Articles: function.
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This article reviews the pathophysiology, clinical relevance, and therapy of the catabolic response to surgical stress. ⋯ Current anticatabolic therapeutic strategies include glycemic control and perioperative nutrition in combination with optimal pain control and the avoidance of preoperative starvation. All these elements are part of Enhanced Recovery After Surgery (ERAS) programs.
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Multiple clinical and laboratory studies have been conducted to illustrate the effects of hypercapnia in a range of injuries, and to understand the mechanisms underlying these effects. The aim of this review is to highlight and interpret information obtained from these recent reports and discuss how they may inform the clinical context. ⋯ Experiments involving hypercapnia have covered a wide range of illness models with varying degrees of success. It is becoming evident that deliberate hypercapnia in the clinical setting should seldom be used, except wherever necessitated to avoid ventilator-associated lung injury. A more complete understanding of the molecular mechanisms must be established.
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Case Reports
Therapeutic hypothermia after cardiac arrest in a patient with systemic sclerosis and raynaud phenomenon.
Therapeutic hypothermia favorably impacts neurologic outcomes in patients after cardiopulmonary arrest, although the appropriate target temperature is less clear. Its safety profile in patients with systemic sclerosis (SSc) and Raynaud phenomenon (RP), who may be at increased risk for ischemic complications, has not been addressed in the literature, to our knowledge. Digital lesions are commonly seen in patients with SSc, and cold-induced myocardial ischemia has also been reported. ⋯ He regained full neurologic function, and except for digital necrosis, no hypothermia-associated adverse events were observed. Other risk factors for ischemia, such as cocaine use, may have contributed to the development of the digital necrosis. However, clinicians should be aware of the risk for ischemic complications in patients with SSc and RP when considering the appropriate target temperature after cardiopulmonary arrest.
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Laura Dattner, John Krai and Linda Oppenheim provided assistance in obtaining archival material and manuscript review. Edwin Rosenthal's decedents, Robert, Eleanore Jane and Edwin Rosenthal II, provided information about their distinguished grandfather's life and commitments. Linda Oppenheim, Michael Angelo, Jessica Lydon, and Sofie Serada, archivists at Princeton University, Thomas Jefferson University, Temple University, and the College of Physicians of Philadelphia provided access to material on Edwin Rosenthal and medical care in Philadelphia at the turn of the 20th century. We thanks Laura Dattner, John Krai and Linda Oppenheim for their manuscript review. ⋯ Mortality from diphtheria dropped precipitously at the end of the 19th century with the introduction of laryngecostomy and a diphtheria antitoxin. However these measures required action by health departments and was dependent on the availability of physicians and medical facilities. Lack of Public Health Departments put all southerners at risk for infectious illnesses. With respect to diphtheria, there was neither an available supply of antitoxin nor physician care available. Philadelphia may have been too mired in corruption to provide antitoxin. Burghardt lived in close proximity to a facility where antitoxin was available, data suggests he would have received appropriate treatment there and was likely to have survived. Similar phenomena-disinterest and dysfunction-affect provision of immunization for children today. Currently, availability of immunization is affected by ethnicity, income levels and immigration status.
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J Clin Monit Comput · Feb 2015
Intraoperative neurophysiological monitoring during spine surgery with total intravenous anesthesia or balanced anesthesia with 3 % desflurane.
Total intravenous anesthesia (TIVA) with propofol and opioids is frequently utilized for spinal surgery when somatosensory evoked potentials (SSEPs) and transcranial motor evoked potentials (tcMEPs) are monitored. Many anesthesiologists would prefer to utilize low dose halogenated anesthetics (e.g. 1/2 MAC). We examined our recent experience using 3% desflurane or TIVA during spine surgery to determine the impact on propofol usage and on the evoked potential responses. ⋯ The data from these cases indicates that 1/2 MAC (3%) desflurane can be used in conjunction with SSEP and tcMEP monitoring for some adult patients undergoing spine surgery. Further studies are needed to confirm the relative benefits versus negative effects of the use of desflurane and other halogenated agents for anesthesia during procedures on neurophysiological monitoring involving tcMEPs. Further studies are also needed to characterize which patients may or may not be candidates for supplementation such as those with neural dysfunction or who are opioid tolerant from chronic use.