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By Y. Ford. Conway School of Landscape Design.

Side effects of epidural clonidine include decreased Muscle spasm can complicate analgesia and may not heart rate and blood pressure discount 60 mg raloxifene menopause in women. Patients receiving respond well to systemic opioids or epidural analge- epidural clonidine should be closely monitored dur- sia purchase 60 mg raloxifene with mastercard breast cancer hoodies. Small doses of benzodiazepines (eg, diazepam ing the first 24 hours of treatment for hypotension, 2. CHRONIC PAIN PATIENT WITH ACUTE PAIN OTHER ADDITIVES UNDER INVESTIGATION Patients who chronically take pain medications at Many agents have been suggested for use as additives home pose a challenge with respect to management of to enhance epidural analgesia. Chronic pain patients on opioids often require A variety of α2 agonists (other than clonidine and epi- higher doses of opioids because of tolerance. PCA only (without a basal rate) may be insufficient 86 V ACUTE PAIN MANAGEMENT to control pain. A basal opioid infusion (equivalent tion between the ports such that all or most of the test to baseline opioid requirements) may be necessary. Chronic pain patients who use a fentanyl trans- dermal patch should continue using the patch throughout the perioperative period (it is neither PLACING THE EPIDURAL necessary nor desirable to discontinue the patch preoperatively). The midline approach is favored in the lumbar region, where the spinous processes are nearly hor- EQUIPMENT izontal in the seated patient. A paramedian approach may be advisable when Epidurals must be performed in an area designed placing a thoracic epidural, especially between T5 for cardiovascular monitoring and airway and and T9, where the spinous processes almost over- cardiopulmonary support, such as a dedicated block lap. The procedure may also midline approach, angle the needle 50°–60° (up be done in a separate area of the patient holding room from the back plane) to pass between the two adja- as long as monitoring and emergency equipment and cent spines (see Figure 18–4). Doing so could shear the catheter Most epidural catheters have a “dead space” equal to tip, leaving it in the epidural space. Modern catheters have The catheter should advance easily into the epidural centimeter markers and a radiopaque distal tip. Ease in advancing the catheter into the On removing an epidural catheter, visually inspect epidural space provides another confirmation of and record that the tip is intact. The Advancing the catheter more than 5 cm increases three-holed design may have arisen from a desire to the potential for knotting or could place the catheter produce lateral full-bore equivalent flow with the tip too far from the intended center of epidural minimum number of holes while at the same time action to allow for adequate analgesia. As manufactur- Catheters placed 3 cm or less into the epidural ing techniques improved, the holes were moved closer space have a tendency to come out. One port can be intrathecal, while others Before the epidural catheter can be used for infusion are epidural. Fluid pressure exerted during test dosing of analgesic medication, confirm that the tip lies is greater than that during continuous pump infusion. It may take 10 minutes or more for the full mani- festations of an intrathecal test dose to be seen. As stated previously, multiport catheters may allow one or more ports to be intrathecal, while others are within the epidural space. Test dosing may inject medication preferentially through some (but not other) ports. This can be repeated several times as long as a sufficient length of catheter remains in the epidural space (at least 1 cm). Often it is easier sim- ply to remove the epidural catheter and reinsert it one interspace above or below. EPIDURAL COMPLICATIONS Complications of epidural analgesia include inade- quate analgesia, excessive blockade, unintentional intrathecal or intravascular injection and its sequelae, and the potentially more serious infections or hematomas that can lead to neurologic damage (Table 18–4). There was 1 subarachnoid catheter migra- used as a “test dose”: tion, 3 intravascular migrations, 40 catheter leaks, 57 About 3 cc of 1. If the catheter tip rests intravascularly, the 5 or 10 Early recognition and management are the keys to µg of epinephrine should cause an increase in heart minimizing poor outcome. The dose is small enough not to result in a Most of these complications were attributed to deter- high spinal. In a review of 39 cases of epidural medication may not display a significant heart rate abscess over a period of 27 years, only one case was 88 V ACUTE PAIN MANAGEMENT TABLE 18–4 Epidural Complications With appropriate training and well-designed proto- COMPLICATION COMMENTS TREATMENT cols, nurses and nurse clinicians can be empowered to assess pain and side effects and to adjust therapy Headache May be result of dural Analgesia puncture (incidence Bed rest at “the point of care. Usually transient reassurance Nurses manage the epidural when patients are With fever or returned to “the floor,” using physician-determined neurologic protocols. High blockade Respiratory distress Resuscitation Standard physician orders facilitate a uniform approach (intercostal block) Cease epidural Bradycardia (high infusion to epidural and adjunct analgesia management. An example of such stan- Numbness or tingling dardized epidural orders is provided in Figure 18–5.

Vocalizations raloxifene 60 mg online menopause odor, other than those with linguistic meaning cheap 60mg raloxifene mastercard womens health 31 meals in 31 days, also are often present. Patients can scream, moan, or otherwise vocally express their distress when they are in pain. In infants, cry powerfully elicits parental attention from afar and effectively encodes the severity of distress, al- though the specific source of distress may not be readily identified (e. Consequentially, parents usually seek other evidence, including the other behavioral signs noted earlier, and use contextual information (e. Other nonverbal pain signals are available (Keefe, Williams, & Smith, 2001). Various studies have examined the validity of a series of behaviors that are associated with pain (e. Keefe and Block (1982) asked patients with low back pain to engage in a series of standardized activities (e. A variety of social, psy- chological, and dispositional variables influence both the expression and experience of pain. Pain expression is often predicted better by psychologi- 100 HADJISTAVROPOULOS, CRAIG, FUCHS-LACELLE cal rather than physical or medical factors (e. A perfect relationship between experience and expres- sion would not be expected, as activation thresholds vary as a function of expressive modality, cognitive modulation of expression, and situational determinants. In fact, studies have shown that nonverbal pain expressions often do not correlate with self-report (Craig et al. Even the simple task of asking people to provide self-report measures of pain could draw attention to the pain state and exacerbate it. Alternatively, completing a question- naire could be a distracting and palliating event. Several studies have con- firmed the presence of reactive effects of measurement in studies of experi- mental pain, postoperative pain, and labor pain (Leventhal, Leventhal, Shacham, & Easterling, 1989; Mikail, VanDeursen, & von Baeyer, 1986), al- though one study of persistent pain (von Baeyer, 1994) failed to find an im- pact of self-report on the experience of pain. Deliberate attempts to misrepresent whether one is in pain or not can af- fect both self-report and nonverbal expression. Because these actions are in- herently dishonest and detection could lead to shame or punishment, it is difficult to know how often they occur, but estimates are usually quite low ( 5%; Craig, Hill, & McMurtry, 1999). Perhaps more common are efforts to conceal pain for a variety of reasons, including the desire to conform to so- cial ideals of stoicism, or the fear of the consequences of being diagnosed, such as loss of privileged positions, loss of independence, or exposure to fearsome drugs, dependency, or addiction. Gender differences in pain expression are present from infancy (Guins- burg et al. This suggests the presence of constitutional differences in pain expression. Men are often socialized to downplay pain reports in order to meet social, religious and cultural ex- pectations (Otto & Dougher, 1985). Fearon, McGrath, and Achat (1996) found that among school-age children and preschoolers, girls were much more likely to react to pain by crying, screaming, and displaying other signs of anger. Men who scored high on masculinity measures were found to dis- play a higher pain tolerance (Otto & Dougher, 1985). Unruh (1996) has re- ported that females show increased emotional responses to pain compared to men. This mediating effect of catastrophizing was main- tained even after controlling for levels of depression. The authors postu- lated that sex differences in catastrophizing may be a function of social 4. But there is also evidence in support of the presence of biological and hor- monal mechanisms that could account for some of the gender differences in pain experience and expression (see Introduction, this volume). Rollman considers cross-cultural influences in chapter 6 of this volume. Given that nonverbal pain expression and self-report differ with respect to the extent to which they are subject to self-control, and represent different features of the complex pain reaction, it is not surprising that studies have varied in whether these separate measures of pain are correlated. A num- ber of studies report nonsignificant correlations (Hadjistavropoulos, La- Chapelle, MacLeod, Hale, O’Rourke, & Craig, 1998; Hadjistavropoulos et al. Facial displays appear to best reflect the immediate onset of pain or exacerba- tions of pain. For example, Craig and Patrick (1985) observed that the most vigorous facial displays of pain occurred at the onset of immersion of the hand and forearm in ice cold water, and dissipated thereafter, whereas self- report of pain increased with time.

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Symptomatic presentation usually occurs in the latter portion of the first decade to adolescence order 60mg raloxifene with mastercard pregnancy yoga exercises. A protective sponge “donut” may be used over the painful corn to relieve discomfort temporarily order 60 mg raloxifene menopause facial hair, but most patients will eventually require more definitive procedures designed to Figure 3. Lateral radiograph illustrating congenital vertical talus with straighten the affected joint and fuse it in a equinus of the calcaneus and dorsiflexion of mid- and forefoot. Surgical treatment should be reserved for those who have failed conservative care. Congenital overlapping fifth toe This condition is nearly always recognizable at birth, but may become more fully manifest symptomatically in the first two to three years of life. The fifth toe is dorsiflexed, adducted, and slightly externally rotated, and literally comes to lie on the dorsal surface of the fourth toe (Figure 3. Soft tissue contracture of the dorsal and medial structures of the fifth metatarsal phalangeal joint has been indicted Figure 3. Clinically, the toe Common orthopedic conditions from birth to walking 40 not only lies dorsally and in an adducted position over the top of the fourth, but it cannot passively be reduced into its normal relationship. Those children who are symptomatic present with discomfort overlying the fifth toe with corns and painful calluses secondary to shoe wear. In general, surgical treatment should be reserved for only those cases in which substantial discomfort is present, and soft protective pads have failed. Most of the cases presenting with symptoms will eventually require surgical correction. Soft tissue releases, tendon rerouting, and metatarsophalangeal joint fusion provide the basis for reconstruction. Supernumerary digits Polydactyly, or supernumerary digits, is one of the most commonly seen congenital conditions in children. Most commonly the extra finger or toe is a mirror image of the digit lying directly adjacent to the extra digit (Figure 3. The apparent extra digit is in competition with the adjacent digit for the tendons activating that finger or toe. It is very important to determine tendon function in the presumed supernumerary digit so as not to become embarrassingly involved in the removal of a very functional part. Nearly always the indication for surgical removal is cosmetic, or as a consequence of difficulties in obtaining conventional shoe wear. Trigger thumb Stenosing tenosynovitis of the thumb, more commonly known as “trigger thumb,” is one of the more common congenital abnormalities of the hand. It is rarely recognized in the first six months of life since children generally maintain Figure 3. As the child begins to reach, grasp, and grip objects, it becomes apparent that the thumb does not fully extend at the interphalangeal joint. The deformity may manifest itself in periodic episodes of flexion deformity of the interphalangeal joint with occasional episodes of popping, clicking or full straightening of the finger. More commonly it is recognized when the thumb is persistently held in a position of interphalangeal joint flexion (Figure 3. The parents relate that the thumb does not fully straighten, and that the child has some difficulty in grasping. On examination, a palpable nodule is readily discerned at the metacarpophalangeal joint level, at or near the proximal metacarpophalangeal thumb crease. There is (a) (b) inability to extend the interphalangeal joint of Figure 3. Anteroposterior (a) and lateral (b) radiographs of the tibia and the thumb. The palpable nodule is actually a fibula demonstrating medial (a) and posterior (b) bowing (posteromedial thickened prominence arising from the flexor bowing). As this nodule enlarges in size, it no longer is capable of passing through the flexor pulley, and complete extension of the Figure 3.

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The lower/intra-thoracic airway Asthma Asthma is an umbrella term for a variety of paediatric chest conditions that result in a persistent or episodic wheeze discount raloxifene 60 mg line breast cancer prognosis, possibly associated with a cough buy 60mg raloxifene otc women's health center hershey pa. Symptoms typically present in children over the age of 3 years and are more common in the winter months, due to an increase in viruses, and in autumn/spring as a conse- quence of pollen. A child known to suffer from asthma does not require radiographic examina- tion with each episode. However, a chest radiograph is indicated if other respi- ratory conditions are suspected (e. Radiographically, patients with asthma may have a normal chest radiograph therefore supporting the view that asthma is a clinical diagnosis. Tracheo-oesophageal fistula A tracheo-oesophageal fistula is a variation of oesophageal atresia that presents during the neonatal period (see Chapter 6). Radiographic identification of the site of atresia can be made following the insertion of a radio-opaque feeding tube into the oesophagus. This tube will ‘curl’ at the site of the atresia and a single antero-posterior projection of the upper abdomen, chest and pharyngeal region should be undertaken. Air identified within the stomach on this projection sug- gests the presence of a distal fistula. Presentation of oesophageal atresia outside the neonatal period is unusual but may occur with an undiagnosed H-type fistula where the patient presents with repeated chest infections. In these cir- cumstances, a fluoroscopic contrast examination will confirm the diagnosis. Bronchiolitis Bronchiolitis is the commonest lower respiratory tract infection of infancy with the peak age at presentation being 3 months2,6. A plain film radiograph of the chest will display marked hyperinflation of the lungs and possible areas of peribronchial thicken- ing and consolidation. Radiographic appearances are dependent upon the aetiology with viral infections causing air trapping, seen as hyperinflation on the chest radiograph (Fig. Bronchiectasis Bronchiectasis is defined as the chronic, irreversible dilation and distortion of the bronchi caused by inflammatory destruction of the muscular and elastic com- 8 ponents of the bronchial walls. It may be congenital or acquired but usually results from a longstanding localised bronchial infection. Plain film chest radi- ography is generally insensitive and seldom demonstrates the anatomic distri- bution of the disease unless the condition is severe when dilated bronchioles will appear as parallel densities (tram lines). Atelectasis may also be seen in severe cases and high-resolution computerised tomography (CT) may be considered to assess the extent and severity of the disease (Fig. Pulmonary tuberculosis Tuberculosis is an infection caused by Mycobacterium tuberculosis and, although it is relatively uncommon, incidences of tuberculosis are increasing throughout the world. In the UK, tuberculosis is associated particularly with the immigrant population (especially from Asia, Africa and Latin America), the homeless, the elderly and the immunosuppressed (e. In children, tuber- culosis infection is typically due to prolonged and close contact with an indi- vidual having active and untreated disease. The radiographic appearances of pulmonary tuberculosis are varied and dependent upon the age of the child. Progressive pulmonary tuberculosis most commonly occurs during infancy as a result of the primary infection not being contained, and subsequently progresses to bronchopneumonia, lobar pneumo- nia (usually middle or lower lobe) and cavitation. In contrast, primary pul- monary tuberculosis in older infants and children is usually an asymptomatic illness with minimal abnormalities demonstrated on the chest radiograph, while adolescent infection will follow more closely the typical adult appearances with upper lobe opacification and possible cavitation. Widespread haematogenous dissemination of tuberculosis following primary infection is uncommon and is 9 normally restricted to children under 2 years of age (Fig. AIDS (acquired immunodeficiency syndrome) The lungs are a common site of infection in the immunocompromised child and consequently over 50% of AIDS-related paediatric mortalities have pulmonary 5 disease (Fig. The radiographic appearances of AIDS-related paediatric 38 Paediatric Radiography Fig. The chest wall and pleura Scoliosis When severe, scoliosis may result in respiratory dysfunction as a consequence of a marked curvature of the thoracic spine and associated chest wall deformity restricting normal thoracic inspiratory and expiratory movement. Significant loss of inspiratory capacity may lead to pulmonary hypertension, recurrent infection, atelectasis and respiratory insufficiency.

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