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The bones are dif- disengagement of the device from the interspinous space fusely osteopenic and there is anterolisthesis at the oper- into the soft tissues posterior to the spinous processes ated level 11 Imaging of Postoperative Spine 579 11 purchase clomiphene 50mg with mastercard pregnancy rib pain. The device is held in in patients with facet arthropathy and spinal place by pedicle screws purchase clomiphene canada womens health workouts. On imaging discount 50mg clomiphene mastercard menstrual cramps 8dpo, the screws stenosis while maintaining normal or near-nor- and plates are radiopaque order cheap cialis extra dosage line, and the central poly- mal biomechanics of the spine order malegra dxt 130mg otc. The total poste- carbonate urethane layer is radiolucent rior facet replacement and dynamic motion (Fig purchase kamagra 100 mg fast delivery. Frontal (a) and lateral (b) radiographs show total posterior facet replacement and dynamic motion segment stabilization system at L4–L5 580 D. Complications include screw loos- to a rigid metal rod and is used to treat lumbar ening, screw breakage, and degeneration in the spinal stenosis and degenerative spondylosis. Frontal (a) and lateral (b) radio- rounding soft tissues, but slightly higher attenuation cen- graphs show bilateral metallic pedicle screws at L3–L5, trally, corresponding to the polyethylene terephthalate which are secured to radiolucent rods. In particular, a com- Syndrome and Related Spine prehensive and systematic assessment of the Surgery Complications postoperative spine includes a review of the neu- ral and vascular structures, including the neural 11. Axial (a) and sagittal (b) images of the lumbar patient is status post anterior-posterior lumbar fusion spine show retropulsion of the interbody box prosthesis arthrodesis at L4–L5 and L5–S1 with placement of bio- into the spinal canal (arrow) mechanical prosthetic interbody fusion device (Pioneer Fig. Frontal radiograph shows inferior translation of the left posterior fusion rod, leaving a gap between the superior end of the rod and the superior pedicle screw 11 Imaging of Postoperative Spine 585 11. Broken screws or lucency surrounding related to the presence of particulate debris acti- hardware vates phagocytes that release enzymes that result in 5. The presence of a broken screw is Fractures strongly associated with loosening and pseudar- throsis, which should be sought on imaging. The patient has a history of myelogram images show a displaced fracture (encircled) three prior lumbar spine surgeries and presents with of the left L5 pedicle screw mechanical back pain. In particular, pseudo- sity extradural fuid collections, spinal meningeal meningoceles represent a form of cerebrospinal enhancement, and dilation of the epidural venous fuid leak contained by a capsule of fbrous tissue plexus. Thus, patients typically present of extradural collections, and their relationship to with orthostatic hypotension, but may also have bony structures. Imaging results in radiation exposure and it is a slightly options for cerebrospinal fuid leakage after spine invasive procedure. If the leak or pseudomeningo- facts and there is a differential diagnosis for the cele persists, dural repair and even fap extradural fuid, including abscess and seroma/ reconstruction may be warranted. Secondary fndings that might be present on post-contrast images related to spinal hypotension include dilatation of the epidural venous plexus and diffuse dural thickening and enhancement.

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The potassium- can cause hyperkalemia as the cationic arginine ions sparing diuretic spironolactone directly antagonizes enter cells and potassium ions move out to maintain aldosterone activity at the kidneys clomiphene 25mg low cost pregnancy journal ideas. Decreased renal excretion of potassium can also occur as a result of an intrinsic or acquired Hyperkalemia due to defect in the distal nephron’s ability to secrete Decreased Renal Excretion potassium buy clomiphene uk womens health neenah wi. Such defects may occur even in the of Potassium presence of normal renal function and are char- acteristically unresponsive to mineralocorticoid Decreased renal excretion of potassium can result therapy discount clomiphene line menopause breast tenderness. The kidneys of patients with pseudohy- from (1) marked reductions in glomerular fltration cheap silvitra 120 mg line, poaldosteronism display an intrinsic resistance to (2) decreased aldosterone activity order sildenafil in united states online, or (3) a defect in aldosterone viagra sublingual 100mg fast delivery. Increased Potassium Intake Hyperkalemia due to decreased aldosterone Increased potassium loads rarely cause hyperka- activity can result from a primary defect in adre- lemia in normal individuals unless large amounts nal hormone synthesis or a defect in the renin– are given rapidly and intravenously. Patients with primary adrenal mia, however, may be seen when potassium intake insufciency (Addison’s disease) and those with is increased in patients receiving β blockers or isolated 21-hydroxylase adrenal enzyme defciency in patients with renal impairment. Treatment is directed to reversal of cardiac Clinical Manifestations manifestations and skeletal muscle weakness, and of Hyperkalemia to restoration of normal plasma [K ]. Drugs contributing to hyperkalemia should muscle membrane, eventually resulting in paralysis. Contrac- mote cellular uptake of potassium and can decrease tility may be relatively well preserved until late in the plasma [K+] within 15 min. Hypocalcemia, cellular uptake of potassium and may be useful in hyponatremia, and acidosis accentuate the cardiac acute hyperkalemia associated with massive transfu- efects of hyperkalemia. An intravenous infusion of glu- tion, and bone metabolism, and abnormalities in cose and insulin (30–50 g of glucose with 10 units of calcium balance can result in profound physiologi- insulin) is also efective in promoting cellular uptake cal derangements. In the absence of renal function, Intestinal absorption of calcium occurs primar- elimination of excess potassium can be accom- ily in the proximal small bowel but is variable. The kidneys are responsible for most cal- Dialysis is indicated in symptomatic patients cium excretion. Hemodialy- 100 mg/d but may vary from as low as 50 mg/d to sis is faster and more efective than peritoneal dialy- more than 300 mg/d. Calcium reabsorption paral- removal with hemodialysis approaches 50 mEq/h, lels that of sodium in the proximal renal tubules and compared with 10–15 mEq/h for peritoneal dialysis. Succinylcholine Plasma Calcium Concentration is contraindicated, as is the use of any potassium- containing intravenous solutions such as lactated The normal plasma calcium concentration is Ringer’s injection. Approximately respiratory acidosis is critical to prevent further 50% is in the free ionized form, 40% is protein increases in plasma [K+]. Ventilation should be con- bound (mainly to albumin), and 10% is complexed trolled under general anesthesia, and mild hyper- with anions such as citrate and amino acids. Changes in plasma albumin concentration afect total but not ionized calcium Disorders of Calcium Balance concentrations: for each increase or decrease of 1 g/dL in albumin, the total plasma calcium con- Although 98% of total body calcium is in bone, centration increases or decreases approximately maintenance of a normal extracellular calcium con- 0. Calcium ions Changes in plasma pH directly afect the degree are involved in nearly all essential biological func- of protein binding and thus ionized calcium con- tions, including muscle contraction, the release of centration. In contrast, calcium normally leaves the Lithium extracellular compartment by (1) deposition into bone, (2) urinary excretion, (3) secretion into the intestinal tract, and (4) sweat formation. Hypercalcemia due to increased turnover metabolic conversion of (primarily endogenous) of calcium from bone can also be encountered in cholecalciferol, frst by the liver to 25-cholecalcif- patients with benign conditions such as Paget’s erol and then by the kidneys to 1,25-dihydroxycho- disease and chronic immobilization.

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Although anes- urinary retention cheap clomiphene online mastercard menopause problems, and exacerbation of glaucoma clomiphene 100mg sale menstruation quotes funny, thetic agents also decrease the shivering threshold buy clomiphene australia menopause 10 day period, particularly in elderly patients purchase forzest 20mg online. Emergence from even brief gen- tive for up to 24 hr cytotec 200 mcg mastercard, and cheap super cialis 80 mg otc, thus, may be useful for eral anesthesia is sometimes also associated with postdischarge nausea and vomiting. Oral aprepitant shivering, and although the shivering can be one (Emend®) 40 mg may be administered within 3 hr of several nonspecifc neurological signs (postur- prior to anesthesia induction. Other causes of shivering should be excluded, adequate hydration (20 mL/kg) afer fasting, and such as bacteremia and sepsis, drug allergy, or trans- stimulation of the P6 acupuncture point (wrist). Small intravenous Color Oxygenation doses of meperidine (10–25 mg) can dramatically Pink SpO2 >92% on room air 2 reduce or even stop shivering. Intubated and mechan- Pale or dusky SpO >90% on oxygen 1 2 ically ventilated patients can also be sedated and Cyanotic SpO2 <90% on oxygen 0 given a muscle relaxant until normothermia is rees- Respiration tablished by active rewarming and the efects of anes- Can breathe deeply Breathes deeply and 2 thesia have dissipated. Criteria can vary according to whether oriented Arousable but readily Arousable on calling 1 the patient is going to be discharged to an intensive drifts back to sleep care unit, a regular ward, the outpatient department No response Not responsive 0 (phase 2 recovery), or directly home. Activity Before discharge, patients should have been Moves all extremities Same 2 observed for respiratory depression for at least Moves two extremities Same 1 20–30 min afer the last dose of parenteral opioid. S t able vital signs for at least 15–30 min meet discharge criteria within 60 min from the time 5. Patients to be transferred to other intensive care areas need not meet all requirements. No obvious surgical complications (such as I n addition to the above criteria, patients receiv- active bleeding) ing regional anesthesia should also be assessed P ostoperative pain and nausea and vomiting for regression of both sensory and motor block- must be controlled, and normothermia should be ade. Documenting regression of a block is impor- Within 20% to 40% of preoperative baseline 1 tant. Failure of a spinal or epidural block to resolve >40% of preoperative baseline 0 6 hr afer the last dose of local anesthetic raises the possibility of spinal subdural or epidural hematoma, Activity level Steady gait, no dizziness, at preoperative level 2 which should be excluded by prompt radiological Requires assistance 1 imaging and neurologic evaluation. Similarly, inpatients who meet the same Pain: minimal or none, acceptable to patient, criteria may be transferred directly from the operat- controlled with oral medication ing room to their ward, if appropriate stafng and Yes 2 monitoring is present. A scoring system has been developed to help assess home readiness discharge (Table 56–3). Recovery of proprioception, sympathetic tone, blad- home can be delegated to a nurse, if approved dis- der function, and motor strengthare additional crite- charge criteria are applied. For example, intact Home readiness does not imply that the patient proprioception of the big toe, minimal orthostatic has the ability to make important decisions, to blood pressure and heart rate changes, and normal drive, or to return to work. Tese activities require plantar fexion of the foot are important signals of complete psychomotor recovery, which is ofen not recovery following spinal anesthesia. All outpa- drinking or eating before discharge are usually no tient centers must use some system of postoperative longer required; exceptions include patients with a follow-up, preferably phone contact the day afer history of urinary retention and those with diabetes.

Less common causes of hypocalcemia include cium may be necessary following rapid transfusions calcitonin-secreting medullary carcinomas of the of citrated blood products or large volumes of albu- thyroid generic 100 mg clomiphene fast delivery women's health magazine subscription, osteoblastic metastatic disease (breast and min solutions buy 100mg clomiphene with visa women's health center bethlehem pa. Clinical Manifestations Disorders of of Hypocalcemia Phosphorus Balance Manifestations of hypocalcemia include paresthe- sias purchase clomiphene on line amex menopause questions, confusion discount super levitra 80mg with amex, laryngeal stridor (laryngospasm) cheap cialis jelly 20mg line, Phosphorus is an important intracellular constitu- carpopedal spasm (Trousseau’s sign) buy discount levitra online, masseter ent. Its presence is required for the synthesis of spasm (Chvostek’s sign), and seizures. Biliary colic (1) the phospholipids and phosphoproteins in cell and bronchospasm have also been described. About 80% of that amount is normally disturbances, its secondary efect on plasma [Ca2+ ] absorbed in the proximal small bowel. Urinary excretion of phosphorus depends on both intake and plasma Treatment of Hyperphosphatemia concentration. Anesthetic Considerations Although specifc interactions between hyperphos- Plasma Phosphorus Concentration phatemia and anesthesia are generally not described, Plasma phosphorus exists in both organic and renal function should be carefully evaluated. Of the inorganic phos- phorus fraction, 80% is flterable in the kidneys and 20% is protein bound. By convention, plasma phosphorus negative phosphorus balance or cellular uptake of is measured as milligrams of elemental phospho- extracellular phosphorus (an intercompartmental rus. Large concentration is usually measured during fasting, doses of aluminum or magnesium-containing ant- because a recent carbohydrate intake transiently acids, severe burns, inadequate phosphorus sup- decreases the plasma phosphorus concentration. In contrast, severe decreased phosphorus excretion (renal insuf- hypophosphatemia (<1. Magnesium impairs the domyolysis, skeletal demineralization, metabolic calcium-mediated presynaptic release of acetylcholine acidosis, and hepatic dysfunction have all been asso- and may also decrease motor end-plate sensitivity to ciated with severe hypophosphatemia. In addition to the treatment of magnesium Treatment of Hypophosphatemia defciency, administration of magnesium is utilized therapeutically for preeclampsia and eclampsia, Oral phosphorus replacement is generally preferable torsades de pointes and digoxin-induced cardiac to parenteral replacement because of the increased tachyarrhythmias, and status asthmaticus. Of that amount, only 30–40% phate replacement is utilized, vitamin D is required is absorbed, mainly in the distal small bowel. Twenty-fve per- Anesthetic management of patients with hypophos- cent of fltered magnesium is reabsorbed in the phatemia requires familiarity with its complications proximal tubule, whereas 50–60% is reabsorbed in (see above). Hyperglycemia and respiratory alkalo- the thick ascending limb of the loop of Henle. Fac- sis should be avoided to prevent further decreases tors known to increase magnesium reabsorption in in plasma phosphorus concentration. Some patients with severe Factors known to increase renal excretion include 11 hypermagnesemia, acute volume expansion, hyper- hypophosphatemia may require mechanical ventilation postoperatively because of muscle aldosteronism, hypercalcemia, ketoacidosis, diuret- weakness. Approximately 50–60% of plasma magnesium Only 1–2% of total body magnesium stores is present is unbound and difusible. Magnesium sulfate therapy Inadequate intake for preeclampsia and eclampsia can cause hyperma- Nutritional gnesemia in the mother as well as in the fetus. Reduced gastrointestinal absorption Malabsorption syndromes Clinical Manifestations of Small bowel or biliary fistulas Hypermagnesemia Prolonged nasogastric suctioning Severe vomiting or diarrhea Symptomatic hypermagnesemia typically presents Chronic laxative abuse with neurological, neuromuscular, and cardiac manifestations, including hyporefexia, sedation, Increased renal losses Diuresis muscle weakness, and respiratory depression.