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The diabetic nephropathy of the transplanted kidney is prevented or minimized despite the nephrotoxic effects of cyclosporine purchase aciphex now gastritis heartburn. Even in pancreas transplantation alone buy 20 mg aciphex mastercard symptoms of gastritis and duodenitis, the damage of cyclosporine on the kidneys is less significant than the damage of the diabetic nephropathy in non-transplanted individuals cheap 10mg aciphex with mastercard gastritis diet ayurveda. There is also evidence that the microcirculation discount aciphex 10mg with mastercard gastritis diet , but not the macro- angiopathy, is improved (less foot ulcers). Finally, fertility of women with transplantation of kidney and pancreas is likely to be restored. Usually the kidney is transplanted extraperitoneally in the left lower quadrant and the pancreas intraperitoneally with part of the duodenum in the right lower quadrant. The pancreas is removed from the donor together with the liver, so that damage of the blood vessels that perfuse them is avoided, and then their separation follows. The pancreas can be maintained in a University of 424 Diabetes in Clinical Practice Wisconsin solution (special buffer solution) for up to 30 hours. The arterial perfusion of the pancreas is ensured with a graft from the bifurcation of the donor’s iliac artery, of a Y shape, while the inter- nal iliac artery is anastomosed to the splenic artery and the com- mon or external iliac artery is anastomosed to the superior mesenteric artery. Afterwards, the Y-shaped arterial graft of the donor is anastomosed with the external iliac artery of the recipient. The portal vein of the graft is anastomosed with the iliac vein or with the portal vein of the recipient. The exocrine part of the graft is drained either to the urinary bladder of the recipient or, more often, to an intestinal loop. Why is intestinal drainage of the exocrine part of the transplanted pancreas preferred today compared to drainage in the urinary bladder of the recipient, which was preferred in the past? Although the survival of both the graft and the recipient are similar in both techniques, intestinal drainage is nevertheless superior concerning the occurrence of metabolic complications (dehydration, acidosis due to bicarbonate loss, pancreatitis and urinary tract infections). Which medicines are administered postoperatively, after a simultaneous kidney and pancreas transplantation? Recently, Rapamycin (sirolimus) has been used as a maintenance treatment, or a medicine that inhibits the complete activation of T lymphocytes, or Daclizumab, an immunosuppressant humanized monoclonal antibody IgG1. This is selectively bound to the alpha-subunit (Tac subunit) of the interleukin-2 receptor, which is expressed on the surface of the activated lymphocytes. Usually, rejection concerns the cells of the exocrine part first, with the islets are rejected later. Therefore, monitoring of glycaemic control is not a reliable tool for the follow-up of the patient. The rejection of the pancreas only is less frequent than the rejection of both organs. In cases where the pancreas has been drained in the urinary bladder, the urinary 426 Diabetes in Clinical Practice amylase levels are monitored, which decrease when a rejection occurs; but in the case of intestinal drainage, this is not possible. A transcutaneous biopsy of the organ and/or the duodenal graft, guided by ultrasound, or transurethral biopsy is performed and antirejection treatment is administered. The islets constitute 2–3 percent of the volume of the pancreas and number roughly one million in a pancreas. They can be isolated from the pancreas of a brain- dead donor and placed with a small intervention (usually through the portal vein, with local anaesthesia) inside the liver of the recipient. New therapies in diabetes 427 number of the transplanted islets determines the sufficient production of insulin. Most research centres report that for every recipient, islets from two cadaveric pancreases are needed. The medicines that are usually given to a patient in an intensive care unit before he or she becomes an organ donor influence the quality of the islets. The process, from the moment of removal of the pancreas until the beginning of the islet isolation, should not exceed 18 hours, since the islets are destroyed quickly. Moreover, an islet transplantation centre has large expenses, since it employs very specialized personnel continuously on standby so that they can receive a cadaveric pancreas and process it to isolate the islets. During the isolation, around 30–50 percent of the cadaveric pancreatic islets are destroyed. It should be noted that every detail of the technique has not yet been determined, and it is not the same at all centres applying it. This entails different results and is one of the reasons why the number of islets received from a pancreas is not yet ideal. The most common undesirable side effect is the thrombosis of a branch of the portal vein or bleeding, which however can be controlled. As is the case for the transplantation of the whole pancreas, immunosuppression is needed, with the same risks as involved in transplantation of the pancreas (risk of infections, small percentage of lymphomas). From 1974 to the middle of 2004, the number of persons who were transplanted with islets and were published in medical journals was 750; from 1999 to 2003 this number was over 300. Before 2000 the rate of success was below 10 percent, and concerned individuals who had been transplanted with islets alone, or with islets and kidney simultaneously, 428 Diabetes in Clinical Practice or with islets after some time post-kidney transplantation. The particularity of this protocol is that it does not include any corticosteroids. It includes the medicines Daclizumab (a monoclonal antibody, inhibitor of the a-subunit of the interleukin-2 receptor) for induction, Sirolimus (a macrocyclic lactone) and Tacrolimus (an inhibitor of calsineurin) as maintenance therapy. The success of the Edmonton protocol resulted in the attempt of other research centres in Europe and America to try and use it as well. The results of the 36 islet transplantation centres that exist internationally were very mixed: in some centres very successful, in some very poor. The successful transplantation of one recipient from only one donor has also been announced. In Europe, a network of centres has been created by which cadaveric pancreases are dispatched to Germany (University of Giessen), Italy (Milan) or Switzerland (Geneva), where the islets are isolated and then sent back to the countries of origin, where they are transplanted, according to the Edmonton protocol. In January 2005 the transplantation of islets from a part of the pancreas of a living donor was also announced. In any case, until the methods of islet isolation are perfected and this protocol has been sufficiently carried out, islet transplantation should still be considered an experimental method of treatment, since the longevity of the transplanted islets is at present poor (up to five years). There have been experimental attempts to transplant porcine pancreatic islets to humans, since the insulin of the pig is almost identical to that of humans. The results are controversial and there is no unanimity for the New therapies in diabetes 429 methods and the real practical value of these experiments. The creation of experimental animals with human genes (transgenic animals), so that their organs are not rejected and an abundance of donors is created, will perhaps offer solutions in the future. The creation of b-cells in the laboratory from immature foetal cells (blastocytes or stem cells) and their transplantation is one more challenge for the researchers of the future. Experimental animal data and indirect evidence from human studies corroborate this belief.

There is less evidence for amitrip- tyline generic aciphex 20 mg without a prescription lymphocytic gastritis definition, capsaicin buy aciphex with mastercard gastritis diet 7 up coupon, duloxetine best 20 mg aciphex gastritis juicing, gabapentin order aciphex 10mg line gastritis diet , valproic acid, 24. Postherpetic neuralgia is continuation of the pain of her- Oxcarbazepine, mexiletine, clonidine, and lamotrigine pes zoster for longer than 3 months afer the rash resolves. A opioids, tricyclic antidepressants, gabapentin, pregaba- lin, and lidocaine patches. Topical afer the onset of herpes zoster symptoms can reduce the lidocaine is useful if allodynia is a problem. Evidence-based guideline sensory abnormalities, motor abnormalities, and trophic update: Pharmacologic treatment for episodic migraine preven- changes. Report of the Quality Standards Subcommittee of sympathetic dystrophy) occurs most ofen afer minor the American Academy of Neurology and the American Headache injury to a limb and is less commonly caused by central Society. A statement for healthcare profes- afer injury to a peripheral nerve that results in focal sionals from the American Heart Association/American Stroke defcits. Report of the Quality Standards Subcommittee of the American Academy of Neurology and the cations such as gabapentin, pregabalin, and carbamaze- American Headache Society. Continuum Dejerine-Roussy syndrome is a thalamic syndrome (Minneap Minn) 2015;21:1041– 1057. Practice parameter: The characterized by pain on the contralateral side of the diagnostic evaluation and treatment of trigeminal neuralgia body with anesthesia to pinprick. An extramedullary Subcommittee of the American Academy of Neurology and tumor can cause radicular pain. An evidence-based report Mutations in the sodium channel can cause increased pain of the Quality Standards Subcommittee of the American Academy sensitivity. Report of the American Academy of Neurology, the American Association of red extremities. An infant with a cranial bruit over the posterior cra- The nasolabial folds are symmetric, and the patient nium and bounding carotid pulses develops congestive closes both eyes well. A bone survey shows calcifcations fetal movements has poor respiratory efort and is of the patellae. His mother has male-pattern baldness, pto- Which of the following is most likely to be present in sis, and a persistent grip. A 1-year-old is found to have leukocoria on exami- not respond to phenobarbital, fosphenytoin, or leve- nation. A couple brings a baby they have adopted from helps to diagnose congenital myasthenic syndromes. Which of the following diagnoses worsen other types of congenital myasthenic syndromes. A 4-month-old is referred because of hypotonia and progressed to visual impairment and spastic tetraple- poor feeding. On examination, he has ptosis, at 16 months but has not done so in the past few weeks. A 9-month-old child presents with rapid eye move- Autism Screening Questionnaire ments. A child presents with fever, confusion, and seizures name is called but does respond to touch. Perinatal herpes simplex virus infection walking about 5 days afer spending time in the woods. Megalencephalic leukodystrophy with subcortical cysts and repetitive nerve stimulation are normal. Later, repeat imaging mother says that the child loses consciousness and then indicates that the narrowing is no longer present. These episodes occur when he is child had a viral illness 3 months before the stroke but exercising or scared. Which of the following diagnoses being prescribed methylphenidate for attention defcit should be suspected? W hat is Her seizures started 2 years ago, about 1 month afer the next diagnostic step? Muscular dystrophy genetic panel epilepsy monitoring unit, where she has an event with asynchronous jerking movements. A 13-year-old girl briefy loses consciousness whenever event, her phone rings, and the movements pause her blood is drawn. The Adrenomyeloneuropathy, arginosuccinase defciency, most common cause in the frst 24 hours of life is hypoxic- and X-linked adrenoleukodystrophy do not usually man- ischemic encephalopathy. It is usually inher- migration defects, intracerebral calcifcations, retinitis, ited from the mother. Adults with myo- also seen in congenital toxoplasmosis, but they tend to be tonic dystrophy type I tend to have male-pattern bald- difuse. Newborns can be diagnosed with Erb palsy (upper trunk plexopathy) is the most common gene testing. In patients with Prader-Willi syndrome, brachioradialis muscles, afecting fexion; and the supina- methylation studies demonstrate the absence of pater- tor muscle. T erefore, the arm is adducted and internally nally imprinted genes at chromosome 15q11-13. It is characterized by myoclonic jerks dur- This patient has Cayler syndrome, which is characterized ing sleep. Later in life, the most common presentation for galactose-1-phosphate uridyltransferase. Classic galacto- childhood stroke is hemiparesis, but this usually is not semia manifests in the newborn period with vomiting, seen in the newborn period. Seizures are a common pre- jaundice, lethargy, and a bleeding diathesis afer exposure sentation in neonates. Increased levels of very-long-chain fatty acids support the Although a child who has had a perinatal stroke may not diagnosis. Also, phytanic acid, pristanic acid, and pipe- have focal defcits at birth, he or she may later demon- colic acid concentrations may be elevated. Abnormal laboratory results should be repeated periventricular white matter injury. Kernicterus is also associated with high-frequency hearing loss and impaired vertical gaze. In the be screened for speech and language disorders, vision and newborn period, vein of Galen malformation typically hearing impairments, feeding and swallowing difcul- manifests with congestive heart failure. B have a brain malformation, a family history of neurologic disorders, or clinical worsening. Congenital Noonan syndrome is associated with pulmonary hypothyroidism is associated with prolonged physiologic valve stenosis. Lack of treatment can cause neurologic complications Menkes disease can cause intracranial hemorrhage such as intellectual disability. Menkes disease can be mistaken for child glossia and enlarged fontanelles that are slow to close. Neonatal hypoglycemia may result from syndrome have characteristic facial features, hypotonia, hyperinsulinism.

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On clinical examination buy generic aciphex on-line gastritis diet 3121, if placenta is found complete and the uterus is well-retracted without any significant vaginal bleeding trusted 10mg aciphex gastritis fundus, we generally do not explore the uterine scar as a routine discount aciphex 20 mg without a prescription diet during acute gastritis. Otherwise it may be done using two fingers inside to palpate the scar for detection of scar rupture buy aciphex from india gastritis mayo clinic. Deficiency anemia of which iron deficiency anemia (microcytic hypochromic) is common [see Fig. Dimorphic anemia is due to deficiency of both iron and folic acid or vitamin B12 (macrocytic or normocytic Fig. Arbitrary gradings with hemoglobin levels done are: Mild—Hb level: 8–10 gm%; Moderate—7–8 gm%; and Severe < 7 gm% (very severe: < 4 gm%). At what time (pregnancy, labor or puerperium) the risk of cardiac failure is greatest? Treatment would be guided according to the cause, period of gestation, type (discussed above) and severity of the anemia. However, as iron deficiency anemia is common, once she is diagnosed as a case of iron deficiency anemia, she is advised balanced diet rich in protein, iron, folic acid and vitamins. Fersolate tablet containing 200 mg ferrous sulfate (60 mg of elemental iron) is prescribed 1 tablet 3 times a day. The dose is to be increased depending upon the tolerance (6 tablets a day) till the blood picture is normal. Maintenance dose (1 tablet a day) is continued at least for 100 days following delivery. More than 50% of pregnant women in India are anemic, nearly 50% of all adolescent girls (adolescent girls constitute 20% of the total population) suffer from nutritional anemia and nearly 60% of all preschool children (< 6 years), suffer from varying degree of anemia. She should take this after the first trimester irrespective of her hemoglobin level. Her obstetric examination revealed, single fetus, longitudinal lie, cephalic presentation. Her investigations revealed fasting plasma glucose level was 110 mg/dl and 2-hour postglucose value was 150 mg/dl. Procedure: A 50 gm oral glucose challenge test without regard to time of the day or last meal, between 24 and 28 weeks of pregnancy, is done. Procedure: In the antenatal clinic, a pregnant woman is given a 75 gm oral glucose load without regard to the time of the last meal. During pregnancy: (a) Preterm labor, (b) infections (urinary tract, vulvovaginitis), (c) increased pre-eclampsia, (d) polyhydramnios (25–50%), (e) diabetic retinopathy, nephropathy. During labor: a) Shoulder dystocia, (b) increased operative delivery (cesarean section). Neonatal: (a) Hypoglycemia, (b) respiratory distress syndrome, (c) hyperbilirubinemia, (d) hypocalcemia, (e) cardiomyopathy. What should be the ideal plasma glucose level in woman with diabetes in pregnancy? Fat = 25–30% Usually three-meal regimen (breakfast 25%, lunch 30% and dinner 30%) of total calorie intake with several snacks in between are adviced. Women are advised to control diet first and if values are exceeded even on diet, insulin therapy is suggested. What are the important issues in the management of a woman with diabetes in pregnancy? Preconceptional counseling to maintain optimum glycemic status actually before conception. Prenatal diagnosis to detect fetal congenital malformations including echocardiography. Dietetic advice to maintain desired glycemic status, if not obtained, to use insulin. What are the indications of cesarean delivery for a woman with diabetes in pregnancy? Once blood glucose levels are controlled, many contraceptive options are there: – Combined oral contraceptive pills (low dose) may be used. Levels > 6, when measured in early pregnancy, increase the risk of fetal congenital malformations. She was advised admission by her physician for the plan of delivery due to the abnormal presentation of the baby. Obstetric examination revealed, single fetus longitudinal lie, podalic pole on the brim, head at the fundus, back on the right side and limbs are on the left side. What other information can be obtained with sonography besides breech presentation? What are the important areas of breech delivery where the cardinal movements take place? How do you formulate the management of a case with breech presentation during the antenatal period? What other information are necessary for planning the management of the above woman? Type of breech presentation (flexed or Frank breech or footling presentation), attitude of the head (flexed or extended), placental localization, estimated fetal weight, any congenital anomaly of the fetus or of the uterus. Successful version and delivery as vertex reduces the need for cesarean section significantly. Dangers are: • Rupture of the membranes and/or preterm labor • Placental abruption • Umbilical cord entanglement around the fetal parts • Fetal distress. What important factors must be considered before allowing her for vaginal breech delivery? What precautionary measures are taken and what principles are followed during the process of assisted vaginal breech delivery? Precautionary measures are taken beforehand for the availability of: (i) An anesthetist, (ii) pediatrician, (iii) assistant, (iv) episiotomy set, (v) a pair of obstetric forceps, and (vi) neonatal resuscitation set. Principles to follow are: (i) Not to be hasty, (ii) never to pull from below but to push from above, (iii) always to keep the fetus with the back anterior. Assistant is to give suprapubic pressure during this period to maintain flexion of the head. When there is difficulty in delivery of the shoulders, what maneuver is commonly done? With this rotation, the posterior shoulder which was initially below the sacral promontory appears below the symphysis pubis. The process is then repeated in a reverse direction to release the anterior shoulder. Obstetric examination revealed— single fetus, cephalic presentation, 3/5th palpable per abdomen, adequate liquor. Pregnancy continuing beyond 2 weeks of the expected date of delivery (> 294 days) is called post-term pregnancy (postmaturity).

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Hypothermia is associated with delayed drug greater than 25% of baseline measures discount 10mg aciphex with visa gastritis operation, may herald metabolism order aciphex with a visa gastritis tips, increased blood glucose discount aciphex 20mg mastercard gastritis reflux diet, vasoconstric- neurological events secondary to decreased cerebral tion cheap aciphex 10mg gastritis y dolor de espalda, impaired coagulation, and impaired resistance oxygenation. To avoid measuring the temperature of tracheal Consequently, temperature must be measured and gases, the temperature sensor should be positioned recorded perioperatively. For more on the clinical considerations T ere are no contraindications, although a particu- of temperature control, see Chapter 52. Insertion of are semiconductors whose resistance decreases pre- a urinary catheter is indicated in patients with con- dictably with warming. A thermocouple is a circuit gestive heart failure, renal failure, advanced hepatic of two dissimilar metals joined so that a potential disease, or shock. Catheterization is routine in some diference is generated when the metals are at dif- surgical procedures such as cardiac surgery, aortic or ferent temperatures. Disposable thermocouple and renal vascular surgery, craniotomy, major abdomi- thermistor probes are available for monitoring the nal surgery, or procedures in which large fuid temperature of the tympanic membrane, nasophar- shifs are expected. Infrared erative diuretic administration are other possible sensors estimate temperature from the infrared indications. Tympanic membrane tem- catheterization is indicated in patients having dif- peratures refect core body temperature; however, culty voiding in the recovery room afer general or the devices used may not reliably measure the tem- regional anesthesia. Complications of temperature monitoring are usually related to Contraindications trauma caused by the probe (eg, rectal or tympanic membrane perforation). Bladder catheterization should be done with utmost Each monitoring site has advantages and dis- care in patients at high risk for infection. The tympanic membrane theoretically refects brain temperature because the auditory Techniques & Complications canal’s blood supply is the external carotid artery. Bladder catheterization is usually performed by Trauma during insertion and cerumen insulation surgical or nursing personnel. Nasopharyngeal probes are sof rubber Foley catheter is inserted into the blad- prone to cause epistaxis, but accurately measure core der transurethrally and connected to a disposable temperature if placed adjacent to the nasopharyn- calibrated collection chamber. The thermistor on a pulmonary artery and minimize the risk of infection, the cham- catheter also measures core temperature. Rapid decom- Liquid crystal adhesive strips placed on the skin are pression of a distended bladder can cause hypoten- inadequate indicators of core body temperature dur- sion. Esophageal temperature sensors, ofen tubing inserted through a large-bore needle is an incorporated into esophageal stethoscopes, provide uncommon alternative. Inadequate pollicis muscle and facial nerve stimulation of the urinary output (oliguria) is ofen arbitrarily defned orbicularis oculi are most commonly monitored as urinary output of less than 0. Because it is the inhibition of the actually is a function of the patient’s concentrating ability and osmotic load. Urine electrolyte composi- tion, osmolality, and specifc gravity aid in the dif- A ferential diagnosis of oliguria. In addition, peripheral nerve B stimulation is helpful in assessing paralysis dur- ing rapid-sequence inductions or during continu- ous infusions of short-acting agents. Furthermore, peripheral nerve stimulators can help locate nerves to be blocked by regional anesthesia. Contraindications T ere are no contraindications to neuromuscu- lar monitoring, although certain sites may be pre- cluded by the surgical procedure. B : Stimulation Determining the degree of neuromuscular block- of the facial nerve leads to orbicularis oculi contraction. The orbicularis oculi recovers from neuromuscular ade using such an extremity could lead to potential blockade before the adductor pollicis. Clinical relax- direct stimulation of muscle should be avoided by ation usually requires 75% to 95% neuromuscular placing electrodes over the course of the nerve and blockade. To deliver a supramaxi- Tetany at 50 or 100 Hz is a sensitive test of neu- mal stimulation to the underlying nerve, peripheral romuscular function. Sustained contraction for 5 sec nerve stimulators must be capable of generating at indicates adequate—but not necessarily complete— least a 50-mA current across a 1000-Ω load. Indeed, acceleromyogra- tivity to neuromuscular blocking agents, use of phy can better predict residual paralysis, compared the peripheral nerve stimulator cannot replace with routine tactile train-of-four monitoring used in direct observation of the muscles (eg, the dia- most operating rooms, if calibrated from the begin- phragm) that need to be relaxed for a specific sur- ning of the operative period to establish baselines gical procedure. Furthermore, recovery of prior to administration of neuromuscular blocking adductor pollicis function does not exactly paral- agents. The diaphragm, rectus abdominis, Clinical Considerations laryngeal adductors, and orbicularis oculi mus- The degree of neuromuscular blockade is monitored cles recover from neuromuscular blockade by applying various patterns of electrical stimula- sooner than do the adductor pollicis. All stimuli are 200 µs in dura- indicators of adequate recovery include sustained tion and of square-wave pattern and equal current (≥5 s) head lift, the ability to generate an inspira- intensity. A twitch is a single pulse that is delivered tory pressure of at least –25 cm H O, and a force- 2 from every 1 to every 10 sec (1–0. Twitch tension is reduced by block results in decreased evoked response to hypothermia of the monitored muscle group stimulation. Decisions regarding adequacy of rever- Train-of-four stimulation denotes four suc- sal of neuromuscular blockade, as well as timing cessive 200-µs stimuli in 2 sec (2 Hz). The twitches of extubation, should be made only by consider- in a train-of-four pattern progressively fade as ing both the patient’s clinical presentation and nondepolarizing muscle relaxant block increases. Because it is difcult to estimate anesthesia care, producing potentially injurious the train-of-four ratio, it is more convenient to airway and respiratory function compromise. Disappearance of the fourth twitch rep- neuromuscular blocking agents instead of longer resents a 75% block, the third twitch an 80% block, acting drugs. The radiologist requests your help in provid- study with sedation, head injured and pediatric ing either sedation or general anesthesia. On the other hand, loss of airway control 1 h) and many scanners totally surround the body, from deep sedation could prove catastrophic be- causing a high incidence of claustrophobia in pa- cause of poor patient access and delayed detection. Good Other important considerations include the moni- imaging requires immobility, something that is dif- toring modalities available at a particular facility ficult to achieve in many patients without sedation and the general medical condition of the patient. The more powerful the scanner’s magnet, a plastic (not metal) precordial stethoscope can help as measured in Tesla units (1 T = 10,000 gauss), the to identify airway obstruction caused by excessive greater the potential problem. Palpation of a peripheral pulse or listening clude poor access to the patient during the imag- for Korotkoff sounds is impractical in this setting. Whenever sedation is ferromagnetic electrocardiographic electrodes, planned, equipment for emergency conversion to graphite and copper cables, extensive filtering and general anesthesia (eg, tracheal tubes, resuscitation gating of signals, extra-long blood pressure cuff bag) must be immediately available. Sedated patients need to have Mashour G, Orser B, Avidan M: Intraoperative continuous monitored anesthesia care to prevent awareness. Moritz S, Kasprzak P, Arit M, et al: Accuracy of a multitude of unforeseen complications, such as cerebral monitoring in detecting cerebral ischemia apnea or emesis. Myles P, Leslie K, McNeil J: Bispectral function monitoring to prevent awareness during anaesthesia. Rubio A, Hakami L, Munch F, et al: Noninvasive control Ben Julian A, Mashour G, Avidan M: Processed of adequate cerebral oxygenation during low fow electroencephalogram in depth of anesthesia antegrade selective cerebral perfusion on adults monitoring. Saidi N, Murkin J: Applied neuromonitoring in cardiac Frye E, Levy J: Cerebral monitoring in the operating surgery; patient specifc management. Semin and the intensive care unit—an introductory Cardiothorac Vasc Anesth 2005;9:17. J Clin Monit Comput Sessler D: Temperature monitoring and perioperative 2005;19:1.