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Increased urine output from di uretics can normalize fluid status order karela 60caps with amex herbs list, but can also affect electrolytes and cause dehydration buy generic karela 60 caps herbals to lower blood pressure. FluId rePlacement Fluid replacement is a large part of therapy in critically ill patients generic 60 caps karela with mastercard herbalsagecom. Rapid administra tion of large volumes of fluid replaces fluid lost from the intravascular space and prevents further decompensation due to purchase karela 60caps online greenridge herbals low circulating volume. This strategy is important in treating many disease states, including shock, trauma, and burns. After the resuscitation period, fluid administration is adjusted to replace ongoing sensible and insensible losses. The main com ponent of crystalloids is water, with additional electrolytes and/or dextrose. Colloid particles are much larger than the electrolyte components in crystal loid solutions, so they tend to provide less free water and stay primarily in the intravascular space. These types of fluids may also contain dextrose to supply a glucose source and calories. Lactated Ringer’s solution contains electrolytes in amounts similar to serum levels and is used most often in trauma and surgery patients. Dextrose 5% in water (D5W) is also considered a crystalloid, but provides free water and distributes to both the intracellular and extracellular spaces. Since the goal of resuscitation is to replete intravascular volume, D5W is not typically used within this phase of treatment. Crystalloids are the primary fluid type for re suscitation and maintenance as they can be provided easily and at low cost. Colloids contain large molecules such as proteins or starches to increase oncotic pressure in the intravascular space. Blood is the only colloid that provides the advantage of intravascular volume expansion and increased oxygen-carrying capacity. The synthetic starches add to intravascular volume, but do not need blood typing and antigen matching as with blood products; similarly, albumin does not require typing and matching, but since it is derived from human sources, it still carries a very low risk of viral transmission. Each of these products has other advantages and disadvantages that will be discussed in individual disease states. Advance Trauma Life Support programs sponsored by the American College of Surgeons recommend crystalloids for resuscitation. These patients may require blood and/or crystalloids depending on patient-specific factors. One of the mainstays for treatment of brain injury has become the use of hypertonic crystalloids, which is intended to increase plasma osmolality and decrease cerebral edema. Chapter 15 has a thorough discussion of fluid management in traumatic brain injury. During the first 6 hours after presentation for sepsis, fluids are nec essary to achieve and maintain goal central venous pressure, mean arterial pressure, urine output, and central venous oxygen saturation. Maximizing fluid resuscitation and other components of Early Goal Directed Therapy as recommended by the Surviving Sepsis Campaign has been shown to reduce 28-day mortality. Either crystalloids or colloids are recommended during the resuscitation phase; generally, normal saline is the crystalloid most commonly used. Sodium is the major cation that determines serum osmolality, which regulates water flow, as water moves from one compartment to another of lower osmolality until ho meostasis is achieved. The total amount of sodium in the body is a component of water balance, but the concentration of sodium in the serum does not determine water balance. Serum sodium only determines the number of cations needed in the intra vascular space to maintain hemostasis with the interstitial and intracellular spaces. Total body sodium may not be accurately reflected by serum sodium concentrations, thus inappropriate treatment of serum sodium alterations may result in further complications. Imbalances in sodium are best evalu ated by first evaluating serum sodium, followed by serum osmolality, and then volume status. The signs and symptoms of hyponatremia are rather non-specific, and include headache, lethargy, disorientation, nausea, depressed reflexes, seizures, and coma. The treatment used to correct hyponatremia depends on the cause and duration of the imbalance, as well as the fluid status of the patient. Recent and acute onset hyponatremia is more likely to be symptomatic and can be more rapidly corrected compared to chronic hyponatremia, which is usually not associated with as severe of symptoms and should be corrected slowly. Common causes of isotonic hyponatremia include hyperlipidemia and hyperproteinemia. This is a not a true state of hyponatremia, as sodium in the aqueous portion of the serum is normal. Isotonic hyponatremia is treated by correcting the underlying cause or discontinuing any protein-based fluids. Hyperglycemia causes water to move into the extracellular space to decrease osmolality via sodium dilution. For every 100 mg/dl increase in glucose above 100 mg/dL, the mea sured serum sodium will decrease by 1. To further determine cause and treatment of hypotonic hyponatremia, volume status must be evaluated. Hypovolemic hypotonic hyponatremia occurs with fluid losses, such as during excessive diuresis, hemorrhage, diarrhea, and burns. In these patients, volume and sodium are replaced with normal saline or lactated Ringer’s solution. In this condition, continued fluid ad ministration will exacerbate the hyponatremia, and so water restriction is the preferred treatment. Diuresis with loop diuretics and administration of hypertonic saline can also be helpful.

Many of the cachectic inmates of concentration camps effective 60 caps karela herbals companies, after the second world war buy discount karela 60 caps line herbs lower blood pressure, suffered from this problem following release buy cheap karela 60caps on line herbals remedies, and many died as a result generic 60caps karela free shipping yogi herbals. Recommendations for the prevention and treatment of refeeding syndrome have been published elsewhere (17). Magnesium Magnesium is distributed mainly in bone (500-600 mmol) and intracellular fluid (500-850 mmol). Only 12-20 mmol is present in the extracellular fluid at a normal concentration of 0. Mg, like Ca is bound to albumin in the circulation and a low serum level must therefore be interpreted in the light of changes in serum albumin concentration. Nonetheless restoration of normal levels is associated in an improvement in wellbeing. At lower levels, there is neuromuscular irritability and, in severe cases, convulsions. All hypocalcaemic patients should therefore have a serum Mg measured and corrected if this is the primary problem. The Mg concentration in the upper small bowel is only 1 mmol/l, which rises in the more distal bowel, so that losses from distal stomas, fistulae, or diarrhoea, as in Crohn’s disease, are more likely to give rise to clinically significant hypomagnesaemia. Maintaining the serum Mg in the normal range in such patients is problematic, since Mg salts not very well absorbed and, in high doses, may exacerbate diarrhoea. Nonetheless these may be administered orally in limited doses in the form of magnesium oxide or glycerophosphate and have some benefit. In severe cases as much as 160 mmol of magnesium may need to be administered intravenously over 48 hours to correct the problem. In patients with recurrent hypomagnesaemia whose nutritional state is reasonable, or who are unsuitable for home parenteral nutrition, we have found (20), as an alternative to weekly visits to the hospital for peripheral intravenous infusions of Mg salts, that self-administered daily or alternate day subcutaneous fluids with Mg are extremely successful and very easy to administer. Although the serum Mg usually reflects the state of Mg stores, it can be unreliable at times. The best measure of repletion is to measure urinary Mg before and after Mg infusion. Phosphate Phosphate is the most abundant anion in the human body, totalling 1300 g or 33,000 mmol. Phosphate excretion is also important in acid-base balance since much hydrogen ion is excreted in this form. Many factors influence phosphate metabolism, although no entirely satisfactory regulatory mechanism has been demonstrated so far. Renal excretion of phosphate rises as plasma concentration increases unless renal failure is present. During catabolic illness, phosphate is lost from the cells and excreted by the kidney. Conversely, with the onset of convalescence and anabolism, or with glucose or nutrient administration, there is net cellular uptake of phosphate, which may lead to a dangerously low serum phosphate unless adequate phosphate supplements are given at the same time (see under Refeeding Syndrome). Hypophosphataemia causes muscle weakness, cardiac and respiratory failure, impaired consciousness, and death. Calcium Calcium is the most abundant cation in the body (1300 g or 33,000 mmol), with 99% being in the skeleton with only1 % being freely exchangeable. Calcium plays a vital role in neural conductivity, muscle contraction, hormone secretion, and as a second messenger in many metabolic processes. Falls in free Ca levels are associated with tetany, fits, unconsciousness, and even death. Adequate supplementation of calcium and vitamin D is therefore a vital part of any long term nutritional management, particularly in infants, children, and pregnant women. Clinical Importance and Consequences of Errors in Treatment Fluid and electrolyte prescribing is often left to the most junior and inexperienced doctors on the team and this may often result in errors in prescribing, leading to morbidity and even mortality (1-5, 21). Both underprescription of fluid and electrolytes and overload are detrimental to patient outcome (Tables 4 and 5) and every effort should be made to ensure, as far as possible, a state of normal balance. Table 4 Some clinical features associated with salt and water overload Peripheral oedema Gastrointestinal oedema Pulmonary oedema Congestive cardiac failure Hyperchloraemic acidosis Confusion Increased intraabdominal pressure Delayed return of gastrointestinal function to normal (prolonged ileus) Impaired wound healing, anastomotic oedema and anastomotic dehiscence Pressure sores Increased risk of deep vein thrombosis Delayed mobilisation Table 5 Clinical features of salt and water depletion. Conversely, failure to replace lost fluids adequately also results in poor outcome. A recent meta-analysis has shown that maintaining perioperative patients in a state of “fluid balance” leads to 59% fewer complications and 3. In fluid and electrolyte therapy, accurate diagnosis, monitoring and prescription combined with a clear understanding of the underlying problem are mandatory to obtain the best results and avoid unnecessary morbidity and mortality. Prescription and Administration Appropriate fluid and electrolyte prescriptions may be administered orally, enterally, subcutaneously, or intravenously, depending on the clinical situation. Before any prescription is written it is important to ask a number of questions: 1) Does the patient need any prescription at all today? If the patient is eating and drinking, the answer to the first question is usually no. In the case of a post-operative patient, for example, any intravenous fluids should be discontinued as soon as possible. Intravenous fluids are often continued unnecessarily, leading to fluid overload as well as increased risk of cannula-site sepsis. Many patients are fluid overloaded because prescriptions based on resuscitation are continued thoughtlessly when maintenance fluids are all that is required.

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The segmental branches of the intrahepatic biliary tree should be preserved and small vessels displaced by tumour growth may be ligated and divided by suture-ligature stitches buy karela 60 caps free shipping bestlife herbals. Accidental ligature of larger intrahepatic vascular structures must be avoided as these could give rise to purchase karela 60 caps on-line herbals 24 biliary fistulae cheap 60 caps karela goyal herbals private limited. Unrecognized small biliary leaks are the most frequent cause of perihepatic infection buy 60caps karela fast delivery zever herbals, giving rise to subphrenic abscesses. Nevertheless, in attempting to simplify the procedure we prefer to use clips to dissect through liver tissue. Maintaining the integrity of the biliary tree For several years cholangiography after tumour excision had been the rule for many surgeons to ensure the absence of biliary fistulae. Nevertheless, this procedure usually involves a cholecystectomy which is unnecessary, particularly when the bile duct is far from the tumour. Less frequently this is undertaken by transhepatic puncture, afterwards compressing the parenchyma in order to force the passage of contrast into the bile duct, or by direct puncture of the common hepatic or bile duct. Nevertheless, identification of a biliary fistula on the raw liver surface—even if this is small in diameter—may be done by wiping with a surgical gauze. By moving this slowly away from the liver surface a small stain of bile can be seen which indicates its exact location. Assisting biliary drainage with a T-tube is not indicated for any type of liver resection, considering the fact that this increases the morbidity of the procedure. Surgical Management of hepatobiliary and pancreatic disorders 296 the raw surface is fulgurated by argon beam coagulation, thus removing any microscopic capsular remains which could have been left behind. This is because reabsorbable polyglycolic acid is sensitive to the high temperatures of fulguration. Drainage in the residual cavity the use of postoperative intra-abdominal drainage has been questioned over the last few years. The basis for avoiding drainage is that perfect haemostasis, absence of biliary fistula, and the avoidance of poorly vascularized tissues will reduce the risk of postoperative collections. For this reason, once confirmed by waiting a few minutes and rinsing with warm saline, it is not necessary to drain the operative field. In addition, the surgical field is located in the free abdominal cavity, so that the transudate produced may be reabsorbed through the peritoneal mesothelium. On the other hand, drainage keeps the external space in contact with the inside of the abdominal cavity, with the attendant risk of subsequent infection. Operative mortality Enucleation or resection of cavernous haemangiomas can only be undertaken in the absence of serious complications and mortality. However, there are reports of between 2 and 5% operative mortality at 30 days after operation. These patients have normal hepatic parenchyma, and are generally between the third and sixth decade of life, without any deranged hepatic function and with normal coagulation studies. Factors which may be related to postoperative mortality are: co-existence of cirrhosis of the liver, respiratory failure, kidney failure and/or cardiopathy. For this reason it is questionable whether patients in poor physical condition at an advanced age, or those with cardiopulmonary disease or kidney or liver failure, even if moderate, should be treated or not. In our experience, out of a total of 78 giant cavernous haemangiomas, no patients died in the postoperative period. Tumour recurrence Provided the considerations described above are observed, recurrence of the excised lesion within the liver is exceptional and must not be confused with the appearance of a haemangioma in the remaining hepatic tissue, far from the surgical field. We have never observed a case of tumour recurrence, and we advise surgical treatment whenever possible. Complications relating to growth of haemangiomas occur in approximately 20% of patients, resulting in subsequent excision when symptoms occur. The occurrence of rupture and haemorrhage is exceptional, and malignant transformation does not occur. One of the dangers of not monitoring these tumours is, without doubt, erroneous diagnosis, since the image of a cavernous haemangioma may be confused with other very vascularized tumours, such as hepatoma when located on a non-cirrhotic liver, when there is no background of viral infection and plasma levels of alphal-phetoprotein are normal. These conditions are not frequent in hepatomas, nor are they, however, exceptional. However, conservative management is acceptable when the diagnosis is absolutely clear and there are no indications to operate. Nevertheless, in spite of most surgeons agreeing with this approach, the reality is that even among experienced liver surgeons, 20–40% of haemangiomas remain undiagnosed with excisional biopsy. Radiotherapy this has been advocated in diffuse haemangiomas or in unresectable voluminous haemangiomas. For this reason it was used in patients who complained of pain in upper right quadrants due to capsular distension as a result of progressive tumour growth, or following episodes of intratumoural haemorrhage. For this reason it was superceded first by cobalt therapy and then subsequently by the linear accelerator. Use of the linear accelerator enables better limitation of the field, both on the surface and deeper within the liver, thus reducing undesirable effects on the surrounding healthy liver parenchyma. Following radiotherapy, reductions in volume of haemangiomas ranged between 20% and 40%, with approximately 30% improvement in symptomatology. However, radiotherapy is associated with a high rate of complications such as radiation hepatitis, and tumour rupture only a few months after completion of treatment, probably due to the increase in capsular fragility. Isolated cases of malignant transformation induced by radiotherapy have been described, as well as the development of malignant Surgical Management of hepatobiliary and pancreatic disorders 298 122 tumours at other sites after administration. Selective hepatic dearterialization Although the role of hepatic dearterialization was described 20 years ago, at present it is not widely indicated for the treatment of liver tumours. However, the effect of dearterialization is temporary, and blood flow is re-established through an intricate network of collateral branches. Short-term results are difficult to evaluate, but in the long term tumour size may be reduced, with a reduction in symptomatology as well, although only in exceptional cases. For this reason, at present embolization is not a procedure that can be widely recommended.

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Protein losses in body fluids can be measured but estimates range from 12-29 grams per liter cheap 60caps karela with visa worldwide herbals. Maintenance Fluids Maintenance fluid requirements for children and adults are calculated based on the lean body weight or body surface area buy 60caps karela otc herbals for high blood pressure. Several issues can affect the suggested rate of fluid administration including environment buy karela 60caps without a prescription herbs nyc cake, patient-related factors and disease-related factors discount karela 60 caps free shipping zain herbals. In addition, during the first week of life, infants are expected to lose 10-15% of body weight and an even greater 154 percentage for premature infants. Environmental factors that impact the amount of fluids needed may include ambient temperature and humidity, and specific treatments such as phototherapy. Patient related factors include skin maturity, birth weight, proportion of body fat, weight loss and urine output. Disease related factors might include large open wounds (such as patients with an open abdomen), burns, severe trauma or major surgery. Abnormal serum sodium levels are more responsive to changes in the rate of fluid administration rather than the amount of sodium supplementation. Beyond the first week of life, children are given 4 ml/kg/hour for the first 10 kg, 2 ml/kg/hour for the next 10 kilograms and 1 mL ml/kg/hour for any weight over 20 kilograms. Environmental losses are higher in radiant warmers compared to a humidified incubator. Infants with phototherapy should have a 50ml/kg/day increase in fluids while on phototherapy. Patients with gastroschisis, ruptured omphalocele, and bladder extrophy have greater evaporative losses requiring a bolus of 20 ml/kg of isotonic fluid at birth and an increase of the maintenance infusion by 20-25% until coverage of the exposed viscera is accomplished. Surgical patients often have gastrointestinal fluid losses that should be replaced with consideration of both the volume and electrolyte concentration of these losses. Electrolytes 156 Electrolyte requirements are related to fluid metabolism and, consequently, are similar between adults and children, with allowances for weight differences. Sodium is the primary extracellular cation, a major component of the serum osmolarity and is essential for growth as well as fluid homeostasis. Requirements may be greater for infants due to renal immaturity and the inability to maximally reabsorb sodium. Sodium requirements may also be affected by the administration of naturetic agents such as theophylline, caffeine, furosemide and dopamine. Hyponatremia is most frequently a result of water retention due to excess antidiuretic hormone secretion. Potassium is the primary intracellular cation and is essential for proper cardiac and neurologic function. Daily requirements are 1-2 mEq/kg/day to account for cellular proliferation and to replace obligatory renal losses. Consequently, for decreased renal function, careful adjustment and often cessation of potassium supplementation may be needed. Potassium is most safely administered by the enteral route; intravenous infusion should generally be 0. Potassium is inflammatory to veins and therefore should be given at concentrations of no more than 60 mEq/L in peripheral lines and 120 mEq/L in central lines, but usually at lower 157 concentrations. Potassium requires careful monitoring for acute and chronic renal failure, abnormal acid base status, abnormal glucose status and during the use of certain drug therapies such as digoxin, amphotericin, high dose beta agonists, insulin drips and diuretics such as furosemide. Chloride is an anion that is provided in parenteral solutions to balance the cations such as potassium and sodium. An overabundance of chloride can lower serum pH, causing a low anion gap metabolic acidosis. Enteral Nutrition Enteral nutrition is the safest and most economical means of providing calories and nutrients, avoiding the complications of parenteral feeding such as the need for central catheter insertion, with all its complications such as mechanical malfunction, sepsis, and metabolic problems. Management of fluid and electrolytes as well as acquisition of all macronutrients (carbohydrates, lipids, proteins) and micronutrients are facilitated by the normal function of gastrointestinal absorption. Infectious complications are diminished by direct nutritional support of the intestinal mucosa. A gastrostomy should be considered for any patient for whom it is anticipated that oral feeding is not possible or safe for a prolonged period of time. For patients with inadequate digestive function due to intestinal loss, predigested or 158 elemental formulas are available. In addition, patients with compromised intestintal length may benefit from the addition of pectin, psylium or loperamide. Special formulations are also available to assist patients with hepatic or renal failure. Most pediatric formulas have a caloric density of 1 kcal/ml, but often have formulations in the 1. Nutritional supplementation can be accomplished by adding Duocal (fat and carbohydrates, 42 kcal/tbsp), vegetable oil, medium chain fat emulsions, Beneprotein or Benefiber as needed. Newborns require 100-200 cal/kg/day for normal growth with an ideal weight gain goal of 15-20 g/kg/day in premies or 20-30 g/day in term babies. When possible, breast milk is the preferred nutrition in the first six to twelve months of life. Infants who are exclusively breast milk fed require 1ml/day of liquid multivitamin. Isomil and Prosobee, based on soy protein and corn syrup, can be used in infants with lactose or milk protein intolerance. Pregestimil and Alimentum are bovine milk based with hydrolyzed protein and are thought to benefit patients with suboptimal digestion and absorption such as short bowel syndrome, malabsorption, cystic fibrosis, and biliary atresia.

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