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Two major forms are described: Hypokalemic Periodic Paralysis It is the most common form of periodic paralysis cheap 50 mg solian with mastercard symptoms for pregnancy. The weakness may progress to flaccid paralysis of all limbs with areflexia and normal sensation order discount solian medications given for uti. It does not cause respiratory compromise despite the presence of dramatic limb paralysis cheap 100mg solian with amex treatment multiple sclerosis. Light exercise can prevent an attack and an acute attack can be relieved by intake of glucose purchase generic solian from india symptoms xxy. Erythema and edema of periorbital area and extensor surfaces may be seen in dermatomyositis. These include critical illness polyneuropathy, acute myopathy or both and manifest as prolonged ventilatory dependency. Critical illness polyneuropathy is characterized by development of neuropathy during a severe illness requiring intensive care. Acute necrotizing myopathy in sepsis or trauma presents as a sudden onset of generalized muscle weakness, high blood creatinine kinase and myoglobinuria. The management strategies in neuromuscular respiratory failure include: Respiratory Management Careful assessment of the upper airway and the patients ability to protect his/her airway is essential. None of these can replace clinical observation and judgment in this cohort of patients. More important is a clinical and constant watch on the patients effort, air entry, pattern of breathing- abdomino-thoracic, loss of diaphragmatic movement etc; use of accessory muscles, diaphoresis, restlessness or drowsiness. Administration of O2 to keep up a falling saturation is foolhardy as it only saves to mask hypoventilation and delay proper intervention. As the lungs are usually normal, a small amount of O2 will cause a quick and steep rise in SpO2 and PaO2 and this will give a false sense of security. Peak flow meters and single breath counts are good bed side tools in the co-operative patient. Although ventilatory support is clearly indicated in the setting of frank respiratory failure, particularly when there is cardiovascular instability, ideally it should be initiated in the setting of emerging respiratory failure when there has been a clear downward trend in respiratory function. The options for ventilatory support include endotracheal intubation, noninvasive positive pressure ventilation and tracheostomy, which are discussed below. It has generally been initiated when the underlying disease process is new or uncontrolled and the patient manifests evidence of emerging respiratory failure. Noninvasive positive pressure ventilation —An alternative to elective intubation in selected patients involves the use of noninvasive positive pressure ventilation. This modality may be tried in patients who present with early acute respiratory failure, are cooperative, can protect their airway with intact brain stem and lower cranial nerve function, have adequate upper airway function, have minimal secretions, and remain hemodynamically stable. This modality is more suited to the chronic patient such as the Duchenne or spinal muscular atrophy patient and not for the acute patient whose disease progression is unknown. Once the child has been intubated and is comfortable, minimal analgesia and sedation is usually needed. Patient triggered modes can be used and the trigger should be carefully adjusted to the level of strength/weakness of the patient’s respiratory muscles. Every effort should be made to keep the wave form, cycle times and pressures as physiological as possible. Tracheostomy — In patients with acute neuromuscular respiratory failure, tracheostomy is an important decision when the need for mechanical ventilation appears prolonged in order to minimize the well described problems associated with prolonged nasotracheal or orotracheal intubation. However, the indications for tracheostomy and the timing will vary with the individual patient and the underlying disease process. Discontinuation of ventilatory support —Although the initial strategy for weaning depends on the individual patient, weaning is often initiated in the pressure support mode. As the patient would be on a trigger, it is easy to see the effort that the muscles are capable off producing. As the patient gets stronger, the levels of support are reduced and the tidal volumes generated are closely watched. In older children who have had a long recovery period on the ventilator, there is often a great deal of anxiety associated with extubation and psychological dependence on the ventilator. Daily counseling and encouragement is needed and the child should never be forced as excessive anxiety will cause failure of extubation. As the recovery of the upper airway protective muscles might lag behind the recovery of the ventilatory musculature, the integrity and function of the upper airway musculature should be closely monitored following extubation. Other Considerations A variety of other considerations are important in the overall management of patients with acute respiratory failure from peripheral neuromuscular disease. Nutritional support — the goals of nutritional support for patients with neuromuscular respiratory failure are similar to those for other critically ill patients and include: • Maintenance of fluid and electrolyte balance, skin integrity, and immune competence. Failure to optimize the nutritional support increases the risk of infectious complications and compromises weaning from mechanical ventilation. Infection — Intercurrent infection may be associated with increased weakness, particularly in patients with myasthenia gravis. Hence there should be a careful search for an infectious process in the deteriorating patient, especially in the setting of immunosuppressive therapy and appropriate antibiotics are to be administered depending on the clinical situation. Psychologic and emotional well-being — As the patient’s stay in the intensive care unit often extends over weeks or months, it is common for feelings of helplessness, anger, fear, isolation, hopelessness, and/or anxiety to emerge. The din and often-incessant activity of the intensive care unit as well as the multiple and changing faces of the caregivers contribute to the patient’s disorientation and often amplify these feelings. These reactions are not only emotionally debilitating but may interfere with the patient’s care and may slow recovery. Consequently, liberal psychologic support, structuring care and testing to optimize rest and privacy, and creating familiar and friendly rooms and effective communication with the patient are all essential to a patient’s emotional well-being iv. Prevention of disability — Efforts should be directed toward preventing pressure sores, compression neuropathies, tendon shortening, and joint malalignment. Important measures in this regard include frequent repositioning, careful attention to skin care, molded ankle and wrists splints, and passive range of motion exercises (physiotherapy and occupational therapy). The presentation to the intensivist can either be as an acute unknown catastrophic illness or an exacerbation of a previously diagnosed chronic process. Critical care management of neuromuscular disease, including long term ventilation. Management of acute childhood poisonings caused by certain Insecticides and herbicides. Principles and practice of pediatric infectious diseases, New York, Church Livingstone, 2003. Infant botulism: A review of 12 year’s experience at the Children’s Hospital of Philadelphia, Pediatrics 1991;87:159-165. Particularly in an Indian scenario where road safety rules are flouted openly, with lack of designated areas for children to cross roads near educational institution, our pediatric population is at a far greater risk than our western counter part. Multisystem injury is a rule rather than exception and therefore all organ systems must be assumed to be injured until proved otherwise.

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Empiric antibiotic regimen for severe sepsis and urinary tract infections3 buy solian from india medicine 10 day 2 times a day chart,4 Condition Etiology Antibiotic regimen Comments Hospitalized E discount solian 50mg mastercard medications joint pain. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients purchase 50 mg solian medicine x ed. Guidelines for the Selection of Anti-infective Agents for Complicated Intra-abdominal Infections solian 100 mg low cost symptoms 32 weeks pregnant. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections. The child is not a miniature adult and so also a newborn is not a miniature child. There are major differences between an adult and a child in the etiology of cytopenias, the effect of cytopenia on homeostasis, the physiological responses by the body to cytopenia, the need of various blood components, the choice and the dose of the blood component used. Accordingly, the guidelines for the use of blood components differ in children and newborns. Each unit of whole blood has at least 4 basic components which include red blood cells, white blood cells, platelets and plasma. All these functions are not deranged in all the patients and hence all the components are not required all the time. Blood is always in short supply and making components from one unit of whole blood will satisfy the needs of more than one patient from the same unit of blood. Besides, giving whole blood can lead to harmful effects like plasma overload; lymphocytes mediated toxicities or allosensitization. From one unit of unrefrigerated whole blood one can make packed red blood cells, platelet pack (random donor platelet), granulocytes and fresh plasma. Pooled plasma can be converted into further components like cryoprecipitate, albumin, gamma globulins, anti-D globulins, plasma proteins, etc. Lastly, one can get stem cells from the umbilical cord blood of a newborn or peripheral blood of an older child for autologous or allogenic bone marrow transplant or rescue as the case may be. Packed red blood cell is stored at 1-4° C and should be used within 24 hrs if packed using an open system. Granulocytes are kept at room temperature and should be used within 24 hours of collection. Whole Blood Whole blood has all the components, but that is only in the first 6-8 hours and that too when stored at room temperature. Whole blood is stored at 1-4° C and has a shelf life of 21 to 42 days as discussed before. It is rarely, if at all, used in nutritional anemia, if a patient has severe anemia with impending cardiac failure or has associated cardio-respiratory disease. Lastly it can be used before surgery, where a patient is anemic with Hb less than 7 gm% and where moderate blood loss is expected during surgery. It is most often misused as “top-up” in patients with nutritional anemia, or during surgery to keep Hb above “10 gm%”. In such cases, it is counterproductive as it can lead to immune suppression of the recipient and delays healing. Red Blood cell cytapharesis can be done using cell separators like the Cobe Spectra machine in a case of falciparum malaria with a very high parasitic index. Though there is no cut off which is a gold standard, this can be done when the parasitic index is more than 20-40%. Very few studies are available on this and they have shown that the mortality is reduced by using red cell cytapheresis as compared to open exchange transfusion which is more hazardous with significant complications. One can use a designated donor repeatedly to obtain single donor platelet using an apharesis machine. Use plastic tubes and never use glassware as platelets will stick to glass surfaces and get activated. One unit/10 kg body weight will raise the platelet count by 20, 000 to 30, 000/cumm. A compatible donor is selected and subjected to continuous or discontinuous apharesis and platelets collected over a 4-6 hr period. The donor should be healthy, off medicines like aspirin and should have a platelet count of more than 1. Criteria to Transfuse Platelet transfusions are usually given to those with thrombocytopenia due to decreased production rather than to those with increased destruction. Only skin bleeds do not warrant a platelet transfusion, but such patients should be closely monitored for any further mucosal bleeds. The chances of spontaneous bleeds increase when the count drops to less than 10 - 20, 000/cumm. Hence the decision of when to transfuse platelets prophylactically is based on the basic disease, type of thrombocytopenia, platelet count, and the presence of associated coagulation abnormalities. A well child is a given prophylactic transfusion when the platelet count is less than 5, 000 - 10, 000/cumm. Chronic stable thrombocytopenia only in presence of significant mucosal bleeding 3. Platelet transfusions have revolutionized the treatment and the outcome of pediatric cancers. The cause of mortality has shifted from bleeding to infections with better platelet support available now. In these cases, there is good platelet recovery at one hour after transfusion, but not at 24 hr suggesting consumption. Platelet transfusions are generally not effective in this group of diseases, as they will be immediately destroyed after transfusion. Again platelet transfusions may not be effective in such cases, as they will be immediately removed from the circulation into the enlarged spleen. Dilutional: Dilutional thrombocytopenia can occur following massive transfusions in patients with massive hemorrhage or following exchange transfusions. Platelet dysfunction: Various congenital and acquired platelet functional disorders may present with significant bleeding. If local measures fail to control bleeding, platelet transfusions will be required. One should use platelets sparingly in such cases as allosensitization may prevent good recovery in future after a number of transfusions are given. People have tried giving granulocyte transfusion in patients with severe uncontrollable infection in the presence of congenital or acquired neutropenia or neutrophil dysfunction. As colony stimulating factors are now easily available and affordable, use of granulocytes has fallen in to disrepute. Various side effects and toxicities are associated with the presence of significant number of donor lymphocytes in the unit of blood component transfused. These donor lymphocytes ordinarily do not serve any beneficial effects and hence should be removed or depleted from the unit transfused to eliminate or reduce the chances of these side effects and toxicities.

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Epilepsia 2013;54 tion magnetic resonance imaging in adults with partial or secondary generalised (Suppl purchase solian on line medications prescribed for migraines. Standard magnetic resonance imag- region: comparison with intraoperative stimulation in patients with brain tum- ing is inadequate for patients with refractory focal epilepsy buy 100mg solian free shipping symptoms 16 weeks pregnant. Epilepsia 1994; 35: and motor functions: validation with intraoperative electrocortical mapping buy solian 100 mg visa medications xerostomia. Functional magnetic resonance imaging Frontal lobe epilepsy: diagnosis and surgical treatment purchase solian 50mg fast delivery medicine vs dentistry. Neurosurg Rev 2002; 25: for presurgical evaluation of very young pediatric patients with epilepsy. In- functional magnetic resonance imaging in preoperative assessment of language dications and evaluation techniques for resective surgery. Spontaneous fuctuations in brain activity observed with of the corpus callosum in an epileptic patient. Intrinsic functional connectivity as a tool for human connectomics: theory, prop- 127. Defning Meyer’s loop-temporal lobe brain tumor patients using spontaneous fuctuations in neuronal activity imaged resections, visual feld defcits and difusion tensor tractography. Neuroimaging in patients with resonance spectroscopic imaging and depth electrodes study. Hippocampal alterations in children with derived with electrical stimulation techniques. Epilepsia 2004; 45 mapping and corticography in the excision of arteriovenous malformations in (Suppl. An electrical stimulation mapping investigation in and a prognostic model for surgical outcome in refractory frontal lobe epilepsy. Temporal lobectomy for re- intrinsic tumors from nondominant face motor cortex using stimulation map- fractory epilepsy. Intraoperative brain mapping techniques in neuro-on- for the surgery for mesial temporal lobe epilepsy: longitudinal analysis. Long-term follow-up of stereotactic lesionectomy in partial epilepsy: predictive 170. Volumetric stereotactic surgical resection of intra-axial brain mass le- discussion 84–85. A comparative study erative subcortical stimulation mapping for hemispherical perirolandic gliomas of lesionectomy versus corticectomy in patients with temporal lobe lesional epi- located within or adjacent to the descending motor pathways: evaluation of mor- lepsy. Cortical language localization in lepsy: characteristics and predictors of surgical outcome. Cortical mapping for defning the limits of tumor resec- Childs Nerv Sys 2006; 22: 931–935. Nonlesional central lobule seizures: use of awake cortical mapping and subdural 204. From mirror focus to secondary epileptogenesis grid monitoring for resection of seizure focus. Extraoperative cortical stimulation of mo- surgery 2012; 70: 921–928; discussion 8. Epilepsia 2012; 53: implanted grid electrodes prior to surgery for gliomas in highly eloquent cortex. Pediatr Neurosurg 2000; implanted grid electrodes prior to surgery for gliomas in highly eloquent cortex. Pediatr Neurosurg 1995; 22: 174– epileptogenic periventricular nodular heterotopia. Neurosurgery 2012; 70: resonance imaging-guided focused laser interstitial thermal therapy for intracra- 1406–1413; discussion 13–14. Clinical outcome afer complete or resection in 332 patients with low-grade gliomas. Low-grade glio- come afer temporal lobectomy for intractable complex partial seizures. Neuro- mas associated with intractable epilepsy: seizure outcome utilizing electrocorti- surgery 1991; 29: 55–60; discussion 1. Improved out- for intractable partial epilepsy guided by subdural electrode arrays. Autopsy fndings and comments on the role children with hemispheric tumors and associated intractable epilepsy: the role of of hippocampus in experiential recall. The Debilitating and intractable epilepsy may itself be life threatening intent of epilepsy surgery is to improve the quality of life in patients and the risk of haemorrhage, overwhelming infection and neurolog- who do not have life-threatening disease, so a low complication rate ical defcit must also be considered in the natural history. Treatment has traditionally been spite considerable research, little is known about the causes of epi- surgical excision to eliminate the risk of future haemorrhage. It was stopped pre- maturely in 2013 by the data and safety monitoring board afer a mean follow-up of 33 months with 224 participants enrolled at 39 sites worldwide, because the event rate in the intervention group was more than three times higher than the medical management group [32]. An obvious criticism of this decision was that many pa- tients in the medical management group who are likely to bleed in the future had not bled during the observation period, whereas a number of patients in the intervention group will had sufered neurological insult as a result of their treatment. The study group are continuing to follow up the 224 enrolled participants and will publish their outcome data in the next few years; however, it will be difcult to draw statistically robust conclusions as the trial is now seriously underpowered. Contrast- ing diferent treatment modalities, they found an 81% Engel class I result with surgery versus 43% with radiosurgery and 50% with embolization [33]. The epileptogenic potential is thought to be caused by neuronal loss, gliosis, demyelination and haemosiderin deposition [37,38]. Perinidal capillaries do not have basement membrane and this may allow erythrocyte extravasation and subsequent haemosiderin dep- osition and gliosis in the surrounding tissues [39], which may ex- plain epileptogenesis in the absence of overt haemorrhage. The scan shows no evidence sufered recurrent haemorrhages, with a mortality rate of 12%. The Spetzler–Martin grade is by far the most commonly used classifcation system but several modifcations have been made. The exam shows a single arterial feeder and a single draining vein discharging judicious selection for surgery and S3V0E0 (large size, superfcial into the proximal sigmoid sinus. The patient remains seizure-free surgical risk that is unclear, or are theoretical lesions with no clini- on phenytoin. Con- Treatment ventional radiotherapy is successful in less than 20% of cases and is therefore not considered efective [46,47]. How- of smooth muscle cells and the elaboration of extracellular collagen, ever, surgery does appear to achieve superior control of seizures leading to stenosis of the vessel and ultimately obliteration of the lu- compared to other treatment modalities and this may be due to re- men over a period of 1–2 years [48]. The same authors state that neither seizures nor focal are more likely to bleed due to increased outfow resistance [49]. Seizures were eration in the setting of repeated haemorrhage [71] and are prob- either decreased or disappeared in 91.

The normal blood volume in an should have adequate knowledge in physiology of blood buy solian paypal symptoms 10 days before period. Study of blood physiology includes the study of different components of blood order solian 50mg on-line medications you cant crush, their formation buy solian once a day medications hard on liver, Composition of Blood their role in different body functions and dysfunctions purchase solian 100 mg line medications rheumatoid arthritis, and study of blood disorders includes the pathophysiology Blood consists of two components: cells and fluid. The cel- of diseases of blood and their management, and patholo­ lular component comprises of different formed elements, gical alterations in blood in other (non­hematological) dis­ and the fluid component is the plasma. The formed elements are red blood cells (erythro­ Blood examination reveals two fundamental aspects cytes), white blood cells (leucocytes), and platelets of hematology: (thrombocytes). The plasma consists of about 55% of the total blood mature cells of hematopoietic lineages volume which is made up of water and solid particles. If development of each hematopoietic lineage is quali­ When blood is collected in an anticoagulated tube tatively normal. Therefore, vasoconstriction preserves body temperature and vasodilation facilitates heat dissipation from the body. Excretory function: Blood helps in excretion of waste materials by transporting them from different parts of the body to the kidney. Water homeostasis: Fifty­five percent of blood con­ tains plasma and 92% of plasma contains water. Loss of water from body as occurs in diarrhea, vomiting, exces­ sive sweating etc. Note, about 1% of are activated to increase the water content of blood that blood forms the buffy coat (present between plasma and red cell aims at maintaining cellular hydration. They (protein and Hb buffers) play from lower red cell mass by a thin buffy coat (Fig. Immunity: Blood forms a critical component of body the thin middle layer that separates the upper plasma immunity. It contains cells that play primary role in and lower red cell mass after centrifugation of blood is the cellular immunity and also contains antibodies that buffy coat. Storage: Blood is the storage site of electrolytes, nutri­ cal or primitive blood cells (atypical mononuclear cells, ents, chemicals, hormones, etc. Nutritive functions: Blood delivers all nutrients, such as glucose, lipids, proteins, vitamins, minerals, etc. Oncotic pressure: the albumin present in blood exerts coat for the detection of the abnormal cells in blood. Also, buffy coat osmotic pressure, known as oncotic pressure that con­ preparationis very useful for the detection of bacteria, fungi or parasites trols capillary filtration and prevents edema formation within neutrophils, monocytes or circulating macrophages. Respiratory functions: Blood transports oxygen from the total blood volume can be roughly calculated as lungs to tissues, and carbon dioxide from tissues to 70–80 ml/kg of body weight. Thus, by transporting gases blood serves an ume of blood is about 5 to 6 liters and in females about important function of respiration. Transport medium: Blood acts as the transport of blood present is significantly less than adults, the vol­ medium for various hormones, chemical substances, ume expressed per kg of body weight is more (80–90 ml/ nutrients, vitamins, etc. Temperature regulation: Blood plays an important Blood volume is determined by determining the plasma role in temperature regulation as it conducts heat volume and cell volume separately. The normal ratio of from the interior of body to the surface through blood plasma volume to cell volume is 55:45. Measurement of Cell Volume Cell volume is measured by measuring the volume of red cells. Note, 92% of plasma is water and they constitute minor fraction of the total cell volume. Usually, loss of water from blood as occurs in dehydra­ 59 tion increases specific gravity. The commonly used chromium isotope is Cr, which is attached to red cells through incubation of cells in the 1. It is mainly due to the number of cells and macromole­ cules like proteins present in the blood. Plasma volume is also meas­ Plasma is the fluid component of blood which constitutes ured by injection of serum albumin labeled with radioac­ about 55% of the total blood volume. However, to preserve clotting factors plasma should be Effective blood volume = the total blood volume – the frozen within 6 hours after collection. This means the volume which is present actually in the circulation that helps in perfusion of tissue. However, it is Composition of Plasma difficult to estimate the sequestered volume of blood in the visceral organs. The Specific Gravity and Viscosity of Blood major solute (solid) content is the plasma proteins, which Specific gravity: Specific gravity or density of whole blood constitutes about 7% of the plasma and other solutes is approximately 1. Globulins include different transport proteins like During blood coagulation, a soluble plasma protein called transferrin, ceruloplasmin, hemopexin, etc. They form different lipoproteins in combination with ting factors is called serum. Antibodies (immunoglobulins) are γ­globulins that are ing serum from blood by allowing the blood to clot formed by plasma cells. The serum is separated from blood by allowing the blood to Fibrinogen coagulate (serum = blood – fibrinogen and other clotting factors). Osmotic pressure: Plasma proteins are osmotically Types of Plasma Proteins active molecules, and the osmotic pressure of plasma Plasma proteins are of three types: albumin (4–5. Oncotic pressure retains fluid in the Albumin vascular compartment and, therefore, prevents loss This is the major constituent of plasma proteins. Being smallest in diameter among the plasma proteins, and kidney diseases, edema manifests due to escape in kidney diseases with glomerular injury it appears of water into the interstitial tissue space. Viscosity: Plasma protein contributes to about 50% Hypoalbuminemia also occurs in in liver diseases due of the viscosity of blood (red cells account for rest of to decreased formation of albumin. The viscosity depends on the molecu- tions, decreased colloidal osmotic pressure (oncotic lar shape of the plasma protein. This is why fibrino­ pressure) of plasma results in edema formation (see gen molecules that are elongated and fibrillar in shape below). Immunity: Antibodies are plasma proteins (gamma This is formed in the liver, cells of reticuloendothelial sys­ globulins). Globulins are divided into three categories: α (α1, α2), cellular pathogens and from the effect of toxic sub­ β (β , β1 2) and γ. Also, other clotting factors like pro­ facilitates rouleaux formation, which in turn increases thrombin are plasma proteins. Buffering: Plasma proteins form an important buffe­ ring system of the body called protein buffers. Protein store: Plasma proteins serve as mobile protein Plasma proteins can be separated by methods like salt reserve of the body, which can be utilized for tissue separation, paper electrophoresis, Cohn’s fractionation, growth, especially in situations of protein depletion. Blood is defined as liquid connective tissue that fills the heart and blood vessels. The normal blood volume in adults is 5 to 6 liters, which accounts for about 8% of the body weight. The plasma consists of about 55% of the total blood volume which is made up of water and solid particles.

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