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Tipos de aneurismas 49 ¾ Según la estructura de su pared Verdaderos: la pared aneurismática es la propia pared de la arteria kamagra oral jelly 100 mg generic, adelgazada y modificada buy kamagra oral jelly 100mg on line. La aorta abdominal kamagra oral jelly 100 mg, en particular, su segmento infrarrenal es la arteria más proclive a la dilatación considerando además, por extensión, a las ilíacas en las que se divide. La segunda localización preferencial pertenece a la arteria poplítea, casi siempre bilateral. Más bien sufre de elongación, tortuosidad, acodamiento y enrollamiento, en particular en los enfermos que sufren de severa hipertensión arterial por largo tiempo. La aorta abdominal está situada en la línea media abdominal, entre el apéndice xifoides y el ombligo, un tanto hacia la izquierda. Buscamos habitualmente más en el hipocondrio derecho, o las fosas ilíacas, también tratamos de definir el bazo agrandado en el hipocondrio izquierdo, incluso palpamos los flancos, pero se nos olvida la palpación de la línea media abdominal. Algunas series muestran mucho más esta asociación que con la hipertensión arterial. Están presentes los infiltrados inflamatorios de linfocitos y monocitos, así como de macrófagos. Se aumentan las citoquinas y otros mediadores, que incrementan la proteolisis en la matriz extracelular. Por otro lado, la depleción de la musculatura lisa y el aumento en la actividad de las metaloproteasas de la matriz extracelular dan lugar a estructuras que no pueden impedir el adelgazamiento y la expansión aneurismática. El médico debe suponer en riesgo a los pacientes de su comunidad por encima de los 60 años, mucho más si tienen otros factores como la hipertensión arterial, el hábito de fumar, entre otros. Es imprescindible palpar la línea media abdominal de todo paciente Medios diagnósticos - Radiografía de tórax: Define si existe dilatación de la aorta a este nivel. Habitualmente existe una crisis de advertencia y si no se piensa en esta posibilidad, sobreviene en pocos días la hemorragia masiva definitiva. También se refiere que el momento para la cirugía debe ser “un segundo antes de romperse”, lo que no es muy demostrativo pero nada práctico. En estos caminos, buscando el candidato para que reciba el beneficio del tratamiento quirúrgico electivo, se han establecido tres premisas como punto de partida para continuar con los detalles de la evaluación preoperatoria: 1. Edad alrededor de 60 años: Es obvio que resulta mucho mejor por ejemplo, operar un enfermo de 62 que uno de 74. Diámetro transversal del aneurisma de 5 cm o más: Se conoce que con estas dimensiones la posibilidad de rotura está más cercana. Enfatizar en la necesidad de buscar los pulsos periféricos como elemento imprescindible en el diagnóstico. Establecer que la paroniquia puede ser la primera manifestación de una enfermedad arterial 7. Concepto La enfermedad arterial periférica se define como aquella que afecta las arterias de las extremidades, en particular las inferiores. En su desarrollo nos referiremos a la enfermedad que afecta desde la aorta abdominal hasta la arteria pedia. Antecedida en primer lugar por la enfermedad arterial coronaria y en segundo por la enfermedad arterial cerebrovascular. El ateroma y su historia natural Sin adelantarnos a la ya conocida marca genética de la enfermedad y sus bien establecidos factores de riesgo podemos aproximarnos a la edificación del ateroma. Toda una serie de moléculas, mediadores químicos, elementos formes de la sangre y otros, dan lugar a una evidente inflamación de las áreas vecinas y a la organización de las “estrías grasas” en “placas perladas” y de ahí sucesivamente hasta el real ateroma, que crece, hace relieve dentro de la luz arterial, disminuye su luz y por lo tanto el flujo que ella conduce. En realidad llega un momento en su desarrollo desordenado pero continuo, que comienza a romperse, fragmentarse, hendirse, ulcerarse, desprenderse. En estas circunstancias, las plaquetas acuden al llamado químico del colágeno expuesto, se adhieren a él y se agregan entre sí. El resultado es un trombo final que termina ocluyendo la arteria enferma o embolizando hacia sus territorios de irrigación. La inestabilidad del ateroma da lugar a los cuadros finales de la enfermedad arterial por ateroesclerosis obliterante en cualquiera de sus tres localizaciones preferenciales: coronaria, cerebral o de las extremidades. Las trombosis y las embolias, en el curso final de la inestabilidad del ateroma, son los temibles protagonistas terminales de discapacidad y muerte. Asintomático En este período el crecimiento de los ateromas en su conjunto, en un territorio arterial, no ha comprometido las dos terceras partes del suministro de flujo sanguíneo, de modo que el enfermo no presenta síntomas, de ahí su nombre. Unos más desarrollados, por ser del sexo masculino o más viejos; otros por fumar o tener elevado el colesterol y otros por ser hipertensos o diabéticos.

Recommendation:-For1 purchase 100mg kamagra oral jelly visa, 2 stone removal with or without prior decompression(depending on the clinical situation) is recommended best 100mg kamagra oral jelly,in situation 100 mg kamagra oral jelly with amex,3,4,5,6 emergency deobstruction of the collecting system is recommended. Various studies have attempted to show the correlation of geometry of the lower calyx to predict the clearance of stone in this location. However the calyceal stone burden is the most important factor in predicting the clearance. Specific stone compositions have different clearance rates because of the varying 22 fragility of stones. Better fragmentation can be achieved with starting the fragmentation (17) at lower energy setting and then ramping up the power. In case of infected stones, antibiotics should be given according to urine culture sensitivity, the (2) same should be continued after surgery for 4 days Clinical experience suggests that stones in the ureter rather than the kidney should be treated with shorter intervals between sessions. Antibiotics should be given according to urine culture sensitivity, the same should be continued after surgery for 4 days. The physicians should refer to the manufacturer recommendation regarding the decision of number, frequency and power of shocks. The tract should be the shortest possible tract from 24 the skin to the desired calyx traversing the papilla. Depending on the stone configuration a calyx should be selected (Supracostal, infracostal or subcostal) so that maximum stone bulk can (23) be cleared minimum number of tracts. Renal tract dilatation either balloon, amplatz or (2) metallic dilators are a matter of surgeon preference and availability. In uncomplicated cases, tubeless percutaneous nephrolithotomy with or without application of (25) (26) tissue sealants is a safe alternative i) Complications The patients should be counseled regarding the complications which are likely to be encountered such as life threatening bleeding with a possible need for angioembolisation or even nephrectomy. The patients should be counseled regarding the possibility of residual calculi and the consequences thereof. The procedure becomes challenging in complex stones, although the complications are not specific to them. Recommendations Technically, most of the renal stones can be managed with a percutaneous nephrolithotomy. The access to the collecting system 25 can be gained either ultrasound guided or fluoroscopy guided depending on the availability of instruments and expertise. Renal tract dilatation either balloon, amplatz or metallic dilators are a matter of surgeon preference and availability. In complicated cases or when secondary intervention is required a nephrostomy tube which serves the dual purpose of tamponade and a conduit for second look is placed. In uncomplicated cases, tubeless percutaneous nephrolithotomy with or without application of tissue sealants is a safe alternative. Due to improved technology and development in accessories and optics the role of flexible ureteroscopy is likely to be expanded in the future. Standard technique for flexible ureteroscopy • Fluoroscopy equipment is advisable in all cases • Preoperative imaging helps to determine the size and location of the stone. The holmium Yag laser is the (29) preferred modality for flexible ureteroscopy • The stenting after an uncomplicated flexible ureteroscopy is optional. Accessories and instrumentation A 365 micron laser fiber is suited for ureteral stones. Nitinol baskets preserve tip deflection, in addition the tipless design reduces the mucosal injury, hence. The size of the available access sheaths ranges from 9-16Fr, they have a hydrophilic coating. The advantages of access sheath are reducing the operating time particularly in large stone burden. Open surgery is desirable in the situation when expertise is not available wherein the stone can be cleared in reasonable number of stages and tracts. Management of ureteric calculi and ureteric colic The most common cause for ureteric colic is ureteric calculus.

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This will require the indi- monly intravenous discount kamagra oral jelly 100mg on-line, occasionally it may be by vidual to be trained in generic kamagra oral jelly 100 mg without prescription, and familiar with proven 100mg kamagra oral jelly, the pro- inhalation. This is usually the re- done by a senior clinician or the person who is to covery unit, but after some surgery it may be the perform the procedure. Their presence may be misinterpreted by the pa- Useful websites tient as indicating unexpected problems. Premedication originally referred to drugs administered to facilitate the induction and main- Anti-emetic (reduction of nausea tenance of anaesthesia (literally, preliminary and vomiting) medication). Nowadays, premedication refers to the administration of any drugs in the period be- Nausea and vomiting may follow the administra- fore induction of anaesthesia. The most commonly prescribed drugs are the ben- Drugs with anti-emetic properties are shown in zodiazepines. Those most commonly gastric contents) used include temazepam 20–30mg, diazepam 10–20mg and lorazepam 2–4mg. In patients who Patients are starved preoperatively to reduce suffer from excessive somatic manifestations of the risk of regurgitation and aspiration of gastric anxiety, for example tachycardia, beta blockers acid at the induction of anaesthesia (see below). A preoperative visit and explanation This may not be possible or effective in some is often as effective as drugs at alleviating anxiety, patients: and sedation does not always mean lack of anxiety. Increases both gastric emptying and lower Increased sympathetic activity can be seen at intu- oesophageal sphincter tone. This is undesirable in certain patients, for example • Omeprazole (proton pump inhibitor):40mg 3–4 those with ischaemic heart disease or raised in- hourly preoperatively. These responses can be If a naso- or orogastric tube is in place, this can be attenuated by the use of beta blockers given used to aspirate gastric contents. Peri- operative beta blockade may also decrease the inci- Anti-autonomic effects dence of adverse coronary events in high risk patients having major surgery. An alternative is to Anticholinergic effects give a potent analgesic at induction of anaesthesia, for example fentanyl, alfentanil or remifentanil. Although the oldest form of premedication, anal- (b) Reduce the vagolytic effects on the heart, for gesic drugs are now generally reserved for patients example before the use of suxamethonium who are in pain preoperatively. The most com- (particularly in children), during surgery on the monly used are morphine, pethidine and fentanyl. Atropine and but is relatively poor as an anxiolytic and has hyoscine have now largely been replaced pre- largely been replaced by the benzodiazepines. Opi- ates have a range of unwanted side-effects, includ- ing nausea, vomiting, respiratory depression and Table 2. These patients will benefit from the methods described above to reduce gastric volume and increase the pH of the contents. In the trauma The majority of the patient’s own regular medications patient the time from last meal to injury may be a should be taken as normal, unless instructed otherwise better indicator of the gastric volume. Managing the airway Preoperative starvation Maintenance of a patent airway is an essential pre- requisite for the safe and successful conduct of Traditionally, patients were starved of both food anaesthesia. However, it is a skill that should be ac- and fluids for prolonged periods preoperatively, quired by all doctors, as during resuscitation pa- but it is now increasingly recognized that, apart tients often have an obstructed airway either as the from certain groups with an increased risk of aspi- cause or result of their loss of consciousness. Anaesthesia frequently results in loss of the airway, • Milk is not allowed as it flocculates in gastric acid and this is most easily restored by a combination of and the fat delays gastric emptying. When • Chewing gum does not increase gastric volume holding a facemask in position with the index fin- and is best treated as for clear fluids. The overall effect desired • The use of opiates or anticholinergics as is that the patient’s mandible is ‘lifted’ into the premedicants has little effect on gastric volume. Nasopharyngeal airway • Round, malleable plastic tubes, bevelled at the Facemasks pharyngeal end and flanged at the nasal end. The common contours of the face with the minimum of sizes in adults are 6–8mm, for small to large adults, pressure. Simple adjuncts The oropharyngeal (Guedel) airway, and to a lesser Problems with airways extent the nasopharyngeal airway, are used in con- junction with the techniques described above to Snoring, indrawing of the supraclavicular, help maintain the airway after the induction of suprasternal and intercostal spaces, use of the ac- anaesthesia. Other problems with these techniques include: Originally designed for use in spontaneously • inability to maintain a good seal between the pa- breathing patients, it consists of a ‘mask’ that sits tient’s face and the mask, particularly in those over the laryngeal opening, attached to which is a without teeth; tube that protrudes from the mouth and connects • fatigue, when holding the mask for prolonged directly to the anaesthetic breathing system. On periods; the perimeter of the mask is an inflatable cuff that • the risk of aspiration, due to the loss of upper air- creates a seal and helps to stabilize it (Fig. The use of the laryngeal mask overcomes some of the problems of the previous techniques: • It is not affected by the shape of the patient’s face or the absence of teeth.

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Specimen examination Urine High concentrations of some drugs or metabolites can impart characteristic colors to urine generic 100 mg kamagra oral jelly. Deferoxamine in iron poisoning color urine red or methylene blue given in treatment of nitrate poisoning may color urine blue) cheap kamagra oral jelly 100mg with mastercard. Strong-smelling poisons such as methylsalicylate can sometimes recognized in urine since they are excreted in part unchanged kamagra oral jelly 100mg without a prescription. Turbidity may be due to underlying pathology (blood, microorganisms, casts, epithelial cells), or carbonates, phosphates or urates (in amorphous or microcrystalline forms). Such findings should not be ignored, even though they may not be related to the poisoning. Stomach contents and scene residues Some characteristic smells can be associated with particular poisons (e. Very low or very high pH may indicate ingestion of acid or alkali, while a green/blue color suggests the presence of iron or copper salts. Microscopic examination using a polarizing microscope may reveal the presence of tablet or capsule debris. Undegraded tablets or capsules and any plant remains or specimens of plants thought to have been ingested should be examined separately. Apparatus Analytical toxicology services can be provided in clinical biochemistry laboratories that serve a local hospital or accident and emergency unit. In addition to basic laboratory equipment, some specialized apparatus, such as that for thin-layer chromatography, ultraviolet and visible spectrophotometry and microdiffusion, is needed. No reference has been made to the use of more complex techniques, such as gas-liquid and high-performance liquid chromatography, atomic absorption spectrophotometry or immunoassays, even if simple methods are not available for particular compounds. Although such techniques are more selective and sensitive than many simple methods, there are a number of factors, in addition to operator expertise, that have to be considered before they can be used in individual laboratories. The standards of quality (purity or cleanliness) of laboratory reagents and glassware and of consumable items such as solvents and gases needs to be considerably higher than for the tests described in this manual if reliable results are to be obtained. Additional complications, which may not be apparent when instrument purchase is contemplated, include the need to ensure a regular supply of essential consumables (gas chromatographic septa, injection syringes, chromatography columns, solvent filters, chart or integrator paper, recorder ink or fibre-tip pens) and spare or additional parts (detector lamps, injection loops, column packing materials). Similarly, immunoassay kits are relatively simple to use, although problems can arise in practice, especially in the interpretation of results. Moreover, they are aimed primarily at the therapeutic drug monitoring and drug abuse testing markets and, as such, have limited direct application in clinical toxicology. Reference compounds and reagents A supply of relatively pure compounds for use as reference standards is essential if reliable results are to be obtained. However, expensive reference compounds of a very high degree of purity, such as those marketed for use as pharmaceutical quality control standards, are not normally needed. Some drugs, such as barbiturates, caffeine and salicylic acid, and many inorganic and organic chemicals and solvents are available as laboratory reagents with an adequate degree of purity through normal laboratory chemical suppliers. Such a reference collection is a valuable resource, and it should be stored under conditions that ensure safety, security and stability. Although the apparatus required to perform the tests described in this manual is relatively simple, several unusual laboratory reagents are needed in order to be able to perform all the tests described. At last, it is beyond the scope of the lecture note to cover all the reagents (See annex I). General laboratory tests in clinical toxicology 36 Toxicology Many clinical laboratory tests can be helpful in the diagnosis of acute poisoning and in assessing prognosis. More specialized tests may be appropriate depending on the clinical condition of the victim, the circumstantial evidence of poisoning and the past medical history. Biochemical tests Blood glucose: Determination of blood glucose is essential to know those toxic substances that affect blood glucose biotransformation. A toxicant that causes hypoglycemia includes insulin, iron, acetyl salicylic acid & so on. Hyperglycemia is a less common complication of poisoning than hypoglycemia, but has been reported after over dosage with acetylsalicylic acid, salbutamol and theophylline. Electrolytes, blood gases and pH Toxic substances or their metabolites, which inhibit key steps in intermediary biotransformation, are likely to cause metabolic acidosis owing to the accumulation of organic acids, notably lactate. Cholinesterase activity Plasma cholinesterase is a useful indicator of exposure to organophosphorus compounds or carbamates, and a normal plasma cholinesterase activity effectively excludes acute poisoning by these compounds.

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