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Pain management in children is often dependent on the ability of parents to recognize and assess pain and on their decision to treat pr not to treat it buy generic kamagra 100 mg line. Pediatric pain service should provide the pain management for acute discount kamagra 50 mg free shipping, post- operative order kamagra 50mg fast delivery, terminal buy kamagra 50mg free shipping, neuropathic and chronic pain kamagra 50 mg low price. These agents are administered 30 enterally: oral, or rectal route and are very useful for inflammatory, bony, or rheumatic pain. Regardless of dose, the non-opioid analgesics reach a “ceiling effect” above which pain can not be relieved by these drugs alone. Aspirin has been abandoned in pediatric practice because of its possible role in Reye’s syndrome, its effects on platelet function, and its gastric irritant properties. Rectal doses for acetaminophen being recommended by some authors are as high as 30-40 mg/kg as loading dose. Regardless of route of delivery, the daily maximum acetaminophen dose in the preterm, term, and older child is 60, 80, 90 mg/kg respectively. Factors to consider when opioids are appropriate are: pain intensity, patient age, co-existing disease, potential drug interactions, prior treatment history, physician preference, patient preference, and route of administration. All opioids are capable of treating pain regardless of its intensity if dose is adjusted appropriately and at equipotent doses most opioids have similar effects and side effects. Codeine, oxycodone (Tylox, Percocet) and hydrocodone (Vicodin, Lortab) are opioids which are frequently used to treat pain in children and adults. They are most commonly administered in the oral form, usually in combination with acetaminophen or aspirin. In equipotent doses, codeine, oxycodone, and morphine are equal as analgesics and respiratory depressants. The analgesic effects for codeine and oxycodone occur in ~ 20 min following oral intake and reach maximum at 60-120 minutes. Approximately 10% of the patients and most newborns cannot metabolize codeine into morphine so codeine has little analgesic effect in these patients. In tablet form oxycodone is commonly available as a 5 mg tablet or as Tylox ( 500 mg acetaminophen and 5 mg oxycodone ) or Percocet (325 mg acetaminophen and 5 mg oxycodone ). Intravenous boluses of morphine may need to be given at intervals of 1-2 hr based on pharmacokinetics of the opioids. Rational pain management requires some form of titration to effect whenever any opioid is administered. All opioids can produce some unwanted side effects, such as pruritis, nausea and vomiting, constipation, urinary retention, cognitive impairment, tolerance, and dependence. Infants are considered premature if they are born before 38 weeks of gestation or weigh less than 2500 g at birth. Anesthetic management: most infants are hypovolemic with a metabolic acidosis requiring fluid resuscitation; blood and blood products should be ordered; awake intubation is intubation of choice; anesthetic agents-opioids and ketamine; hypothermia is common problem. Pyloric stenosis – incidence is higher in males; common in first-born males of parents who had pyloric stenosis; presentation: persistent, bile-free vomiting; the infant is dehydrated and lethargic; vomiting may be projectile, causing loss of hydrogen, chloride, sodium, and potassium ions from stomach; this results in hypokalemic, hypochloremic metabolic alkalosis. Olive-sized mass may be palpated in the mid-epigastrium; noninvasive diagnostic tests include ultrasound; pyloric stenosis is a medical emergency not a surgical emergency. Anatomically pediatric airways are narrower, resulting in greater resistance to air flow, and the tongue is relatively larger; all patients can be divided into those who will be difficult to intubate but can be ventilated by mask and those who are difficult or impossible to ventilate by mask. The latter group poses a more difficult anesthetic challenge and may require emergency tracheostomy; if child can be ventilated by mask, then a number of options-fiberoptic intubation, blind nasal intubation or use of a retrograde transtracheal wire can be attempted. Hurler’s syndrome /mucopolysaccharidosis type 1H/-associated with severe mental retardation, deafness, stiff joints, dwarfism, pectus excavatum, hepatosplenomegaly and severe valvular and early coronary artery disease; upper airway obstruction and difficult intubation are common, getting worse with age. Crouzon’s syndrome – congenital craniofacial synostosis, wide, towering skull with proptosis, maxillary hypoplasia and a beaked nose; maxillary hypoplasia can make mask ventilation difficult. Cleft lip and palate – associated with more than 150 syndromes; risk for pulmonary aspiration; large defects can cause difficulty with intubation; postoperative airway problems are also common. Fluid management in infants-normal daily water consumption in the infant is 10% to 15% of body weight; estimated fluid requirements may be calculated using formula”4-2-1” for weight less than 10kg – 4 ml/kg/hr, 10-20kg - 2ml/kg/hr. Blood replacement: estimated blood volume ranges from 90 ml/kg in neonates to 65 ml/kg in teenagers; the decision to transfuse depends on preoperative hemoglobin level, estimated surgical loss, the patient cardiovascular response.

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This is the case especially because clinical standards are constantly changing through research and regula- tion generic kamagra 50mg otc. Conscious Sedation Consulting therefore disclaims all liability for direct or consequential damages resulting from the use of material presented on the web-site purchase 100 mg kamagra otc, in seminars or presentations cheap kamagra 50 mg with mastercard, or in written or spoken responses to questions or requests 100 mg kamagra amex. For sedative drugs discount kamagra 50 mg online, it is infuenced by 1) the type, location, and duration of the procedure being performed in which sedation is being administered. The Onyx is the only finger pulse oximeter with scientifically proven accuracy in the most challenging cases, including patients with low perfusion or dark skin tones. By placing onds and will be able to adjust the water temperature, one DermaThermÔ band on the affected site and one rather than risking unnecessary injury. This is one quick and inexpensive pre-test can be done with Der- of the leading applications for DermaTherm. By using pairs of DermaTherm, the tem- place a DermaTherm monitor at the distal end of the perature of an affected pain site, its contralateral site, affected extremity. The nificant change in temperature, indicating a successful presence or lack of significant temperature difference block. DermaTherm gesting the need to re-dose and/or adjust the dosage Perfusion Monitors, especially in the soft band form, given. Post-operatively you will have a continu- is an excellent application of DermaTherm, for both ous monitor, which will indicate possible clotting or you and your patient. By applying a the DermaTherm and learn to associate the change DermaTherm to the affected limb and checking it peri- in temperature with their level of comfort. When odically, you will know when Heparin treatments begin they leave with the DermaTherm on, they will have a to be effective because you will see the temperature tool to provide quantifiable feedback all day as they decrease, even before swelling reduces! DermaTherm them inconspicuous and the patient won’t feel embar- is a fast and easy way to check the circulation of a re- rassed. It is generally accepted that apply DermaTherm post-operatively and record the temperature affects conductivity. Subsequent readings should be thae inexpensive way to determine if an extremity is at a same or warmer. Whether for contralateral limbs or even upper and lower portions wound debridement or muscle therapy, or any of the of a limb with DermaTherm may show a 1° or greater many other times you choose a hot water therapy difference and aid in your diagnosis. A secondary or backup source consists of gas cylinders (oxygen or O2, nitrous oxide or N2O, Even though anesthesia machines differ, test and air), which are regulated at 45 psig through questions are usually not manufacturer specific. Pipeline pressure is higher than the cylinder pressure (50>45 psig), One of the safety features you will see on anes- which is the reason why the anesthesia machine thesia machines is called a fail-safe device. You may also hear oxide is hazardous, and so this feature stops the term “drive gas” for the 50 psig pipeline gas the amount of nitrous oxide delivered when the source. In other words, if the anesthesia machine was leaking The cylinder pressure regulators have two func- oxygen, then the flow of nitrous oxide would drop tions: Reduce the cylinder pressure to a constant automatically to prevent harm to the patient. This prevents usage and depletion of that links the nitrous oxide flow control valve to the backup cylinder gases when there is still an the oxygen flow control valve. The percentage of oxygen To prevent mixing up the pipeline hoses, the non- within a mixture should always be at least 21%. An example cylinder yoke of a particular gas have a unique would be if there was 9 L/min of nitrous oxide configuration that fits into corresponding holes flowing through the system, then oxygen flow in the cylinder valve. During the inspiratory phase, continuously pressing this button will cause the Safety Features lungs to overinflate. During expiration, if the oxy- gen flush button is pressed, the bellow will initially In today’s health care facility, all gas tanks are fill rapidly to its maximum capacity. This part of the breathing circuit con- be failure of the pressure relief valve, which is tains dead space. This is confirmed the dead space in the Y connector by ensuring if manual ventilation resolves the problem. When looking at an anesthesia machine, you will notice there is an absorber canister with small Device Functions white granules. The function of soda lime is to absorb The manual ventilation mode or bag mode is carbon dioxide from the exhaled gas before the when the user manually bags the patient to patient breathes it back again.

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At secondary hospital / Non metro situation – optimal standards of treatment in situations where technology and resources are limited order kamagra 50 mg online. Appropriate antibiotics are chosen and administered for a period of 7 to 10 days intravenously cheap kamagra 100 mg on-line. It should be followed by oral chemo prophylaxis till the reflux subsides with periodical monitoring of the urine culture especially during febrile episodes cheap kamagra 50 mg mastercard. Ultrasonogram done shows some structural abnormalities generic 50 mg kamagra free shipping, should be investigated further with Intravenous urogram and sent to higher centres for intervention purchase 50mg kamagra free shipping. Situation 2 At super specialty at metro location where higher end technology is available Investigations. Endoscopic injection therapy 3 Diversion procedures like Ureterostomy and vesicostomy. Long term management will include surveillance of the child and addressing bladder dysfunction if present. Surgical and endoscopic procedures should be done in institutions with proper cystoscopes for different age groups including 66 the neonates. Assists the surgeon  Scrub nurse  Theatre technician  X- Ray technician to monitor C Arm  Ward staff Further Reading and references Consensus statement of management of Urinary tract infections Indian Paediatric nephrology group Ind Paeditrics 2001:38:106-1155 Progress in Paediatric urology Edited bY Minu bajpai. Material for facility, 67 urodynamics expert nuclear medicine urodynamics tests, operation theatre 68 Neonatal Jaundice-Unconjugated hyperbilirubinemia Prepared by: 1. Physiologic jaundice is benign and self limiting, but pathologic jaundice can cause severe hyperbilirubinemia , which if not treated appropriately can result in kernicterus g. Case definition : For both situation of care ( mentioned below) Neonatal jaundice : indicates presence of visible jaundice. Subsides over 7-10 days Preterm :  Onset on day 2 of life  Reaches peak of 15mg/dl on day 6-8  Subsides over 10-14 days of life There is no clear consensus on what is bilirubin cut off for physiological jaundice. However levels greater than 17 mg% are unlikely to be due to physiologic jaundice Pathological jaundice : 8. Signs of underlying illness in an infant with jaundice ( vomiting, lethargy, poor feeding, excessive weight loss, apnoea, tachypnoea, temperature instability ) 12. The most important aspect is to differentiate neonates with self limiting physiologic jaundice from those having neonatal jaundice due to underlying problems ( pathologic jaundice ), as the latter group can develop severe hyperbilirubinemia which can result in neuronal damage 2. Neonatal unconjugated hyperbilirubinemia should always be differentiated from neonatal cholestasis. It is essential to make sure that the parents are informed about newborn jaundice. Early discharge (<48 hours) is one of the reasons for missing neonates with hyperbilirubinemia ( as breast feeding is not yet established and jaundice usually peaks at about 3 to 5 days ) c. It is preferable to keep the mother and baby pair in the hospital at least for a period of 48 hours even for normal deliveries d. Those with major risk factors*** should definitely not be discharged early (preferably observed for 72 hours) e. If for any reason early discharge is planned, a pre- discharge bilirubin should be done and treatment planned as per the bilirubin nomogram ( appendix 1) and frequent follow up is essential 15. Decision is taken depending on which part of the graph the value falls  In addition to providing phototherapy for those who require the following policy needs to be practiced for all intramural neonates  Promote & support successful breast feeding  Establish nursery protocols for identification and evaluation of hyperbilirubinemia  Assess all neonates for presence of risk factors  Only visual estimation of degree of jaundice can lead to errors in darkly pigmented infants, therefore frequent bilirubin estimations will have to be done  Perform systemic assessment on all infants prior to discharge for the risk of hyperbilirubinemia  Do a serum bilirubin for infants discharged before 48 hours  Interpret all babies bilirubin levels according to infant age, in hour specific nomogram  Provide appropriate follow up based on the time of discharge and risk assessment. It is advisable to keep the neonate in hospital for a period of 12 to 24 hrs or repeat a bilirubin value 12 to 24 hrs after stopping phototherapy as rebound hyperbilirubinemia can occur, particularly in neonates with hemolytic jaundice Types of light: Single or double surface phototherapy. It is an invasive procedure requires cannulation of the umbilical vein/any other peripheral vein. Out patient : Sampling blood for investigations,cross matching , no prccedure on outpatient basis Referral criteria : No referral from tertiary centre 13. Fanaroff and Martin’s Neonatal- Perinatal medicine- Diseases th of the fetus ans infant- 8 edition 81 82 Appendix 1 Appendix 2 83 Appendix 3 84 Methods of giving Phototherapy Baby fulfills the criteria for phototherapy  To make sure that the lights are in usable condition (been used not more than 1000 hrs or > 3 months whichever is earlier)  If double light phototherapy is given , infant lies on a fiberoptic blanket with conventional phototherapy overhead or a double surface phototherapy can be given  To place the light as close to the baby as possible, if double light phototherapy not given, position of the baby to be changed frequently  If an incubator is used there should be a 5-8 cm space between it and the lamp cover to prevent over heating  The most effective lights for phototherapy are those with output 425- 475 nm  The baby should be naked with eyes and genitalia covered  Temperature should be monitored and maintained  Infant should be weighed daily  To monitor the hydration status of the baby and adjust the fluid/ feeds accordingly  Frequent breast feeding, additional oral fluids only if significant weight loss is present ( > 10% wt loss )  Skin colour is not a guide to hyperbilirubinemia in infants on phototherapy ,hence bilirubin should be monitored every 12 hrs  Once satisfactory decline in bilirubin has occurred, infants can be removed from phototherapy for feeding Exchange transfusion  To make sure the baby fulfills the criteria for exchange transfusion  Choice of blood:  Fresh, less than 7 days old, irradiated ( if possible ), whole blood  In Rh hemolytic disease, blood is prepared before delivery, type O Rh negative crossed matched against mother. Ramesh Santhanakrishnan, Professor and Head, Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bangalore. Case definition: Intestinal Obstruction in a new born child caused by intrinsic or extrinsic factors involving the stomach / duodenum / jejunum / ileum / any part of the colon.

There is now good evidence that limiting inflation pressures by accepting lower tidal The rationale for vasodilator therapy is that the volumes (e buy cheap kamagra 50mg on-line. Pulmonary arterioles associated with 15cmH2O) also helps to minimize the extent of poorly ventilated alveoli remain unaffected generic kamagra 50mg line. Intravenous amiodarone is the most effec- Prone ventilation of patients tive drug used to treat atrial fibrillation in critically The potential benefits of this technique are derived ill patients cheap kamagra 100 mg otc, and acts either by reducing the from the fact that prolonged adoption of the ventricular response rate or by pharmacological supine posture leads to collapse of dependent cardioversion back into sinus rhythm generic kamagra 50 mg. Turning vasoconstricts systemic arterioles) is necessary purchase 100mg kamagra with visa, for patients prone is potentially hazardous and may example noradrenaline. However, majority of patients who benefit from these drugs when undertaken by teams of doctors and nurses have usually suffered a myocardial infarction. The use of inotropes and vasopressors require in- vasive monitoring of the cardiovascular system to Cardiovascular failure direct therapy. Lac- • Correcting hypovolaemia with fluid challenges tic acid is produced by anaerobic metabolism and Increasing left ventricular preload so that it is trends in serum lactate concentration can provide functioning at the peak of the Frank–Starling useful information on whether or not oxygen de- curve. This first step is the single most impor- livery to the tissues and oxygen consumption by tant prerequisite for optimal cardiovascular the tissues is adequate. On the neously when the patient is adequately fluid resus- other hand, younger patients may tolerate a lower 134 Recognition and management of the critically ill patient Chapter 5 pressure. Until relatively recently, it was quite commonplace to attempt to drive the cardiac output to the maximum attain- able using a combination of fluid loading and inotropic support. However, most intensivists now adopt a more conservative approach, following evidence that driving the cardiovascular system towards ‘supranormal goals’ did not improve mortality and could even increase it. Accordingly, when cardiac output is measured, values at the upper end of normal or moderately above it are ac- cepted as satisfactory, taken in the overall context of a stable or improving clinical situation. Acute renal failure Critically ill patients who have acute renal failure as a component of their multiple organ failure have significantly different requirements in terms of renal support from patients with isolated acute or chronic renal failure. An inherently unstable cardiovascular system, the need for continued in- fusion of large volumes of fluid to combat the ex- travasation of circulating volume through leaky capillaries and the use of potent inotropic and va- Figure 5. The vertical, central struc- sopressor drugs mean that these patients are often ture is the filter/dialysis membrane. There are four pumps: bottom right pumps blood in from a central vein into the fil- unable to tolerate the rapid fluid and ionic shifts ter; bottom left pumps fresh dialysate fluid into the filter; associated with intermittent haemodialysis tech- top left pumps out effluent from the filter (consisting of niques, which may precipitate cardiovascular col- dialysate fluid plus ultrafiltrate); and top right pump delivers lapse. Peritoneal dialysis is also of limited value in replacement fluid to the patient to maintain fluid balance. An extracorporeal circulation imum creatinine clearance obtained is much less is set up, containing a filter with an artificial semi- than that during haemodialysis. The problem is that the host response becomes amplified and uncon- week) episodes of standard haemodialysis. How- trolled, contributing to further tissue damage and ever, as alluded to above, this disadvantage is also dysfunction. This them, they describe subtly different clinical may require repeated blood cultures and analysis conditions. Such patients do not recover if surgical bacterial products that may be released into the drainage is not undertaken. However, it is possible that ad- causes include major trauma, burns and acute vances in this area may be made as further research pancreatitis. Elsewhere, severe sepsis due to both excessive consumption oxygen delivery to cells is compromised by shunt- and reduced activation, and the size of the decrease ing of blood away from capillary beds through ar- correlates with mortality. Consequently, micro- teriovenous channels that open in response to the thrombi develop throughout the circulation in inflammatory response. Oxygen consumption by sepsis syndrome and this is one of the main causes cells may also be reduced as a consequence of in- of end-organ dysfunction. Tight control of blood sugar during critical Confidential inquiry into quality of care before illness also improves survival. Efficacy and safety of recombinant Early goal-directed therapy in the treatment of human activated protein C for severe sepsis. Clinical Review: hemodynamic multiprofessional training course in the care of monitoring in the intensive care unit. This is achieved by clear shot at goal compared to losing the tackle and the careful application of clinical physiology, phar- with it the chance of victory!

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