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If the vertical division of the inter- be both an unhappy patient and an unhappy surgeon buy norpace 150 mg line. The sur- mediate crus is performed near the angle or junction of the geon must sense that a sound rapport has been developed with medial crura and intermediate crura order 100mg norpace mastercard, a hanging infratip lobule the prospective patient—one that will weather potential turbu- can be reduced cheap norpace 100mg. The patient must also be physically and psy- or biconvex lobular arch can be narrowed. It is important to get an accurate sense of the technical and psycho- In the authors’ hands, the open approach provides the best logical challenges involved. The ideal rhinoplasty patient has a exposure for accurate tip structure diagnosis and surgical cor- clearly defined and realistic complaint of a long duration. Using scissors allows exact visual definition of the tip cartilages, even in revision cases—there is no guessing as to the position of the caudal mar- gins of the lower lateral cartilages as there may be in revision cases using the marginal incision. Once the nasal soft tissue has been adequately reflected and the underlying tip structures are visualized, diagnosis can be adequately performed. As stated previously, the length, tip pro- jection, and tip rotation have been previously assessed during the external physical exam. Now with the nasal tip fully exposed in its natural state, accurate diagnosis can be made as to the cause of these foundational abnormalities. Consideration should be given to the following tip assessments with the tip structures exposed: (1) medial crural length; (2) lateral crural length; (3) symmetry of the two paired medial and two paired lower lateral cartilages; (4) domal position and symmetry; (5) Fig. This previously placed tip grafts; (7) stability and strength of the tip technique allows complete exposure of the caudal septum for repair. Many variations and abnormalities may be encountered with proper diagnosis, including twisted and crooked tip complexes, caudal septum may be completely distorted or severely weak- asymmetric lower medial cartilages, asymmetric lower lateral ened and/or previously transected. In cases of curvature, scor- cartilages, biconvex or broadly curved lower lateral cartilages, ing can be successfully employed to straighten the curvature by asymmetric knuckling of cartilages at the domes, overresected scoring the cartilage along its concave side. Care is taken to cartilages, previously placed tip grafts, and weakened tip score superficially, avoiding complete transection and over- complexes. In cases of base deflection off the With tip assessment completed, attention should then be maxilla, a No. Many times, the length of the cartilage base must deformities of the caudal septum include curvature of the sep- be shortened to allow it to sit properly in the midline without tum and/or deflection of the septum and septal base off the midline anterior nasal spine. Other abnormalities may include a weakened or severely deformed caudal septal strut as a result of previous septorhinoplasty. Once diagnosis (and when done properly, confirmation of physical exam) is complete, attention should be turned first at correction of any caudal septal abnor- malities. We prefer to divide the soft tissue between the medial crura and domes to expose the caudal septum at the anterior septal angle. In cases of septal cartilage harvest or septoplasty, these procedures can be per- formed at this time. The strut is then secured in erally consists of either septal curvature, deflection of the base place. In cases of previously transected, severely deformed, or an overly weakened caudal septum, the caudal septum must be completely reconstructed and replaced or reinforced with a strong cartilage graft. This is best done with a straight portion of harvested septal cartilage combined with extended spreader grafts when necessary. Though removing the entire caudal sep- tum may seem daunting to the novice rhinoplasty surgeon, inadequate correction of a severe caudal septal deformity will inhibit adequate correction of the twisted tip and ultimately result in patient and surgeon dissatisfaction. This is done using a strong columellar strut to ensure that the base foundation is as straight as it can be. Analogous to building a house, if the foundation is crooked, the entire house will follow. In the case of the crooked tip, the foundation is likely already uneven and setting the new foundation will set up the rest of the procedure for success. Once the base is set, the upper half of the tip (top of the house) can be fine-tuned for symmetry. A second Keith needle is then placed just behind the first with a 4–0 Vicryl suture and the columella. The author’s technique for ensuring a straight base foundation follows: Construct an adequate columellar strut from the harvested cartilage (again, septum is best and rib base of the columella. A pocket needs to be dissected between the domes and retracted anteriorly straight up to provide optimal lower medial cartilages down to the anterior nasal spine. The nee- strut is then placed between the medial crura, with the base of dle is then passed through the opposite medial crura and mem- the graft resting on the spine. A second needle is then passed behind the col- through the membranous septum, through the right medial lat- umellar strut near the most caudal posterior aspect of the sep- eral cartilage, and into the columellar strut, low near the very tum from one side to the other; 4–0 Vicryl is used and the strut is secured in place. At this point, the surgeon assesses the straightness of the nasal base from the true basal view. If the columella is canting to one side or the other, or the columella is not straight, the sutures are removed and the process is repeated until the columella is completely straight up the midline. The key to this maneuver is focusing only on the nasal base at this point—pay no attention to the domes, as they may be uneven at this point. As long as the base has been corrected and straightened, the domes can be fine- tuned at a later step. In fact, when the cut cartilage edges are overlapped and stabilized, the M- arch is actually strengthened as compared with its native state. The arch is incised vertically and overlapped cartilage to analyze the lower two thirds of the columella and make sure that the construct is straight. Alternatively, 4–0 Vicryl sutures can be used to stabilize the cartilages through the ves- applied. This technique can be applied predictably to ally or bilaterally depending on the anatomic diagnosis at this achieve rotation, deprojection, and lobular refinement; to cor- point. Again, understanding the ideal tip structure will allow rect asymmetries; or to improve the nostril:columellar ratio any surgeon to assess and treat each of the problems associated. Alar Strut Grafting (Lateral Crural Grafting) Cephalic Trim Often, tip asymmetry is a direct result of the intrinsic asymmet- ric shape of the lower lateral cartilages. One cartilage may be The lateral crura are initially addressed to effect some degree of relatively convex, or biconvex, compared with the opposite car- lobule refinement. Horizontal resection of the cephalic margin of the lower lateral cartilage can achieve some reduction in supratip fullness and may allow for rotation by other means, though it does not in itself produce substantial rotation. Consid- erably more important than the cartilage resected is the amount and symmetry of cartilage retained, a principle that is readily noted using the open technique. Reduction of the crural arch to less than 8 to 10mm will serve only to heighten the risks of postoperative alar retraction and buckling. Lateral Crural Flap When significant domal asymmetry exists as a consequence of asymmetric lower lateral cartilage length, or when the nasal tip needs to be deprojected and rotated, a vertical division of the lower lateral cartilages with overlapping flap stabilization can be employed to achieve better symmetry and the desired result.

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Mortality is higher in patients with a sustained elevation of creatinine than in those who recover function buy cheap norpace 150 mg on line. Its inappropriate use can lead to intravascular hypovolaemia and worsening renal function buy norpace 100 mg line. Loop diuretics can be used to correct volume overload in patients who are still responsive to treatment order generic norpace on line. Key point: contrast-induced nephropathy Identify patients at risk and carefully assess their fuid status. If creatinine clearance is <60mL/min stop for 24 hours prior to contrast being given. It is easily measured and specifc for renal function; however, an acute decline in kidney function is not refected by a rise in serum creati- nine for several hours. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Meta-analysis: low dose dopamine increases urine output but does not prevent renal dysfunction or death. Defnition and staging the term acute renal failure implies that the function of the kidney is sig- nifcantly deranged. General management the aims of non-rrt management should be prevention of further kidney injury and supportive care to allow functional recovery. Management should begin with prompt diagnosis and correction of the underlying cause of renal injury. Interpret a low urine output in the context of the patient’s cardiovascular parameters: • the oliguric patient may not be hypovolaemic. Balanced electrolyte solutions (ringer’s lactate or hartmann’s solution) should be used in preference to 0. Key point the ability of critically ill patients to excrete excess Na and water is impaired placing them at i risk of interstitial oedema. During treatment blood comes in to contact with a semipermeable membrane where solute transfer occurs prior to it being returned to the patient. When the urine output is ≥400mL/24 hours and the clinical condition of the patient is improving, discontinuation of rrt can be considered. Accurate assessment of fuid, electrolyte, and metabolic status is essential and rrt should be reconsidered if clinically indicated. Anticoagulation Due to the requirement of extracorporeal blood fow in both Irrt and Crrt some form of anticoagulation is usually required to prevent throm- bosis in the blood circuit. Access • In the acute setting access is veno-venous and the access site depends on the clinical condition of the patient. Complications of vascular access • Catheter-related bacteraemia: the catheter should be reserved for extracorporeal treatment only to minimize the risk of catheter-related infection. Clinical manifestations can vary from anaphylaxis to abdominal pain, fevers, or headaches. Onset of symptoms is usually during or shortly after Irrt, however the syndrome is now rare as rrt is initiated at an earlier stage. T sufx: the addition of t to a stage indicates the patient has a renal transplant. Specialist advice should be sought in patients who have evidence of renal bone disease. Mesenteric ischaemia can be occlusive, non-occlusive and rarely due to mesenteric venous thrombosis. If suspected and the patient does not need urgent laparotomy for bowel necrosis (as indicated by severe acidosis, peritonitis, Ct fndings) the diagnosis can be made with mesenteric angiography showing the characteristic ‘string of sausages’ signs due to constrictions in the mesenteric arteries. Management is usually operative with laparotomy, revascularization, and resection of necrosed bowel. Where there is agreement that bowel ischaemia is part of progressive and irreversible organ dysfunction syndrome due to poor perfusion, a multidis- ciplinary decision (along with relatives) should be made to limit intervention in a patient who is deemed to be in an end of life situation. Contrast-enhanced Ct should always be performed to confrm the diagnosis and rule out other conditions that may require urgent operative intervention. Acute cholecystitis Cholecystitis typically occurs 5–5 days postoperatively and rarely presents with classical symptoms of right upper quadrant pain. It is therefore important to intervene before gangrene and perforation occurs (within 24 hours of onset of symptoms) as the mortality rises sharply thereafter. Management has to be individualized: • percutaneous cholecystostomy (at the bedside under ultrasound guidance) is an option for unstable patients in the absence of perforation. Large drains are recommended as cystic duct/gallbladder remnant bile leaks are not uncommon. Liver failure and hyperbilirubinaemia after cardiac surgery up to 25% of patients may experience a rise in biliru- bin, usually peaking on the st or 2nd postoperative day with a mortality rate of around 4%. Liver failure, as defned by the loss of synthetic and metabolic function of the liver (d production of clotting factors and albu- min) and the development of hepatic encephalopathy, occurs in <0. It is often a manifesta- tion of multiple organ dysfunction syndrome, but may be drug induced. Management includes: • Improving haemodynamics and liver perfusion • stopping hepatotoxic drugs • Liver screen for underlying hepatic and haematological disease • Ultrasound and Ct to rule out biliary obstruction, portal venous obstruction, and hepatic vein thrombosis. It remains one of the greatest clinical and diag- nostic challenges in cardiac ItU. It is easier to diagnose these patients more accurately with clini- cal examination, laboratory, and imaging investigations. Clinical history and examination post-cardiac surgery patients are often sedated and ventilated. Physical examination • focal tenderness is a more indicative sign than generalized tenderness. Laboratory test No laboratory test can reliably establish or eliminate the diagnosis of mes- enteric ischaemia. It is, however, useful to diagnose pancreatitis, bowel obstruction, cholecystitis, and perforation. Ultimately, the only objectively reliable ‘investigation’ is laparotomy and this should be ofered early in patients with suspicious fndings. In the absence of frank dead bowel it may be difcult, even at laparotomy, to distinguish mesenteric ischaemia. Limited reports of diagnostic laparoscopy found it safe and accurate in this setting. Helicobacter pylori does not appear to be associated with stress ulceration in post-cardiac surgery patients. Less common lesions include varices (rare in cardiac surgery patients), Mallory–Weiss syndrome and vas- cular lesions, e. Unstable patients despite adequate resuscitation need intubating (if not already intubated) and endoscopy should take place as part of the resuscitation. It may be necessary to lavage the stomach to remove blood clots to identify the source of bleeding.

The incision on t he t ube is not re-approximat ed because sut uring may lead to stricture formation buy discount norpace 100mg line. Conservative treatment of the tube is associated wit h a 10% to 15% chance of persistent ectopic pregnancy purchase norpace us. It is usually given as a one-time buy 100 mg norpace free shipping, low-dose, intramuscular injection, reserved for ect opic pregnancies less t han 3. Methotrexate is highly successful, leading to resolu- tion of properly chosen ectopic pregnancies in 85% to 90% of cases. Most women may be observed; however, hypotension, worsening or persistent pain, or a falling hematocrit may indicat e tubal rupture and necessit at e surgery. About 10% of women t reat ed wit h medical therapy will require surgical intervention. Rare types of ectopic gestations such as cervical, ovarian, abdominal, or cornual (moved to above) pregnancies usually require surgical therapy. A trans- vagin al u lt r aso u n d exam in at io n t o d ay sh ows n o clear p r egn an cy in the u t er u s and no adnexal masses. She is 6 weeks’pregnant and on examinat ion has diffuse significant lower abdominal t enderness. W h en the h C G is below the threshold in an asymp t om at ic patient, the h C G level may be repeat ed in 48 h ours t o assess for viabilit y. Since t h ere is st ill a ch ance that this is a viable pregnancy, met hot rexat e should not be used since it could dest roy any int rauterine gest at ion. D ilat ion and curett age would also dest roy any viable int rauterine pregnancy, and would not be a good option for treat ment of an ectopic pregnancy since they exist outside the uterus. It is unlikely that this patient had an incomplete or a completed abortion, given that she does not recall any passage of tissues. Spott ing and lower abdominal pain can be a normal occurrence in pregnancy, especially very early in the first trimester. Some patients have symptoms of lower abdominal pain, similar to menstrual cramps, an d vagin al spot t in g dur ing the fir st few weeks of pr egn an cy wh en the embryo implants into the wall of the uterus. Color Doppler flow in the adnexal region is typically used when there is sus- picion of ovarian torsion and concern that the ovarian vessels are constricted and unable to perfuse the ovaries. Assessment of adnexal masses using t rans- vaginal ult rasound is not very specific. A hemoperitoneum can be confirmed by culdocentesis, but not typically a transvaginal ultrasound (one could argue that with current ultrasound technology, clotted blood appears different from simple flu id an d h em op er it on eu m that is clot t ed can be d iagn osed by ultrasound, especially if in pouch of Douglas). Methotrexate requires several days to weeks to act, and is appropriate in an asymptomatic patient with an ectopic pregnancy less than 3. Sh e r e p o r t s that she had a deep venous thrombosis when she took the combination oral contraceptive p ill 2 years ago. She cannot rememb er to take the p ill every day and wants contraception that will allow her to be spontaneous. Her blood pressure is 120/70 mm Hg, heart rate is 80 beats per minute (bpm), and temperature is 99°F (37. Pe lvic e xam in at ion re ve als a n orm al ante ve rte d uterus and no adnexal masses. Know the various types of contraceptive agents including indications and con- traindications, mechanisms of action, and efficacy. Know benefits, risks, and contraindications for the combination oral contra- cept ive pill. Co n s i d e r a t i o n s Each form of contraception has advantages and disadvantages, and the individual patient situation should be evaluated to find the best contraceptive choice. Factors that assist the physician in the counseling of the patient include agents requir- ing more pat ient act ion, such as remembering to t ake a pill each day, or putt ing on a barrier device (diaphragm or condom), duration of contraception desired, history of sexually transmitted infections, amount of vaginal bleeding, medical condit ions, and cont racept ion side effect s. The progestin implant is inserted subdermally in the arm by a provider and can be left in place for up t o 3 years. T h e progest in in t hese devices is released slowly over t ime and can decrease the amount and frequency of menses. Thus, the history and physical examination should focus on a patient’s preference of method, factors such as t he abilit y to remember t o t ake a pill every day, and ot her medical condi- t ions (see Table 44– 2). Barrier contraceptives prevent sperm from entering the upper female reproduc- tive tract. Various forms include the male condom, female condom, vaginal dia- phragm, cervical cap, and spermicides. The latex condom is t he most effect ive met hod of cont racept ion to prevent transmission of sexually transmitted infections. It is the second most com mon ly u sed m et h od of r ever sible cont r acept ion in the Un it ed St at es. One ring is placed inside the vagina at the closed end of the sheath and provides an insertion mechanism and anchor. The second ring is at the outer edge of t he device and is out side the vagina providing coverage for the labia and the base of the penis. It should be placed 1 to 2 hours before intercourse, should be used wit h a spermicide, and should be left in place for at least 8 hours after coitus. D rawbacks include higher rate of urinary t ract infections and increased risk of ulceration to the vaginal epithelium with prolonged usage. Compared to a diaphragm, the cap can be left in place for up t o 48 h ou r s an d is mor e comfor t able. It also car r ies a risk of ulceration and infection of the cervix if left in place for too long. The active agent is nonoxynol-9 which disrupts the sperm cell membrane and provides a mechanical barrier. The contraceptive sponge is made of polyurethane impregnated with 1 mg of nonoxynol-9 and does not have to be insert ed int o t he vagina before each act of intercourse. Because barrier met hods are used only at t ime of coitus, t he advant ages include low cost, decreased t rans- mission of certain sexually transmitted infections with condoms (not cervical cap or diaph r agm), an d n o exp osu r e t o cont inu ou s h or mon es or on goin g I U D use. Disadvantages include relatively high failure rate (approximately 20%) due to required use with each act of intercourse. T hese quickly became the most-used method of reversible contraception among women. Oral steroid contraceptives come in combination pills at a fixed dose or a phased dose, or a progestin-only pill (minipill). The main effect of the progestin is to inhibit ovulation and cause cervical mucus thickening. The main effect of the estrogen is to maintain the endometrium, prevent unscheduled bleeding, and inhibit follicular development.

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