Indocin

By F. Taklar. Arizona State University.

Treatment Appropriate dilution purchase indocin 75mg mastercard, no emesis Fluids discount indocin 25mg amex, antibiotics, (steroids controversial) Fiberoptic laryngoscopy / intubation Esophagoscopy - 48 hours, stop at first evidence of burn Barium swallow 3 - 4 weeks, intermittently thereafter Later dilatation for strictures Surgery usually not necessary early Sepsis / full-thickness necrosis: cervical esophagostomy, gastrostomy with isolation, later reconstruction, (resection controversial) 8. Evaluation and Therapy If cause not obviously apparent, malignancy must be ruled out Barium swallow Esophagoscopy, brushings, biopsy If peptic: anti-reflex therapy If benign: dilatation - up to 50 Fr If mucosa / bx normal: external compression, motility disorder, submucosal lesions 10. Surgical Considerations Tight strictures, severe scarring, repeated dilatations increase risk of perforation Consider surgery, particularly in young patient Anti-reflux procedure (peptic stricture) High stricture - intra-op dilatation + anti-reflux procedure Consider motility disorder, pre-op motility studies 12. Esophageal reconstruction for benign disease: self-assessment of functional outcome and quality of life. Esophageal atresia: historical evolution of management and results in 371 patients. Esophageal Atresia and Tracheoesophageal Fistula: Surgical Experience Over Two Decades. Corrosive burns of the esophagus and stomach: a recommendation for an aggressive surgical approach. Sources for further reading Textbook Chapters Chapter 25: Surgery of the Esophagus in Infants and Children. Histology and Final Development Adventitia: outer loose connective tissue containing nerves, lymphatics, blood vessels Muscularis: two layers of muscle--outer longitudinal and an inner circular Submucosa: connects muscularis with the mucosa--strongest layer--elastic tissue; collagenous fibers; network of vessels & nerves Mucosa: squamous, columnar; Z-line 3. Lymphatics: Submucosal lymphatics form long channels that run parallel to esophageal axis May travel long distances before draining into regional nodes 5. Peristalsis Primary: normal propulsive wave in response to the stimulation of normal voluntary deglutition Secondary: normal wave without voluntary deglutition: best defense Tertiary: abnormal; may occur spontaneously or following deglutition 8. Esophageal Body Proximal striated muscle: direct innervation to its motor end plate from nucleus ambiguous Smooth muscle: indirect neural input from dorsal motor nucleus (X) via myenteric plexus Innervation: longitudinal muscle shortens; circular muscle contracts; peristalsis Duration and amplitude: weaker in proximal esophagus; stronger, longer in distal esophagus 10. Oropharyngeal Dysphagia Neurologic: central vs peripheral Myogenic Cricopharyngeal Muscle Dysfunction Iatrogenic Lower esophageal disease 13. Esophageal myotomy: improves obstructive symptoms more effectively than dilatation Can be done via left thoracotomy, laparotomy, or scope 5 - 7 cm myotomy on distal esophagus Extends 1 cm onto gastric wall Mucosa dissected from muscularis 90% relief of dysphagia short and long term? Nutcracker or Supersqueeze Esophagus Normal peristalsis Contraction amplitude is > 2 standard deviations above normal > 180 mmHg in distal esophagus Duration of contractions >6 sec. Idiopathic Gastroesophageal Reflux Frequent association with Type I hiatal hernia Alterations in the anatomy of the hiatus Phrenoesophageal membrane Secondary causes Delay of gastric emptying Pyloric stenosis Gastric mass Poor esophageal wall muscle tone (scleroderma) 28. Acid-peptic or pancreaticobiliary secretions must reach the esophagus with increased frequency 2. Esophagus must be unable to clear those refluxed materials back into the stomach Treatment Medical treatment Surgical treatment if medical treatment fails 29. Anatomy a) Begins (transition from pharynx to esophagus) at lower end of sixth cervical vertebra/cricoid cartilage b) Ends (transition to stomach) at 11th thoracic vertebra c) Esophagus is midline, passing to the left in lower neck and upper thorax, then back to midline, then to left again in lower thorax to pass through diaphragmatic hiatus d) Follows curve of vertebral column except to pass anteriorly to pass through diaphragmatic hiatus e) Sites of perforation during rigid esophagoscopy: i) Cricopharyngeus ii) Terminal left anterior deviation f) Measurements i) Incisors to cardia = 38-40cm (men), 36-38 (women) ii) Cricopharyngeus to cardia =23-30cm, avg. Normal structure and function a) Pharyngeal phase of swallowing i) Tongue is piston - propels food bolus as soft palate is closed ii) Swallowing is reflex, once initiated iii) Larynx is elevated and epiglottis covers opening of larynx iv) Pharyngeal pressure increases to 45mm Hg v) Food propelled by pressure gradient into thoracic esophagus vi) Upper, striated portion of esophagus relaxes, then contracts within 0. The presence of a paraesophageal hernia, regardless of the size or symptoms, is an indication for repair S Types: #1—true sliding hernia; the phrenoesophageal ligament fails to keep the esophagogastric junction below the diaphragm and within the abdomen. The fundus/body of the stomach is rotated into the chest with the greater curve as the leading point; usually no esophagitis present. Anatomy: -Intact posterior fixation of the esophagus to the preaortic fascia and the median arcuate ligament -The reason why the greater curve of the stomach herniates is because it is the most mobile portion—gastric cardia is fixed by the left gastric vessels, the gastrosplenic and gastrohepatic ligaments; the pylorus is fixed by the duodenum. This is the path of least resistance because the aorta lies to the left and the heart lies left and anterior. The stomach becomes twisted and angulated in its midportion just proximal to the antrum. Surgical therapy a) Failure of medical tx or complications (stricture, bleeding, severe ulceration) b) Significant symptoms and esophagitis in a young pt. Anatomy and physiology a) Definition=esophagus is lined w/columnar mucosa more than 3cm proximal to the distal end of the muscular esophageal tube b) 3 types of mucosa - gastric fundic, junctional, specialized columnar (80%) c) Acid (and pepsin and gastrin) is produced, but amount is insufficient to explain peptic ulceration of Barrett’s 2. Pathogenesis a) Nearly every patient has pathologic reflux b) Metaplasia of pleuropotential cells in submucosa c) Migration of gastric mucosa not felt to be mechanism 3. Medical management a) Lifestyle changes - behavior, food and drugs b) Medications c) Resolution of symptoms does not correlate with regression of Barrett’s 8. Surveillance a) Surveillance allows detection at an early stage and improves long-term survival b) Endoscopy at least every year 9. Kirschner - Roux-en-Y drainage of esophageal remnant - others say it is unnecessary B.

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The duration of effect is directly proportional to the water-solubility of the com- pound discount indocin 50 mg without a prescription, with hydrophilic compounds such as morphine providing the longest relief purchase 50 mg indocin free shipping. Epidural analge- sia can be used to provide pain relief for days through the infusion of a solution containing local anesthetic, opioid or both. Intermittent or “bolus” doses lack titratabil- ity and are associated with a higher incidence of side effects such as respiratory depression. Continuous epidural infusions provide a steady level of analgesia while reducing the side-effects associated with bolus administration. It is believed to 78 lead to a decreased stress response to surgery, im- Peripheral Nerve Blocks proved post-operative pulmonary function and in high Almost any peripheral nerve that can be reached with a risk patients, decreased cardiac morbidity. The bra- management relies on proper patient selection, appro- chial plexus, intercostal and femoral nerves are exam- priate catheter placement (depending on the level of ples of nerves which are commonly blocked to provide the surgical site), adequate post-operative monitoring post-operative analgesia. A block may be used as the and specific training of personnel to identify and treat sole method of post-operative analgesia or it may be complications (including inadequate analgesia). A common use would brachial plexus) lend themselves to the insertion of be following (open) abdominal aortic aneurysm repair catheters for the continuous infusion of local anesthet- where the catheter might be left in for 48-72 hours. In the absence of catheter insertion, the major draw- casionally, the need for post-operative thrombosis pro- back of this method of post-operative analgesia is that phylaxis triggers the removal of the catheter as cathe- the duration of effect of a single block is limited, usu- ters should not be removed or left indwelling in the an- ally to less than 18 hours. A typical example of the use of a peripheral nerve block for post-operative pain would be the use of a femoral/sciatic nerve block for a patient undergoing total knee arthroplasty. You will develop an understanding of how anesthetic care is modified to accommodate these “special patients”. Malignant Hyperthermia terized by the onset of a hypermetabolic crisis in neuromuscular disorders, such as Duchenne Mus- response to certain triggers. The earliest sign The ryanodine receptor is located on the sarco- is tachycardia followed by evidence of increased plasmic reticulum. The remainder of pected that in the near future, the development of a ge- treatment is supportive and involves hyperventilation netic blood test will obviate the need for the invasive with 100% oxygen, fluid administration and active cool- muscle biopsy in the majority of patients. One should be prepared The anesthetic management of a patient known to be to treat hyperkalemia and cardiac dysrhythmias. Dantrolene prophy- surgical procedure should be terminated as quickly as laxis can be given preoperatively to high risk patients. Triggers are avoided by using a Patients should be monitored for recrudescence of the “trigger-free” anesthetic machine which is free of va- reaction as well as for complications such as myoglobin- pourizers, and has been flushed clear of residual vola- uria, renal failure and disseminated intravascular co- tile gases. The patient 82 can be discharged home if instructions regarding worri- some symptoms have been given and understood, and if the patient has reasonable access to the hospital from home, should problems arise. The best Physiologic Changes of Pregnancy means of avoiding this outcome is to avoid gen- Physiologic and anatomic changes develop across 1. Physiologic Changes of eral anesthesia (by using a regional technique) Pregnancy many organ systems during pregnancy and the and thus maintain intact laryngeal reflexes. Pretreatment of all par- changes are those that affect the respiratory and turients with a non-particulate antacid (30 cc so- circulatory systems. Finally, There is an increased risk of difficult or failed intu- a rapid sequence induction with cricoid pressure bation in the parturient. Laryngoscopy can be further With the apnea that occurs at induction of anesthe- impeded by the presence of large breasts. Gastric motility is decreased and “oxygen reserve” during apnea, has decreased by gastric secretions increase. This, combined with a 20% due to upward displacement of the dia- decrease in the integrity of the gastroesophageal phragm. In fact, airway complications (dif- Adequate ventilation must be maintained during ficult intubation, aspiration) are the most common anesthesia. The concomitant rightward shift in Labour Analgesia the oxyhemoglobin dissociation curve allows increased fetal trans- There are many methods of relieving the pain and stress of labour. This is significant for two rea- oxide), intravenous (opioids) or regional (epidural) are associated sons. Firstly, the normal signs of hypovolemia may not be seen un- with side effects and risks to both fetus and mother. This extends to include sacral segments (S2-4) during Due to the increasing uterine size, aortocaval compression (obstruc- the second stage. Thus, the principle of epidural analgesia is to ad- tion of the inferior vena cava and aorta) becomes relevant in the minister local anesthetics (with or without opioids) into the third trimester. When the pregnant patient is in the supine posi- epidural space to block the aforementioned spinal segments.