By M. Corwyn. New York University.

These include nitroprusside (Nipride) generic tadalafil 2.5 mg, hydralazine (Apresoline) order tadalafil 20 mg, labetalol (Normodyne) discount 20 mg tadalafil overnight delivery, a beta-blocker generic 20 mg tadalafil, or nitroglycerin purchase tadalafil 10 mg amex. Beta-blockade should be used with Nipride in treating hypertension associated with an 20 Critical Care 393 aortic aneurysm. The emergency management of hypertension is discussed in Chapter 21, page 470 and the specific agents are discussed on page 439 and in Chapter 22. Pulse Pressure Pulse pressure is the difference between systolic and diastolic blood pressures. A wide pulse pressure is associated with: • Thyrotoxicosis • Arterial venous fistula • Aortic insufficiency Narrow Pulse Pressure: A pulse pressure <25 mm Hg. A narrow pulse pressure is associated with: • Significant tachycardia • Early hypovolemic shock • Pericarditis • Pericardial effusion or tamponade • Ascites • Aortic stenosis Mean Arterial Blood Pressure MAP is calculated by taking the diastolic pressure plus one third of the pulse pressure. Paradoxical Pulse: Paradoxical pulse is a function of the change in intrathoracic pres- sures during inspiration and expiration. If this variation occurs over a range >10 mm Hg, the patient is said to have a paradoxical pulse (Figure 20–1). Conditions associated with a paradoxical pulse: • Pericardial tamponade • Asthma and COPD • Ruptured diaphragm • Pneumothorax Heart Murmurs Monitor the ICU patient for the development of a new murmur. All new murmurs should be characterized by their intensity, location, and variation with position and respiration. Systolic Murmurs: Abrupt onset caused by conditions that have clinical significance 20 for the acutely ill patient: 1. Papillary muscle dysfunction following AMI is characterized by an apical systolic murmur. After rupture of the papillary muscle, a sudden pansystolic murmur of grade II–IV/VI may appear. The diagnosis of papillary muscle rupture can be made ei- ther at cardiac catheterization or by echocardiography. Diastolic Murmurs: The major concern is the appearance of a diastolic murmur in the acutely injured patient is bacterial endocarditis, an entity that is becoming more common in patients who are treated in ICUs for long periods. Foreign bodies, such as central venous lines, hyperalimentation lines, and pulmonary artery catheters, all contribute to the increas- ing incidence of bacterial endocarditis. Defined as three sequential heart sounds in which the first two beats of the triplet are closer together than the third. A newly occurring gallop may herald the onset of one or more of the following: • M I • Severe CHF • Mitral regurgitation secondary to injury of the papillary muscle 20 • Anemia 2. Common following open heart surgery (in this setting, does not necessarily indicate pathologic changes). Definitions Cardiac Output: Defined as the quantity of blood pumped by the heart each minute. Determinants of Cardiac Output Cardiac output is determined by heart rate and stroke volume. Stroke volume depends on the following: • Preload • Afterload • Contractility Preload: The initial length of the myocardial muscle fiber is proportional to the left ven- tricular end-diastolic volume. As the volume of blood remaining in the heart after each beat (end-diastolic volume) increases, the stretch on individual myocardial muscle cells in- creases. As the stretch increases, the energy of contraction increases proportionally until an optimal tension develops. Contractility: The ability of the heart to alter its contractile force and velocity indepen- dent of fiber length. In simple terms, it represents the intrinsic strength of the individual muscle fiber cells. Contractility can be increased by stimulation of beta-receptors in the heart (see below). Brief Review of the Adrenergic, or Sympathetic Nervous System Cardiac output and its determinants (preload, afterload, and contractility) are all influenced 20 by the adrenergic nervous system. The adrenergic system releases catecholamines (epineph- rine and norepinephrine), which bind to end-organ receptors. These adrenergic receptors are divided into two classes, designated alpha (α) and beta (β), and their actions are summa- rized in Table 20–1.

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Calculated by the formula Hemoglobin (g / dL) MCHC = Hematocrit Increased: Very severe purchase 20mg tadalafil, prolonged dehydration; spherocytosis Decreased: Iron deficiency anemia buy cheap tadalafil 2.5 mg on line, overhydration generic tadalafil 10 mg without prescription, thalassemia discount tadalafil 5mg fast delivery, sideroblastic anemia MCV (Mean Cell [Corpuscular] Volume) • 76–100 cu µm (SI: fL) The average volume of red blood cells best tadalafil 2.5mg. Increased: Sudden exercise, after trauma, bone fracture, after asphyxia, after surgery (espe- cially splenectomy), acute hemorrhage, polycythemia vera, primary thrombocytosis, 5 leukemias, after childbirth, carcinoma, cirrhosis, myeloproliferative disorders, iron deficiency Decreased: DIC, ITP, TTP, congenital disease, marrow suppressants (chemotherapy, alco- hol, radiation), burns, snake and insect bites, leukemias, aplastic anemias, hypersplenism, infectious mononucleosis, viral infections, cirrhosis, massive transfusions, eclampsia and preeclampsia, prosthetic heart valve, more than 30 different drugs (NSAIDs, cimetidine, as- pirins, thiazides, others) PMNs (Polymorphonuclear Neutrophils) (Neutrophils) • 40–76% • See also the “Left Shift” page 100. Severe exercise, last months of pregnancy, labor, surgery, new- borns, steroid therapy Pathologic. Bacterial infections, noninfective tissue damage (MI, pulmonary infarction, pancreatitis, crush injury, burn injury), metabolic disorders (eclampsia, DKA, uremia, acute gout), leukemias Decreased: Pancytopenia, aplastic anemia, PMN depression (a mild decrease is referred to as neutropenia, severe is called agranulocytosis), marrow damage (x-rays, poisoning with benzene or antitumor drugs), severe overwhelming infections (disseminated TB, sep- ticemia), acute malaria, severe osteomyelitis, infectious mononucleosis, atypical pneumo- nias, some viral infections, marrow obliteration (osteosclerosis, myelofibrosis, malignant infiltrate), drugs (more than 70, including chloramphenicol, phenylbutazone, chlorpro- mazine, quinine), B12 and folate deficiencies, hypoadrenalism, hypopituitarism, dialysis, fa- milial decrease, idiopathic causes RDW (Red Cell Distribution Width) • 11. Increased: Many anemias (iron deficiency, pernicious, folate deficiency, thalassemias), liver disease LYMPHOCYTE SUBSETS Specific monoclonal antibodies are used to identify specific T and B cells. Lymphocyte sub- sets (also called lymphocyte marker assays, or T- and B-cell assay) are useful in the diagno- sis of AIDS and various leukemias and lymphomas. The designation CD (“clusters of differentiation”) has largely replaced the older antibody designations (eg, Leu 3a or OKT3). Absolute CD4 count is used to initiate therapy with antiretrovirals or prophylaxis for PCP (see page 75). The CDC includes in the category of AIDS any patient with a CD4 count < 200 who is HIV-positive. General terms include poikilocytosis (irregular RBC shape such as sickle or burr) and anisocytosis (irregular RBC size such as microcytes and macrocytes). Sickling: Sickle cell disease and trait Spherocytes: Hereditary spherocytosis, immune or microangiopathic hemolysis, severe burns, ABO transfusion reactions Target Cells (Leptocytes): Thalassemia, hemoglobinopathies, obstructive jaundice, any hypochromic anemia, after splenectomy WBC MORPHOLOGY DIFFERENTIAL DIAGNOSIS The following gives conditions associated with certain changes in the normal morphology of WBCs. Activated Clotting Time (ACT) • 114–186 s • Collection: Black top tube from instrument manufacturer This is a bedside test used in the operating room, dialysis unit, or other facility to docu- ment neutralization of heparin (ie, after coronary artery bypass, heparin is reversed. Decreased: Autosomal-dominant familial AT-III deficiency, PE, severe liver disease, late pregnancy, oral contraceptives, nephrotic syndrome, heparin therapy (>3 days) Increased: Coumadin, after MI Bleeding Time • Duke, Ivy <6 min; Template <10 min • Collection: Specialized bedside test performed by technicians. A small incision is made, and the wound is wicked with filter paper every 30 s until the fluid is clear. In vivo test of hemostasis that tests platelet function, local tissue factors, and clotting factors. Nonsteroidal medications should be stopped 5–7 d before the test because these agents can affect platelet function. Nearly all of the coagulation factors ap- parently exist as inactive proenzymes (Roman numeral) that, when activated (Roman numeral + a), serve to activate the next proenzyme in the sequence. Increased: DIC, thromboembolic diseases (PE, arterial or venous thrombosis) 5 Fibrin Degradation Products (FDP), Fibrin Split Products (FSP) • <10 µg/mL • Collection: Blue top tube Generally replaced by the fibrin D-dimer as a screen for DIC Increased: DIC (usually >40 µg/mL), any thromboembolic condition (DVT, MI, PE), hepatic dysfunction Fibrinogen • 200–400 mg/dL (SI:2. Fibrinogen is cleaved by thrombin to form insoluble fragments that polymerize to form a stable clot. Increased: Inflammatory reactions, oral contraceptives, pregnancy, cancer (kidney, stomach, breast) Decreased: DIC (sepsis, amniotic fluid embolism, abruptio placentae), surgery (prostate, open heart), neoplastic and hematological conditions, acute severe bleeding, burns, venomous snake bite, congenital Lee-White Clotting Time • 5–15 min • Collection: Draw into plain plastic syringe; clotting time measured in sepa- rate tube Increased: Heparin therapy, plasma–clotting factor deficiency (except Factors VII and XIII). Most commonly used to monitor heparin therapy Increased: Heparin and any defect in the intrinsic coagulation system (includes Fac- tors I, II, V, VIII, IX, X, XI, and XII), prolonged use of a tourniquet before drawing a blood sample, hemophilia A and B Prothrombin Time (PT) • 11. The use of INR instead of the Patient/Control ratio to guide anticoagulant (Coumadin) ther- apy is becoming standard. INR provides a more universal and standardized result be- cause it measures the control against a WHO standard reference reagent. Most useful in serial measurement to follow the course of disease (eg, polymyalgia rheumatica or temporal arteritis). Wintrobe Scale: Males, 0–9 mm/h, females, 0–20 mm/h ZETA Scale: 40–54% normal, 55–59% mildly elevated, 60–64% moderately elevated, >65% markedly elevated Westergren Scale: Males <50 years 15 mm/h, >50 years 20 mm/h; female <50 years 20 mm/h, >50 years 30 mm/h Increased: Any type of infection, inflammation, rheumatic fever, endocarditis, neo- plasm, AMI Thrombin Time • 10–14 s • Collection: Blue top tube A measure of the rate of conversion of fibrinogen to fibrin and fibrin polymerization. Used to detect the presence of heparin and hypofibrinogenemia and as an aid in the evalua- tion of prolonged PTT Increased: Systemic heparin, DIC, fibrinogen deficiency, congenitally abnormal fib- rinogen molecules 6 LABORATORY DIAGNOSIS: URINE STUDIES Urinalysis Procedure 24-Hour Urine Studies Urinalysis, Normal Values Other Urine Studies Differential Diagnosis for Routine Urinary Indices in Renal Failure Urinalysis Urine Output Urine Sediment Urine Protein Electrophoresis 6 Spot or Random Urine Studies Creatinine and Creatinine Clearance URINALYSIS PROCEDURE For a routine screening urinalysis, a fresh (less than 1-h old), clean-catch urine is accept- able. If it cannot be interpreted immediately, it should be refrigerated (urine standing at room temperature for long periods causes lysis of casts and red cells and becomes alkalin- ized. Check the specific gravity with a urinometer or optic refractory urinometer (refractometer) on the remain- ing sample. While the sample is in the centrifuge and using the dipstick (Chemstrip, etc) supplied by your lab, perform the dipstick evaluation on the remaining portion of the sample. Make sure to allow the time noted before reading the test because reading before the time (up to 60 s) may yield false results. Record glucose, ketones, blood, protein, pH, nitrite, and leukocyte esterase if available. Agents that color the urine (phenazopyridine [Pyridium]) may interfere with the results of the dipstick. Mix the remaining sediment by flicking it with your finger and pour or pipette one or two drops on a microscope slide.

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For the stable larger (>1500 g) premature infant purchase tadalafil 20mg mastercard, the first feeding may be given within the first 24 h of life order tadalafil 20 mg overnight delivery. Early feeding may allow the release of en- teric hormones that exert a trophic effect on the intestinal tract discount tadalafil 10mg without a prescription. No established policies are available trusted tadalafil 2.5 mg, and delay and duration of delay in establishing feeding with those conditions varies for every institution tadalafil 5 mg low price. In general, enteral feeding is started in the first 3 d of life, with the objective of reaching full enteral feeding by 2–3 wk of life. Parenteral nutrition including amino acids and lipids should be started at the same time to provide for adequate caloric intake. Breast-feeding has many advantages: It is ideal for virtually all infants, produces fewer infantile allergies, is immunoprotective to the infant due to the presence of immunoglobulins, is convenient and economical, and offers several theo- retical psychologic benefits to both the mother and child. Occasionally, an infant cannot be breast-fed due to extreme prematurity or other problems such as a cleft palate. If commercial infant formula is chosen, no special considerations are needed for normal full-term newborns. The majority of infant formulas are isoosmolar (Similac 20, Enfamil 20, and SMA 20 with and without iron). Formulas for pre- mature infants, containing 24 Cal/oz (Similac 24, Enfamil 24, “preemie” SMA 24), are also isoosmolar and are indicated for rapidly growing premature infants. Many other “specialty” formulas are available for such conditions as milk and protein sensitivity, among others. For the initial feeding for all infants, use sterile water or 5% dextrose in water (D5W) if the infant is not being breast-fed. Ten % dextrose in water (D10W) should not be used because it is a hypertonic solution. There is controversy over whether infant formulas should be di- luted for the next several feedings if the infant tolerates the initial one. Some clinicians advocate diluting formulas with sterile water and advance as tolerated (eg, ¹ ₄ strength, increase to ¹ ₂ and then ³ ₄ strength). Others feel this is unnecessary and that full- strength formula can be used if infants tolerate the initial feeding without difficulty. Oral Rehydration Solutions: Infants with mild or moderate dehydration, often due to diarrhea or vomiting, may benefit from oral rehydration formulas. These solutions typically include glucose, sodium, potassium, and bicarbonate or citrate. Peripheral veins simply cannot tolerate 12 these hypertonic fluids, and thus peripheral IV alimentation can be used only as a supple- ment. Parenteral nutrition bypasses the GI tract and should be reserved for patients who are unable to receive nutritional support enterally. The following indications are appropriate for TPN initiation: • Preoperatively, in the malnourished patient. The interval between surgery and initiation of nutritional support to prevent complications is not defini- tively known. However, many practitioners wait 7–10 d after surgery, anticipating the return of bowel function. This may include patients with organ failure, severe metabolic stress, malignancies, burns, or trauma. NUTRITIONAL PRINCIPLES Nutritional assessment to determine the need for TPN requires a history (which in- cludes weight changes over the previous 6 mo), physical, and laboratory evaluation. In- dicators of long-term nutritional depletion include serum albumin and prealbumin levels, 227 Copyright 2002 The McGraw-Hill Companies, Inc. The best method for calculating the BEE re- quirements for nonprotein calories is the Harris–Benedict equation (Chapter 11, page 209). The weight used in this equation determines the amount of calories needed to maintain that weight; therefore, if the patient is morbidly obese, the ideal weight should be established as a goal. Stress, in nutritional terms, is correlated with the amount of cate- cholamines and cortisol released endogenously.

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