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By: P. Murak, M.A., M.D., M.P.H.

Clinical Director, Texas A&M Health Science Center College of Medicine

In the 1990s diabetic diet 1500 calorie acarbose 50mg line, intensive clinical investigation involving anesthetic technique blood sugar symptoms discount 25 mg acarbose otc, sympatholytic drugs diabetes mellitus que la causa order 25 mg acarbose amex, hemodynamic control, and analgesic technique was undertaken and provided important insight into the prevention, treatment, and mechanisms of cardiac and other morbidity. During this time, a guideline-based approach to health care was initiated, primarily in the United States (see also Chapter 102). Additionally, over the last decade the multidisciplinary field of endovascular surgery has provided less invasive approaches or alternatives to conventional vascular reconstruction. These less invasive procedures, initially offered to patients traditionally considered unfit for open surgery, are being widely applied to the larger cohort of patients undergoing vascular surgery. The goal of this chapter is to review issues related to the perioperative care of patients undergoing vascular surgery and to address the underlying controversies. For simplicity, the five major categories of vascular surgical procedures are discussed separately: abdominal aortic surgery, thoracoabdominal aortic surgery, endovascular aortic surgery, lower extremity vascular surgery, and carotid surgery. The lesions of atherosclerosis occur primarily in large and medium-sized arteries and tend to form at sites with disturbed laminar flow, such as branch points. The most common sites are the coronary arteries, carotid bifurcation, abdominal aorta, and iliac and femoral arteries. Although atherosclerotic lesions result from a variety of complex pathogenetic processes, progression of atherosclerosis occurs in several stages. The fatty streak lesion consists largely of T cells and lipidladen macrophages called foam cells. With the progressive accumulation of apoptotic and degenerated foam cells, cell debris, and cholesterol crystals, the fatty streak progresses to an atheromatous plaque with a necrotic lipid core. A more complex lesion develops with the formation of a fibrous cap of variable thickness composed of collagen and proliferated smooth muscle cells. The advanced lesions of atherosclerosis represent a progression of the fibroatheromatous plaque, with an expanded lipid-rich core, accumulation of calcium, and disruption of endothelial integrity. Atherothrombosis may lead to complete vascular occlusion at the site of plaque rupture or detach to become an embolus that can block blood flow distal to its origin. The American Heart Association Committee on Vascular Lesions has provided a numerical classification of histologically defined atherosclerotic lesion types. Isolated macrophage foam cells Lipid and cells accumulate faster and advanced lesions develop first at highly susceptible rather than moderately susceptible sites Figure 69-1. The diagram lists the main histologic characteristics of each sequential step (lesion type). Thick or differentiate between the relative ease with which lesions develop at specific sites, or they indicate the relative frequency and importance of a pathway section. Established pharmacologic strategies against atherosclerosis are largely limited to treating hypertension and hyperlipidemia and controlling hemostasis to prevent thrombotic complications. Inflammation in the arterial wall plays a fundamental role in both atherogenesis and atheroprogression. As a result of this new understanding, inflammation has become a therapeutic target in the prevention and treatment of atherosclerosis and its complications. Because of the systemic nature of atherosclerotic disease, patients with vascular disease frequently have arterial disease affecting multiple vascular territories. This perioperative and long-term morbidity and mortality persist despite aggressive medical and surgical therapy.

The consequences of natural disaster may affect services and infrastructure in developed and developing nations alike blood glucose 275 acarbose 50mg discount, but the effects in developing nations are usually greater and provide the biggest challenge for mounting an emergency medical response diabetes beauty treatments discount acarbose generic. During the first weeks after an earthquake blood glucose bluetooth order 25 mg acarbose with mastercard, trauma workload increases and nontrauma workload decreases. The length of time for return to normalcy depends on the magnitude and severity of the earthquake. Within this framework a cycle of disaster onset, response, and recovery has been described. Both affect anesthesiology and intensive care in terms of the volume of casualties with both injuries and infection. Natural disasters occur regularly and involve mechanisms related to climate and seismic activity. Human-induced disasters, however, involve the accidental or deliberate release of toxic substances and pathogens, explosions, and fire. The anesthesiologic management of conventional trauma and burns is considered in other sections of this book (see also Chapter 81). This chapter deals with the implications for anesthesia in natural disasters and of chemical and biologic agent release as human-induced disasters. Natural disasters occur in both developing and developed countries but the impact on poorer nations where the medical infrastructure is already fragile magnifies the effect. Planning and training: Establishing techniques for the use of unfamiliar equipment that is not used in everyday practice in developed nations 2. Recovery: Dealing with the chronic effects of trauma and reestablishing the normal local anesthetic practice Of these, earthquakes are the events that produce most casualties with mass physical trauma that requires an emergency surgical response. This disruption creates a challenging background through which emergency medical services, including anesthesia, must be mobilized before any organized medical response can be mounted. Time for resuscitation, investigation, and preparation of such casualties for surgery is often limited, and resources may be stretched. The complex equipment in such units depends on power and gas supplies, all of which may be disrupted by the effects of the disaster. Nevertheless, critical care must still be provided for victims of both physical and toxic trauma alike. A piecemeal, "disaster tourism" approach with a short stay and no postoperative patient follow-up presents problems that have been highlighted by van Horning and colleagues. For those with military and humanitarian aid experience or who have worked in developing nations where facilities are often basic, the transition to emergency circumstances will be familiar. However, many anesthesia providers have never worked outside the setting of a sophisticated modern hospital with facilities and abilities to support complex high-technology equipment. This group will require training that familiarizes them with the relatively basic equipment and facilities of field anesthesia. This may be as a result of entrapment (such as after earthquakes and collapsed buildings) in which anesthesia may be required for extraction (emergency amputation). Such teams are able to provide immediate triage; assessment; and medical care, including surgery. Planning and preparation of necessary equipment is essential, preferably as part of an existing special response plan that was established before a disaster occurs.

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Retrospective data from the University of Pittsburgh Medical Center suggest that primary acute renal failure after weight loss surgery occurs in approximately 2% of patients metabolic bone disease icd 9 code buy acarbose 25mg. This allows skilled nursing and ancillary care to be provided to patients on a consistent basis control diabetes exercise discount acarbose 50 mg with visa. At the Hospital of the University of Pennsylvania in Philadelphia diabetes insipidus drug induced generic acarbose 50 mg mastercard, patients identified as having difficult airways are distinguished with armbands, and with visible signs on their beds, their hospital charts, and on the electronic medical records for the remainder of their hospital stay. Additionally, a note by the attending anesthesiologist explaining the difficulty in intubation, as well as the means used to secure the airway in the operating room, is available in the room. In case of an unexpected emergency intubation, for whatever reason, we believe that this extra information is extremely useful to the resuscitation team. Morbidity occurring during the immediate postoperative in-hospital period typically falls into one of four categories of complications: wound, gastrointestinal, pulmonary, and cardiovascular. The complication rates are significantly lower in each category for patients undergoing laparoscopic rather than open procedures, and they range from 1. The most common complications requiring reoperation include postoperative intraabdominal bleeding, anastomotic leakage, suture line dehiscence, small bowel obstruction, and deep wound infection,143-148 all of which may require general anesthesia for laparotomy. Despite deep vein thrombosis prophylaxis therapy in the perioperative period, patients can also present postoperatively with deep vein thrombosis or pulmonary embolism and require anesthesia for placement of an inferior vena cava filter device. Specific attention should be paid to the documentation of patient position and technique employed for airway management in the prior anesthetic regimen. Patients may be hypovolemic from blood loss, inadequate hydration, vasodilatation, and insensitive fluid losses associated with fever and infection. It is especially important to consider additional or new risks of aspiration of gastric contents. These risks may result from the presence of postoperative ileus, small bowel obstruction, and surgical creation of a Roux-en-Y gastric bypass limb that excludes the pylorus as an element of protection from reflux of intestinal contents. Decompression of the gastric pouch in patients undergoing surgery to relieve small bowel obstruction can be achieved with careful introduction of a nasogastric or orogastric tube just before induction of general anesthesia. Although this may increase the risk of violating a fresh, competent anastomotic suture line, communication between anesthesiologist and surgeon can be pursued to determine the risks and benefits of performing this maneuver. During the ensuing laparotomy, any perforation of a fresh suture line resulting from the attempt to decompress the gastrointestinal tract can be repaired immediately, and the nasogastric or orogastric tube can subsequently be left in place for continued postoperative drainage. Depending on the extent of reoperation, requirement for volume resuscitation, blood transfusion, degree of peritonitis with anastomotic leak, presence of sepsis, or other significant continued risks to health, patients undergoing reoperation may require prolonged postoperative ventilation. Requirements for postoperative pain management may also be considerably different from those associated with the initial bariatric procedure. In patients who are sufficiently hemodynamically stable immediately before reoperation, an epidural catheter can be placed before induction for pain management as part of the postoperative care. This is especially valuable in obese patients undergoing laparotomy, as described earlier in this chapter. Certain potential major complications require surgical intervention weeks, months, or even years after a bariatric surgical operation has been performed. Patients may develop anastomotic strictures or ulcers, ventral hernias, gastrogastric fistulas, and severe reflux disorders requiring additional surgery. The anesthetic considerations for such patients should include a review of the prior anesthetic record to glean information regarding airway and pain management. Myelopathy occurs most frequently but does not manifest until approximately 10 years postoperatively. Although neurologic symptoms accompanying weight loss surgery are not likely to result in additional surgery, they represent new or additional comorbidities that should be fully considered by the anesthesiologist caring for patients having previously undergone bariatric surgery. The nutritional and metabolic complications of bariatric surgery also include protein and protein-calorie malnutrition. Patients may have excessive weight loss occurring either too rapidly or beyond the predetermined goals, steatorrhea or severe diarrhea, hypoalbuminemia, marasmus, edema, and hyperphagia.

The distal end of the elephant trunk serves as the proximal attachment site for the stent graft diabetes test otc discount acarbose 50mg visa. Several regional techniques have been used diabetes insipidus in dogs treatment buy 25 mg acarbose visa, including paravertebral diabetic diet chart pdf purchase acarbose without a prescription, spinal, continuous spinal, epidural, and combined spinal and epidural. General anesthesia was commonly used with early-generation devices because the surgical procedure times were often long. A sedation technique using dexmedetomidine with local anesthesia has been reported. Given the retrospective nature of these reports and the significant selection bias regarding assignment of anesthetic technique, specific recommendations regarding the use of local, regional, and general anesthesia are premature. As with open aortic repair, maintenance of vital organ perfusion and function by the provision of stable perioperative hemodynamics is probably more important to overall outcome than is the choice of anesthetic technique. I commonly use a general anesthetic technique for endovascular aortic repair in patients requiring extensive groin dissection or any retroperitoneal dissection and those requiring complex repairs, where conversion to open repair may be more likely. A balanced technique using relatively short-acting agents maximizes management flexibility. Opioid requirements are usually minimal (fentanyl 2 to 4 g/kg), and postoperative pain is easily managed. Esmolol, sodium nitroprusside, nitroglycerin, and phenylephrine should be available and used to maintain appropriate hemodynamics. Epidural and spinal anesthesia are used selectively based primarily on patient and surgeon preference. Placement of a radial artery catheter should be routine for all endovascular aortic repairs. It should be placed on the right side because a catheter may be placed percutaneously in the left brachial artery for aortic angiography. Although blood loss and fluid requirements are not usually excessive, the potential for rapid blood loss is real. The possibility of acute aortic rupture necessitates the availability of fluids, blood, and a rapid infusion device. Monitoring of urine output can help guide fluid management, particularly when large volumes of heparinized flush solution and radiographic contrast material are used and when diuretics. Endovascular repairs involving the descending thoracic aorta require additional preparation and monitoring. These procedures are often performed in the operating room under general anesthesia. Although current-generation devices are much less prone to graft migration during deployment, pharmacologically. Paraplegia is a recognized complication after endovascular repair of the descending thoracic aorta and is reported to be as high as 8%. Endoleaks can be detected by arteriography, computed tomographic scanning, magnetic resonance imaging, and duplex ultrasound scanning. The structural failure may be due to tears in the graft fabric or separation of individual components of a modular endograft. Type V endoleak refers to persistent pressurization of the aneurysm sac after endovascular repair without an identified leak on imaging studies. Endoleaks are also classified as primary (after deployment) or secondary (after initial seal). The rate of occurrence of endoleak depends on many factors, including the endograft device, the method of deployment, vascular anatomy, and progression of disease. Management of endoleak after endograft placement is controversial and ranges from observation with periodic imaging surveillance to immediate endovascular or surgical correction.