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Increased venous pressure below the level of compression of the inferior vena cava diverts venous blood return from the lower half of the body via the paravertebral venous plexuses to the azygos vein hiv infection symptoms ppt order zovirax without a prescription. Flow from the azygos vein enters the superior vena cava to bypass the obstruction and maintain venous return to the heart antiviral elderberry extract safe 800mg zovirax. Dilation of the epidural veins in pregnancy may make unintentional placement of the epidural catheter more likely hiv infection rates philippines order zovirax uk. An unintended intravenous bolus of local anesthetic can have significant Cardiac Output By the end of the first trimester hiv infection from blood test trusted zovirax 800 mg, maternal cardiac output typically increases approximately 35% above prepregnancy values and continues to increase 40% to 50% above nonpregnant values by the end of the second trimester, where it remains throughout the third trimester. This increased cardiac output is secondary to increases in both stroke volume (25% to 30%) and heart rate (15% to 25%). Labor further increases cardiac output, which fluctuates with each uterine contraction. Increases above prelabor values of 10% to 25% occur during the first stage and 40% in the second stage. The largest increase in cardiac output occurs immediately after delivery, when cardiac output can increase by 80% to 100% more than prelabor values. This abrupt increase is secondary to the autotransfusion from the final uterine contraction, reduced vascular capacitance from loss of the intervillous space, and decreased lower extremity venous pressure from release of the aortocaval compression. This large fluctuation in cardiac output presents a unique postpartum risk for patients with cardiac disease, especially those with fixed valvular stenosis and pulmonary hypertension. Cardiac output returns toward prelabor values approximately 24 hours postpartum and decreases substantially toward prepregnant values by 2 weeks postpartum, with complete return to nonpregnant levels between 12 and 24 weeks after delivery. Systemic Vascular Resistance Although cardiac output and plasma volume increase, systemic blood pressure decreases in an uncomplicated pregnancy secondary to a reduction in systemic vascular resistance. Although affected by positioning and parity, systolic, diastolic, and mean blood pressure may all decrease 5% to 20% by 20 weeks gestational age and then gradually increase toward nonpregnant values as the pregnancy progresses. Cross-sectional views of aortocaval compression from the gravid uterus in the supine position with loss of compression in the lateral position (A). Alterations in heart rate, stroke volume, and cardiac output for both supine and lateral positioning with increasing gestation of pregnancy (B). A small, nontoxic test dose is thus employed to decrease the likelihood of unrealized intravascular placement with initiation of neuraxial blockade. In cardiac auscultation an accentuated first heart sound (S1) can be heard, with an increased splitting noted from dissociated closure of the tricuspid and mitral valves. A third heart sound (S3) is often heard in the final trimester, and a fourth heart sound (S4) can also be heard in a few pregnant patients as a result of increased volume and turbulent flow. In addition, a benign grade 2/6 systolic ejection murmur is typically heard over the left sternal border and is secondary to mild regurgitation at the tricuspid valve from the annular dilation associated with the increased cardiac volume. Table 77-1 details the effects of pregnancy on the electrocardiogram and echocardiography. Women who present with chest pain, syncope, high-grade flow murmurs, and clinically significant shortness of breath or severe arrhythmias should undergo appropriate diagnostic investigation and referral. This larger minute ventilation is attained primarily as a result of a larger tidal volume and a slight increase in respiratory frequency. Maternal Paco2 decreases from 40 mm Hg to approximately 30 mm Hg during the first trimester as a reflection of the increased minute ventilation. Later, Pao2 becomes normal or even slightly decreased, most likely reflecting small airway closure with normal tidal volume ventilation and intrapulmonary shunt. Arterial oxygenation can be significantly improved by moving the patient from the supine to the lateral position. Maternal Hb is right shifted, with the P50 (partial pressure of O2 at which Hb is 50% saturated with oxygen) increasing from 27 to approximately 30 mm Hg. The higher P50 in the mother and lower P50 in the fetus mean that the fetal blood has higher affinity for O2 and offloading of O2 across the placenta is facilitated. During the first stage of labor, O2 consumption increases above prelabor values by 40% and during the second stage it is increased by 75%. The pain of labor can result in severe hyperventilation causing Paco2 to occasionally decrease below 20 mm Hg. Philadelphia, 2002, Lippincott Williams & Wilkins; and Gaiser R: Physiologic changes of pregnancy. The Upper Airway During pregnancy, capillary engorgement occurs with increased tissue friability and edema of the mucosal lining of the oropharynx, larynx, and trachea. As a result, an increased risk for bleeding exists during manipulation of the upper airway, in addition to an increased risk of difficult ventilation and intubation of the trachea. Suctioning of the airway and placement of devices (nasal instrumentation should be avoided) should be performed gently to prevent bleeding. Furthermore, there is increased risk for airway obstruction during ventilation and both laryngoscopy and tracheal intubation are more difficult. Also, after extubation, the airway may be compromised as a result of edema, with subsequent risk for airway obstruction in the immediate recovery period. Consequently, attempts at laryngoscopy should be minimized and a smaller size cuffed endotracheal tube (6. Airway edema can be more severe in patients with coexisting preeclampsia, in upper respiratory tract infections, and after active pushing as a result of associated increased venous pressure. Preoxygenation before general anesthesia is critical for patient safety to mitigate these physiologic changes.
The appearance of severe hypocalcemia during liver transplantation is well documented (see also Chapter 74) hiv infection blood test zovirax 200 mg with visa. This can be prevented by warming the blood to body temperature before transfusion hiv infection treatment guidelines 200mg zovirax. More subtle reasons exist for warming all blood xem phim antiviral purchase 800 mg zovirax with amex, even in patients receiving only 1 to 2 units intraoperatively uganda's soaring hiv infection rate linked to infidelity zovirax 800mg low price. Because of the cool temperature of the operating room, body temperature often decreases, particularly in patients undergoing extensive abdominal surgery; administration of cold blood further decreases temperature. More than half of these mistakes occurred after the blood had been issued by the blood bank and were committed by nurses and physicians in the operating room, emergency department, or ward. The incidence of hemolytic transfusion reactions is sufficient enough that the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations)152 requires peer-review programs to reduce transfusion errors and complications. Specifically, two patient identifiers are required before a blood product can be given (see discussion on compatibility testing). New technologies are being used to facilitate a decreased incidence of transfusion-related errors. Intravascular hemolysis occurs when there is a direct attack on transfused donor cells by recipient antibody and complement. Correlation between the amount of blood administered (milliliters) and corrected base excess intraoperatively. When this solution is added to a unit of freshly drawn blood, the pH of the blood immediately decreases from 7. A large portion of the acidosis can be accounted for by the Pco2 of 150 to 220 mm Hg. The Pco2 is high mainly because the plastic container of blood does not provide an escape mechanism for carbon dioxide. With adequate ventilation in the recipient, the high Pco2 should be of little consequence. Even when the Pco2 is returned to 40 mm Hg, metabolic acidosis is still present in blood (see Table 61-2). Still, the empirical administration of sodium bicarbonate is not indicated, but it actually may also be unwise without concomitant analysis of arterial blood gases and pHs. Blood transfusions provide a substrate, namely, citrate, in large quantities for the endogenous generation of bicarbonate, and this accounts for the significant incidence of metabolic alkalosis after blood transfusions. Signs and Symptoms the clinical consequences of incompatible blood transfusions are very serious but quite variable. Factors include volume of transfused blood, number of antigenic sites on the red cell membrane, and activity of the reticuloendothelial system. The properties of the antibody, including concentration and ability to activate complement, are also important. The classic signs and symptoms (see Table 61-7) of a hemolytic transfusion reaction-chills, fever, chest and flank pain, and nausea-are masked by anesthesia. Under general anesthesia, the only signs may be hemoglobinuria, bleeding diathesis, or hypotension. As little as 50 mL of incompatible blood may exceed the binding capacity of haptoglobin, which is a protein that can bind approximately 100 mg of Hb/100 mL of plasma. When Hb not exceeding this amount is injected or liberated into the bloodstream, the Hb circulates as a complex with haptoglobin, which is cleared by the reticuloendothelial system. In general, the quantity of the free Hb in the plasma correlates with the volume of incompatible blood transfused. Also, complement activation causes release of various substances, including histamines and vasoactive amines. The symptoms can be so alarming that cessation of blood is indicated, even if Hb is not seen in plasma. Laboratory tests that should be performed if hemolytic transfusion reaction is suspected include serum haptoglobin, plasma and urine Hb, bilirubin, and direct antiglobulin determinations. Although several consequences of intravascular hemolysis are possible, mainly the renal and coagulation systems are affected. The cause of acute renal failure from intravascular hemolysis is likely that Hb in the form of acid hematin precipitates in the distal tubule and causes mechanical tubular blockage. The magnitude of the precipitation probably is inversely related to the volume of urine flow and its pH. The primary emphasis of therapy should be directed toward maintaining urinary output in excess of 75 mL/hr by generous administration of intravenous fluids and diuretics. One approach is summarized in Box 61-1 and includes the administration of crystalloids to maintain the central venous pressure between 10 and 15 cm H2O while initially administering 12. If this is ineffective, the dose of mannitol may be increased or the use of more potent diuretics, such as furosemide, which increases blood flow to the renal cortex, may be required to maintain adequate urinary output. Alkalinization of the urine to prevent precipitation of acid hematin in the distal tubules is of questionable value but is easy and therefore recommended. Hypotension during a hemolytic transfusion reaction may result from activation of the kallikrein system. Another approach to treatment of a severe hemolytic transfusion reaction has been proposed by Seager and co-workers,156 who postulated that the kidneys might be spared from exposure to massive amounts of hemolyzed red cells by removing all blood from a patient and replacing it with compatible blood. This was accomplished in a patient who had received 3000 mL of incompatible blood by hemodilution by use of an extracorporeal circuit.
Other neurologic complications include injury to the phrenic nerve hiv infection rate san diego trusted 800 mg zovirax, which can result from use of slushed ice in the pericardial well to provide surface cooling for the heart anti viral entry inhibitors discount zovirax 800 mg without prescription. Preoperative efforts to minimize pulmonary complications after cardiac surgery include optimizing pulmonary function for patients undergoing elective surgical procedures stages of hiv infection to aids cheap zovirax 400 mg with mastercard. With regard to the surgical approach hiv infection rates europe 400 mg zovirax otc, investigators have theorized that off-pump surgery causes fewer changes in pulmonary mechanics than on-pump surgery. Certainly, it is clinically important to have a period of controlled ventilation to allow rewarming and emergence from anesthesia, optimize cardiac function, and ensure hemodynamic stability and the absence of unacceptable bleeding. However, many patients are currently extubated within 3 to 6 hours of arriving in the postoperative care unit (fast tracking), if appropriate criteria have been met (Box 67-22). In planning for fast tracking, one should avoid using highdose narcotic anesthetic techniques; in addition, the postoperative administration of analgesics and sedatives, as well as any muscle relaxants, must be done at appropriate doses and with appropriate timing. These include formal infection control programs, handwashing, maintaining adequate endotracheal tube cuff pressure, avoiding gastric overdistention, semirecumbent positioning of the patient, scheduled drainage of condensate from ventilator circuits, daily sedation "vacation," adequate nutritional support, early removal of endotracheal and nasogastric tubes, and avoiding unnecessary reintubation. The reader is referred to the later section on pain after cardiac surgery for other options for improving postoperative pain control and thereby minimizing splinting and complications such as lobar collapse, pneumonia, and increased duration of hospitalization. Fortunately, only a few patients require prolonged mechanical ventilation after cardiac surgical procedures. Nonpulmonary complications such as persistent postoperative bleeding, neurologic complications (including stroke and delirium), renal insufficiency or failure, gastrointestinal complications, and sepsis also may result in a need for prolonged mechanical ventilation. Of the blood product usage in the United States, 15% to 20% occurs in association with cardiac surgery. Spiess and associates found that the frequency of transfusion varies from 3% to 92% among institutions,439 a similar variation to that shown in an international cardiac surgery database. A study of more than 1900 cardiac surgical patients found that patients who received transfusions had a 70% increased risk of death and a doubling of their 5-year mortality rate, after adjustment for comorbidities, compared with patients who received no transfusions. Noncardiac comorbidities the Task Force gave specific recommendations on blood conservation that included the following five points444: 1. Consideration should be given to the use of drugs that either increase preoperative blood volume. Techniques of conserving blood, including cell saver sequestration and retrograde priming of the pump, should be included in the operative plan. A multimodal application of all of the previously mentioned guidelines is the best way to conserve blood. These recommendations are parallel to and completely congruous with the tenets of patient blood management, which is a novel approach to blood transfusion that focuses on patient-centered therapies. Perioperative optimal treatment of anemia also often help clinicians determine whether to return the patient to the operating room for surgical exploration. However, the lowest tolerable hemoglobin level clearly differs among patient populations and remains ill-defined in the literature. The platelet count provides quantitative information about platelet concentrations but little, if any, qualitative information about platelet function. Platelet counts lower than 100,000/L are often viewed as the cutoff for thrombocytopenia, but counts greater than 50,000/L do not correlate with postoperative bleeding. Laboratory measures of platelet function, including bleeding time, aggregometry, and cytometry, are not rapid (requiring >1 hour to produce results) and therefore are impractical for obtaining timely information intraoperatively. The viscoelastic tests are dynamic measures of whole blood clot formation and can measure platelet integrity and the strength of the platelet-fibrinogen bond. The response of platelets to an agonist stimulus is another means of measuring platelet function. The excessively bleeding patient who has a surgical source of bleeding should be carefully assessed, and often, allogeneic blood products are required to maintain hemoglobin and the integrity of hemostasis until the source of bleeding is found. Many sources state that excessive chest tube drainage can be defined as more than 250 mL of bleeding per hour for at least 2 consecutive hours, or 300 mL of bleeding in a single hour. The evidence for the use of aprotinin for reducing perioperative bleeding in cardiac operations was reappraised in the updated guidelines because of conflicting reports of renal dysfunction and other adverse outcomes. They bind to plasminogen and plasmin, thus inhibiting their ability to bind to lysine residues on fibrin and thereby impeding fibrinolysis. This sort of approach to bleeding postpones the moment when allogeneic blood products are needed and thus has been successful in reducing their use. Preliminary work suggests that no increase in thrombotic events occurs with this "pharmacologic" approach to bleeding, but large-scale studies have not yet been conducted. In summary, interdisciplinary approaches to blood conservation are vital to the care of cardiac surgical patients. Perioperative and critical care personnel must use a series of combined approaches to reduce transfusions and the adverse effects of transfusion and anemia. Pain after cardiac surgical procedures can also cause respiratory complications related to diaphragmatic dysfunction. However, at present, evidence to state definitively that any postoperative analgesic technique significantly affects morbidity or mortality after cardiac surgery is insufficient. Painrelated anxiety, depression, and sleep deprivation may contribute to delirium in patients in the intensive care setting. Once bleeding was diagnosed, patients received transfusions based on the results of tests in the algorithm. Opioids remain the gold standard for pain control after cardiac surgery, but these drugs have side effects that include nausea, vomiting, urinary retention, decreased gastric motility, pruritus, sedation, and respiratory depression.
Therefore hiv infection means zovirax 800 mg sale, fluid resuscitation is the mainstay of therapy hiv infection pathogenesis 200mg zovirax visa, followed by vasoactive infusions as needed hiv infections and zoonoses order discount zovirax on line. The ideal fluid has not been defined hiv infection globally order zovirax 200mg with visa, but perhaps hypertonic saline solutions are optimal. Correction of anemia from acute blood loss is the first priority; however, an optimal target hematocrit has not been defined. This can create a cycle that ultimately produces multiple compartment syndrome and necessitates opening of the abdomen, even in the absence of primary abdominal trauma. Early studies demonstrated that moderate, systemic hypothermia reduces both the rate of cerebral edema and mortality after cortical injury in laboratory animals. The previously described therapies should be continued throughout the perioperative period, including positional therapy (when possible), aggressive hemodynamic monitoring and resuscitation, administration of osmotic agents (with attention to maintaining euvolemia), and deep levels of analgesia and sedation. Appropriate anesthetic choices include opioids and low concentrations of volatile anesthetics. Most spinal injuries are in the lower cervical spine, just above the thorax, or in the upper lumbar region, just below the thorax. The vertebral column is divided longitudinally into three columns: anterior, middle, and posterior; injuries to any two of these three columns suggest biomechanical instability. Patients with unstable cervical spine injuries who meet criteria for emergency intubation, should undergo rapid-sequence induction (see section on protection of the cervical spine). However, clinically significant injury to the cervical spinal cord can occur in the absence of visible skeletal injury. Incomplete deficits may be worse on one side than the other and may improve rapidly in the first minutes after injury. Complete deficits-representing total disruption of the spinal cord at one level-are much more ominous, with generally little improvement seen over time. Spine injuries above the level of T4-6 are accompanied by significant hypotension because of inappropriate vasodilatation, loss of cardiac inotropy, and bradycardia resulting from denervation of the cardiac accelerator fibers (neurogenic shock). The Eastern Association for the Surgery of Trauma has published guidelines regarding which patients require cervical spine radiographs, which views and studies should be obtained, and how to determine the absence of significant ligamentous injury in an unconscious patient. The most commonly missed cervical fractures are at the C1-2 and C7-T1 levels, usually because of the result of inadequate imaging. Early intubation of the trachea is almost universally required for patients with cervical spine fracture and quadriplegia. Ventilatory support is almost always required for patients with a deficit above C4, because they will lack sufficient diaphragmatic function. Patients with levels from C6 to C7 may need support because of impairment in respiratory muscle function resulting from (1) loss of chest wall innervation, (2) paradoxical respiratory motion, (3) inability to clear secretions, and (4) decreased lung and chest wall compliance. Early tracheal intubation is recommended and, if elective, often can be accomplished by awake fiberoptic bronchoscopy or video laryngoscopy before hypoxia renders the patient anxious and uncooperative. Mechanical trauma to the spinal cord is exacerbated by systemic hypoperfusion or hypoxia. All patients with injuries at C5 and above required intubation, and 71% of these progressed to tracheostomy. Current recommendations by the American Association of Neurological Surgeons and the American College of Surgeons state that steroid administration is an option and should be undertaken with the knowledge that harmful side effects are more consistent than any proved benefit. First and foremost is the need for intubation of the trachea in a patient with a known injury to the cervical spine (see also Chapter 55). Direct laryngoscopy with in-line stabilization is appropriate in the emergency setting and in unconscious, combative, or hypoxemic patients when the status of the spine is not known. Oral intubation may be more challenging technically but will be of greater value if the patient remains mechanically ventilated. Again, in comparative studies of direct laryngoscopy, video laryngoscopy, fiberoptic examination, blind nasal intubation, or cricothyrotomy in patients with known cervical cord or spine injuries, no difference is seen in neurologic deterioration with technique used and no clear evidence exists that direct laryngoscopy worsens outcome. The important concept is to successfully achieve tracheal intubation while minimizing motion of the cervical spine and preserving the ability to assess neurologic function after positioning. Patients with either no deficit or complete deficit may require surgical stabilization to facilitate mobilization, but are less urgent cases. Hypotension from neurogenic shock is characterized by an inappropriate bradycardia resulting from loss of cardiac accelerator function and unopposed parasympathetic tone. However, this situation can be difficult to distinguish from hypotension resulting from acute hemorrhage, and a trial of fluid administration is still indicated, subject to the end points of resuscitation listed earlier. This approach is highly controversial and remains an option in treatment according to the American Association of Neurological Surgeons. In addition to physical handicaps that these patients may endure, orthopedic injuries incurred in both civilian and military settings lead to long-term psychological trauma. For the last 15 years, the emphasis in trauma management of a multiply injured patient has included early stabilization of long-bone, spine, pelvic, and acetabular fractures. Failure to do so results in increased morbidity, pulmonary complications, and length of hospital stay. Regional anesthesia is associated with decreased odds of inpatient mortality and pulmonary complications among patients with hip fracture in contrast to general anesthesia. Although unadjusted rates of mortality and cardiovascular complications did not differ by anesthesia type, regional anesthesia was associated with a decreased adjusted odds of mortality (odds ratio. Whereas the fracture itself can be safely managed on a delayed basis or nonoperatively, the dislocation is a medical emergency that must be promptly addressed if the patient is to have a good functional outcome. Failure to promptly diagnose and reduce a dislocated hip joint is a significant risk factor for avascular necrosis of the femoral head.
Serum Na+ concentrations are maintained within a tight range (138 to 142 mEq/L) despite wide variation in water intake by the systems Figure 59-2 hiv infection top vs. bottom buy 200mg zovirax visa. In the chronic setting arterial pressure (Pa) depends on daily water and sodium intake (dripping tap) and the renal pressure-natriuresis relationship (represented by the height of the holes in the arterial column) rather than cardiac output (Q) and peripheral resistance (R) hiv infection in zambia buy zovirax master card. This may be represented by kidney holes positioned further up the arterial column hiv infection process cheap zovirax on line. Natriuresis occurs to a degree similar to that in normotension hiv infection effects purchase zovirax mastercard, so as to maintain a stable body water volume, but requires a higher arterial pressure to do so. Long-term ingestion of excess salt combined with low potassium ingestion contributes to hypertension, a condition not seen in populations with daily salt intake less than 50 mmol. The mechanism involves renal salt retention and initial extracellular volume expansion (later mitigated by pressure natriuresis), with release of an Chapter 59: Perioperative Fluid and Electrolyte Therapy 1775 endogenous digitalis-like factor and stimulation of renal Na+ pumps, furthering renal Na+ retention. Daily requirements reflect age and growth, with more K+ required in higher metabolic rates. Transmembrane potentials particularly depend on K+ permeability, with K+ egress occurring through ion channels down its concentration gradient. This leaves behind intracellular anions, with a resultant negative transmembrane potential. The resting value of this potential is achieved when the tendency of K+ to move extracellularly as a result of its concentration gradient is matched by the tendency of K+ to move intracellularly because of the electrical gradient. K+ is freely filtered at the glomerulus, then undergoes extensive unregulated reabsorption along the proximal tubule, with only 10% to 15% reaching the distal nephron, where its reabsorption or secretion is tightly controlled. Increased distal tubular Na+ content leads to a steeper Na+ concentration gradient and increased principal cell reabsorption of Na+. To maintain electroneutrality of the tubular fluid, K+ efflux into the tubule increases; this is partly responsible for the hypokalemia associated with diuretics that increase delivery of Na+ to the cortical collecting ducts (thiazides and loop diuretics). In contrast, amiloride blocks the principal cell luminal Na+ channel and therefore does not affect K+ efflux here. Low K+ settings lead to up-regulation of this luminal antiporter, reabsorbing more K+ at the expense of renal acid loss. Intracellular Ca2+ entry may have direct effects-for example, leading to neurotransmitter release or inducing further large-scale release of Ca2+ from intracellular stores (Ca2+-induced Ca2+ release), in cardiac and skeletal muscle contraction. Increases in cytoplasmic free Ca2+ concentration occurring as a result of cellular energetic failure and impaired Ca2+ transport are a key mediator of cell death pathways. For example, Ca2+ levels remain normal after loss of the calcitonin-secreting parafollicular (C-) cells during thyroidectomy. Approximately 50% of circulating Ca2+ is in the biologically active ionized form (normal range 2 to 2. Hypoalbuminemia decreases the total serum Ca2+ but has less effect on the biologically important ionized form. The degree of albumin-protein binding is affected by pH, with acidemia reducing protein binding and increasing the ionized fraction. Specimens should ideally be taken without tourniquet (uncuffed), because local acidosis increases the ionized fraction. It is primarily an intracellular anion, although most is sequestered within organelles, bound to phospholipids, proteins, and nucleic acids. Of total body Mg2+, 50% is within bone, 20% within muscle, and the rest in liver, heart, and other tissues. In addition, effects on ion channels underlie one of the core functions of Mg2+, namely physiologic competitive antagonism of Ca2+. These effects result in inhibition of a diverse array of excitable tissue cellular actions, including neurotransmitter release, muscular contraction, cardiac pacemaker and action potential activity, and pain signal transmission. Seventy-five percent is freely filtered at the glomerulus, and proximal tubule reabsorption is minimal, with 60% to 70% being reabsorbed at the thick ascending loop of Henle and 10% reabsorbed under regulation in the distal tubule. Inhibition of neuronal Ca2+ influx reduces catecholamine release from adrenal medulla and adrenergic nerve endings. Pharmacologic use of Mg2+ in obtunding pressor response to intubation or during surgery for pheochromocytoma. Mg2+ administration typically leads to a minor reflex increase in inotropy despite the direct action of Mg2+ on reducing cardiac contractility. Increases atrioventricular nodal conduction time and refractory periods, suppresses accessory pathway transmission, and inhibits early and delayed afterdepolarizations. Clinical use is in supraventricular tachycardias, atrial fibrillation rate control and postoperative prophylaxis, and tachyarrhythmias associated with dyskalemia, digoxin, bupivacaine, or amitriptyline. Other influences may alter the intracellular-extracellular balance of magnesium distribution. Catecholamines, acting by both -adrenoreceptors and -adrenoreceptors, and glucagon lead to extrusion of magnesium from intracellular stores. Although experimental models have shown that adrenergic stimulation may increase serum Mg2+ concentrations, decreases in serum Mg2+ concentrations actually occur after stressors such as cardiac, orthopedic, and abdominal surgery, trauma, burns, and sepsis. Of total body phosphorus, 80% to 90% is stored in bone, with the remainder in the intracellular (soft tissues and erythrocytes) and extracellular fluid compartments.
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