, but you’re a good candidate for a facelift if you:\n- Are a healthy individual with no existing medical conditions that would impair healing\n- Are a non-smoker\n- Have a positive outlook with realistic expectations of the surgery\nAfter a thorough evaluation, Dr. Ver Halen will recommend the best of three primary facelift techniques for you.\n1. Mini Facelift\nIf your face and neck have mild jowls or sagging skin, you could be a good candidate for a mini facelift. This technique is less invasive than a traditional facelift. It includes smaller incisions and may be performed with local anesthesia. A mini facelift can address signs of aging early, postponing the need for extensive surgery.\n2. Traditional Facelift\nTo address “turkey neck,” as well as deep folds and wrinkles, Dr. Ver Halen may recommend a traditional facelift. This procedure involves larger incisions and more recovery time, but the results tend to be more dramatic.\n3. Neck Lift\nIf you are only interested in improving the appearance of your neck, Dr. Ver Halen can address this through a small incision behind your chin. This procedure is performed under local anesthesia.\nDoes a Facelift Cause Scars?\nBecause facelift surgery involves incisions, scarring is possible, but incisions run behind the hairline and ears. Hidden in the natural folds of your face, facelift scarring is never visible. You can also minimize the appearance of scars with proper post-surgery skin care.\nFacelift Surgery: The Consultation\nAs a Board-certified plastic surgeon, Dr. Ver Halen’s top priority is patient care and safety. You can anticipate a thorough consultation. If you have questions about the procedure, use your consultation to ask Dr. Ver Halen. He’ll take ample time to address any concerns you have. He’ll also go over the following:\n- Your desired outcome and expectations\n- Your family medical history\n- Any previous surgeries you’ve had\n- Any existing medical conditions\n- Your current use of alcohol, tobacco products, supplements and/or prescription medications\n- Any known allergies\n- The use of anesthesia during your facelift procedure\n- Any potential risks of the procedure\nAlso expect Dr. Ver Halen or one of his medical associates to take photographs of your face. Dr. Ver Halen will use these images to assess your cosmetic needs and make the best recommendation. All photographs are kept in your medical records, so you can view the change in your overall appearance after facelift surgery.\nFacelift Surgery: The Procedure\nDr. Ver Halen performs facelift surgery at our Colleyville office or at our surgery center in Plano. You may be given certain facial products that prepare skin for surgery. You also may be asked to:\n- Adjust your current medications\n- Stop smoking\n- Avoid taking herbal supplements, aspirin, and other over-the-counter anti-inflammatories\nFor your comfort and safety, arrange a friend or family member to drive you to and from surgery. If you’re undergoing a traditional facelift, expect to be in surgery for three to four hours. It can take up to six hours when combined with other procedures, such as a neck lift or brow lift. Most mini facelifts are performed in under two hours\nWhether you’re getting a mini facelift or a traditional facelift, Dr. Ver Halen follows the same basic steps:\nStep 1: Administering anesthesia either by local anesthesia, intravenous sedation, or general anesthesia. Dr. Ver Halen will discuss the best option for you.\nStep 2: Placing incisions depending on the facelift technique Dr. Ver Halen and you agree on For a traditional facelift, an incision begins behind the hairline, at your temple, and follows your hairline down around your ear and back toward your lower scalp. For a mini facelift, Dr. Ver Halen makes shorter incisions that start at your temple and continue down around your ear. Incisions usually don’t go past the ear. For a neck lift, only one incision behind the chin is required.\nStep 3: Removing or re-positioning fat. Deeper layers of the face and muscles are lifted and re-secured to define the contours of your face. Dr. Ver Halen removes excess skin, leaving you with a tighter, firmer appearance. To lift a sagging neck, a second incision may be drawn under your chin.\nStep 4: Closing incisions with sutures or skin glue. Sutures will either dissolve on their own or need to be removed at a later date. For optimal results, a facelift is often combined with a neck lift, brow lift, or eyelid lift. In these cases, Dr. Ver Halen will perform multiple procedures in one operation.\nFacelift: Post-Surgery Care & Recovery\nImmediately after facelift surgery, Dr. Ver Halen will likely apply a bandage around your face to minimize bruising and swelling. You may also have a small tube inserted at your incisions to drain excess blood and fluid. These open sites will need proper cleaning and care to prevent infection and promote healing. Even with bandaging, you’ll likely experience some bruising and swelling. These symptoms tend to peak two days after facelift surgery and then gradually improve as you heal. While you’re healing, wear sunscreen and a wide-brimmed hat. Post-surgery, your face will be extremely sensitive to sun exposure. Keeping it protected from the sun helps healing and reduces scarring. After 24 to 48 hours, you’ll return to Dr. Ver Halen’s office for a follow-up visit. At that point, he will likely remove the sutures (unless they dissolve). Most facelift patients can resume their daily routines within two weeks. Four weeks post-surgery, you should be cleared for more strenuous exercise.\nRisks of Facelift Surgery\nLike any facial rejuvenation, it’s important to understand the potential risks as well as you do the results. At Ver Halen Aesthetics and Plastic Surgery, you will be asked to sign consent forms before your facelift surgery to ensure you fully understand the procedure. Facelift risks include:\n- Facial nerve injury or weakness that can cause numbness\n- Discoloration or other skin irregularities\n- Deep vein thrombosis, cardiac, or pulmonary issues\n- Temporary or permanent hair loss at the incision sites\n- Fluid accumulation\n- Bleeding from the incisions\n- Issues with wound healing, which may lead to infection\n- Unfavorable scarring\n- Persistent discomfort\n- Anesthesia complications\nThese risks will be thoroughly discussed during your consultation and prior to consent. If you’re not completely satisfied with your results, Dr. Ver Halen will discuss revisional surgery or may recommend a different cosmetic procedure.\nHow to Pay for Facelift Surgery\nDr. Ver Halen accepts healthcare credit cards issued by Synchrony Bank (CareCredit®) and Comenity® Capital Bank (Alphaeon Credit®). Should you need it, Dr. Ver Halen will accept a secured loan from United Medical Credit or Enhance Patient Finance. United Medical Credit is suitable for prime and subprime lenders and has multiple plan options with flexible terms. The following payment methods are always accepted:\n- Credit card\n- Cashier’s check\n- In-house financing\n- Other types of loans\nA facelift can turn back the clock, helping restore your youthfulness—and your confidence. Don’t wait to discuss your options and get a customized plan to meet your needs. Call the medical professionals at Ver Halen Aesthetics and Plastic Surgery to request an appointment and make your cosmetic dreams come true. |
In Reply:-It appears that in their letter, Pond and Aiken have misinterpreted some of our results. First, one of the strengths of this study was that the "confounding variables" mentioned in the letter have all been controlled for a priori. Second, we did not "suggest that parental presence appeases some children." This study demonstrated that children who were older than 4 yr, had a parent with low trait anxiety, or had a low baseline level of activity, as assessed by temperament ratings, benefited from parental presence during induction of anesthesia.\nIt is important to distinguish between "normal" childhood separation and separation in traumatic settings. A child who is left at the church nursery does not undergo (we hope) a traumatic experience of induction of anesthesia, surgery, and postoperative pain. Therefore, comparing separation for surgery to other childhood events such as separation for nursery school is inappropriate at best.\nIt is oversimplification on the part of Pond and Aiken to categorize all parents into two groups, those who are calm and those who are anxious. For example, among many anxious parents, there are individuals who nonetheless cope effectively with their anxiety and, therefore, can help their children with induction. When we say "Parental anxiety mediates children's response to stressful situations ...", we also allow that the mediating effect may be to minimize children's anxiety as well as potentially increase it. In addition, we do believe it is the role of the anesthesiologist to tell the parent whether they are allowed to be present during induction. From our clinical experience, parents who are overly anxious and want to participate in the induction usually withdraw their wishes once the anesthesiologist explains to them that they may actually increase the anxiety of their child.\nWe strongly disagree with the reasons provided by Pond and Aiken for forbidding parental presence during induction. First, there is proof that three subgroups of children benefit from this intervention. Second, although society may tolerate some forms of normal childhood separation (e.g., church nursery), it does strongly reject other forms. For example, until the early 1960s, parents were not allowed to room with their children during hospitalization. After public pressure, it is very rare to have a hospital today that does not allow parental rooming. Do Pond and Aiken want to go back to the 1960s? Third, currently, there are no data to show that the anesthesiologist's job may be obstructed by this practice. In fact, in our investigation, the rate of complications and duration of induction were similar in both groups, and a large scale study reported a very low rate of parental disruptive behavior. [1,3]Finally, this practice is very prevalent in Great Britain and is supported (although not always implemented) by many anesthesiologists, surgeons, and parents in the United States. [2,4,5]\nIn conclusion, we do not recommend parental presence for every anesthesia induction in children. The individual child, parent, and anesthesiologist should be considered whenever the question of parental presence arises. [1,6]We do however, strongly reject the suggestion that parental presence should never take place.\nZeev N. Kain, M.D., Assistant Professor of Anesthesiology and Pediatrics, Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06510.\n(Accepted for publication August 15, 1996.) |
What Is the Process of Emergency Tooth Extraction?\nNo dentist or dental specialist will ever recommend tooth extraction unless it is the only viable solution for your problem and the optimal decision for you. So if a tooth extraction or a series of tooth extractions does become inevitable and dental restoration is no longer an option, such as in case of damage caused by trauma, disease or dental crowding, you need to know what to expect.\nThe more you know about the process, the less fear and uncertainty you will experience in the days leading up to the procedure. But are emergency teeth extractions in Murrieta, Temecula and the surrounding areas any different from a planned tooth extraction? Here’s what you need to know.\nWhat is the process of a tooth extraction?\nThe specific details of the process of a tooth extraction and the duration of the procedure depend on complexity of the patient’s case. Based on that, we can differentiate between two types of dental extraction:\n- Simple extraction: This is a simple, straightforward procedure that general dentists can perform. The dentist loosens the tooth with an instrument called an elevator and then uses forceps to perform the extraction.\n- Surgical extraction: This is a complex extraction which is necessary when the tooth is broken at the gum line or when it has failed to fully erupt. The procedure should be performed by an oral surgeon.\nWhat happens during a tooth extraction?\nRegardless of the type of extraction, the steps in the process are essentially the same:\n- Numbing the tooth to minimize your discomfort\n- Enlarging the tooth socket to extract the tooth\n- Closing the empty socket\n- Controlling the bleeding\n- Minimising the swelling\n- Post extraction care\nHow painful is a tooth extraction?\nWhile tooth extractions can be painful, modern science and technology have eliminated much of the discomfort. Each method of anesthesia comes with its own advantages, and your doctor will let you know what they are during your initial consultation.\nHow long does a tooth extraction procedure take?\nAlthough the duration of a tooth extraction procedure depends on the specific circumstances you are in, an experienced oral surgeon can be performed in as little as 30 minutes even when it concerns a complex extraction of premolars or molars.\nHow do you prepare for a tooth extraction?\nTo prepare for a tooth extraction, especially if you are going to receive intravenous (IV) anesthesia:\n- Wear short sleeves and loose-fitted clothes\n- Do not eat or drink for six to eight hours prior to the appointment\n- Do not smoke prior to the procedure\n- Inform your dental surgeon of any specific circumstances, such as if you have cold, nausea or similar health issues, as this may be a legitimate reason to reschedule or change your preferred method of anesthesia.\n- If you are going to receive general anesthesia, you should have someone accompany you to and from the appointment.\nYour doctor may advise you to take antibiotics before the procedure to ensure you are stable in the following scenarios:\n- You have an infection or a compromised immune system\n- The surgery is expected to take long\n- You suffer from a specific medical condition\nBringing the full continuum of quality care to Murrieta: emergency teeth extractions\nIf an emergency tooth extraction still sounds intimidating, we understand, which is exactly why Temecula Facial Oral Surgery is your go-to place. We will do everything in our power to give you a safe and comfortable experience. At our office, an emergency tooth extraction is an efficient procedure which includes X rays, evaluation and any follow-up care required, as well as a high standard of patient care throughout, which is our number one priority.\nDr. Tsvetov will evaluate the situation and recommend your optimal course of action to dispel your fear and restore your smile. You will be enjoying a family dinner in Downtown Murrieta before you know it. Book your appointment today!\nComments are closed. |
Hill Regional Hospital’s surgery department offers the convenience of same-day surgery and inpatient care, when necessary.\nOutpatient surgeries are generally scheduled in the morning, and patients are discharged home between two and six hours later, depending on the nature of the procedure and recovery time. When a surgical procedure requires a patient to stay overnight, our medical/surgical unit offers personalized inpatient care to help you through your stay.\nOur services include:\n- Abdominal Surgery\n- Breast Biopsies\n- Carpal Tunnel Procedures\n- Cataract Surgery\n- Hernia Repairs\n- Polyp Removal\n- Varicose Veins, Spider Veins, and Sclerotherapy Injections\nMild sedation surgeries:\n- Cauterization of a Bleeding Ulcer\n- Dilation for Esophageal Strictures\n- Obstetrical / Gynecological Surgeries |
Something that never seems to go out of fashion is the desirable flat tummy and abs that we often see in magazines and on social media.\nBut it’s not always possible to spend the amount of dedication to working out and keeping a clean diet. Life sometimes just doesn’t allow for that.\nThat’s why tummy tucks have been an option that some women have resorted to in New York City. But it can be costly.\nA full tummy tuck in New York City can cost between $9.500-$10,500. More often than not a surgeon’s office will offer a mini tummy tuck and a full tummy tuck.\nIf you require less work and opt for the mini tummy tuck then you can end up saving thousands of dollars. This is because you will need less appointment time, less anesthesia, and less service in general.\n- What Is The Difference Between A Mini And A Full?\n- What Is The Cost Breakdown and Factors In New York City?\n- What Are The Benefits Of A Tummy Tuck?\n- Related Questions\nWhat Is The Difference Between A Mini And A Full?\nBecause there is a few thousand dollar difference between a full and mini tummy tuck there is also a difference in the procedures.\nAside from the time needed to perform the procedure and the additional anesthesia that may be needed, there are a few differences that may be included in the full tummy tuck but not the mini.\nFull Tummy Tuck\nA full tummy tuck is more invasive than a mini tummy tuck. This process tightens the skin from the entire abdominals by making an incision in the lower abdomen but pulling the skin down from the top.\nThe incision will go from one hip to the other hip. If navel contouring is necessary you may also need an incision there. Often, liposuction is also used to remove the excess fat.\nMini Tummy Tuck\nA mini tummy tuck doesn’t mean smaller incisions necessarily. While it is a smaller incision the whole procedure is focused just on the lower abdomen by trimming the excess fat around the bottom.\nThis is for those who may have minimal to no fat on the upper abdomen. Navel contouring is not done in the mini tummy tuck. These procedures usually start at around $6,000.\nWhat Is The Cost Breakdown and Factors In New York City?\nKnowing that the cost is a direct result of the amount of work your tummy needs to get to your desired goals. Generally, this can be discussed through the consultation that you will have with your doctor.\nFees start to rack up with longer anesthesiology, hospital and surgical center fees (time), medications,\nThe extensiveness of the Procedure\nThe longer the procedure takes the more help a surgeon will need. This means fees will add up for paying an assistant licensed staff alongside the surgeon.\nThe surgeon’s fee alone typically averages $5,232. Sometimes the procedure cannot be done in one visit in more extensive situations.\nWhile facility fees of the hospital or surgical center range from $700-$1000, they can go past that with longer or multiple procedures.\nIt’s very common to need multiple appointments and it’s more likely that you will spend on the higher number than the lower.\nThe anesthesiologist fees are usually between $500-$700 but can go upwards with any additional required time. In some expensive instances, anesthesiologists can cost $450 an hour.\nWhile both the mini tummy tuck and the full tummy tuck require anesthesiology, the full process can take a lot longer and require much more anesthesiology to stay asleep.\nFor instance, a full tummy tuck can take up to five hours while a mini tummy tuck can take as little as an hour. Another thing that can add up when it comes to paying the anesthesiologist is multiple visits.\nSometimes a complication or a more severe procedure may require additional visits as one procedure may not be enough.\nAdditional Measures (Lipo)\nLiposuction is an additional surgical procedure that is used solely for the purpose of removing excess fat. It is commonly referred to as Lipo.\nIt is almost always used in a full tummy tuck but not always in a mini tummy tuck. How it differs from a tummy tuck is that the tummy tuck focused on removing the excess skin whereas lipo focuses on removing small fat deposits.\nRegardless of how big your small your procedure is your doctor will prescribe medications to deal with your aftercare of the surgery. The bigger the procedure the more recovery time you can expect and ultimately more medication.\nYou may also require additional check-ins for larger procedures to make sure the desired results were met. This is how the fees can start to add up even after the original consultation number has been passed.\nWhat Are The Benefits Of A Tummy Tuck?\nSo many men and women desire to get rid of that extra belly fat that exercise and diet just can’t seem to get rid of. In fact, more than 127,000 Americans got tummy tucks in 2017 and the number just keeps rising.\nOther than appearance, there are some other benefits of having a tummy tuck. But with any procedure, there are risks and drawbacks.\n- The first benefit that is obvious is your appearance will change for the desired result. This always automatically brings confidence levels up and can affect mental health in positive ways. Feeling good and looking good are two directly related things and tummy tucks affect both.\n- A tummy tuck can actually restore previously weakened muscles because of the rightened connective tissue. This can also result in less back pain because a strong core can support your lower back.\n- Because of your new results, it can also motivate that individual to keep those good looks by improving their overall health. Usually, this procedure leads people directly to the gym to continue their health journey.\n- This is no cost-effective procedure. Unfortunately, because it is considered a comment surgery it can be very costly and paid out of pocket. The more extensive the procedure as we know, the more the bills will add up at a quicker rate.\n- Ultimately, the procedure can cause swelling because of how invasive it is. It may take several months to actually see the results because of this and can lead to discouraged patients.\n- Tummy tucks before pregnancy can negatively affect the results or “lose” the results. This can also be true of weight gain which is why it is important for patients to keep healthy habits after the procedure.\nWhat Is A Fleur De Lis Tummy Tuck?\nSometimes a Doctor may refer to a specific kind of tummy tuck called the Fleur De Lis tummy tuck. This version is a special treat for those patients who have more excess skin than normal.\nThis would usually be the type of treatment for those who have lost excess weight or have gotten plastic surgery to lose all the excess fat and excess skin that remains. The incisions are not only done horizontally but are also made vertically.\nWhat Is The Recovery Aftercare Of A Tummy Tuck Like?\nAfter the procedure of a tummy tuck, you will need to lay bent at the waist for two weeks in bed. So no work, or doing normal daily activities.\nFor at least one of those weeks, you will have a draining tube. After the two weeks, you can return to work but you will have a compression wrap around your stomach that will need to be worn for at least 6 weeks to help with the swelling.\nKeep in mind that this process may take place over a few appointments so you may not have a one-and-done situation.\nYou may have to take 6-8 weeks for recovery the first time around for larger procedures and then have an additional procedure to remove more skin and have another few weeks of recovery with the same routine.\nWhat Is The Scarring Like?\nAfter your procedure, you will have scars likely below the bikini waistline so that they aren’t visible if you were to go to the beach.\nOn average mini tummy tucks will leave a scar 6-8 inches long whereas a full tummy tuck will be a few inches longer. A Fleur De Lis tummy tuck will have both horizontal scars and vertical.\nThese scars are typically thin and pink and can heal for about a year. Doctors normally provide creams and treatment to help minimize the visual of permanent scarring after the procedure. |
It's been a busy day for Noelle. She started her morning getting spayed and spent most of the day in recovery at the animal hospital. We've learned that little Noelle is only 15.8 lbs! I think she's going to be a big girl, though, she's so lanky!\nI've got nothing all that new to report, but wanted everyone to know that Noelle is safe and healthy and recovering from her spay surgery! We took a nap earlier, and she's definitely uncomfortable (poor thing groaned every time she moved), but she will be fine in the next couple of days. She is eating normally, drinking normally, etc., so it's good. I was concerned that with her health issues there could be complications from the anesthesia, but I am happy to report that there was nothing to worry about.\nNoelle is officially vaccinated as well, and is ready to find her forever home! This is such exciting news, she's come so far in such a short time, and I am just so proud of her. She is a really special little dog, and such a tough cookie to make it through all that she's been through. Please help us find her perfect forever home by sharing her petfinder link: HERE!\nHope everyone is having a good night!! We're getting snow already... I'm not looking forward to being snowed in! |
Community Memorial Health System is proud to offer a broad-based, clinically focused residency program in general surgery. Our emphasis is on training academically strong surgeons with critical thinking skills and procedural expertise in caring for the diverse patients seen in the practice of general surgery. We focus on a range of general surgical procedures, including abdominal, endocrine, and breast surgery; robotic surgery and GI endoscopy. Our residents also gain experience in anesthesia, and plastic, vascular, and cardiothoracic surgery.\nOur primarily MD faculty surgeons are from diverse backgrounds. Each resident will spend time with an individual surgeon or group on monthly rotations caring for their private patients and taking ER call, with increasing levels of independence and responsibility. The residents also staff General Surgery clinic under the supervision of attending faculty, providing continuity of care pre-, intra-, and postoperatively.\nOur residency has initial accreditation with ACGME and AOA accreditation. We are a five year training program with the majority of time, including the entire 5th year, spent at CMH. We will send residents to affiliated institutions for rotations in trauma, pediatric surgery, and transplant. Our affiliations with Ventura County Medical Center as well as the surgical residency program at Santa Barbara Cottage Hospital provide additional didactics.\nOur goal is to shape general surgeons who are expert in providing compassionate, up to date care; competent to handle the challenges of a career in General Surgery; and dedicated to the concept of lifelong learning. We hope that our residents become busy, actively-practicing board certified surgeons providing expert care within the community.\nGosta Iwasiuk, MD, F.A.C.S.\nGeneral Surgery Residency\nDepartment of GME\n147 N Brent St\nVentura, Ca 93003 |
CRNA Jobs in Williamstown, Kentucky\nAre you a professional in the CRNA field and want a travel job in Williamstown, Kentucky area? trustaff connects health employers to qualified professionals every day. We are looking for experienced, caring CRNA to fill jobs throughout the country. Experience williamstown and get a chance to explore beautiful Kentucky on your time off.\n**We are having difficulty finding exact matches for your search right now. Click here for a more advanced search or fill out the form on the right to trigger a deeper search of available positions.\nTravel Nurse and Allied Health Jobs in Williamstown, KentuckyFind a travel CRNA job in beautiful Kentucky. Known as The Bluegrass State, you'll find horse racing, bourbon distilleries, coal and car manufacturing in Kentucky. Home to world-class hospitals such as University of Kentucky Albert B. Chandler Hospital in Lexington, Baptist Health Louisville in Louisville and St. Elizabeth Healthcare Edgewood-Covington Hospitals in Edgewood, Kentucky ensures you'll be working among some of the best healthcare professionals in the country. Outside of work, you'll find Mammoth Cave National Park, Red River Gorge, Cumberland Falls, and the Cumberland Gap and a multitude of enticing natural and cultural attractions.\nAs a Certified Registered Nurse Anesthetist (CRNA), you will be responsible for administering anesthesia to patients under the direction of a surgeon. The Nurse Anesthetist will review patient medical history and condition in order to determine proper methods of anesthesia and how the patient should respond to anesthetics. The CRNA will attend to patient needs before, during, and after surgery.\nFind my CRNA Travel Assignment Today!\nThe Best Benefits, Incredible Pay for CRNA Jobs - the 'trustaff' wayFor over 15 years, trustaff has specialized in matching skilled healthcare professionals like you with high-paying travel jobs at the best facilities across the country. Nicknamed The Bluegrass State, Kentucky is known for horse racing, bourbon distilleries, coal and car manufacturing. When you travel with trustaff, you'll enjoy the best of both worlds: not only are our travel nurses some of the highest-paid in the industry, trustaff travelers enjoy great employee benefits, access to hundreds of jobs, and unmatched personal service. From handling your paperwork to delivering your paycheck, our promise is people who care.\nWhat People are Saying\nView Related Pages |
The Department of Anesthesiology at Mayo Clinic is a highly integrated, collaborative group of adult and pediatric anesthesiologists. The department comprises more than 90 staff doctors, 60 residents, 200 nurse anesthetists and 150 respiratory therapists, who are committed to providing the best possible care to adult and pediatric patients requiring anesthesia and intensive care. Members of the department also conduct basic and clinical research and teach postgraduate and continuing education programs.\nMayo Clinic anesthesiologists supervise many critical care cases each year. This large number of cases, integrated with ongoing research and education, results in wide-ranging expertise in the anesthetic management of patients of all ages.\nThe field of anesthesia changes continually with the introduction of new drugs, equipment and surgical and radiological interventions. Department members are organized into subspecialty groups, each focusing on a segment of anesthesiology. Their expertise is a resource for everyone, enabling the department to stay at the forefront of the specialty.\nIn addition to caring for patients in their clinical practices, Mayo Clinic's faculty members are committed to teaching and facilitating the growth of medical knowledge and are recognized leaders in their field. You will have direct access to these individuals throughout your training.\nYou will be assigned a faculty adviser who can provide comprehensive educational advice and personal support. Your adviser also will serve as a contact point, introducing you and your family to Rochester and the Mayo Clinic system.\nMany prominent professors visit Mayo Clinic each year. They present their work during noon and/or morning lectures and participate in hospital rounds. You will be encouraged to take advantage of these opportunities. |
Liposuction is an effective way to eliminate stubborn deposits of fat from the body. Dr. Andrea Doyle offers safe and effective liposuction techniques that can provide pleasing and long-lasting results.\nThe cost of liposuction in Rhode Island is dependent on factors including which areas of the body are being treated and how much fat is being removed. At the Centre for Aesthetic and Reconstructive Surgery, the liposuction cost you are quoted will include all applicable fees, including hospital fees, to help you plan accordingly.\nDuring your initial consultation, we can discuss financing as appropriate to assist you in making the best decision for your needs. Please call 401-336-3770 to schedule your consultation and learn more. Dr. Andrea Doyle is a board-certified plastic surgeon serving East Greenwich and all surrounding Rhode Island communities.\nAbdominoplasty, more commonly known as tummy tuck surgery, involves removing excess skin and fat from the midsection. With a tummy tuck, Dr. Andrea Doyle can produce a toned, firm, and defined midsection – eliminating stretch marks and reattaching separated abdominal muscles in the process – that improves clothing options and enhances your overall appearance.\nCosts for tummy tuck surgery, which include surgical fees, anesthesia fees, and related operating costs, can vary depending on the scope and extent of the procedure. The best way to find out what your tummy tuck surgery will cost is through a one-on-one consultation with our board-certified plastic surgeon.\nDuring your initial consultation, we can discuss financing options, including CareCredit, to help you plan accordingly.\nCall the Centre for Aesthetic & Reconstructive Surgery at 401-336-3770 to schedule your consultation today. We serve East Greenwich and all surrounding Rhode Island communities. |
Generic Name: methohexital (METH oh HEX i tal)\nBrand Name: Brevital Sodium\nWhat is methohexital?\nMethohexital is a barbiturate (bar-BIT-chur-ate). Methohexital slows the activity of your brain and nervous system.\nMethohexital is used to cause you to fall asleep before a surgery or other medical procedure.\nMethohexital may also be used for purposes not listed in this medication guide.\nWhat is the most important information I should know about methohexital?\nYou should not use this medicine if you have a history of porphyria (a genetic enzyme disorder that causes symptoms affecting the skin or nervous system).\nWhat should I discuss with my health care provider before receiving methohexital?\nYou should not use this medicine if you are allergic to methohexital or other barbiturates (butabarbital, pentobarbital, phenobarbital, Luminal, Nembutal, Seconal, and others), or if you have:\na history of porphyria (a genetic enzyme disorder that causes symptoms affecting the skin or nervous system).\nTo make sure methohexital is safe for you, tell your doctor if you have:\nepilepsy or other seizure disorder;\nasthma or chronic obstructive pulmonary disease (COPD);\nanemia (lack of red blood cells);\nan endocrine disorder;\nhigh or low blood pressure;\nheart disease, congestive heart failure; or\nTell your doctor if you are pregnant.\nAnesthesia medicine may affect brain development in a child under 3, or an unborn baby whose mother receives this medicine during late pregnancy. These effects may be more likely when the anesthesia is used for 3 hours or longer, or used for repeated procedures. Effects on brain development could cause learning or behavior problems later in life.\nNegative brain effects from anesthesia have been seen in animal studies. However, studies in human children receiving single short uses of anesthesia have not shown a likely effect on behavior or learning. More research is needed.\nIn some cases, your doctor may decide to postpone a surgery or procedure based on these risks. Treatment may not be delayed in the case of life-threatening conditions, medical emergencies, or surgery needed to correct certain birth defects.\nAsk your doctor for information about all medicines that will be used during your surgery or procedure. Also ask how long the procedure will last.\nIt is not known whether methohexital passes into breast milk or if it could affect the nursing baby. Tell your doctor if you are breast-feeding.\nHow is methohexital given?\nMethohexital is given as an injection into a muscle, or into a vein through an IV. This medication is also given rectally when used in young children.\nA healthcare provider will give you this injection.\nTell your caregivers if you feel any burning, pain, or swelling around the IV needle when methohexital is injected.\nMethohexital should make you fall asleep very quickly.\nYour breathing, blood pressure, oxygen levels, and other vital signs will be watched closely while you are receiving methohexital. You will also be watched closely while you are coming out of the anesthesia.\nDrowsiness may last for several hours. You will need someone to drive you home from after you receive methohexital.\nWhat happens if I miss a dose?\nSince methohexital is used as a single dose, it does not have a daily dosing schedule.\nWhat happens if I overdose?\nSince this medication is given by a healthcare professional in a medical setting, an overdose is unlikely to occur.\nWhat should I avoid after receiving methohexital?\nThis medication may impair your thinking or reactions. Avoid driving or operating machinery for 8 to 12 hours after you awake from anesthesia.\nDo not drink alcohol just after receiving methohexital. Dangerous side effects could occur.\nMethohexital side effects\nGet emergency medical help if you have signs of an allergic reaction: hives; difficult breathing; swelling of your face, lips, tongue, or throat.\nTell your caregivers right away if you have:\nsevere burning or swelling where the medicine was injected;\nnumbness or tingly feeling;\na light-headed feeling, like you might pass out;\nweak or shallow breathing; or\nconfusion, anxiety, or restless feeling when coming out of anesthesia.\nSide effects such as confusion, depression, or excitement may be more likely in older adults and those who are ill or debilitated.\nCommon side effects may include:\nnausea, vomiting, stomach pain;\nchills or shivering;\nmuscle twitching; or\nmild skin rash or itching.\nThis is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.\nMethohexital dosing information\nUsual Adult Dose for Anesthesia:\nInduction of anesthesia:\nA 1% solution is administered intravenously at a rate of about 1 mL/5 seconds. Gaseous anesthetics and/or skeletal muscle relaxants may be administered concomitantly. The dose required for induction may range from 50 to 120 mg or more but averages about 70 mg. The usual dosage in adults ranges from 1 to 1.5 mg/kg. The induction dose usually provides anesthesia for 5 to 7 minutes.\nMaintenance of anesthesia:\nMaintenance of anesthesia may be accomplished by intermittent injections of the 1% solution or by continuous intravenous infusion of a 0.2% solution. Intermittent injections of about 20 to 40 mg may be given as required, usually every 4 to 7 minutes. For continuous infusion, the average rate of administration is about 3 mL of a 0.2% solution/minute. The rate of flow must be individualized for each patient. For longer surgical procedures, gradual reduction in the rate of administration is recommended. Other parenteral agents, usually narcotic analgesics, are ordinarily employed along with methohexital during longer procedures.\nUsual Pediatric Dose for Anesthesia:\nFor induction of anesthesia:\n1 month or older:\nIntramuscular: 6.6 to 10 mg/kg using a 5% solution.\nRectal: 25 mg/kg using a 1% solution.\nWhat other drugs will affect methohexital?\nTell your doctor about all other medications you use, especially:\nphenytoin or other seizure medications;\na blood thinner--warfarin, Coumadin, Jantoven; or\nsteroid medicine--prednisone, dexamethasone, prednisolone, and others.\nThis list is not complete. Other drugs may interact with methohexital, including prescription and over-the-counter medicines, vitamins, and herbal products. Not all possible interactions are listed in this medication guide.\nSee also: Side effects (in more detail)\nMore about methohexital\n- Side Effects\n- During Pregnancy or Breastfeeding\n- Dosage Information\n- Drug Interactions\n- Support Group\n- En Español\n- 0 Reviews – Add your own review/rating\n- Drug class: general anesthetics\nOther brands: Brevital Sodium\nRelated treatment guides\nWhere can I get more information?\n- Your doctor or pharmacist can provide more information about methohexital.\n- Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed.\n- Disclaimer: Every effort has been made to ensure that the information provided by Cerner Multum, Inc. ('Multum') is accurate, up-to-date, and complete, but no guarantee is made to that effect. Drug information contained herein may be time sensitive. Multum information has been compiled for use by healthcare practitioners and consumers in the United States and therefore Multum does not warrant that uses outside of the United States are appropriate, unless specifically indicated otherwise. Multum's drug information does not endorse drugs, diagnose patients or recommend therapy. Multum's drug information is an informational resource designed to assist licensed healthcare practitioners in caring for their patients and/or to serve consumers viewing this service as a supplement to, and not a substitute for, the expertise, skill, knowledge and judgment of healthcare practitioners. The absence of a warning for a given drug or drug combination in no way should be construed to indicate that the drug or drug combination is safe, effective or appropriate for any given patient. Multum does not assume any responsibility for any aspect of healthcare administered with the aid of information Multum provides. The information contained herein is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or adverse effects. If you have questions about the drugs you are taking, check with your doctor, nurse or pharmacist.\nCopyright 1996-2012 Cerner Multum, Inc. Version: 2.01.\nLast reviewed: March 10, 2017\nDate modified: September 05, 2017 |
This article is only available in the PDF format. Download the PDF to view the article, as well as its associated figures and tables.\nTo the Editor:—\nMorphine is frequently used to supplement pentothal sodium in the production of anesthesia. It is definitely synergistic with and potentiates the action of pentothal. One frequently observes that administration of morphine during the course of a pentothal anesthetic will decrease the required pentothal dose.Occasionally it has been overlooked not only that morphine potentiates the action of pentothal but that pentothal will potentiate the action of morphine. When morphine is administered to a patient postoperatively it is important to know whether such a patient has received a pentothal anesthetic. If he has, and the fact is disregarded, the morphine administered may produce a clinical narcotic effect far greater than was desired or anticipated. Such a situation will exist when a high concentration of pentothal persists for several hours after surgery, a situation to be suspected when a patient has received several grams of pentothal or when prolonged\nLieberman SL. MORPHINE WITH PENTOTHAL ANESTHESIA. JAMA. 1945;127(17):1147. doi:10.1001/jama.1945.02860170059023\nCustomize your JAMA Network experience by selecting one or more topics from the list below.\nCreate a personal account or sign in to: |
Total proctocolectomy and ileal-anal pouchRestorative proctocolectomy; Ileal-anal resection; Ileal-anal pouch; J-pouch; S-pouch; Pelvic pouch; Ileal-anal pouch; Ileal pouch-anal anastomosis; IPAA; Ileal-anal reservoir surgery\nTotal proctocolectomy and ileal-anal pouch surgery is the removal of the large intestine and most of the rectum. The surgery is done in one or two stages.\nYou will receive general anesthesia before your surgery. This will make you sleep and pain free.\nGeneral anesthesia is treatment with certain medicines that puts you into a deep sleep so you do not feel pain during surgery. After you receive the...\nYou may have the procedure in one or two stages:\n- Your surgeon will make a surgical cut in your belly. Then your surgeon will remove your large intestine.\n- Next, your surgeon will remove your rectum. Your anus and anal sphincter will be left in place. The anal sphincter is the muscle that opens your anus when you have a bowel movement.\n- Then your surgeon will make a pouch out of the last 12 inches (30 centimeters) of your small intestine. The pouch is sewn to your anus.\nSome surgeons perform this operation using a camera. This surgery is called laparoscopy. It is done with a few small surgical cuts. Sometimes a larger cut is made so the surgeon can assist by hand. The advantages of this surgery are a faster recovery, less pain, and only a few small cuts.\nIf you have an ileostomy, your surgeon will close it during the last stage of the surgery.\nWhy the Procedure Is Performed\nThis procedure may be done for:\nRisks of anesthesia and surgery in general are:\nRisks of having this surgery include:\n- Bulging tissue through the cut, called an incisional hernia\n- Damage to nearby organs in the body and nerves in the pelvis\n- Scar tissue that forms in the belly and causes a blockage of the small intestine\n- The place where the small intestine is sewn to the anus (anastomosis) may come open, causing infection or abscess, which can be life threatening\n- Wound breaking open\n- Wound infection\nBefore the Procedure\nAlways tell your health care provider what medicines you are taking, even medicines, supplements, or herbs you bought without a prescription.\nBefore you have surgery, talk with your provider about the following things:\n- Intimacy and sexuality\nDuring the 2 weeks before your surgery:\n- Two weeks before surgery, you may be asked to stop taking medicines that make it harder for your blood to clot. These include aspirin, ibuprofen (Advil, Motrin), Naprosyn (Aleve, Naproxen), and others.\n- Ask which medicines you should still take on the day of your surgery.\n- If you smoke, try to stop. Ask your provider for help.\n- Always let your provider know about any cold, flu, fever, herpes breakout, or other illnesses you may have before your surgery.\nThe common cold most often causes a runny nose, nasal congestion, and sneezing. You may also have a sore throat, cough, headache, or other symptoms....Read Article Now Book Mark Article\nThe flu is an infection of the nose, throat, and lungs. It spreads easily. This article discusses influenza types A and B. Another type of the flu ...Read Article Now Book Mark Article\nThe day before your surgery:\n- You may be asked to drink only clear liquids, such as broth, clear juice, and water after a certain time.\n- Follow the instructions you have been given about when to stop eating and drinking.\n- You may need to use enemas or laxatives to clear out your intestines. Your provider will give you instructions on how to use them.\nOn the day of your surgery:\n- Take the medicines you have been told to take with a small sip of water.\n- You will be told when to arrive at the hospital.\nAfter the Procedure\nYou will be in the hospital for 3 to 7 days. By the second day, you will most likely be able to drink clear liquids. You will be able to add thicker fluids and then soft foods to your diet as your bowel begins to work again.\nWhile you are in the hospital for the first stage of your surgery, you will learn how to care for your ileostomy.\nYou will probably have 4 to 8 bowel movements a day after this surgery. You will need to adjust your lifestyle for this.\nMost people recover fully. They are able to do most activities they were doing before their surgery. This includes most sports, travel, gardening, hiking, and other outdoor activities, and most types of work.\nAraghizadeh F. Ileostomy, colostomy, and pouches. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 10th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 117.\nMahmoud NN, Bleier JIS, Aarons CB, Paulson EC, Shanmugan S, Fry RD. Colon and rectum. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 20th ed. Philadelphia, PA: Elsevier; 2017:chap 51.\nReview Date: 9/3/2018\nReviewed By: Debra G. Wechter, MD, FACS, general surgery practice specializing in breast cancer, Virginia Mason Medical Center, Seattle, WA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team. |
Having unwanted fat in various areas of your body can have a substantial influence on your health and self-esteem. While standard weight loss through exercise and diet is a fantastic way to drop weight in general, even the very best exercises cannot target issue areas like the tummy, inner thighs, arms, and butts. Liposuction is a time checked treatment that is used to remove excess fat from particular areas of the body, enabling a specific to form and contour their body to their preference. Is liposuction right for you? Discover now.\nPros of Liposuction\nThere are lots of benefits to this cosmetic treatment, consisting of:\n• Instantly visible changes. Unlike standard weight loss, liposuction develops changes that are right away noticeable in the body. Some distinction is visible immediately, and the preferred outcomes are typically attained in just a couple of days.\n• Proven and safe. This cosmetic treatment has actually been carried out by skilled specialists all over the world for several years and the strategy has actually been improved over and once again to be safe and efficient.\n• Healing time is normally fast. The downtime required after having this kind of procedure is usually much less than exactly what is required for other types of cosmetic procedures, consisting of abdominoplasty, breast reduction, and more. Individuals who have had the procedure can often go back to work far more quickly than they anticipated and can get back to living a healthy, active way of life.\n• Weight-loss can be permanent. With the right maintenance strategies, the fat that was gotten rid of throughout the liposuction procedure will not return.\n• Complete control over your body. With liposuction, a person can have complete control over how they want to look, beyond exactly what conventional diet plan and exercise can supply. Giving individuals this power over their bodies enhances self-confidence and help individuals feel their best.\nWhile there many advantages to liposuction, there are naturally a couple of caveats that should be taken into consideration prior to making the decision to move on with the treatment.\nCons of Liposuction\nBefore having actually liposuction done, it's important to analyze the potential drawbacks of the procedure and identify if the benefits outweigh the risks in your certain case. Your cosmetic surgeon can assist you find out more about the risks related to the treatment and can assist you decide if moving forward is the best thing for you.\n• Issues with general anesthesia. Because liposuction is performed under general anesthesia, the procedure carries the very same threats as other type of surgery where general anesthesia is utilized. Underlying medical conditions may increase these dangers.\n• Unfavorable responses. Bruising, bleeding, and discomfort are all to be expected, however, in unusual cases can cause more significant problems.\n• The potential to get the weight back. After having liposuction done, it is crucial to preserve a healthy diet plan and exercise effectively as suggested by your doctor. Failure to do so might result in acquiring back the weight that was lost or potentially much more.\nThere are threats associated with liposuction, for many people, the benefits far surpass them. Educate yourself about the procedure by having thorough conversations with your cosmetic surgeon and consider how liposuction has the prospective to affect you as a distinct individual. Just you and your specialist can determine if liposuction will provide you with the outcomes you are searching for within your expectations.\nLaser Liposuction procedure is a new non invasive procedure to loose unwanted bodyfat in Pine Valley NY\nLaser liposuction is a more recent, minimally invasive procedure that involves heating the fat cells to melting point and getting rid of the melted fat through a little cannula. The procedure is normally done right in your doctor's workplace and is an outstanding option for individuals who have less than 500 ml of fat to get rid of from any one area. Laser liposuction can be a safe, complementary treatment to weight reduction in order to shape the body you've constantly desired.\nContact a Specialist in your Pine Valley NY today.If you're considering liposuction as a weight-loss solution, it is essential that you discuss your desires with a qualified cosmetic surgeon in your location. Your cosmetic surgeon will perform a complete test and health history survey to determine if liposuction can benefit you and help you reach your physical and emotional objectives. Call today for a consultation and learn more about how liposuction can assist you attain the body of your dreams. |
For many die-hard and casual horse racing fans of a certain age, the sight of Barbaro suffering a life-threatening injury during the Preakness summoned a sadness they had not experienced during a sporting event since the beloved, filly Ruffian – who like Barbaro was undefeated – broke down during a match race with Foolish Pleasure at Belmont on July 6, 1975, and had to be euthanized the next day. Here is how The Post covered the Ruffian incident.\nJULY 6-7, 1975\nRuffian is dead.\nThe horse widely heralded as the greatest filly and possibly the best thoroughbred of all time was destroyed early today after reinjuring herself as she came out of the anesthetic from an operation undertaken in a desperate attempt to save her life.\nShe had shattered her right front leg on the backstretch at Belmont Park yesterday afternoon as she was leading the colt Foolish Pleasure in one of the most eagerly awaited match races in the history of the turf.\nRuffian will be buried privately tonight in the Belmont infield, the first horse to be so honored.\nLate today, after the racing program is over, a grave was to be dug across from the clubhouse near the base of the flagpole. The filly was to be buried shortly afterward with only a few people present.\nRuffian underwent a threehour emergency operation through the late hours yesterday.\nThere was little chance to save her and shortly after 2 a.m., as she came out of anesthesia, she flailed out with her powerful legs and shattered the protective cast.\nThe leg then began hemorrhaging.\nHer owner, Stuart Janney, said: “Don’t let her suffer any more.” A massive dose of phenobarbital was then injected and Ruffian went to sleep forever.\nThe State of Kentucky had offered a burial spot, but Ruffian’s owners requested the Belmont burial.\nIn as brilliant a career as any thoroughbred has ever had, Ruffian never was behind another horse in her 10 starts. She was in front as always when she took the last sound stride of her life.\nFor one brief moment yesterday, Ruffian was again the beautiful bounding filly who may have been the best thoroughbred anyone has ever seen. In a matter of seconds, she was floundering grotesquely, straining to keep on running, a shell of a horse with only heart and instinct, unable to do what she was bred to do.\nThe tall, stately, black filly who cantered to the post, her head held high, was half an hour later a pain-racked horse, her sweaty head drooping low over the webbing of her stall as men worked frantically under her. She was held tightly by one as others, with tears in their eyes, patted and caressed her dripping neck.\nIn one step just before the six furlong marker on the Belmont backstretch, unbeaten Ruffian had shattered both sesamoid bones. Not just fractured them, but splintered them so that fragments of bone protruded at different angles, penetrating the back of the fetlock to create an open wound.\nAlmost immediately after X-rays confirmed the desperateness of her injury, the filly was taken by horse ambulance from her stall to Dr. William O. Reed’s animal hospital outside the track on Plainfield Avenue.\nThere she was strapped to a huge vertical operating table and anesthetized and then the hydraulic table was lowered to a horizontal position and the complex emergency operation began.\nTwice during surgery, the doctors said, Ruffian suffered pulmonary shock – a sharply reduced heartbeat – but, they added, they were unable to pull her out of it both times. The reduced heartbeat had nothing to do with the tragic outcome, they said. |
Corrective osteotomy (of the upper part of the tibia or the lower part of the thigh bone) is a surgical method reserved for the treatment of moderate osteoarthritis of the knee which allows patients a high level of activity.\nThe word 'osteotomy' literally means "to cut or cut a bone". Osteotomy in the knee area is used in the earlier stages of osteoarthritis, when only one side of the knee joint is damaged. The procedure involves removing or adding a wedge of bone to the lower leg (shin bone) or thigh bone (femur) to shift body weight off the damaged part of the knee joint. By transferring the load from the damaged to the healthy side of the joint, osteotomy can relieve pain and improve the function of the knee affected by arthritis.\nKnee osteotomy is most often performed in people younger than 60 who are physically active. Many people who undergo this procedure for arthritis may need a total knee replacement—usually about 10 to 15 years after the knee osteotomy.\nThat's why it's important to start on time with the examinations and alleviate the complaints.\nWhy is it performed?\nIn a healthy knee, when walking or standing, the load is transferred through the middle of the knee joint. If the normal anatomical relationships are disturbed for any reason (varus and valgus deformities), increased wear occurs on the inner (medial) or outer (lateral) side of the knee. Some patients have deformities visible to the naked eye in terms of "O" or "X" legs. The reconstruction of normal biomechanical relations by corrective osteotomy of the femur or lower leg contributes to the relief of the damaged part, restores the normal function of the joint and delays the installation of a total endoprosthesis.\n- a young, active patient (<60 years) in whom arthroplasty would not succeed due to excessive wear\n- knee valgus or varus\n- a healthy person with a good vascular status\n- patients with a moderate physique (BMI <35)\n- pain and disability that interfere with daily life\n- involvement of only one section of the knee\n- a cooperative patient who will be able to follow the protocol\n- inflammatory arthritis\n- obese people (BMI> 35)\n- flexion contracture (> 15 degrees)\n- incomplete knee flexion (<90 degrees)\n- >20 degrees of necessary correction\n- patellofemoral arthritis\n- ligament instability\n- "varus thrust" during walking\n- uncooperative patient\nRisks of corrective osteotomy surgery in the knee area may include:\n- infection in the bone or in the surrounding soft tissues\n- failure to join bone parts\n- nerve injuries or vascular trauma around the knee\n- incomplete pain relief\nWhat to expect?\nWhat can you do before seeing an orthopedic surgeon?\n- Imaging studies (magnetic resonance (MR) of the painful knee )\n- Prepare answers to the orthopedic surgeon's questions that include:\n- List the symptoms, how long do they last, when did they start?\n- On a scale from 0 to 10, how much does it hurt you at rest, and how much during exercise?\n- Are there activities that increase the pain? Do you have pain at night?\n- Have you had any knee injuries so far?\n- Do you take any medications or nutritional supplements?\n- Do you have any other medical problems?\n- Prepare questions for the orthopedist\nOrthopedic specialist examination\nIn order to establish an indication for a corrective osteotomy in the knee area, an orthopedic specialist will determine the range of motion and stability of your knee through a clinical examination. For the indication, radiological images (X-rays) of the knee joint are also necessary, which should preferably be done before the examination. The orthopedic specialist will decide on any additional imaging studies (panoramic X-ray of the lower extremities) required for additional preoperative planning following the clinical examination.\nAfter the patient makes a decision about the surgical procedure, he arranges the date of the operation and receives all the necessary information needed for quality preoperative preparation. The patient receives instructions on the necessary laboratory and diagnostic tests that must be performed before the scheduled surgery, and which must not be older than 30 days.\nSchedule your examination date!\nAfter setting the indication and agreeing on the date of the operation, it is necessary to have an examination by an anesthesiologist who will decide on the type of anesthesia. The patient fills in the "Questionnaire before anesthesia" in which they enter information about their current state of health, possible allergies and medications they may be taking. Based on these data, the anesthesiologist makes a decision on possibly necessary additional specialist examinations and diagnostic or laboratory tests.\nArrival at the hospital\nUpon arrival at the hospital, the patient is placed in a room and receives informed consent with all relevant information related to the surgical procedure. He signs it and the patient is prepared for the operation. Every patient is given an antibiotic before, during and after surgery to prevent post-operative infections.\nBefore the surgery, it is necessary to do precise preoperative planning, which includes determining the osteotomy site and the angle of correction. Depending on the location of the damage, surgery may involve your lower leg or femur. The most common form of knee osteotomy involves the lower leg. Corrective osteotomies in the knee area can be:\n- opening-wedge osteotomy\n- closing-wedge osteotomy\nOpening-wedge osteotomy is an operation that consists in cutting the femoral or lower leg bone, the bone is "opened" in the shape of a wedge (the degree of opening is determined by preoperative planning) and then fixed in the desired position with a plate and screws. The cavity in the bone created by the operation is filled with bone tissue over time, and in some cases it can be filled with an "artificial bone" preparation.\nAnother option is to cut the lower leg or thigh bone and then remove the bone wedge. The cut edges of the bone are joined and fixed with a plate and screws. This is called a closing-wedge osteotomy.\nAt the end of surgery, the cut tissues are sewn up in layers and the skin is closed with stitches. The operation itself lasts 1 to 2 hours. After the operation, the sutured wound is covered with plaster and bandages, and the patient is transferred to the ward.\nDuring surgery, the patient is under general or spinal anesthesia, which is decided by the anesthesiologist. In general anesthesia, the patient is unconscious and wakes up after the operation. In spinal anesthesia, on the other hand, the patient is awake but does not feel pain from the waist down.\nA gradual increase in load after surgery has a beneficial effect on the bone healing process. It is believed that full bone healing (depending on the location and size of the correction) takes 6-8 weeks.\nAfter the operation, the patient is transferred to the ward, where he stays in the room for several (2-3) days. Pain management after surgery will be taken care of by our anesthesiologists. During your stay in the hospital, our doctors and nurses will take care of dressing the surgical wound, while our physiotherapists will perform physical therapy in order to increase the range of motion in the operated knee as soon as possible, but also to teach you after the operation how to perform certain movements such as walking with crutches and climbing and descending stairs.\nIt starts with stretching the knees, and special emphasis is placed on strengthening the hamstring muscles. After leaving the hospital, it is advisable to continue rehabilitation in our Center for physical medicine & rehabilitation. In order to ensure the fastest and highest quality recovery, it is important to follow the instructions on dressing the wound, diet, physical activity, etc.\nYou will need to use crutches for about two months to allow your bone to heal properly. Until the first control examination and X-ray control (6 weeks after surgery), it is mandatory to walk with two forearm crutches and impose partial weight bearing on the operated leg. After that, it is allowed to discard one crutch and gradually increase the load on the operated leg, which has a positive effect on the bone healing process. Discarding the second crutch is recommended when the patient feels satisfactory safety and stability of the operated leg, and usually occurs within the next 4 weeks. Rehabilitation can last up to six months. Exercises are important during rehabilitation:\n- strengthening of thigh muscles (quadriceps)\n- increasing the range of motion of the knee\n- improving balance\nControl examinations, their frequency and additional postoperative radiological scans will be indicated by the operator, and in most cases the next controls are 3, 6 and 12 months after the operation.\nDo you need to have a check-up? Make an appointment now.\nIn most cases, knee osteotomy relieves arthritis pain and delays the need for total knee replacement by 10 to 15 years.\nSt. Catherine is one of the hospitals in this part of Europe that, in one place, with a multidisciplinary approach and using the most modern equipment, provides top diagnostics, the best therapeutic and surgical procedures and individually prepared rehabilitation, which sets it apart from other hospitals. Corrective osteotomy surgery in our Hospital is a routine procedure that we do every day.\nSee for yourself why St. Catherine is the best choice and book an appointment. |
In the United States, over 45 million people has at least one tattoo and that number continues to grow every day. When we think about tattoos we think about those days when we were young and naïve, when our mothers threatened us with “tattoos are forever”.\nSome people put a lot of thought before getting a tattoo and still to continue to love their tattoo while other people may fall out of love with a tattoo they got many years ago. With more people making the decision to remove a tattoo permanently, it ultimately led to new technology advances to do so; technology like the Spectra Laser.\nThe Lutronic Spectra Laser is specifically designed for tattoo removal as well as resurfacing the skin to reduce wrinkles, fine lines, rosacea, and active acne. But what ultimately allowed for the Spectra Laser to become such a necessity in many medical practices is that it is currently the most efficient and advanced way to safely remove unwanted tattoos using laser energy.\nWhat to Expect During Your Treatment\nTo ensure that you are a good candidate for Spectra Laser tattoo removal a brief consultation will be conducted prior to starting your treatment. At the Spa at MidAmerica Plastic Surgery, we offer three different anesthetics for Spectra Laser procedures; a topical agent anesthetic, an injection and our newest form of pain management, Pro-Nox.\nPro-Nox is a gas system that is designed to deliver fifty percent oxygen and fifty percent nitrous oxide to patients during procedures for immediate relief of pain and anxiety. Once the numbing agent or anesthetic is applied and working, treatment will continue.\nLaser passes are relatively quick but can vary depending on the size and color of the tattoo. The laser is working to break up the tattoo, which will eventually allow your body to flush the ink away.\nAfter your treatment, it is typical that the area will blister or be sensitive. We will supply an at-home care kit to ensure recovery is simple.\nCommonly Asked Questions About Tattoo Removal\nWhy do I need multiple treatments? The number of treatments required depends on the size, location, depth and color of the tattoo. Tattoo ink consists of pigment particles that are stacked upon one another giving it that very dark and concentrated appearance, which is why the pigment cannot be simply broken down in one session.\nThe Spectra Laser is designed to break up these pigment particles little by little. As your body heals, fading of the tattoo will be more noticeable after each session. Tattoo removal treatments should be performed four to eight weeks apart to give the body time to heal and to allow the body to also remove the tattoo ink fragments that were targeted at the previous session.\nHow long do treatments take? Each session usually last ten to thirty minutes but this all depends on the size of the tattoo. However, if you use an anesthetic this could extend the length of session time to allow the anesthetic to work properly.\nHow does the body dispose of the ink? Once the Spectra Laser breaks down the layer of ink, the body responds by signaling fluid to the targeted area to remove away the ink. This is why redness and some swelling are often seen after each session.\nThe removal of the ink within the body takes days and sometimes even weeks which is another reason why numerous sessions must be conducted.\nIs there any downtime involved? The area treated will be slightly sore for 1-2 weeks after your treatment. However, it will not hinder your day to day life.\nWith the colder months upon us now is the perfect time to book your consultation for tattoo removal with the Spectra Laser! We will be announcing a contest on our social media to win three treatments of tattoo removal during the month of October. If you are someone who has had second thoughts about a tattoo you currently have, then this is perfect opportunity for you! |
Year : 2016 | Volume\n| Issue : 3 | Page : 259-264\nTo determine block establishment time of supraclavicular brachial plexus block using blunt versus short bevel needle: A prospective randomized trial\nV Ahuja, D Thapa, S Gombar, D Dhiman\nDepartment of Anesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India\nDepartment of Anesthesia and Intensive Care, Government Medical College and Hospital, Sector 32, Chandigarh\nSource of Support: None, Conflict of Interest: None\n|Date of Web Publication||2-Jun-2016|\nBackground: Unintentional intraneural injection under ultrasound guidance (USG) with fine caliber needles and lower success rate with large caliber Tuohy needles in supraclavicular brachial plexus block (SCB) have been reported.\nMaterials and Methods: We undertook study to standardize the use of 20-gauge short versus blunt bevel needle for SCB. After approval of Institutional Ethics Committee and written informed consent, patients were randomized using computer-generated random number table to either of the two groups; blunt bevel needle group (n = 30): SCB under USG using 20-gauge Tuohy needle or short bevel needle group (n = 30): SCB under USG using 20-gauge short bevel needle. The primary outcome of the study was time to establishment of sensory and motor block of individual nerves, and secondary outcome was tolerability and any adverse effects.\nResults: The time to establishment of sensory and motor block in individual nerve territory was similar in both the groups. The complete sensory and motor anesthesia was achieved in 78.3% patients and complete sensory and motor anesthesia after supplementary block was achieved in 86.6% patients. Paresthesias during SCB were recorded in 15 patients. Out of these eight patients were of blunt bevel group and seven patients were of short bevel group. None of the patients experienced any neurological adverse effects.\nConclusion: The establishment of sensory and motor blockade of individual nerves was similar to 20-gauge short and blunt bevel needle under ultrasound guide with no neurological adverse events.\nKeywords: Needle; supraclavicular brachial plexus block; ultrasound guided; upper limb\n|How to cite this article:|\nAhuja V, Thapa D, Gombar S, Dhiman D. To determine block establishment time of supraclavicular brachial plexus block using blunt versus short bevel needle: A prospective randomized trial. Saudi J Anaesth 2016;10:259-64\n|How to cite this URL:|\nAhuja V, Thapa D, Gombar S, Dhiman D. To determine block establishment time of supraclavicular brachial plexus block using blunt versus short bevel needle: A prospective randomized trial. Saudi J Anaesth [serial online] 2016 [cited 2022 Jun 26];10:259-64. Available from: https://www.saudija.org/text.asp?2016/10/3/259/174910\n| Introduction|| |\nUltrasound-guided supraclavicular brachial plexus blocks (SCBs) have increasingly been used for upper limb surgeries for higher block success rate and negligible incidence of pneumothorax in comparison to the blind technique. , Intraneural placement of an injectate had been a problem and can be visualized under ultrasound guidance (USG) as an immediate change in nerve morphology. , Direct trauma to plexus nerves, intraneural placement of drugs and its attendant neurological complications have been reported with sharp beveled needles even under USG. ,, To address the issue of nerve injury and intraneural injections, Fredrickson et al. used an 18-gauge Tuohy needle for supra and infraclavicular blocks. Though there were no long-term neural injury in that study the block quality degraded and the reasons were attributed to use of wider gauge Tuohy needle. There is no clear consensus regarding optimal configuration of needle required with regard to its caliber, type for SCB and its clinical implication postoperatively.\nIn the present study, we hypothesized that reducing Tuohy needle caliber to 20-gauge for SCB could be beneficial in improving block quality while simultaneously retaining the advantage of atraumatic blunt tip. Hence, the present study was aimed to evaluate and compare time to establishment of sensory and motor SCB with 20-gauge blunt versus short bevel needle under USG for patients undergoing upper limb surgeries.\n| Materials and Methods|| |\nWe undertook this prospective, randomized clinical trial to evaluate the onset time of sensory and motor block of individual nerves in SCB under USG. The study was conceived in accordance with the Declaration of Helsinki and its amendments. The study protocol was approved by the Hospital Institutional Ethics Committee (GMC/TA-I (19)/2011/20317) and registered with Clinical Trials Registry India (CTRI/2011/07/001876). Written informed consent was obtained from all subjects recruited during June 2011 to March 2015. The design and conduct of the trial adhered to the CONSORT statement. Inclusion criteria were patients of ASA physical status 1-2, aged between 18 and 60 years scheduled for upper limb surgeries. Exclusion criteria was patients with neuropathy involving the arm undergoing surgery, mental incapacity, body mass index >35 kg/m 2 , known allergy to local anesthetics, local infection, coagulopathy, and any other contraindication to peripheral nerve blocks.\nThe patients were evaluated a day prior to surgery, and all routine and required investigations were done. All patients fasted for 8 h prior to surgery and were premedicated with pantaprazole 40 mg and alprazolam 0.25 mg per oral at night and 2 h prior to surgery. On arrival of patient in the operating room intravenous (IV) access was secured and standard anesthesia monitoring (Aestiva 5™ 7900, GE healthcare, Datex-Ohmeda division, Helsinki, Finland) including noninvasive blood pressure, heart rate, oxygen saturation and electrocardiographic monitoring were started and recorded every 5 min.\nThe patients were placed in supine position with the head turned 45° to opposite side of the surgery. A single operator anesthesiologist (VA) experienced in ultrasound performed all the SCBs. Under strict asepsis, the supraclavicular area of the side to be operated was cleaned and draped. The ultrasound probe (8-15 MHz Sono Site ® Titan, Washington, USA) was placed in coronal oblique plane in supraclavicular fossa to visualize subclavian artery and brachial plexus. The brachial plexus appeared as a cluster of hyperechoic nodules usually found lateral to the round pulsating subclavian artery lying on the top of the hyperechoic first rib.\nAllocation concealment was done with opaque sealed envelopes. Patients were randomized using computer-generated random number table, and the envelope was opened immediately before block placement by an anesthesiologist who was not involved in the study and assessment of patients. The patient and the assessor were blinded to the group allocation. Local anesthesia with 2 ml of 2% lignocaine was given subcutaneously in all the patients for insertion of block needle. The patients received SCB under USG with needle using in plane technique (to facilitate visualization of spread of local anesthetic and direction of block needle in real time and at the same time avoiding inadvertent vessel and pleural injury) as per group allocation to either of the two groups.\nBlunt bevel needle group (n = 30): SCB under USG using 20-gauge Tuohy needle (BD Medical, 1 Becton Drive, Franklin Lakes, NJ 07417, USA).\nShort bevel needle group (n = 30): SCB under USG using short bevel needle 20-gauge (150 mm) insulated needle with extension set (B. Braun Medical Inc., Bethlehem, PA, USA).\nUltrasound probe was placed inside a sterile cover, and needle movement was observed in the real-time. The tip of the needle was positioned at the junction of first rib and artery under USG and normal saline 2 ml was injected to confirm the spread around the plexus. In an event of any paresthesias, the needle was repositioned, and care was taken to avoid intraneural injection. If the local anesthetic spread did not reach some parts of brachial plexus, the needle was repositioned. A mixture of local anesthetic (1: 2 mixture of lignocaine 2% with 1:200,000 adrenaline and bupivacaine 0.5%) at a dose 0.5 ml/kg up to a maximum of 40 ml was given in increments of 3-5 ml every minute carefully after negative aspiration. The maximum dose of lignocaine with adrenaline was 7 mg/kg and 2 mg/kg for bupivacaine.\n- Performance time was scanning time + needle time. If time required to visualize the anatomy and placement of block was >20 min then, the procedure was abandoned, and the block was considered a failure.\n- Scanning time was recorded from the time ultrasound probe was placed on skin until a satisfactory image was obtained.\n- Needle time was taken from the time blunt or short bevel needle tip penetrated the skin and exited after block placement.\n- Immediately after block placement an observer blinded to group allocation asked the following questions.\n- How will you rate your discomfort during the block on a scale of 0-10? If zero was no discomfort and 10 was the worst discomfort imaginable.\n- Did you experience an electric shock like sensation in the arm during the procedure? Yes/No. The same observer then assessed sensory and motor block.\n- Sensory block was graded as 2 = Normal, 1 = Reduced and 0 = Absent to pinprick (26-gauge needle) sensation relative to the contralateral arm every 5 min for up to the time the grade = 0 occurred in all the nerve territories or up to a maximum of 60 min had elapsed. Musculocutaneous nerve = Lateral side of forearm, radial nerve = Dorsum of the hand over the second metacarpophalangeal joint, median nerve = Thenar eminence, ulnar nerve = Hypothenar eminence, medial cutaneous nerve of arm = Medial side of the arm and medial cutaneous nerve of forearm = Medial side of the forearm.\n- Motor block: Block was scored as 2 = Normal, 1 = Reduced, 0 = Unable to overcome gravity relative to the contralateral arm that was recorded every 5 min for up to the time the grade = 0 occurred in all the territories or up to a maximum of 60 min. Radial nerve = Push the arm by extending the forearm at the elbow against the resistance, musculocutaneous nerve = Resisting the pull of the forearm at the elbow, median nerve = Thumb and second digit pinch, ulnar nerve = Thumb and fifth digit pinch.\n- Surgical anesthesia success was considered as the performance of surgery without the requirement of block or general anesthesia (GA) supplementation. If block did not occur in one nerve territory, then block supplementation and surgical wound infiltration was done and recorded. If required, patients received propofol infusion 50-100 μg/kg/h for intraoperative sedation.\n- Block failure was defined as partial or absent nerve block in more than one nerve territory. These patients received GA. The principal investigator recorded the requirement for block supplementation, surgical wound infiltration, patient request for sedation and conversion to GA.\n- Tourniquet time was observed.\n- A postblock radiograph in full exhalation was obtained if a patient complained of respiratory distress. After 24 h an anesthesia resident blinded to treatment group contacted the patients and asked when was the first oral analgesic taken and on postoperative day 10 regarding any neurological symptoms like numbness, tingling or altered sensation in the upper extremity or any other adverse effects until it resolved.\nAssuming that the establishment of sensory and motor block occurred in 30 min and a standard deviation (SD) of 7 min with an α of 0.05, and a power of 80%, it was calculated that a sample size of 30 patients per group would be required to show a difference of 5 min for establishment of successful surgical block. This sample size could also detect a 30% reduction in block success assuming a control block success of 70%. Data was analyzed using statistical software International Business Machines Corporation (IBM) SPSS Statistics (version 22.0) and expressed as mean ± SD or median with interquartile range as applicable. Student's t-test or the Fisher's exact test for 2 × 2 contingency tables used for statistical comparisons. Procedure related time and pain scores were analyzed using Mann-Whitney U-test, P < 0.05 was considered statistically significant.\n| Results|| |\nDuring June 2011 and March 2015, 70 patients were screened, of these 10 patients did not fit the inclusion criteria. Hence, 60 patients were randomized to either of the two groups, and all the patients completed the study [Figure 1]. The patient and clinical characteristics for each group showed no significant difference between the groups as shown in [Table 1]. The surgeries performed under SCB were similar in both the groups. The needle time was shorter in short bevel group due to superior visualization as compared to blunt bevel needle under USG, but the performance time was similar in both the groups as shown in [Table 2]. The time to establishment of sensory block and motor block in individual nerve territory was similar in both the groups as shown in [Table 3] and [Table 4]. Patients requiring conversion to GA were similar in both the groups. The patients requiring supplementary block were higher in ulnar and median nerve territory as compared to other nerve territories in both the groups as shown in [Table 5]. The complete sensory and motor anesthesia was achieved in 78.3% patients and complete sensory and motor anesthesia after supplementary block in 86.6% (eight patients required GA). Electric shock like sensation during block placement was recorded in 15 patients. Of these, eight patients were of blunt bevel group and seven patients were of short bevel group. Of 15 patients, one patient (short bevel group) received GA due to incomplete block, two patients required supplementary block (one patient of blunt bevel and short bevel group each) and 12 patients attained complete surgical block. None of the patients has any hemodynamic instability in the perioperative period. No neurological adverse effects were reported on day 10 of follow-up.\n|Table 3: Sensory block establishment time (min) in different nerve territories |\nClick here to view\n|Table 4: Motor block establishment time (min) in different nerve (n) territories |\nClick here to view\n| Discussion|| |\nThe major finding of the present study was similar time to establishment of sensory and motor blockade in SCB, when performed with 20-gauge blunt or short bevel needles in patients undergoing upper limb surgeries. According to literature, the choice of needle has an important role in onset of sensory-motor block and intraneural peripheral nerve injuries. , Long-bevel needles were known to produce more fascicular injuries as they probably impaled the nerves. , We used 20-gauge short bevel versus blunt bevel needles and did not include long-bevel needle as comparator group as it would have been unethical due to evidence of harm described in the literature. The nerve trauma has a direct relation on the diameter of the needle used in the "intentional nerve" injury. The rational given by Fredrickson et al. of using an 18-gauge needle in their study was, that use of a larger diameter needle would avoid penetration of the needle into the peineural neurovascular sheath when performed under USG. The literature reports no evidence of intraneural injection with an 18-gauge needle. Combining the evidences from these studies we kept our needle choice as a 20-gauge short bevel needle to overcome the failure rate as evidenced by use of 18-gauge Tuohy's needle and also to avoid any inadvertent intraneural injection which may occur by a fine bore needle long-bevel needle. Fredrickson et al. reported lower success rate of 57% SCB and the possible causes attributed to it were reduced local anesthetic volume (25-30 ml), large caliber needle and more likely nonutilization of neuro stimulation. A significant neurological nerve injury was observed in one patient in supraclavicular group, but the patient did not require any electrophysiological evaluation. In the present study, the higher surgical success rate was attributed to correct placement of tip of the needle confirmed on USG as uniform spread of local anesthetic that bathed the brachial plexus. The mean local anesthetic volume used in the present study was 35 ml (0.5 ml/kg) which was slightly higher than the earlier study but does not seem to be the only cause of higher success of surgical block in our study. The literature suggests that time, quality and duration of block was not be improved only by arbitrarily increasing drug mass or its determinants, volume and concentration. \nHigher neurological complications occur in proximal brachial plexus block due to direct nerve trauma (1-6%) and reduced nonneural tissue. , Block placement under USG with a smaller gauge blunt tip block needle can still result in an unintentional intraneural injection occurred in 17% of patients. Intraneural placement on USG is shown as an increase in nerve area >15%, echo-lucent areas within the nerve and visualization of the needle tip indentating and penetrating the nerve wall. , Neurological dysfunction is influenced with factors, such as obesity, neurologic and metabolic diseases, neurotoxicity, mechanical and ischemic injury, may contribute to the development of acute and/or chronic nerve damage. These patients were not enrolled in the present study. Elicitation of paresthesia during regional techniques is not linked to anesthesia related nerve injury but rather it is the pain on injection that is more consistently linked to injury. , Patients were asked to report painful injections suggestive of intrafascicular injection and injury that would prompt repositioning of the needle. However, we did not use any device for pressure measurement to detect high intraneural injection pressure and relied on the pressure by the syringe's feel, which can be at times variable.\nSurprisingly, one patient in the present study had complete motor block but reported partial sensory block in the medial cutaneous nerve of arm and required GA. Partial or no nerve block was observed in (2/30 patients) in ulnar and (4/30 patients) in median nerve territories in blunt bevel needle in the present study. In an earlier study ulnar (11/30 patients) and median (4/30 patients) nerves had partial or no block with 18-gauge Touhy needle for placement of SCB. This probably occurred due to corner pocket technique used by the authors. The sparing of ulnar and median nerves usually occurs due to nonplacement of needle tip near the lower trunk that is close to first rib due to risk of pneumothorax. An earlier study showed superior results with stimulation of lower trunk of SCB. \nThe limitation of the study was nonutilization of pressure manometer during injection of local anesthetics and patients were followed only till 10 days postoperatively. Further multicenter trials are required to validate the results of this study.\n| Conclusion|| |\nThe time to establishment of sensory and motor blockade in SCB performed with either 20-gauge short or blunt bevel needle under USG were similar, in patients undergoing upper limb surgeries with no significant neurological adverse effects.\nWe would like to thank Palak gupta for data compilation.\nFinancial support and sponsorship\nDepartment of Science and Technology, Chandigarh, India.\nConflicts of interest\nThere are no conflicts of interest.\n| References|| |\nFranco CD, Vieira ZE. 1,001 subclavian perivascular brachial plexus blocks: Success with a nerve stimulator. Reg Anesth Pain Med 2000;25:41-6.\nWedel DJ. Nerve blocks. In: Miller RD, editor. Millar's Anesthesia. 5 th\ned. Philadelphia, Pennsylvania: Churchill Livingstone; 2000. p. 1520-48.\nMorau D, Levy F, Bringuier S, Biboulet P, Choquet O, Kassim M, et al.\nUltrasound-guided evaluation of the local anesthetic spread parameters required for a rapid surgical popliteal sciatic nerve block. Reg Anesth Pain Med 2010;35:559-64.\nLiu SS, YaDeau JT, Shaw PM, Wilfred S, Shetty T, Gordon M. Incidence of unintentional intraneural injection and postoperative neurological complications with ultrasound-guided interscalene and supraclavicular nerve blocks. Anesthesia 2011;66:168-74.\nKapral S, Krafft P, Eibenberger K, Fitzgerald R, Gosch M, Weinstabl C. Ultrasound-guided supraclavicular approach for regional anesthesia of the brachial plexus. Anesth Analg 1994;78:507-13.\nDingemans E, Williams SR, Arcand G, Chouinard P, Harris P, Ruel M, et al.\nNeurostimulation in ultrasound-guided infraclavicular block: A prospective randomized trial. Anesth Analg 2007;104:1275-80.\nNeal JM, Gerancher JC, Hebl JR, Ilfeld BM, McCartney CJ, Franco CD, et al.\nUpper extremity regional anesthesia: Essentials of our current understanding, 2008. Reg Anesth Pain Med 2009;34:134-70.\nFredrickson MJ, Patel A, Young S, Chinchanwala S. Speed of onset of 'corner pocket supraclavicular' and infraclavicular ultrasound guided brachial plexus block: A randomised observer-blinded comparison. Anesthesia 2009;64:738-44.\nJeng CL, Torrillo TM, Rosenblatt MA. Complications of peripheral nerve blocks. Br J Anesth 2010;105 Suppl 1:i97-107.\nSelander D, Dhunér KG, Lundborg G. Peripheral nerve injury due to injection needles used for regional anesthesia. An experimental study of the acute effects of needle point trauma. Acta Anesthesiol Scand 1977;21:182-8.\nMacías G, Razza F, Peretti GM, Papini Zorli I. Nervous lesions as neurologic complications in regional anesthesiologic block: An experimental model. Chir Organi Mov 2000;85:265-71.\nSteinfeldt T, Nimphius W, Werner T, Vassiliou T, Kill C, Karakas E, et al.\nNerve injury by needle nerve perforation in regional anesthesia: Does size matter? Br J Anesth 2010;104:245-53.\nBigeleisen PE, Moayeri N, Groen GJ. Extraneural versus intraneural stimulation thresholds during ultrasound-guided supraclavicular block. Anesthesiology 2009;110:1235-43.\nMoayeri N, Bigeleisen PE, Groen GJ. Quantitative architecture of the brachial plexus and surrounding compartments, and their possible significance for plexus blocks. Anesthesiology 2008;108:299-304.\nBrull R, McCartney CJ, Chan VW, El-Beheiry H. Neurological complications after regional anesthesia: Contemporary estimates of risk. Anesth Analg 2007;104:965-74.\nvan Geffen GJ, Moayeri N, Bruhn J, Scheffer GJ, Chan VW, Groen GJ. Correlation between ultrasound imaging, cross-sectional anatomy, and histology of the brachial plexus: A review. Reg Anesth Pain Med 2009;34:490-7.\nNeal JM, Bernards CM, Hadzic A, Hebl JR, Hogan QH, Horlocker TT, et al.\nASRA practice advisory on neurologic complications in regional anesthesia and pain medicine. Reg Anesth Pain Med 2008;33:404-15.\nSchafhalter-Zoppoth I, Zeitz ID, Gray AT. Inadvertent femoral nerve impalement and intraneural injection visualized by ultrasound. Anesth Analg 2004;99:627-8.\nMarhofer P, Sitzwohl C, Greher M, Kapral S. Ultrasound guidance for infraclavicular brachial plexus anesthesia in children. Anesthesia 2004;59:642-6.\n[Table 1], [Table 2], [Table 3], [Table 4], [Table 5] |
If you maintain your post-lipo weight, your surgical result should be long-lasting. But if you gain even five pounds, the fat cells in other areas of your body—as well as those that remain in the treated area—will grow larger, possibly diminishing your results. In cases of considerable weight gain, new fat cells can develop all over the body, including in the treated areas, though the area will still look better than if you didn’t have liposuction.\nIf you decided that this is something you would like to do or you are interested but have more question. Please book a free consultation with Dr. Alhallak (PhD in Pharmacy) and he will answer all your questions. We provide all type of cosmetic and aesthetic services such as facelift, Botox, fillers, body slimming, fat removal, skin tightening, laser, Fat freezing, PRP, peels\n“Adding a breast implant to the procedure sometimes allows the surgeon to shorten or even eliminate scarring, since the implant will then take up some of the slack caused by the breasts’ sagging,” says Fort Worth, TX plastic surgeon Dr. Jonathan Heistein. “Some breast augmentation patients may even be candidates for a radiofrequency treatment called BodyTite, which can provide a slight lift without requiring additional surgery.”\nDuring your private consultation, Dr. Fouda Neel will review your medical history, talk with you about the improvements you hope to attain, and create a treatment plan personalized to you. If you are also bothered by excess loose skin, you may be a good candidate for BodyTite, a less invasive form of liposuction that also incorporates skin tightening.\nCost is incredibly variable. It depends on the city and the provider. If you go to a plastic surgeon in New York City, it costs a lot more than seeing a non-plastic surgeon in a rural area. There are plenty of non-plastic surgeons offering discount liposuction. But, this can be somewhat risky due to their limited training backgrounds. And bad liposuction is very difficult to fix - I perform a lot of revision liposuction trying to fix poorly performed liposuction.\nLiposuction is needed in order to perform a Brazilian butt lift procedure. If you are simply having liposuction in 1 or 2 areas then local anesthesia can be used. If you are having liposuction done in more than a few areas, you may require the use of a general anesthetic. Brazilian butt lifts require fat transfer and re-injection. Buttock lifts are a surgical procedure that often involve implantation.\nThe patient's medical history and overall health can elevate the level of difficulty of the surgery. For example, if you are suffering from an immune deficiency or a chronic condition, such as uncontrolled diabetes, you instantly increase the complexity of the surgery. This also affects your recovery. You may need more time to relapse and get back to your everyday routine, which might mean you will need to take more medications after the surgery (for a longer time than usual), and potentially more time off work. All that equals more money spent on your behalf.\nFor more invasive liposuction procedures, we encourage our patients to stay with a friend or family member afterward. If this is not possible, you may want to consider hiring a home health care worker to help take care of you. The cost of this will depend on the type of worker you hire (registered nurse, registered practical nurse, or personal support worker), and how long they stay.\nOffice liposuction under tumescent local anesthesia costs from about 4-7500, and more extensive procedures need to be done in the operating room under general anesthesia. Depending on the time the cost can go up to 15,000. Multiple areas are discounted in the sense that when done in the operating room under general, the additional areas are charged by the total time, not per area, which is a savings.\nDespite the increase in research on fat grafting to the butt, many questions remain. For example, there is no exact science behind how much fat to harvest or inject. The fat that is injected must develop its own blood supply to survive — and, on average, just half of it does. This means that 50 percent of the injected fat dissolves. To compensate, some plastic surgeons will over-inject. They don’t always get it right, and repeat treatments are often needed.\nAt DePerro Plastic Surgery the cost of Liposuction is $1750 for the first area and $1000 for each additional area. There is also approximately $2000 in costs for anesthesia and the facility fee. We perform all of our liposuction procedures in our attached surgery center under general anesthesia and sterile conditions. This maximizes your safety and comfort so you don't feel any pain during the procedure. Also, because you're asleep we are able to be more thorough and remove more fat. So in total 1 area of liposuction under general anesthesia would cost approximately $3750, two areas $4750.\nThe “crescent lift” technique is mostly used for women who have a very small amount of sagging to correct, and involves one small incision that runs halfway around the top half of the edge of the areola. It’s usually only done when a patient is undergoing a breast augmentation, and even then only rarely. It’s more of a preventative measure, unlike the other options, which are focused on breasts that have more advanced sagging.\nThe fat used in a Brazilian butt lift comes from your own body from areas where it is in excess like the abdomen, thighs, arms, upper and lower back, and flanks (sides and love handles). Because the fat is purified and cleaned before being re-injected into the body, it will not be reabsorbed, allowing it to help shape the new contours of your backside. If you are not looking to use fat injections, implants are also available for a buttock lift procedure.\nMost doctors on RealSelf say that a good compression garment is essential to minimize swelling and bruising, help the skin smoothly adhere to the underlying tissue, and speed up healing; but some don’t think it’s necessary. Doctors who recommend compression garments often have patients wear them 24/7 (with a break for showering) for at least two weeks and then gradually reduce the number of hours they need to be worn over a period of three or more weeks. As a bonus, doctors say, compression helps ease discomfort. Follow your doctor’s instructions. Some surgeons recommend lymphatic massage starting at about four weeks post-op, to help drain fluid and bring down swelling. “I don’t suggest self-massage, because you can counteract the surgery,” Dr. Mesa says. “But going to a massage therapist who specializes in post-surgical massage does make the healing process faster and prevent irregularities.”\nEach year, thousands of women undergo breast lift procedures to restore the shape and volume of their breasts for a more youthful breast contour. Oftentimes breast lifts are combined with other procedures such as breast augmentation or breast reduction. In cases like these, the breasts are lifted as they are increased or decreased in size. The result are breasts that look and feel better!\nThankfully, there’s a slew of solutions that have been proven to help with scarring, even completely removing the visual effect. One of the first solutions that may be offered is a steroid injection into the area, which helps with the discomfort and redness of scarring. Cortisone creams are another option that may help to reduce the size of the blemish. Targeted cryotherapy, similar to the type of therapy used to remove warts, may also reduce scarring by freezing the tissue away. |
- What is a Bunion?\n- Is surgery the only way to fix a bunion?\n- Who is a candidate for bunion removal surgery in Poland?\n- Will my insurance company pay for the bunion surgery?\n- What type of anesthesia will be used during bunion surgery abroad?\n- Is the surgery painful?\n- How much is bunion surgery in Poland?\n- Can bunion surgery be performed on both feet at the same time?\n- How long will I need to stay in Poland after my bunion surgery?\n- Can my bunion come back after surgery?\n- How soon can I walk after bunion surgery abroad?\n- How soon can I go back to work after bunion surgery Poland?\n- How long is the recovery from bunion surgery in Poland?\n- What are the possible complications of bunion surgery?\n- How soon after bunion surgery can I travel home?\nWhat is a Bunion?\nBunion is a deformity of the joint that is connecting the big toe to the foot. The joint moves out of line and becomes a painful hump on the bone. It can be very painful because the weight of your body is not evenly distributed on the foot.\nIs surgery the only way to fix a bunion?\nThe surgery is not the only way to fix bunion. There are few other ways of treating bunions without surgery:\n- bunion splints\n- toe spacers\n- special footwear\nYou can ask your doctor how to help yourself with the pain and discomfort.\nWho is a candidate for bunion removal surgery in Poland?\nThe bunion surgery abroad is recommended for patients who experience pain in their bunion joint. Good candidates for bunion surgery commonly have:\n- significant pain that can limit their routine\n- chronic inflammation and swelling in the big toe area\n- deformed toe\n- stiffness in their deformed toe\nWill my insurance company pay for the bunion surgery?\nIf you choose to have your surgery done in our clinic in Poland, then the surgery will not be covered by the insurance. In your country there might be some clinics that will offer you bunion surgery, but it needs to be done for medical reasons not aesthetic ones.\nWhat type of anesthesia will be used during bunion surgery abroad?\nThe surgery is done under local anesthesia. You will not feel your foot, so there will be no pain. There are over 100 methods for performing this surgery, but the main goal is the same – proper aligning of the big toe.\nIs the surgery painful?\nThe surgery itself is not painful at all! However, after the procedure, you might experience pain in the treated area. Usually, painkillers help and they are prescribed by the surgeon.\nHow much is bunion surgery in Poland?\nThe price of the procedure depends on the method used and chosen clinic. In UK the price in private hospitals is very high – around 5500 GBP. There are more affordable destinations, such as Poland, where you can have the surgery done for even 1200 GBP. You can contact our patient advisers to find out your individual quotation for cheap bunion surgery.\nCan bunion surgery be performed on both feet at the same time?\nIt is not advised to have the surgery done on both feet at the same time. For a while after the procedure, you will need to save your leg and put pressure on the other leg. Therefore it is not advised to have both surgeries at the same time.\nHow long will I need to stay in Poland after my bunion surgery?\nYou should stay in Poland for at least 6 days. On the first day you will have blood tests, on the second the surgery will be performed. Next there will be few days of rest and finally, on the 5th day, there will be final check up with the surgeon. It is important to travel with someone as you will not be able to walk normally and it may be difficult to carry luggage.\nCan my bunion come back after surgery?\nUnfortunately, the bunion can come back after the surgery. It is caused by many different factors and sometimes the surgeon has no way of knowing the way. There are possible revision surgeries and procedures that can help with the bunion.\nHow soon can I walk after bunion surgery abroad?\nThis depends on the stage of your bunion. Some people can walk slowly and carefully almost right after the surgery. However, in around 80% cases it can take from 2 weeks to 2 months to start walking normally. After the surgery, you may require crutches to walk and not put weight on the leg.\nHow soon can I go back to work after bunion surgery Poland?\nIt depends on your occupation. If your work requires sitting behind the desk, then you can go back to work as soon as you stop taking medications. However, you will wear a special boot that will stabilize your leg. You should speak with your surgeon about this issue and he will tell you how long you need to wait until going back to work.\nHow long is the recovery from bunion surgery in Poland?\nBasic recovery from the surgery can take from 4 to 6 weeks. However, to fully recover it may take up to six months. As always recovery time depends on many factors, such as your age, health and occupation.\nWhat are the possible complications of bunion surgery?\nAs with any surgical procedure, bunion surgery carries some risks of complications. Possible complications after the surgery are:\n- deep vein thrombosis\n- stiffness in the toe\n- healing of the bone in the wrong position\n- damaged nerves in the foot\n- continued pain\n- the bunion returning\nHow soon after bunion surgery can I travel home?\nTime of stay in Poland depends on the range of the procedure. With the individual quotation, the surgeon will tell you how long you need to wait until going back home. Some patients were allowed to fly 3 days after the procedure, but usually, the patient stay for a week in Poland just to have more time to heal.\n+44 748 315 53 11\nLatest posts by Marek (see all)\n- Gastric Sleeve Complications - What ifGastric Sleeve Fails? - 2019/03/15\n- Recovery from bariatric surgery - how does it look like? - 2019/01/11\n- Rate of regain after gastric bypass - 2019/01/11 |
"The US Food and Drug Administration (FDA) has approved diclofenac sodium injection (Dyloject, Hospira Inc), a proprietary nonsteroidal anti-inflammatory drug (NSAID) for the treatment of mild to moderate pain, and for the management of mod"...\nMechanism Of Action\nTapentadol is a centrally-acting synthetic analgesic. The exact mechanism of action is unknown. Although the clinical relevance is unclear, preclinical studies have shown that tapentadol is a mu-opioid receptor (MOR) agonist and a norepinephrine reuptake inhibitor (NRI). Analgesia in animal models is derived from both of these properties.\nTapentadol is 18 times less potent than morphine in binding to the human mu-opioid receptor and is 2-3 times less potent in producing analgesia in animal models. Tapentadol has been shown to inhibit norepinephrine reuptake in the brains of rats resulting in increased norepinephrine concentrations. In preclinical models, the analgesic activity due to the mu-opioid receptor agonist activity of tapentadol can be antagonized by selective mu-opioid antagonists (e.g., naloxone), whereas the norepinephrine reuptake inhibition is sensitive to norepinephrine modulators. Tapentadol exerts its analgesic effects without a pharmacologically active metabolite.\nThe minimum effective plasma concentration of tapentadol for analgesia varies widely among patients, especially among patients who have been previously treated with agonist opioids.\nConcentration-Adverse Experience Relationships\nThere is a general relationship between increasing opioid plasma concentration and increasing frequency of adverse experiences such as nausea, vomiting, CNS effects, and respiratory depression.\nEffects on the Cardiovascular System\nThere was no effect of therapeutic and supratherapeutic doses of tapentadol on the QT interval. In a randomized, double-blind, placebo- and positive-controlled crossover study, healthy subjects were administered five consecutive doses of NUCYNTA® 100 mg every 6 hours, NUCYNTA® 150 mg every 6 hours, placebo and a single oral dose of moxifloxacin. Similarly, NUCYNTA® had no relevant effect on other ECG parameters (heart rate, PR interval, QRS duration, T-wave or U-wave morphology).\nEffects on the Central Nervous System (CNS)\nThe principal therapeutic action of tapentadol is analgesia. Tapentadol causes respiratory depression, in part by a direct effect on the brainstem respiratory centers. The respiratory depression involves a reduction in the responsiveness of the brain stem respiratory centers to both increases in carbon dioxide tension and electrical stimulation. Tapentadol depresses the cough reflex by direct effect on the cough center in the medulla.\nTapentadol causes miosis, even in total darkness. Pinpoint pupils are a sign of opioid overdose but are not pathognomonic (e.g., pontine lesions of hemorrhagic or ischemic origin may produce similar findings). Marked mydriasis rather than miosis may be seen with hypoxia in overdose situations [see OVERDOSAGE]. Other effects of tapentadol include anxiolysis, euphoria, and feeling of relaxation, drowsiness and changes in mood.\nEffects on the Gastrointestinal Tract and on Other Smooth Muscle\nGastric, biliary and pancreatic secretions are decreased by tapentadol. Tapentadol causes a reduction in motility and is associated with an increase in tone in the antrum of the stomach and duodenum. Digestion of food in the small intestine is delayed and propulsive contractions are decreased. Propulsive peristaltic waves in the colon are decreased, while tone is increased to the point of spasm. The end result is constipation. Tapentadol can cause a marked increase in biliary tract pressure as a result of spasm of the sphincter of Oddi, and transient elevations in serum amylase. Tapentadol may also cause spasm of the sphincter of the urinary bladder.\nEffects on the Endocrine System\nOpioid agonists have been shown to have a variety of effects on the secretion of hormones. Opioids inhibit the secretion of ACTH, cortisol, and luteinizing hormone (LH) in humans. They also stimulate prolactin, growth hormone (GH) secretion, and pancreatic secretion of insulin and glucagon.\nEffects on the Immune System\nOpioids have been shown to have a variety of effects on components of the immune system in in vitro and animal models. The clinical significance of these findings is unknown.\nCNS Depressant/Alcohol Interaction\nAdditive pharmacodynamic effects may be expected when NUCYNTA® is used in conjunction with alcohol, other opioids, or illicit drugs that cause central nervous system depression.\nThe mean absolute bioavailability after single-dose administration (fasting) of NUCYNTA® is approximately 32% due to extensive first-pass metabolism. Maximum serum concentrations of tapentadol are typically observed at around 1.25 hours after dosing.\nDose-proportional increases in the Cmax and AUC values of tapentadol have been observed over the 50 to 150 mg dose range.\nA multiple (every 6 hour) dose study with doses ranging from 75 to 175 mg tapentadol showed a mean accumulation factor of 1.6 for the parent drug and 1.8 for the major metabolite tapentadol-O-glucuronide, which are primarily determined by the dosing interval and apparent half-life of tapentadol and its metabolite.\nThe AUC and Cmax increased by 25% and 16%, respectively, when NUCYNTA® was administered after a high-fat, high-calorie breakfast. NUCYNTA® may be given with or without food.\nTapentadol is widely distributed throughout the body. Following intravenous administration, the volume of distribution (Vz) for tapentadol is 540 +/- 98 L. The plasma protein binding is low and amounts to approximately 20%.\nMetabolism and Elimination\nIn humans, about 97% of the parent compound is metabolized. Tapentadol is mainly metabolized via Phase 2 pathways, and only a small amount is metabolized by Phase 1 oxidative pathways. The major pathway of tapentadol metabolism is conjugation with glucuronic acid to produce glucuronides. After oral administration approximately 70% (55% O-glucuronide and 15% sulfate of tapentadol) of the dose is excreted in urine in the conjugated form. A total of 3% of drug was excreted in urine as unchanged drug. Tapentadol is additionally metabolized to N-desmethyl tapentadol (13%) by CYP2C9 and CYP2C19 and to hydroxy tapentadol (2%) by CYP2D6, which are further metabolized by conjugation. Therefore, drug metabolism mediated by cytochrome P450 system is of less importance than phase 2 conjugation.\nNone of the metabolites contribute to the analgesic activity.\nTapentadol and its metabolites are excreted almost exclusively (99%) via the kidneys. The terminal half-life is on average 4 hours after oral administration. The total clearance is 1530 +/- 177 mL/min.\nThe mean exposure (AUC) to tapentadol was similar in elderly subjects compared to young adults, with a 16% lower mean Cmax observed in the elderly subject group compared to young adult subjects.\nAUC and Cmax of tapentadol were comparable in subjects with varying degrees of renal function (from normal to severely impaired). In contrast, increasing exposure (AUC) to tapentadol-O-glucuronide was observed with increasing degree of renal impairment. In subjects with mild (CLCR = 50 to < 80 mL/min), moderate (CLCR = 30 to < 50 mL/min), and severe (CLCR = < 30 mL/min) renal impairment, the AUC of tapentadol-O-glucuronide was 1.5-, 2.5-, and 5.5fold higher compared with normal renal function, respectively.\nAdministration of NUCYNTA® resulted in higher exposures and serum levels to tapentadol in subjects with impaired hepatic function compared to subjects with normal hepatic function. The ratio of tapentadol pharmacokinetic parameters for the mild hepatic impairment group (Child-Pugh Score 5 to 6) and moderate hepatic impairment group (Child-Pugh Score 7 to 9) in comparison to the normal hepatic function group were 1.7 and 4.2, respectively, for AUC; 1.4 and 2.5, respectively, for Cmax; and 1.2 and 1.4, respectively, for t½. The rate of formation of tapentadol-O-glucuronide was lower in subjects with increased liver impairment.\nPharmacokinetic Drug Interactions\nTapentadol is mainly metabolized by Phase 2 glucuronidation, a high capacity/low affinity system; therefore, clinically relevant interactions caused by Phase 2 metabolism are unlikely to occur. Naproxen and probenecid increased the AUC of tapentadol by 17% and 57%, respectively. These changes are not considered clinically relevant and no change in dose is required.\nNo changes in the pharmacokinetic parameters of tapentadol were observed when acetaminophen and acetylsalicylic acid were given concomitantly.\nIn vitro studies did not reveal any potential of tapentadol to either inhibit or induce cytochrome P450 enzymes. Furthermore, a minor amount of NUCYNTA® is metabolized via the oxidative pathway. Thus, clinically relevant interactions mediated by the cytochrome P450 system are unlikely to occur.\nThe pharmacokinetics of tapentadol were not affected when gastric pH or gastrointestinal motility were increased by omeprazole and metoclopramide, respectively.\nPlasma protein binding of tapentadol is low (approximately 20%). Therefore, the likelihood of pharmacokinetic drug-drug interactions by displacement from the protein binding site is low.\nAnimal Toxicology And/Or Pharmacology\nIn toxicological studies with tapentadol, the most common systemic effects of tapentadol were related to the mu-opioid receptor agonist and norepinephrine reuptake inhibition pharmacodynamic properties of the compound. Transient, dose-dependent and predominantly CNS-related findings were observed, including impaired respiratory function and convulsions, the latter occurring in the dog at plasma levels (Cmax) which are in the range associated with the maximum recommended human dose (MRHD).\nThe efficacy and safety of NUCYNTA® in the treatment of moderate to severe acute pain has been established in two randomized, double-blind, placebo- and active-controlled studies of moderate to severe pain from first metatarsal bunionectomy and end-stage degenerative joint disease.\nOrthopedic Surgery – Bunionectomy\nA randomized, double-blind, parallel-group, active- and placebo-controlled, multiple-dose study demonstrated the efficacy of 50 mg, 75 mg, and 100 mg NUCYNTA® given every 4 to 6 hours for 72 hours in patients aged 18 to 80 years experiencing moderate to severe pain following unilateral, first metatarsal bunionectomy surgery. Patients who qualified for the study with a baseline pain score of ≥ 4 on an 11-point rating scale ranging from 0 to 10 were randomized to 1 of 5 treatments. Patients were allowed to take a second dose of study medication as soon as 1 hour after the first dose on study Day 1, with subsequent dosing every 4 to 6 hours. If rescue analgesics were required, the patients were discontinued for lack of efficacy. Efficacy was evaluated by comparing the sum of pain intensity difference over the first 48 hours (SPID48) versus placebo. NUCYNTA® at each dose provided a greater reduction in pain compared to placebo based on SPID48 values.\nFor various degrees of improvement from baseline to the 48-hour endpoint, Figure 1 shows the fraction of patients achieving that level of improvement. The figures are cumulative, such that every patient that achieves a 50% reduction in pain from baseline is included in every level of improvement below 50%. Patients who did not complete the 48-hour observation period in the study were assigned 0% improvement.\nFigure 1: Percentage of Patients Achieving Various\nLevels of Pain Relief as Measured by Pain Severity at 48 Hours Compared\nto Baseline- Post Operative Bunionectomy\nThe proportions of patients who showed reduction in pain intensity at 48 hours of 30% or greater, or 50% or greater were significantly higher in patients treated with NUCYNTA® at each dose versus placebo.\nEnd-Stage Degenerative Joint Disease\nA randomized, double-blind, parallel-group, active- and placebo-controlled, multiple-dose study evaluated the efficacy and safety of 50 mg and 75 mg NUCYNTA® given every 4 to 6 hours during waking hours for 10 days in patients aged 18 to 80 years, experiencing moderate to severe pain from end stage degenerative joint disease of the hip or knee, defined as a 3-day mean pain score of ≥ 5 on an 11-point pain intensity scale, ranging from 0 to 10. Pain scores were assessed twice daily and assessed the pain the patient had experienced over the previous 12 hours. Patients were allowed to continue non-opioid analgesic therapy for which they had been on a stable regimen before screening throughout the study. Eighty-three percent (83%) of patients in the tapentadol treatment groups and the placebo group took such analgesia during the study. The 75 mg treatment group was dosed at 50 mg for the first day of the study, followed by 75 mg for the remaining nine days. Patients requiring rescue analgesics other than study medication were discontinued for lack of efficacy. Efficacy was evaluated by comparing the sum of pain intensity difference (SPID) versus placebo over the first five days of treatment. NUCYNTA® 50 mg and 75 mg provided improvement in pain compared with placebo based on the 5-Day SPID.\nFor various degrees of improvement from baseline to the Day 5 endpoint, Figure 2 shows the fraction of patients achieving that level of improvement. The figures are cumulative, such that every patient that achieves a 50% reduction in pain from baseline is included in every level of improvement below 50%. Patients who did not complete the 5-day observation period in the study were assigned 0% improvement.\nFigure 2: Percentage of Patients Achieving Various\nLevels of Pain Relief as Measured by Average Pain Severity for the Previous 12\nhours, Measured on Study Day 5 Compared to Baseline- End Stage\nDegenerative Joint Disease\nThe proportions of patients who showed reduction in pain intensity at 5 days of 30% or greater, or 50% or greater were significantly higher in patients treated with NUCYNTA® at each dose versus placebo.\nLast reviewed on RxList: 12/4/2014\nThis monograph has been modified to include the generic and brand name in many instances.\nAdditional Nucynta Information\nReport Problems to the Food and Drug Administration\nYou are encouraged to report negative side effects of prescription drugs to the FDA. Visit the FDA MedWatch website or call 1-800-FDA-1088.\nChronic Pain/Back Pain\nFind tips and advances in treatment. |
We're waiting in the same-day surgery waiting room for Mariska to be finished with her Cath surgery.\nThis morning Misky was sooo happy just jabbering away, and full of smiles. Sam and I are doing pretty well, I feel so emotional like anything could push me over the edge and just cry.\nThis morning we checked in. Misky got to wear this cute little gown with a koala bear holding a little teddy bear and above says best friends, It looks so cute on her. Had Rose the PA do a physical on Misky. I took some pictures I'll add later.\nMariska's sats have dropped since the last visit they are now in the mid 60s 64-65. This is where she used to be at with out O2, I really hope that its just because she has a plugged up nose. We knew this would happen its just hard to think the time has already come.\nDr. Day is going to do the Cath and Dr. Pulver will assist him. Dr. Morray is going to be her anesthesiologist and I forgot who her nurse is going to be, something Ann. They all came to talk to use before the surgery. It helped to know the people that would be with her for a few hours.\nThey gave us a warm blanket to wrap her in to keep her legs warm. She was really good just sat there and looked around. We cleaned her nose out that she wasn't very happy with, I cant blame her she had a bloody nose on both sides. poor thing. She did pretty well for not being aloud to eat for a few hours. We walked her down to the Cath Lab, that's where we'll meet her when its all done.\nThe nurses all loved her piggy tails and said shes a very alert and cute baby on the way to the lab. After we dropped her off we went and got something to eat to\nJesus The Christ Reading... - I've really enjoyed reading James E. Talmage's Jesus the Christ. I learned something new about how cool Jesus is. I've been wanting to write it down for a ...\n1 day ago |
Dr. Michael Loiacono is an anesthesiologist practicing in New Britain, CT. Dr. Loiacono ensures the safety of patients who are about to undergo surgery. Anestesiologists specialize in general anesthesia, which will (put the patient to sleep), sedation, which will calm the patient or make him or her unaware of the situation, and regional anesthesia, which just numbs a specific part of the body. As an anesthesiologist, Dr. Loiacono also might help manage pain after an operation.\nEducation and Training\nNy Coll Of Osteo Med Of Ny Inst Of Tech- Old Westbury Ny 1988\nNew York Institute of Technology College of Osteopathic Medicine 1988\nAnesthesiologyAmerican Board of AnesthesiologyABA\n- Yale New Haven Hosp, Anesthesiology\n- Yale-New Haven Hospital\nDr. Michael Anthony Loiacono DO's Practice location\nNew Britain, CT 06052Get Direction\nDr. Michael Anthony Loiacono DO's reviewsWrite Review\nPatient Experience with Dr. Loiacono\n- Risk Factors for Levodopa-induced Dyskinesia in Parkinson’s Patients Study\nThere are motor as well as some non-motor symptoms that characterize Parkinson's disease. Parkinon's causes rigidity, tremors, and motor disabilities, as well as non-motor symptoms, including anxiety and depression. The most effective treatment to control Parkinson’s systems to date is Levodopa....\n- What’s Getting in the Way of Treatment for Rare Types of Ovarian Cancer?\nWomen who present to their healthcare provider with acute symptoms often already have progressed ovarian cancer. It is difficult to make medical advances with rare ovarian cancers because there are even fewer patients. Additionally, by the time patients begin to receive treatment, the cancer is...\n- Recovery After a Laminectomy\nLaminectomy is a surgical procedure done for the removal of the lamina, bone spurs, and ligaments that may be putting pressure on your spinal nerves and causing lower back pain. The procedure is said to be one of the most commonly performed back surgeries. Below is a detailed information on what...\n- What Are the Risks of Laminectomy?\nYour doctor will first attempt to give you other alternative treatments before recommending surgery. If your back pain still persists after treatment, your doctor may suggest for surgery as one of the solutions. Laminectomy is the most probable surgical procedure that you will have to undergo.Facts...\n- What Is the Epiglottis?\nWhat is Epiglottis?Epiglottis is a elastic flap of tissue that is shaped like a thin leaf and situated at the root of the tongue. It protects the opening between the vocal cords, known as the entrance of the glottis. Epiglottis is covered with mucous membrane, which is a yellow elastic cartilage...\n- Different Types of Physicians Explained\nDoctors or physicians are categorized according to different factors including medical specialties and subspecialties. Most doctors specialize in a specific area of medicine. This article provides a summary of the different types of doctors in the medical field. AllergistsAllergists are also...\n- Dr. Muhammad Anwar MD59 Maple Avenue North Haven Connecticut 06473\n- Dr. Mark A. Paradis M.D.99 E River Dr East Hartford CT 06108\n- Ildiko E. Toth51 South Main Street Middletown Connecticut 06457\n- Dr. Yasser Shaheen MD677 S Main St Cheshire CT 06410\n- Dr. Michael J. Cerullo M.D.80 S Main St Middletown CT 06457\n- Dr. Thomas Craig Mort M.D.111 Founders Plz East Hartford CT 06108 |
Record your patient’s vital signs as the procedure is ongoing. Record them either as values in a table or plot them using our clean, easy to read, user friendly chart. You can also note anesthetic drugs used and any other medications used intraoperatively, which automatically display on your patients treatment sheet - meaning your nursing staff always know exactly what a patient has been given without needing to go searching through different sheets.\nThink of our GA Sheet as a cheat sheet for your team for ordering anesthetic drugs, charting vitals and recording patient data. Easily set up your anesthesia record template for standard items your practice will monitor and use, intraoperatively and during other procedures. Your team will be able to start from a useful point every time they plan a general anesthetic.\nEach anesthesia monitoring sheet can be tailored to a patient’s requirements using GA preferences. Just set up from your default template and add any custom parameters or drugs you need and get started. You can quickly add others during the procedure and all of them remain when complete to be added to your patient's digital clinical record.\nYou'll likely be used to using paper to monitor your patient's anesthesia. These digital anesthesia forms allow veterinary professionals to track your patient's vitals and the anesthesia drugs adminisistered throughout a procedure.\nWorking in medicine is extremely complex as it is, why not make your processes more streamline to reduce mental overheads and reduce stress? When you use these digital sheets, all the items you need to bill for will appear on your patient's bill automatically, so you don't need to copy items over from your paper records into your PMS.\nYes, you can easily set default items to monitor and allow your staff to get started quickly, reducing set up time for every anesthetic or sedation, every time.\nYes we do, we have all types covered from Intravenous (IV), IV bolus and IV continuous rate infusion (CRI) Calculators to Fluid Calculators for continuous, fluid bolus and single injection delivery methods to make your maintenance fluid calculations easy and we include calculators for anesthesia drugs on our anesthesia and sedation chart.\nYes, everything in Plexi remains in your database forever so you can easily access your patient files without needing to worry about bespoke cloud storage solutions and filing systems. |
Moving to Baltimore\n- Quick Facts\n- Missions, Goals, & Objectives\n- How to Apply\nWelcome to the Adult Cardiothoracic Anesthesiology Fellowship website. Take a moment to discover what our Program has to offer.\nAt Johns Hopkins we have a long tradition of training not only clinical academic Anesthesiologists, but also leaders in the Anesthesiology community at large. We are a division of 15 Cardiac Anesthesia attendings within a department of over 200 Anesthesiology and Research faculty. What makes us unique are the limitless opportunities for research, mentorship and education combined with a robust, varied and intensive clinical experience. The Cardiac Anesthesiology faculty are the recipients of numerous extra-mural grants (NIH, AHA, NASA, etc). The Department also has a T32 NIH Training Grant to support junior faculty in their academic careers. This is a mechanism that interested fellows can progress onto as junior faculty. The academic accomplishments of the faculty is reflected in both the quality and quantity of their publications (see linked web pages) in journals such as Anesthesiology, Nature, Circulation, Anesthesia and Analgesia, Science, Stroke, and Hypertension to name just a few.\nThe fellows are part of an integrated team that affords them the opportunity to grow both as teachers and learners. Our philosophy not only serves to promote clinical acumen but also encourages and promotes the development of leaders in education and management. Fellow education is a priority and therefore our fellows are given dedicated time to attend lectures, etc. Echocardiography training, an important component of a fellow's training, is aggressively supported via, for example, teaching in the OR, dedicated lectures, double reading with sub-specialty cardiologists, dedicated rotations and support for meeting attendance. We have a 100% pass rate for the NBE Advanced PTEx. Our current echocardiography capabilities include TEE-exposure to 2D TEE and 3D TEE as well as an echocardiography simulator with both TEE and TTE capabilities.\nOur case load includes routine but importantly, non-routine cases, for example, Valve sparing aortic root replacement, minimally invasive mitral valve replacement, Transcatheter Aortic Valve Implantation, and complex aortic reconstructions. Hopkins has been one of the leading Institutions in the world in the surgical management of Aortic Disease with a National and International referral base. We balance a busy clinical schedule with dedicated Fellow-oriented lectures and teaching activities that will guide/develop you into an expert in the field of Cardiac Anesthesiology.\nDaniel Nyhan, MD, MMBCh\nFellowship Program Director\nAssociate Fellowship Program Director\nClass of 2015-2016, Adult Cardiothoracic Anesthesiology\nFrom left to right: Rosanne Sheinberg, MD; John McNeil, MD;\nMegan Kostibas, MD; Ami Naik, MD; Farrah Sajan, MD; Zahra Malik, MD; Heather Hayanga, MD;\nand Dan E. Berkowitz, MD (Cardiothoracic Anesthesia Division Chief).\n- Accredited by: Accreditation Council for Graduate Medical Education (ACGME)\n- Length of Fellowship: One Year\n- Start Date: July 1st\n- Positions Available: 6\n- Application Dates/Deadline: January 1 to March 31 (One year before matriculation)\n- Applicant Qualifications: Successful completion of ACGME Anesthesiology Residency\n- San Francisco Match Participant: Yes\nThe Division of Cardiac Anesthesia offers a one year ACGME Accredited Cardiothoracic Fellowship following the completion of three years of clinical anesthesia. The division provides anesthesia for approximately 1200-1400 cases per year. Case types include coronary artery bypass procedures, valve replacement and repair, pediatric and congenital disease related procedures, VAD insertion, heart and lung transplantation, transcutaneous aortic valve implantation, and major aortic surgery. Our practice employs transesophageal echocardiography extensively, and fellows typically train not only in the OR, but with the Department of Cardiology as well.\nA number of our faculty are board certified in Critical Care Medicine and divide their clinical time between cardiac anesthesiology and ICU medicine in our Cardiac Surgical Intensive Care Unit. In addition, both the Cardiac Anesthesia Division and the Department of Anesthesiology support a number of faculty with well-established basic science programs which offer extensive opportunities in areas directly applicable to cardiovascular medicine. We also have a Transesophageal and Transthoracic Echocardiography simulator available for learning echocardiography within our division.\nApplications are accepted from January 1st – March 31st, one year prior to start date.\nThe mission of The Johns Hopkins Hospital is to improve the health of the community and the world by setting the standard of excellence in patient care. Diverse and inclusive, The Johns Hopkins Hospital in collaboration with the faculty of The Johns Hopkins University supports medical education and research, and provides innovative patient-centered care to prevent, diagnose and treat human illness.\nThe overall goal of the Adult Cardiothoracic Fellowship at Johns Hopkins is to develop the future leaders and consultants that will pave the way of our specialty.\nBy the end of this fellowship, fellows will be able to:\n- Provide compassionate, appropriate, and effective anesthetic care for adult patients presenting for cardiothoracic surgery;\n- Foster a thorough understanding of the breadth and depth of the specialty of Adult Cardiothoracic Anesthesiology;\n- Develop the skills necessary for research and appraise the medical literature and scientific evidence relevant to the individualized plan of patient care and to advance the specialty.\nThis fellowship is devoted to the preoperative, intraoperative, and postoperative care of adult patients undergoing cardiothoracic surgery, vascular surgery and related invasive procedures. With respect to didactic lectures, there are three DIVISIONAL series of lectures as well as some adjunctive lecture series outside of our Division:\n- A Cardiac Divisional Conference every Thursday for 45 minutes which encompasses a range of cardiovascular related research and clinical topics. Speakers include faculty from the division, faculty from other JHU departments as well as external faculty.\n- A series is a TEE lecture series that consists of lectures focusing on cardiothoracic structures and their pathophysiology based on the content outline of the Advanced Perioperative TEE Examination by the National Board of Echocardiography. As part of the TEE curriculum, we offer basic and advanced level workshops/didactic lectures that utilize an echocardiography simulator. The simulator is housed within our division and when not being used for educational workshops, is available for practice to our fellows.\n- There is an additional lecture series that is available online that addresses the curriculum as delineated by the ACGME. In addition, lectures on fatigue; and physician impairment are included. Our fellows also attend at least one TEE conference during their fellowship for which funding is provided. In addition, through the Faculty Development Office, our fellows can participate in grant writing courses as well as other research/clinical courses, free of charge.\nThe Department of Anesthesiology holds weekly Grand Rounds. In addition, we hold multidisciplinary conferences with the cardiology and cardiac surgery departments. Because several lecture series occur simultaneously at Johns Hopkins within different department/divisions, our fellows are welcome to attend any that are offered at the institution.\nOur Fellows are required to complete two academic projects – a Case Report presentation and a Journal Club presentation. Both of these are presented individually during our morning Divisional Grand Rounds. Additionally, our fellows have the opportunity to present their research and ongoing projects at conferences throughout the year.\nCardiac Thoracic Anesthesia\nElective: Perfusion, Electrophysiology/ Catheterization laboratory\nCardiac Surgical ICU\nTransesophageal Echocardiography within the Department of Cardiology\nResearch in Anesthesiology is diverse and develops new dimensions relevant to patient care and fostering state-of-the-art molecular approaches. Our faculty includes world-class investigators (MD, MD/PhD, and Ph.D scientists) conducting multidisciplinary research in a number of research areas with major programs. The majority of the cardiac anesthesiology faculty are NIH and/or AHA funded. Research has traditionally focused on a systems biology approach, consistent with the discipline's clinical role in monitoring critical systems and ensuring survival during our most vulnerable periods. We strive to achieve true translational research, linking our basic and clinical research programs to deliver novel therapeutics and devices to the bedside, to directly investigate interventions and outcomes in our clinical arenas, and to perform relevant and insightful investigations at the basic, mechanistic level.\nOne critical aim of the department is to bridge the gap between basic research and clinical medicine by performing research of the highest quality in both areas (translational research). The key aspect revolves around the idea of having clinicians and basic scientists working together in the research laboratory as well as in the clinical facilities.\nRosanne Sheinberg, MD – Assistant Professor. Academic Focus: Integrative Medicine for Perioperative Patients.\nViachaslau Barodka, MD – Assistant Professor\nDan E. Berkowitz, MD – Professor. Division Chief. Research Focus: studying the mechanisms that underlie vascular disorders, with a concentration on the effect of deep-space radiation on the cardiovascular system.\nMary Beth Brady, MD – Assistant Professor. Director of Interoperative TEE.\nCharles Brown, MD – Assistant Professor. Research Focus: Cognitive Dysfunction.\nJeffrey Dodd-o, MD – Associate Professor. Research Focus: understanding the factors that contribute to ischemia/reperfusion injury of the lung and how ischemia/reperfusion contributes to lung dysfunction in the early post-cardiopulmonary bypass period.\nNauder Faraday, MD – Associate Professor. Associate Professor. Research Focus: Translational and clinical research programs in platelet biology and perioperative genomics.\nWei Dong Gao, MD – Associate Professor. Research Focus: Defining the molecular and cellular mechanisms of contractile dysfunction in the failing heart.\nNadia Hensley, MD – Assistant Professor.\nRoger Johns, MD – Professor. Research Focus: investigating the mechanisms that underlie anesthesia, analgesia, chronic pain, and inflammatory lung disorders (such as pulmonary hypertension and asthma).\nLaeben Lester, MD – Assistant Professor\nDaniel Nyhan, MD – Professor, Program Director. Research Focus: Studying vascular changes, specifically those that accompany aging, to determine the underlying causes and find ways to reverse the process.\nJochen Steppan, MD, DESA – Assistant Professor. Research Focus: Vascular Stiffness.\nClass of 2015-2016\nAmrita Cheema, MD\nLee Goeddel, MD\nMichael Grant, MD\nBrijen Joshi, MD\nFrancis Lou Kirk, MD\nDaria Lymar, MD\nComplete application and supporting documentation via the SF Match website (https://www.sfmatch.org/).\nAdult Cardiothoracic Anesthesiology Fellowship\nDepartment of Anesthesiology and Critical Care Medicine\nThe Johns Hopkins University School of Medicine\nSheikh Zayed Tower\n1800 Orleans Street, Zayed 6208\nBaltimore, MD 21287\nDaniel Nyhan, MD, MMBCh\nProgram Director, Cardiothoracic Anesthesia Fellowship\nMegan Kostibas, MD\nAssociate Program Director, Cardiothoracic Anesthesia Fellowship |
Hamlet Garabedian, DMD, MD, FACS\nPacific Oral and Maxillofacial Surgery and Dental Implant Center\nDentist Expert Witness, Oral Surgery Expert Witness\nOral Surgery, complicated tooth extraction, implant surgery and bone grafting, Facial trauma, mandible fracture, TMJ, TMD, offers IV(intravenous anesthesia) and treats a variety of oral tumors, head and neck infection, facial trauma, orthognathic surgery (corrective jaw surgery)and oral tumors\nDr. Hamlet Garabedian is a board certified Oral and Maxillofacial Surgeon and a Fellow of American College of Surgeons. He attended dental school at the Harvard School of Dental Medicine in Boston, Massachusetts from where he graduated with the highest academic honors in 1999. He then went on to attend medical school at UCLA School of Medicine in Los Angeles, California. He completed his internship in general surgery and his residency in Oral and Maxillofacial Surgery at what is now the Ronald Reagan UCLA Medical Center where he also served as chief resident.\nAfter completing his training, Dr. Garabedian moved to New Jersey where he practiced the full scope of Oral and Maxillofacial Surgery for seven years with an emphasis on complex implant reconstructive surgery, bone grafting, facial trauma, wisdom teeth extraction and office anesthesia. Dr. Garabedian and his family then moved back to Southern California where he currently practices all aspects of the oral and maxillofacial surg...\nClick for Full Listing and Contact Info |
10 Remarkable Lidocaine Powder Uses You Can’t Afford To Miss!\nLidocaine powder is a flexible substance that has acquired fame for its surprising aggravation-easing properties. This strong local anesthetic is normally utilized in clinical and dental methods to numb the impacted region. Lidocaine powder, a local anesthetic, has received consideration because of its outstanding aggravation easing capacities. Explore 10 astonishing Lidocaine Powder uses that will amaze you. Discover its versatility in pain relief, beauty treatments, and more!\nUnderstanding Lidocaine Powder\nLidocaine is a normally utilized local anesthetic that has a place with the class of amide-type sedatives. It works by blocking nerve signals in a specific area, numbing the region and reducing pain sensations. Lidocaine powder is a pure form of the anesthetic, typically available in crystalline form. Buy Lidocaine Powder\n1. Topical Applications of Lidocaine Powder\nLidocaine powder is widely used topically to alleviate pain. It very well may be applied to the skin or mucous films to give transitory help from conditions, for example, minor consumes, bug nibbles, and rashes. The powder is easily absorbed and starts working quickly, offering immediate comfort.\n2. Dental Uses of Lidocaine Powder\nDentists often utilize lidocaine powder to numb the oral cavity before carrying out various procedures. It helps to alleviate pain associated with tooth extractions, root canals, and gum treatments. The fast-acting nature of lidocaine powder ensures that patients can undergo dental procedures with reduced discomfort.\n3. Sports and Fitness Applications\nAthletes and fitness enthusiasts can profit from the aggravation freeing impacts of lidocaine powder. It very well may be utilized to address muscle irritation, injuries, and strains. The powder can be applied directly to the affected area, allowing athletes to continue their training or recover from injuries more comfortably.\n4. Tattoo and Body Piercing Procedures\nLidocaine powder is commonly used in the tattoo and body piercing industry to minimize pain during procedures. It can be applied topically to numb the skin, making the experience more tolerable for individuals seeking body modifications.\n5. Managing Hemorrhoids and Anal Fissures\nHemorrhoids and anal fissures can cause significant discomfort. Lidocaine powder can provide relief by reducing the pain and itching associated with these conditions. It very well may be applied topically or utilized as cured creams or balms.\n6. Soothing Sunburns and Skin Irritations\nSunburns and skin irritations can be incredibly painful and bothersome. Lidocaine powder can offer instant relief by numbing the affected area.Its cooling impact can give a mitigating sensation, lightening the uneasiness brought about by burns from the sun, bug chomps, and other skin disturbances.\n7. Relieving Arthritis Pain\nIndividuals suffering from arthritis often experience joint pain and inflammation. Lidocaine powder can be utilized as creams or gels to give confined help. By numbing the affected joints, it helps reduce pain, allowing individuals to manage their condition more effectively.\n8.Post-Surgical Pain Relief\nAfter surgeries, patients might encounter post-employable agony. Lidocaine powder can be utilized as a component of an extensive aggravation the board intend to give prompt help. Its application at the surgical site helps minimize discomfort, allowing patients to recover more comfortably.\n9. Treating Nerve-related Conditions\nLidocaine powder has shown promise in treating specific nerve-related conditions, for example, neuropathic torment. When applied topically, it can focus on the impacted nerves, providing alleviation from persistent agony related to conditions like post-herpetic neuralgia and diabetic neuropathy.\n10. Lidocaine Powder in Veterinary Medicine\nLidocaine powder is not limited to human applications; it is also used in veterinary medicine. Veterinarians may employ lidocaine powder to provide local anesthesia during minor surgical procedures or to alleviate pain in animals.\nPrecautions and Safety Considerations\nWhile lidocaine powder offers effective pain relief, it is essential to follow proper precautions and safety guidelines. Prior to utilizing lidocaine powder, it is prescribed to talk with medical services proficient to decide on the proper measurements and application technique. Adhering to safety measures ensures optimal results and reduces the risk of adverse reactions. Exploring the Legal and Ethical Considerations When Buying\nLidocaine powder is a remarkable substance with diverse applications in pain management. Its ability to provide instant relief makes it invaluable in various medical, dental, and everyday scenarios. From topical applications to dental procedures, and sports injuries to skincare, lidocaine powder offers a versatile solution for those seeking effective pain relief.\nQ1. Is lidocaine powder safe to use?\nLidocaine powder can be safe when used correctly and under the guidance of a healthcare professional. It is vital to adhere to legitimate measurement directions and comply with somewhere-safe insurance to limit the gamble of unfriendly impacts.\nQ2. Can lidocaine powder be used on children?\nThe use of lidocaine powder on children should be supervised by a healthcare professional. The fitting dose and application strategy might differ in view of the kid’s age and explicit conditions.\nQ3. How long does lidocaine powder’s numbing effect last?\nThe duration of lidocaine powder’s numbing effect varies depending on factors such as the application method and individual response. Generally, the numbing sensation can last for a few hours.\nQ4. Are there any side effects associated with lidocaine powder?\nWhile lidocaine powder is for the most part protected, it can cause aftereffects like skin bothering, unfavorably susceptible responses, or deadness in encompassing regions. It is crucial for end use and look for clinical consideration assuming any antagonistic responses happen.\nQ5. Where can I obtain lidocaine powder?\nLidocaine powder can be obtained from authorized healthcare providers or licensed pharmacies. It is essential to guarantee that you source it from respectable and solid sources to guarantee its quality and security.\nIn conclusion for 10 Lidocaine Powder Uses, lidocaine powder is a valuable asset for instant pain relief across a wide range of applications. Its versatility and effectiveness make it a preferred choice for medical professionals, athletes, and individuals seeking relief from various painful conditions. By understanding its uses and following proper guidelines, lidocaine powder can provide the comfort and relief needed to enhance well-being and quality of life.\nread more : |
Sunday, December 8, 2013\nWhat are the names of one or more anesthetic for the dental office that contain no epinepherene and also no sulfite preservatives?\nSulfites are chemicals to prevent oxidation (chemical breakdown) of vasoconstrictors like epinephrine and levonordefrin. Vasoconstrictors are in most dental local anesthetics to make them last longer and reduce surgical bleeding. Sulfites are also in red wine for the same purpose, to prevent the wine from losing its flavor due to oxidation from air that might leak inside the bottle through the cork before it is opened.\nThere are many other local anesthetics used in medicine that do not contain vasoconstrictors or sulfites, but these do not come in the small glass cartridges that dentists like to use in their syringes. However they can be used in standard syringes for dentistry -- 0.25%, 0.5%, and 0.75% bupivacaine, 0.5%, 0.75%, 1% ropivacaine, and 0.25%, 0.5%, and 0.75% levobupivacaine are excellent local anesthetics without vasoconstrictors or sulfites.\n- 3% mepivacaine plain and 4% prilocaine plain contain no epinephrine and therefore no sulfites.\n- 2% Lidocaine plain without epinephrine also contains no vasoconstrictor and no sulfites, but it is so short-acting that it is rarely used in dentistry.\n- 2% mepivacaine contains no epinephrine but does contain a somewhat similar vasoconstrictor (levonordrrin) and contains sulfites.\n- 4% prilocaine with epinephrine is another prilocaine product that does contain epinephrine and sulfites.\nJoel M Weaver, II, DDS, PhD\nCollege of Dentistry\nThe Ohio State University |
Dr. Sudhanshu Bhatnagar is a well practiced consultant Pediatric Dentist, associated with Tooth Talez dental clinic, Jaipur. He has worked as an assistant professor at Jodhpur Dental College Hospital from 2001 to 2003. He has been working as assistant professor at Jaipur Dental college and Hospital from 2003. Dr. Sudhanshu Bhatnagar has done certifications in Conscious sedation, Esthetic cosmetic dentistry, MDS Periodontics and Preventive Dentistry, Non surgical wisdom teeth extractions, Rotary endodontics and smile designing.\nAstt. Professor, Jodhpur Dental College General Hospital\nMDS, 2010, V S Dental College & Hospital\nBDS, 2005, Nair Hospital Dental College (NHDC), Mumbai\nYour participation in the survey will help other patients make informed decisions. You will also be helping Dr. Sudhanshu Bhatnagar and his staff know how they are doing and how they can improve their services.\nHow was your experience with Dr. Sudhanshu Bhatnagar?\nHelp other patients, and let the doctor know how he's doing |
If the classic liposuction cosmetic surgery as implemented in 1977 by Dr. Yves Gérard Illouz and for a long time was considered the only option for the elimination of fat cells rebellious to sport exercises, today there is a more recent act that uses ultrasonic energy to permanently remove fat deposits.\nWhat is Vaser liposuction?\n"Vaser liposuction" or "soft liposuction", an alternative to traditional liposuction achievable by conventional surgical means, which uses ultrasound to remove subcutaneous fat and improve the aesthetics of a specific region of the figure.\nThis act is particularly indicated to peel off fat masses while protecting and conserving other tissues with less bleeding and bruising through the use of saline.\nVaser liposuction, is distinguished by the selection of fat in order to preserve the surrounding tissues. That is why it is referred to as "Lipo Selection". In addition, it sucks localized fat cells away from blood vessels and nerves.\nThis procedure, is a more selective system in comparison with other liposuction techniques that removes fat and retains tissues that remain important for the anatomical structure.\nThe Vaser Lipo, also allows to reach regions on which the fat is localized beyond the blood vessels and nerves.\nIn addition, the improvement of the contours of the silhouette and the aesthetic results would be more remarkable.\nA preoperative checkup is carried out in accordance with the prescriptions.\nIt is recommended that the patient stops smoking for 1 month before and after the operation as well as any medication containing aspirin during the 10 days preceding the day of surgery.\nThe cosmetic surgeon, inserts the ultrasound probes at the level of the adipose tissue in order to gently break down the fat cells located on:\n- The belly,\n- Love handles,\n- Chin and neck.\nIn fact, the vibration will take off and gently release the fat cells as well as the tumescent fluid that has been injected into the area to be treated and that mixes with the fat cells that have just been peeled off.\nOnce the emulsion is started, the practitioner uses a cannula to be able to remove fluid and fat cells. Only a small amount of local anesthetic persists in the tissues to reduce postoperative pain.\nIn practice, the waves will destroy the fat cells that will be extracted using a Vasetou cannula probe that make it possible to obtain shorter incisions compared to conventional liposuction and therefore avoid stitches and possible complications.\nThe vaser Lipo operation, lasts 1 hour on average depending on the number of areas to be treated, it takes place under local anesthesia during a stay in a clinic of 1 day.\nThis operation, is less invasive compared to the classic technique of which requires a faster recovery time.\nThe postoperative pain of this act is reduced, in fact, a small amount of local anesthetic always remains on the patient's tissues.\nThis is a short recovery phase since the patient would be able to resume his professional activities immediately.\nBruises and hematomas are less important compared to conventional liposuction.\nThe Vaser lipo, eliminates in a way both definitively and radically excess fats without any pain or social eviction with an appreciable aesthetic result immediately.The skin, would be firmer, softer and without bumps or cavities. As for the silhouette, it would be better defined. |
Experience NOCITA®(bupivacaine liposome injectable suspension)\nNow your veterinarian can help extend pain relief after your dog’s cranial cruciate ligament surgery.\nAll surgical procedures result in some degree of tissue trauma and pain. As pain can delay healing and return to function, veterinarians strive to minimize your dog’s discomfort following surgery.\nNow NOCITA® is here to help. As an extended-release medication, it can help veterinarians better manage post-operative pain in dogs undergoing cranial cruciate ligament surgery.\nLong-acting pain relief\nThe use of bupivacaine (a well-known local anesthetic) in a long-acting injectable formula has been proven to extend the duration of human post-operative analgesia from up to seven hours1 to as long as 72 hours. Now similar results have been demonstrated in dogs with the use of NOCITA®.\nAsk your veterinarian\nNOCITA® has been thoroughly tested in clinical studies. Ask your veterinarian for more details on how it could extend post-operative pain relief for your dog undergoing cranial cruciate ligament surgery.\n- 1Marcaine [package insert]. Lake Forest, IL: Hospira, Inc; 2014.\nDOG INDICATION: For single-dose infiltration into the surgical site to provide local post-operative analgesia for cranial cruciate ligament surgery in dogs.\nIMPORTANT SAFETY INFORMATION: NOCITA® (bupivacaine liposome injectable suspension) is for local infiltration injection in dogs only. Do not use in dogs younger than 5 months of age, that are pregnant, lactating or intended for breeding. Do not administer by intravenous or intra‐arterial injection. Adverse reactions in dogs may include discharge from incision, incisional inflammation and vomiting. Avoid concurrent use with bupivacaine HCl, lidocaine or other amide local anesthetics. Please see the full Prescribing Information for more detail.\nAre you a veterinary professional?\nLearn more about how long-acting NOCITA® could provide the post-surgical pain relief for your patients undergoing cranial cruciate ligament surgery.\n“We began using Nocita on canine patients undergoing cranial cruciate ligament stabilization surgeries and have been very pleased with the results. The product is intuitive to use and we have observed nothing but positive effects for our patients post-operatively. Specifically, these patients appear to bear more significant weight immediately post-op than usually expected, require very little rescue analgesia, and are willing to eat early in the recovery period which has allowed easy transition to oral medications. Nocita has quickly become standard protocol for analgesia on our canine cruciate ligament stabilization procedures.”Veterinary Surgeon\nOther therapeutics from Aratana\nFinally, appetite stimulation is in your control.\nENTYCE® (capromorelin oral solution) is the ONLY FDA-approved veterinary therapeutic designed to safely and effectively stimulate appetite in dogs. Administered orally once a day, ENTYCE is appropriate for treating inappetence caused by chronic and acute conditions.\nIMPORTANT SAFETY INFORMATION: ENTYCE® (capromorelin oral solution) is for use in dogs only. Do not use in breeding, pregnant or lactating dogs. Use with caution in dogs with hepatic dysfunction or renal insufficiency. Adverse reactions in dogs may include diarrhea, vomiting, polydipsia, and hypersalivation. Should not be used in dogs that have a hypersensitivity to capromorelin. Please see the full Prescribing Information for more detail. |
WHAT WILL ACHIEVE?\n- Examine the different categories and causes of traumatic shock and approaches to treating each case including:\n- Global High Intensity Trauma: electrocution, hallucinogens, drowning, suffocation, strangulation, fetal distress, traumatic birth, intrauterine stress, and invasive medical procedures in utero\n- Inescapable Attack : wild animals, rape, war, bombings, physical abuse, mugging, incest, molestation\n- Physical Injury : surgery, anesthesia, burns, poisoning, hospitalizations, stabbing, gunshot wounds\n- Failure of Physical Defense : falls, high impact accidents, head injury\n- Emotional Trauma : severe neglect and abandonment, severe loss, ongoing abuse\n- Natural Disasters : earthquakes, fires, tornadoes, floods, social dislocation from the natural world and community\n- Horror : seeing an accident (especially with blood, gore), watching someone else be abused, raped, killed or tortured, killing or hurting someone yourself\n- Torture and Ritual Abuse : war torture, repeated rape in war, concentration camp, and systematic abuse (sometimes with the person drugged)\nConsists of two 6-day seminars\nCada módulo consiste en tres días de trabajo, un día de descanso y tres días de trabajo.\n|MODULE 1 (I/II)||May, 2020||Pedro Prado\n|MODULE 2 (II/III)||September/October, 2020||Pedro Prado|\nSomatic Experiencing® formation takes place in the Hotel Fuerte El Rompido (Cartaya, Huelva) |
Enhanced Services The State encourages the Contractor to cover programs that enhance the general health and well-being of its Hoosier Healthwise members, including programs that address preventive health, risk factors or personal responsibility. These enhanced programs and services are above and beyond those covered in the Hoosier Healthwise program. In addition, all enhanced services shall comply with the member incentives guidelines set forth in Section 6.2.2 and other relevant state and federal rules regarding inducements. All enhanced services offered by the Contractor must be pre-approved by OMPP prior to initiating such services. Enhanced services may include, but are not limited to, such items as:\nPharmacy Services The Contractor shall establish a network of pharmacies. The Contractor or its PBM must provide at least two (2) pharmacy providers within thirty (30) miles or thirty (30) minutes from a member’s residence in each county, as well as at least two (2) durable medical equipment providers in each county or contiguous county.\nCollection Services 5.01 General 5-1 5.02 Solid Waste Collection 5-1 5.03 Targeted Recyclable Materials Collection 5-3\nInpatient Services Hospital This plan covers services provided while inpatient in a general or specialty hospital including, but not limited to the following: • anesthesia; • diagnostic tests and lab services; • dialysis; • drugs; • intensive care/coronary care; • nursing care; • physical, occupational, speech and respiratory therapies; • physician’s services while hospitalized; • radiation therapy; • surgery related services; and • room and board. Notify us if you are admitted from the emergency room to a hospital that is not in our network. Our Customer Service Department can assist you with any questions you may have about your coverage. Rehabilitation Facility This plan covers rehabilitation services received in a general hospital or specialty hospital. Coverage is limited to the number of days shown in the Summary of Medical Benefits.\nAnesthesia Services This plan covers general and local anesthesia services received from an anesthesiologist when the surgical procedure is a covered healthcare service. This plan covers office visits or office consultations with an anesthesiologist when provided prior to a scheduled covered surgical procedure.\nEducation services 1.1 Catholic education is intrinsic to the mission of the Church. It is one means by which the Church fulfils its role in assisting people to discover and embrace the fullness of life in Xxxxxx. Catholic schools offer a broad, comprehensive curriculum imbued with an authentic Catholic understanding of Xxxxxx and his teaching, as well as a lived appreciation of membership of the Catholic Church. Melbourne Archdiocese Catholic Schools Ltd (MACS) governs the operation of MACS schools and owns, governs and operates the School.\nADMINISTRATION SERVICES The Administrator shall provide the following services, in each case, subject to the control, supervision and direction of the Fund and the review and comment by the Fund's auditors and legal counsel and in accordance with procedures which may be established from time to time between the Fund and the Administrator:\nCloud Services If You would like to deploy Cloud Services, We grant You and Your Affiliates a non-exclusive, non-transferable, worldwide right to authorize individuals solely within Your and Your Affiliates’ organization (“Users”) to access or exchange data via the Cloud Services during the Term (as defined in Section 8 below), but only for Your own internal business purposes and subject to the terms and conditions of this Agreement and terms associated with the specific Cloud Services contained in the Order and applicable schedule(s). We are not responsible for web pages or servers that are not owned or controlled by Us, even if linked to (including via application programming interfaces) the Cloud Service. We do not endorse any sites on the Internet that are linked through the Cloud Service; such links are provided to You and your Users only as a convenience. In addition, certain third-party providers of ancillary software, hardware or services may require Your agreement to additional or different licence or other terms prior to Your or Your Users’ use of or access to such software, hardware or services. Cloud Services offerings may include a limited-use subscription to on- premise Software as described in the applicable schedule(s) and use of such Software must comply with all licence terms. Under no circumstances may the Cloud Services be used for any illegal or illicit purpose in any geography where the Cloud Services are used. You must: (i) protect the secrecy of Your authorized user IDs and passwords; (ii) notify Us immediately of any unauthorized use of any user ID or password or any other known or suspected breach of security; and (iii) report to Us immediately and use reasonable efforts to stop any copying or distribution of content not authorized by Us. You agree that anyone who inputs a valid user ID and password will be deemed an appropriate User unless and until You notify Us otherwise in writing. Any individual User who has violated this Section may have its account suspended.\nMedical Services Plan 10.1.1 Regular Full-Time and Temporary Full-Time Employees shall be entitled to be covered under the Medical Services Plan commencing the first day of the calendar month following the date of employment.\nDistribution Services The Distributor shall sell and repurchase Shares as set forth below, subject to the registration requirements of the 1933 Act and the rules and regulations thereunder, and the laws governing the sale of securities in the various states ("Blue Sky Laws"): |
Having unwanted fat in various locations of your body can have a substantial impact on your health and self-esteem. While standard weight loss through workout and diet plan is a terrific way to slim down overall, even the best workouts cannot target issue locations like the stomach, inner thighs, arms, and buttocks. Liposuction is a time tested treatment that is utilized to eliminate excess fat from particular locations of the body, allowing a specific to shape and contour their body to their liking. Is liposuction right for you? Learn now.\nPros of Liposuction\nThere are lots of benefits to this cosmetic procedure, consisting of:\n• Immediately obvious modifications. Unlike standard weight loss, liposuction develops modifications that are instantly noticeable in the body. Some difference is obvious right away, and the wanted outcomes are generally attained in just a couple of days.\n• Proven and safe. This cosmetic procedure has actually been performed by experienced cosmetic surgeons all over the world for many years and the method has actually been improved over and again to be safe and effective.\n• Healing time is usually quickly. The downtime needed after having this type of procedure is usually much less than exactly what is required for other kinds of cosmetic treatments, including tummy tucks, breast reduction, and more. Individuals who have had the treatment can often return to work much more quickly than they anticipated and can return to living a healthy, active way of life.\n• Weight loss can be long-term. With the best upkeep methods, the fat that was eliminated during the liposuction treatment will not return.• Complete control over your physique. With liposuction, an individual can have complete control over how they wish to look, beyond exactly what standard diet plan and exercise can provide. Providing people this power over their bodies increases self-confidence and help people feel their very best.\nWhile there countless advantages to liposuction, there are obviously a few cautions that need to be considered before making the decision to move on with the treatment.\nCons of Liposuction\nPrior to having actually liposuction done, it's important to analyze the prospective downsides of the procedure and figure out if the benefits outweigh the threats in your particular case. Your surgeon can help you find out more about the dangers associated with the procedure and can help you decide if moving on is the right thing for you.\n• Issues with basic anesthesia. Because liposuction is performed under general anesthesia, the treatment carries the very same risks as other kind of surgery where general anesthesia is utilized. Hidden medical conditions might enhance these risks.\n• Adverse reactions. Bruising, bleeding, and discomfort are all to be expected, nevertheless, in uncommon cases can cause more significant complications.\n• The prospective to get the weight back. After having actually liposuction done, it is crucial to maintain a healthy diet plan and exercise appropriately as recommended by your doctor. Failure to do so might cause acquiring back the weight that was lost or possibly much more.\nAlthough there are threats connected with liposuction, for many individuals, the benefits far outweigh them. Educate yourself about the treatment by having thorough discussions with your specialist and consider how liposuction has the possible to affect you as a special individual. Just you and your cosmetic surgeon can figure out if liposuction will supply you with the results you are searching for within your expectations.\nLaser Liposuction procedure is a new non invasive procedure to loose unwanted bodyfat in Stafford Springs CT\nLaser liposuction is a more recent, minimally intrusive treatment that involves heating the fat cells to melting point and eliminating the melted fat through a small cannula. The procedure is normally done right in your doctor's office and is an excellent alternative for individuals who have less than 500 ml of fat to get rid of from any one location. Laser liposuction can be a safe, complementary treatment to weight-loss in order to sculpt the body you have actually constantly desired.\nContact a Specialist in your Stafford Springs CT today.\nIf you're thinking about liposuction as a weight loss option, it is very important that you discuss your desires with a qualified plastic surgeon in your area. Your cosmetic surgeon will carry out a complete test and health history survey to determine if liposuction can benefit you and assist you reach your physical and emotional objectives. Call today for an assessment and learn more about how liposuction can help you attain the body of your dreams. |
Transoesophageal Echocardiography in Anaesthesia and Intensive Care Medicine, 2nd Edition\nAugust 2004, BMJ Books\nPerioperative transoesophageal echocardiography.\nGlobal left ventricular systolic function.\nLeft ventricular diastolic function.\nMitral valve disease.\nCongenital heart disease.\nCardiac masses, air, and foreign bodies.\nMinimally invasive and minimal access cardiac surgery.\nCirculatory assist devices, artificial heart, and heart and lung transplantation.\nArtifacts and pitfalls.\nTraining and certification in the United States.\nTraining and certification in Europe.\nTOE and assist devices, artificial heart and heart transplantatiaon\n- First book in English edited by European specialists, with cooperation of both American and European anesthesiologist, intensivists and cardiologists.\n- Relevant for everyone working in the field of perioperative evaluation and monitoring |
Paul Darcy, MD, Elected Chairman of CMIC Underwriting Committee at Company Board Meeting\nNovember 20, 2017by\nCMIC Group, a member-owned medical professional liability insurance provider, recently appointed CMIC board member Paul Darcy, MD, as chairman of the Underwriting Committee.\n“Dr. Darcy is a highly skilled, experienced and well-respected physician whose attributes will benefit not only the Underwriting Committee but the company as a whole,” said Denise Funk, chief executive officer of CMIC Group. “His unique skillset will further enhance our highly diligent and responsible underwriting processes and decisions.”\nDarcy graduated from Johns Hopkins University and received his medical degree from the University of Massachusetts Medical School. He completed his residency and fellowship training at Beth Israel Hospital/Harvard Medical School. As a board certified anesthesiologist, he is chairman of the Department of Anesthesia and medical director of Perioperative Services at Milford Regional Medical Center in Milford, Mass., and president of Milford Anesthesia Associates (Massachusetts). He serves on the Board of Trustees and the Medical Executive Committee at Milford Regional Medical Center. |
Roles of Operating Room Personnel\nA successful surgery requires the close cooperation of many operating room personnel. They must all know their roles and responsibilities and be prepared to execute them quickly and confidently. A newcomer to the interaction of so many medical workers can easily be overwhelmed. As with most unfamiliar experiences, a little pre-emptive preparation can go a long way toward alleviating anxiety and confusion.\nSurgeons are often thought of as the captains of the ship. It is their responsibility to ensure that the operation proceeds smoothly and without complications. They direct the nursing personnel and assistants in the steps of the operations and work closely with the anesthesiologists in the management of the patient's condition. A standard surgical team will have one senior surgeon (known as the "attending") and one resident surgeon in the process of completing his five-year residency training. More complicated operations can involve three or even four surgeons working together.\nThe anesthesiologist is the physician in charge of the maintenance of the patient's level of consciousness, pain-numbing medication, heart rate, blood pressure and respiration. Typically, a patient will meet with the anesthesiologist before the surgery to discuss medication options and any history of allergic reactions. The anesthesiologist will then give the patient medication to help with anxiety before they are brought into the operating room, then for a complex operation might induce unconsciousness and paralysis and insert a tube to take control of the patient's breathing. For less complex operations, the anesthesiologist might numb the involved area locally or with a spinal or epidural block. As technology increases, the anesthesiologist's job becomes more complicated because of the array of tools available and simpler because of the advanced monitoring equipment.\nTwo to four nurses are normally present in the operating room during surgery. One of these is the scrub nurse. This nurse is "scrubbed in," or wearing a special sterile gown and gloves, and is in charge of the instruments used during the operation. The scrub nurse anticipates what the surgeon will need, passes the instruments to the surgeon as requested, keeps track of where every instrument and piece of gauze is during the operation and prepares samples for biopsy. The circulating nurse is not scrubbed in and therefore has more freedom to move around and outside the operating room. They retrieve supplies that were not gathered before the surgery, open their nonsterile outer wrappings to expose the sterile interior for the scrub nurse, and assist with the typically large amounts of paperwork all operating room personnel must complete.\nIf the hospital is a teaching hospital, there will typically be a number of students present to observe and sometimes assist with the surgery. Some of these will be medical students. One or two of the medical students often will have the opportunity to scrub in with the surgeon and perform some simple tasks such as suctioning. There might also be nursing students present to assist the nurses with their tasks.\n- "Journal of the American College of Surgeons;" Operating Room Teamwork among Physicians and Nurses: Teamwork in the Eye of the Beholder; M. Makary, J. Sexton, J. Freischlag, C. Holzmueller, E. Millman, L. Rowen, P. Pronovost; May 2006\n- "The Journal of Nursing Administration;" Improving Operating Room Coordination: Communication Pattern Assessment; Moss, Jacqueline PhD, RN; Xiao, Yan PhD; February 2004\n- Thomas Northcut/Digital Vision/Getty Images |
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