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Assistant Professor, University of North Carolina School of Medicine
Anticoagulants are indicated in patients with atrial fibrillation (see Chapter 51) or a history of an embolic event blood pressure 3 readings cheap lasix express. Asymptomatic ventricular arrhythmias (see Chapter 52) require no therapy pulse blood pressure monitor buy lasix 100mg with visa, but electrophysiologic devices may reduce the risk of death in patients who have sustained ventricular tachycardia or ventricular fibrillation or who have been resuscitated from sudden death blood pressure numbers close together purchase lasix 40mg without prescription. Patients with heart failure are predisposed to the proarrhythmic effects of antiarrhythmic drugs and the cardiodepressant effects of calcium channel blockers blood pressure monitoring chart template buy 40mg lasix amex, and such agents should be avoided. Drugs for the Control of Fluid Retention the first step in the treatment of patients with chronic heart failure is the control of fluid retention. This step is generally not necessary in patients with asymptomatic left ventricular systolic dysfunction. Diuretics Diuretics interfere with the sodium retention of heart failure by inhibiting the reabsorption of sodium and chloride at specific sites in the renal tubules. Of the commonly used agents, furosemide, torsemide, and bumetanide act at the loop of Henle (i. All diuretics increase urine volume and sodium excretion, but these agents differ in their pharmacologic properties. The loop diuretics increase the fractional excretion of sodium up to 20 to 25% of the filtered load, enhance the clearance of free water, and maintain efficacy even when renal perfusion and function are impaired. In contrast, the thiazide diuretics increase the fractional excretion of sodium to only 5 to 10% of the filtered load, tend to decrease free water clearance, and lose their effectiveness in patients with only moderately impaired renal perfusion and function. Consequently, the loop diuretics have emerged as the preferred diuretic agents for patients with heart failure. Controlled trials have shown that diuretic drugs can decrease signs and symptoms of fluid retention, but diuretics alone cannot maintain the clinical stability of patients with heart failure for long periods of time. However, the risk of clinical decompensation can be reduced if diuretics are combined with a neurohormonal antagonist. These observations indicate that diuretics are a necessary, but not sufficient, component of any successful therapeutic strategy for heart failure. Diuretics play a pivotal role in the treatment of heart failure for three reasons. First, diuretics are the only drugs that can adequately control the fluid retention of heart failure. Third, diuretics modulate the responses to other drugs used for the treatment of heart failure, because the effects of neurohormonal antagonists are highly dependent on sodium balance. Diuretics are generally initiated in low doses (Table 48-1), and the dose is increased until signs and symptoms of fluid retention are alleviated. Once this goal has been achieved, treatment with the diuretic is continued long term to prevent the recurrence of salt and water retention. As heart failure advances and renal function declines, patients will become resistant to the effects of low doses of these drugs and will respond only when high doses are used or when diuretics with different renal tubular sites of action are used in combination. Non-steroidal anti-inflammatory drugs can decrease the efficacy and increase the risk of diuretics and should be avoided. The principal adverse effects of diuretics include (1) electrolyte depletion, (2) neurohormonal activation, and (3) hypotension and azotemia. Diuretics can cause the depletion of potassium and magnesium, which can predispose patients to serious cardiac arrhythmias, particularly in the presence of digitalis therapy. The loss of electrolytes is related to enhanced delivery of sodium to distal sites in the renal tubules and the exchange of sodium for other cations, a process that is potentiated by activation of the renin-angiotensin-aldosterone system. Food and Drug Administration for use in the management of chronic heart failure, April, 1999. Although the use of diuretics can lower blood pressure or cause azotemia, these changes are generally asymptomatic and require no specific treatment. The dose of diuretic should not be reduced for asymptomatic changes in blood pressure or renal function if the patient has signs of fluid overload. Drugs That Antagonize Neurohormonal Mechanisms Drugs that interfere with the actions of endogenous neurohormonal systems. Yet, their major advantage over traditional treatments is their ability to inhibit the cardiotoxic effects of the neurohormonal system and thereby retard the progression of heart failure. As a result, neurohormonal interventions have emerged as essential agents in the management of heart failure. Two types of neurohormonal antagonists have been approved for the treatment of heart failure by the U. However, the benefits of these drugs may not be entirely explained by their actions on the renin-angiotensin system.
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Compared with gram-positive organisms blood pressure 50 over 70 order lasix australia, gram-negative bacteria are somewhat more likely to produce septic shock arrhythmia nursing diagnosis cheap lasix online. Culture-positive gram-negative bacteremia produces shock in approximately 50% of infections blood pressure 6 year old discount 100mg lasix fast delivery, whereas gram-positive bacteremia produces shock in about 25% of infections blood pressure chart spreadsheet order lasix 40mg on-line. Frequent causes of sepsis are pyelonephritis, pneumonia, peritonitis, cholangitis, cellulitis, meningitis, or abscess formation at any site. Many of these infections are nosocomial and occur in patients hospitalized for other medical problems. In patients with normal host defenses, a site of infection is identified in most patients. In neutropenic patients, however, a clinical site of infection is found in less than 50% of septic patients, probably because small, clinically inapparent infections in skin or bowel can lead to blood stream invasion in patients with inadequate circulating neutrophils. Definitions have incorporated manifestations of the systemic response to infection (fever, tachycardia, tachypnea, and leukocytosis) as well as evidence of organ system dysfunction (cardiovascular, respiratory, renal, hepatic, central nervous system, hematologic, or metabolic abnormalities). Sepsis is severe and has a poorer prognosis when it is associated with organ dysfunction, hypoperfusion (lactic acidosis, oliguria, or altered mental status), or hypotension (septic shock). Septic shock is defined as sepsis-induced hypotension that persists despite adequate fluid resuscitation and is associated with hypoperfusion abnormalities or organ dysfunction. In clinical practice, many patients with these signs and symptoms are receiving vasopressor and/or inotropic agents and are no longer hypotensive when they manifest hypoperfusion abnormalities or organ dysfunction, but they still are considered to be experiencing septic shock. These organism-derived products can stimulate the release of a large number of endogenous host-derived mediators from plasma protein precursors or cells (monocytes-macrophages, endothelial cells, neutrophils, and others). The endogenous mediators can produce profound physiologic effects on the vasculature and organ systems. When released in small amounts, these mediators result in beneficial effects such as regulating immune function, killing bacteria, and detoxifying bacterial products. Systemic inflammatory response syndrome: the systemic inflammatory response to a variety of severe clinical insults. The response is manifested by two or more of the following conditions: Temperature >38° C or <36° C Heart rate >90 beats/min Respiratory rate >20 breaths/min or Pa co2 <32 mm Hg (<4. This systemic response is manifested by two or more of the following conditions as a result of infection: Temperature >38° C or <36° C Heart rate >90 beats/min Respiratory rate >20 breaths/min or Pa co2 <32 mm Hg (<4. Hypoperfusion and perfusion abnormalities may include, but are not limited to , lactic acidosis, oliguria, or an acute alteration in mental status. Septic shock: Sepsis with hypotension, despite adequate fluid resuscitation, along with the presence of perfusion abnormalities that may include, but are not limited to , lactic acidosis, oliguria, or an acute alteration in mental status. Patients who are on inotropic or vasopressor agents may not be hypotensive at the time that perfusion abnormalities are measured. Hypotension: A systolic blood pressure <90 mm Hg or a reduction >40 mm Hg from baseline in the absence of other causes for hypotension. Multiple organ system failure: Presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention. Adapted from American College of Chest Physicians Society of Critical Care Medicine Consensus Conference: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Although certain mediators are undoubtedly more important than others in producing sepsis, probably dozens of organism- and host-derived mediators interacting, accelerating, and inhibiting one another are responsible for the pathogenesis of septic shock. Approximately 50% of patients who have hypotension secondary to sepsis and who are admitted to an intensive care unit survive; the other 50% develop refractory hypotension or multiple organ system failure and die from progressive septic shock. Early and throughout the course of most of these patients, cardiovascular evaluation reveals a low systemic vascular resistance and a high cardiac output-the hyperdynamic response to sepsis. Despite this elevated cardiac output, cardiac performance is abnormal, with a decreased ventricular ejection fraction and a dilated ventricle. In approximately 20% of patients, progressively diminished cardiac performance results in an abnormally low cardiac output. Death results from progressive hypotension or complete failure of one or more organ systems. Certain microorganisms synthesize and release exotoxins that can activate the cascade. More frequently, the structural components of the microorganism initiate the sequence. The polysaccharide surface of Candida albicans, the teichoic acid antigens of staphylococci, and the polysaccharide capsule of Streptococcus pneumoniae can all initiate the sepsis pathway. The endotoxin molecule consists of an outer core with a series of oligosaccharides that are antigenically and structurally diverse, an inner oligosaccharide core that has similarities among common gram-negative bacteria, and a core lipid A that is highly conserved across bacterial species.
Home-based exercise and simple recommendations to exercise are much less effective than supervised programs arrhythmia kidney disease lasix 100mg otc. Unfortunately heart attack symptoms in women lasix 100 mg on-line, there are very few supervised training programs across the country arrhythmia quiz online buy lasix line, and third-party payers often do not reimburse for exercise training blood pressure below 100 generic 100mg lasix with mastercard. Analgesics may also be needed, and spinal cord stimulation may reduce ischemic pain. Topical antibiotics, growth factors, and debriding agents have not been effective in treating ulcerated lesions of the lower extremity. Patients in whom cellulitis develops around an ischemic ulceration should be treated with systemic antibiotics. Invasive therapies should be limited to patients who fail initial medical treatment, have severe disability as defined by validated questionnaires or treadmill testing, and have an appropriate anatomic lesion for bypass or angioplasty. Angioplasty guidelines emphasize that more proximal lesions have better patency rates and durability than do more distal lesions (Table 67-1). Below the inguinal ligament, the initial success and long-term patency rates have been less well studied but are not as good as for more proximal lesions. Surgery is principally used to treat severe chronic leg ischemia rather than claudication because of the associated morbidity and mortality of surgery, the relatively benign natural history of 361 Figure 67-2 Interventional therapy for peripheral arterial disease. Aortoiliac surgery is associated with an average mortality of 3% and morbidity of 8%. Femoropopliteal surgery with vein bypass is associated with a mortality of 2%, morbidity of 5 to 10%, and a 5-year patency rate of 70 to 80%. The use of prosthetic material (required if a vein is not available) reduces 5-year patency rates to 50%. Distal femorotibial operations for limb salvage have a similar morbidity and mortality as femoropopliteal surgery but slightly lower 5-year patency rates of 50 to 60%. Additional cardiac evaluation should be considered in patients undergoing peripheral vascular or aortic surgery because the risk of cardiovascular morbidity and mortality can be as high as 30%. Several clinical decision rules have been proposed to separate patients into low- and high-risk groups. Additional risk stratification can be obtained by using dipyridamole thallium scintigraphy (see Chapter 44) or stress echocardiography with dipyridamole or dobutamine (see Chapter 43). An abnormal result would presumably lead to coronary revascularization before the planned peripheral vascular intervention. This approach will obviously result in exposing the patient to two invasive procedures with the attendant increased risk. Patients may have sudden onset of claudication, rest pain, or a cool or cold extremity. The majority of acutely ischemic limbs will be salvageable; skeletal muscle can generally tolerate 6 hours of warm ischemia before irreversible loss. Paralyzed, insensate extremities with fixed skin mottling and hard calf musculature are not salvageable and require primary amputation as soon as the patient is medically prepared for the procedure. The decision to proceed with limb salvage in marginal cases usually relies on the judgment of the vascular surgeon. The ability to palpate pedal pulses is often limited, even in the hands of experienced vascular surgeons. Therefore, unless pulses are grossly obvious, Doppler should be used to determine signals at the three major tibial arteries in the ankle. The most common cause of acute arterial ischemia is occlusion of an existing bypass graft. Patients have either rest pain or increasing claudication, depending on the degree of acute change in ischemia. A vascular surgeon should be consulted immediately to assess the timing of arteriography and surgery. Management of co-morbid diseases such as heart failure, respiratory insufficiency, and infection should be initiated, and central venous access should be obtained while preserving arm veins as potential conduits for vascular reconstruction. Cardiac embolism is most commonly encountered in patients who have pre-existing valvular heart disease, mural thrombus of the ventricle or atrium, or underlying rhythm disturbances.
Cooper and colleagues reconsidered these concepts and in 1994 reported that lung volume reduction surgery produces a significant improvement in expiratory flow blood pressure log sheet printable buy lasix 40 mg lowest price, exercise tolerance arteria auditiva order cheap lasix on line, and quality of life heart attack high blood pressure generic lasix 100 mg mastercard. The role of lung volume reduction surgery in the management of patients with emphysema is currently the subject of active investigation and several large clinical trials arrhythmia during exercise buy genuine lasix. Most experts believe that patients with other causes of airflow obstruction, including bronchiectasis, asthma, or chronic bronchitis, are unlikely to benefit. Types of Lung Volume Reduction Surgery A variety of approaches may be taken in the common goal of reducing lung volume by about 30%. In the absence of a specific contraindication, bilateral lung volume reduction surgery is currently the procedure of choice. Currently favored techniques include stapled resection of peripheral lung tissue, with or without the use of exogenous material to buttress the suture lines, and plication, in which the lung is rolled on itself and stapled without resection. Considerations in the Evaluation of Potential Candidates for Lung Volume Reduction Surgery the evaluation of candidates for lung volume reduction surgery can be viewed as both an assessment of risk and an attempt to identify those most likely to benefit from the procedure. Few of the criteria used to select or exclude patients have been subject to prospective validation. In general terms, the principles of evaluation are similar to those before lung transplantation. In addition, pulmonary hypertension and marked deconditioning are contraindications to lung volume reduction surgery. The ideal candidate has severe airflow obstruction due to emphysema but is otherwise in good health. Patients undergo computed tomographic scanning, pulmonary function testing (with lung volumes by plethysmography), echocardiography to assess pulmonary artery pressure, and some form of noninvasive screening for significant coronary artery disease. If a candidate appears suitable for lung volume reduction surgery, most programs require completion of a 6 to 10 week course of pulmonary rehabilitation prior to surgery. The ideal candidate for this experimental procedure has anatomic evidence of emphysema; severe obstruction not reversed by bronchodilators on spirometry; no significant cardiac, hepatic, or renal disease; a pulmonary artery systolic pressure less than 45 mm Hg; does not smoke cigarettes; has completed pulmonary rehabilitation; and has no significant pleural disease or prior thoracic surgery. Contraindications include severe deconditioning (6-minute walk <150 m); use of parenteral corticosteroids. Hypercarbia, age greater than 75 years, marked anatomic deformity of the thorax, or marked pleural scarring are relative contraindications. Patients who seem most likely to benefit at present are those with emphysema that is primarily in the upper lobe or is heterogeneously distributed, with evidence of dynamic airway collapse rather than fixed airway disease, and with an elevated residual volume/total lung capacity ratio. Outcomes of Lung Volume Reduction Surgery the available data show that most patients attain significant improvements in exercise tolerance, expiratory flow rates measured by spirometry, and self-reported quality of life; however, about 30% do not benefit from the procedure. On average, arterial oxygen levels improve, but some patients show no improvement. The limited data available suggest that some patients may experience a decline in pulmonary function after experiencing improvement over the first 12 months after surgery. Criteria for reliably identifying which patients will benefit from lung volume reduction surgery are the subject of several large clinical trials currently in progress. With improved light sources and video-optic instrumentation, the thoracoscope provides a panoramic view of the hemithorax and has been integrated into most thoracic surgical procedures. The coincident development of advanced endoscopic surgical instrumentation has facilitated the performance of these operations through "minimally invasive" thoracic incisions. The widespread application of the thoracoscope in thoracic surgery has led to the more inclusive term of "video-assisted thoracic surgery. Although the access ports are small, the rigid instruments result in trauma to the intercostal nerves and rib periosteum that can result in substantial postoperative discomfort. Incisions can be expanded, depending on the goals of the procedure and the anatomic findings at the time of exploration. Unexpected pleural symphysis or incomplete lobar fissures may require extension of the incision to facilitate visualization as well as the use of more standard instrumentation. In patients undergoing anatomic resection, such as segmentectomy or lobectomy, at least one of the incisions is extended to permit extraction of the lung from the hemithorax.
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