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By: S. Randall, M.B.A., M.D.

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Improvement or maintenance of functional status is the major goal of medical care in the geriatric population medicine dictionary order cefuroxime 500 mg online. Functional disability occurs faster and takes longer to correct in the elderly treatment sinus infection buy cefuroxime on line amex, necessitating early preventive measures symptoms 6dpiui generic cefuroxime 250 mg overnight delivery. Active efforts should be made to maintain functional level even during intensive care symptoms lactose intolerance generic 250mg cefuroxime visa. For example, regaining the ability to oppose the thumb to other fingers may enable a geriatric patient to become independent in feeding. For example, close attention should be paid to prevent the development of pressure ulcers. A pressure ulcer can develop in just few hours, and the mortality rate of those who develop the lesions in the first 2 weeks of intensive care has been reported to be as high as 73%. Multiple concurrent illnesses, cognitive and sensory impairments, age-related changes in physiology and pharmacodynamics, increased vulnerability to delirium, and complications from immobility make management of acute illness in the elderly a clinical challenge for all physicians and other health care providers who care for patients in this age group. Physiologic Changes with Age the Aging Heart Heart disease is the leading cause of death in people over 75 years of age and the fourth most prevalent chronic disease in the elderly. Moreover, occult cardiac disease can cause marked functional impairments in otherwise apparently healthy elderly people. Coronary atherosclerosis increases exponentially with age and, in the elderly, can present as heart failure, pulmonary edema, arrhythmias, or exercise intolerance rather than as angina or obvious myocardial infarction. Age-related changes in collagen and elastin contribute to progressive stiffness and loss of recoil of elastic tissues. In the systemic arteries, this process contributes to an increase in systolic blood pressure. In addition, the systolic pressure may be underestimated by the cuff sphygmomanometer in the elderly. Resistance to blood flow leads to increased left ventricular wall tension and compensatory left ventricular hypertrophy. The myocardium is also affected by changes in collagen and elastin that cause stiffness of the left ventricle that can result in diastolic dysfunction. The left ventricular filling rate during early diastole declines markedly with age (approximately a 50% reduction between age 20 and age 80). Heart rate At rest: unchanged Maximal heart rate with exercise: decreases At rest: unchanged With exercise: increases At rest: unchanged With exercise: fails to increase as much as in younger subjects At rest: unchanged Low- and medium-intensity exercise: unchanged High-intensity exercise: fails to increase as much as in younger subjects Decreases Increases Decreases the Aging Lung Cross-sectional population studies consistently show a progressive age-related decline in pulmonary function. The decrements in flow rates and lung volumes are not uniform throughout life but tend to accelerate with age. Given the large individual differences in the elderly, longitudinal studies would be preferable for observing the change in pulmonary function, which is influenced not only by age but also by environmental factors such as smoking, air pollution, infections, and other comorbid conditions. Age-related changes in collagen and elastin produce a decrease in lung compliance, but this is not physiologically significant. However, rigidity of the chest wall with aging has measurably negative mechanical implications resulting in significantly increased work of breathing. All expiratory flow rates decrease with age and tend to fall faster in men, taller individuals, and those with increased airway reactivity. Age-related changes in lung structure and chest wall mechanics lead to premature closure of terminal airways. The following equation predicts PaO2 at sea level in the adult: Stroke volume Ejection fraction Cardiac output Early diastolic left ventricular filling rate Late diastolic left ventricular filling rate (atrial "kick") Ventricular compliance heart failure when atrial fibrillation or flutter occurs. Decreased filling also makes the elderly more vulnerable to small decreases in venous filling with volume loss or when given opioids, diuretics, or positive-pressure ventilation. On the other hand, systolic function is relatively preserved in the healthy elderly.

Nitroprusside is a potent reducer of left ventricular afterload and is particularly valuable in treating severe congestive heart failure symptoms knee sprain cefuroxime 250mg cheap. Disadvantages include toxicity in patients with renal insufficiency who are given nitroprusside over a prolonged period of time medications without a script cefuroxime 500 mg low price. Digoxin and diuretics are still important despite development of newer classes of drugs medicine allergies cefuroxime 250mg lowest price. Because of negative inotropic effects medicinenetcom best order cefuroxime, calcium channel blockers and beta-blockers are used with extreme caution, if at all, in patients with acute congestive heart failure. Occasionally, however, congestive heart failure may be secondary to tachyarrhythmias, left ventricular diastolic dysfunction, or severe transient ischemia, and these drugs then play an important role. Close hemodynamic monitoring, usually with a pulmonary artery catheter, allows the physician to titrate multiple drugs optimally. In cases of severe cardiogenic shock with low cardiac output, use of mechanical devices including intraaortic balloon pump or left ventricular assist devices is a consideration. The use of these devices involves decisions regarding long-term treatment options, prognosis, and underlying disease etiologies. The decision to intervene at this level requires consultation with a cardiac catheterization team and the heart transplant team or heart failure specialists. General treatment of congestive heart failure in critically ill patients includes oxygen, bed rest, and reduction of metabolic derangements that increase myocardial oxygen demand (eg, fever and anemia). Endotracheal intubation and mechanical ventilation usually are not necessary, except in severe cardiogenic pulmonary edema. Specific Treatment of Congestive Heart Failure- Patients with congestive heart failure can be subdivided into several groups for which specific treatments can be described as follows: 1. Systolic dysfunction without hypotension-These patients have low stroke volumes and ejection fractions and usually have tachycardia. Cardiomegaly may be due to ventricular hypertrophy, right ventricular dilatation, or pericardial effusion rather than an enlarged left ventricle itself. In patients who present with symptoms and signs of primarily right-sided heart failure-such as elevated jugular venous pressure, ascites, edema, and evidence of right ventricular hypertrophy- lung disease resulting in cor pulmonale, or pulmonary arterial hypertension (eg, pulmonary arteriopathy, idiopathic or secondary pulmonary arterial hypertension, or pulmonary emboli) should be considered. Patients with hypotension from cardiac failure should be distinguished from those with volume depletion, sepsis, and pulmonary embolism. Diuretics are useful in reducing volume overload, particularly when signs of right-sided failure such as peripheral edema, elevated jugular venous pressure, and liver engorgement are present. Metolazone or hydrochlorothiazide can augment the effectiveness of furosemide by further inhibiting reabsorption of sodium. Sustained diuresis with any of these agents is associated with significant loss of potassium and magnesium. Nesiritide is a recombinant human B-type natriuretic peptide that is indicated for intravenous treatment of acutely decompensated congestive heart failure. Spironolactone has been shown to decrease mortality in chronic congestive heart failure and can be added to help spare potassium loss in the acute situation. Finally, patients in severe congestive heart failure with renal dysfunction may be unable to excrete large amounts of sodium and water, so ultrafiltration may be needed to correct volume overload. Newer devices allow removal of fluid at rates up to 400 mL/h using specially designed 18-gauge peripheral lines and therefore eliminate the need for a large-bore vascular catheters. However, if electrolyte abnormalities and renal dysfunction compound the volume overload, dialysis may be required. Noninvasive positive-pressure ventilation using tight-fitting masks can be useful in acute pulmonary edema. A significant reduction in the need for mechanical ventilatory support has been demonstrated in patients present with acutely decompensated congestive heart failure with the use of this noninvasive form of ventilation compared to standard therapy. It appears that the positive-pressure breathing lowers preload and left ventricular afterload, improves oxygenation, and provides time for pharmacologic therapy to work.

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Patients received either 5 or 6 plasma exchanges of 25-45 ml/kg on alternate days or 0 medications used to treat bipolar generic 500mg cefuroxime. Myeloma kidney (cast nephropathy) accounts for approximately 30-80% of such cases symptoms diagnosis 500 mg cefuroxime overnight delivery, depending on the class of M-protein medications hydroxyzine purchase cefuroxime paypal. Autopsy studies show distal renal tubules obstructed by laminated casts composed of light chains (Bence-Jones protein) medicine 2015 lyrics cheap cefuroxime 500 mg online, albumin, Tamm-Horsfall protein and others. This may result from the overwhelming of proximal tubule processing of light chains when light chain production is rising due to tumor progression Other contributing factors may include hypercalcemia, hyperuricemia, dehydration, intravenous contrast media, toxic effects of light chains on distal tubular epithelium, etc. Current management/treatment Therapeutic approaches rely on inducing an alkaline diuresis through intravenous administration of normal saline and sodium bicarbonate with or without loop diuretics. Anti-myeloma chemotherapy consisting of an alkylating agent with a corticosteroid is used to diminish M-protein production. More recently, immune modulation (thalidomide, lenalidomide) and proteosome inhibition (bortezomib) have emerged as effective therapy. Rationale for therapeutic apheresis Although chemotherapy and alkaline intravenous fluid are the primary modes of therapy, plasma exchange has been used to acutely decrease the delivery of light chains to the renal glomerulus for filtration. Peritoneal dialysis (but not hemodialysis) can also remove light chains but with lower efficiency than plasma exchange. A randomized trial of 21 patients with biopsy-proven myeloma kidney (cast nephropathy) who received melphalan, prednisone and forced diuresis with or without plasma exchange showed no statistically significant outcome differences. However, among a dialysis-dependent subgroup, 43% in the plasma exchange group and none in the control group recovered renal function. This led to an endorsement of plasma exchange for myeloma kidney by the Scientific Advisors of the International Myeloma Foundation. The largest randomized trial of chemotherapy and supportive care with or without plasma exchange failed to demonstrate that 5 to 7 plasma exchange procedures over 10 days substantially reduces a composite outcome of death, dialysis dependence or estimated glomerular filtration rate of <30 ml/min/1. This study has called into question the role of plasma exchange in the treatment of myeloma kidney in an era of rapidly effective chemotherapy. On the other hand, this study has been criticized in that most of the enrolled patients were not proven to have cast nephropathy by renal biopsy, confidence intervals were wide, suggesting the study was underpowered, and the composite outcome undervalued an end result of dialysis independence for many patients. Survival at six months, as opposed to end points more specific to recovery of renal function, has also been questioned as part of the composite outcome. More recent data suggest that plasma exchange has only transient effects on serum free light chains as measured using a clinically available assay. Biopsy-proven cast nephropathy may be an important supportive finding if plasma exchange is contemplated. Technical notes Initial management, especially in the case of nonoliguric patients, should focus on fluid resuscitation (2. If serum creatinine remains elevated after several days, consider addition of plasma exchange. All of the published studies combine plasma exchange with chemotherapy and other forms of supportive care described above. Published studies vary with respect to treatment schedules and replacement fluids employed for plasma exchange. If plasma exchange and hemodialysis are to be performed on the same day, they can be performed in tandem (simultaneously) without compromising the efficiency of the hemodialysis procedure. Smaller trials have demonstrated improved 1-year survival in the groups whose treatment included plasma exchange, the largest, randomized trial did not demonstrate improved survival at six months. In all cases ultimate survival depends on a satisfactory response to chemotherapy. It has also been seen in patients with hepatorenal syndrome and in the perioperative period following liver transplantation. It occurs in 2 to 7% of patients with chronic renal failure receiving Gd contrast agents. Additional findings may include hair loss, gastroenteritis, conjunctivitis, bilateral pulmonary infiltrates, and fever. Over 6 to 12 months, the swelling, pruritus, and sensory changes resolve while the skin progresses to a thickened, hardened dermis/subcutis with epidermal atrophy. Fibrosis results in joint contractures leading to wheel chair dependence and may extend into deeper tissues including skeletal muscle, heart, pericardium, pleura, lungs, diaphragm, esophagus, kidneys, and testes. In 5% of patients, the disease progresses rapidly to death within weeks to months while the remaining demonstrate slow progression.

A sufficiently large endotracheal tube-preferably at least 8 mm-is usually needed medications zopiclone discount cefuroxime 250mg with amex. If extensive bleeding continues medicine 44390 generic 500mg cefuroxime overnight delivery, selective endobronchial intubation of the nonbleeding lung for ventilation can be performed by advancing the endotracheal tube into a main bronchus to protect the nonbleeding lung medications ok for pregnancy order cefuroxime 500 mg fast delivery. For uncontrolled right-sided bleeding treatment authorization request generic cefuroxime 500mg with visa, the endotracheal tube should be inserted into the left main bronchus under fluoroscopic or bronchoscopic guidance. The left lung is selectively ventilated, and blood is allowed to come up the trachea around the tube. For left-sided bleeding, however, the endotracheal tube cuff should be placed in the trachea, and a balloontipped catheter (eg, Fogarty-type 14F balloon) is used to seal the left main bronchus while the right lung is selectively ventilated. This method permits ventilation of the entire right lung, including the right upper lobe, because its opening is usually close to the carina and is frequently blocked by the insertion of an endotracheal tube into the right mainstem bronchus. Placement of the balloon-tipped catheter may be difficult while there is active bleeding. Although the use of double-lumen endobronchial tubes for split lung ventilation during thoracic surgery has been advocated to separate the bleeding lung from the nonbleeding lung, these tubes are not placed easily by inexperienced persons and are subject to displacement even if situated properly. In addition, the two lumens are small, which limits the amount of blood that can be suctioned. Both Carlens-type double-lumen tubes and newer plastic double-lumen tubes with soft low-pressure tracheal and bronchial cuffs have been used to achieve lung separation in hemoptysis, but only experienced personnel familiar with these devices should be asked to insert them. To maintain the position of these tubes, patients generally require heavy sedation and sometimes even paralysis. Bronchial Artery Embolization-Bronchial arteriography and selective bronchial artery embolization with artificial material (eg, polyvinyl alcohol, steel coils, and gelatin sponge) have greatly changed the management of severe hemoptysis. Control of bleeding is achieved with a high degree of success in patients with a variety of causes of hemoptysis. Bronchial artery embolization is performed by identifying bronchial arteries leading to the affected side, the usual patterns consisting of one or two bronchial arteries on each side arising from the aorta between the fifth and sixth thoracic vertebrae. Branches of these arteries also may supply anterior spinal arteries and intercostal arteries. Complications of this procedure include distal arterial embolization if the catheter is not placed far enough into the selected artery and spinal cord damage if embolization is performed into a branch supplying both the bronchial artery and the spinal cord. If performed with proper care, this procedure is highly effective and may lead to long-term resolution of hemoptysis as well as short-term control prior to definitive therapy. Estimates of immediate control of bleeding by bronchial arterial embolization range as high as 90% of patients. Recurrent bleeding after successful embolization may suggest the need for repeat embolization in the same or other areas. In some patients with chronic inflammatory lung disease, identification of collateral arterial vessels may be important. In one study, lasting control of hemoptysis was achieved in 82% of patients during follow-up for as long as 24 months. Surgical Treatment-Surgical resection of the bleeding lobe or segment in patients who can tolerate the procedure removes the threat of recurrent bleeding. Earlier reports of mortality rates higher than 30% from resectional surgery in massive hemoptysis are now considered to be due to ongoing bleeding, poor pulmonary function, and failure of preoperative localization of the bleeding site. Local control of bleeding by airway management or bronchial artery embolization allows surgery to be performed under more controlled conditions, and emergency surgery is now quite rare, with a corresponding decrease in surgical deaths. On the other hand, many patients with severe hemoptysis will not be surgical candidates because of extensive bilateral lung disease and severe reduction of lung function. Of the remainder, medical management is usually adequate to control bleeding, and early surgical therapy is reserved for those with progressive aspiration of blood or inability to control bleeding. There is debate about prophylactic surgical resection after severe hemoptysis has resolved. This risk of recurrent life-threatening hemoptysis has prompted some to perform elective resectional surgery in all patients with hemoptysis in whom surgery is deemed tolerable. However, while there is nearly universal agreement that surgery is indicated for recurrent hemoptysis from a tuberculous or other cavity in which a mycetoma is identified, prophylactic surgery is not universally recommended. Potential candidates for resection include those with well-localized disease, adequate pulmonary function, minimal pleuropulmonary adhesions, and a high likelihood of recurrence.