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A hair loss gluten discount finpecia 1 mg mastercard, Anatomic landmarks for lateral femoral cutaneous hair loss on mens lower legs buy genuine finpecia on-line, femoral hair loss uterine cancer discount finpecia on line, and obturator nerve blocks hair loss cure may 2013 buy finpecia 1 mg low price. B, For an obturator nerve block, the needle is walked off the inferior pubic ramus in a medial and cephalad direction until it passes into the obturator canal. The use of ultrasound can be useful in patients in whom it is difficult to palpate a femoral pulse, because of weight, anatomic variability, or changes to the needle insertion site (before radiation or surgery). The femoral nerve can be identified lateral to the artery as a triangular shaped structure. The clinical applications for its use are the same as those for femoral nerve block. The double pop refers to the sensation felt as the needle traverses the fascia lata then the fascia iliaca. Penetration of both layers of fascia is important for successful fascia iliaca blockade. To facilitate the appreciation of the "clicks" or "pops," the use of a short bevel or bullet-tipped needle has been advocated to provide more tactile feedback than cutting needles. The needle entry site for the fascia iliaca block is determined by drawing a line between the pubic tubercle and the anterior superior iliac crest and dividing this line into thirds. The needle entry point is one centimeter caudal to the intersection of the medial Chapter 57: Peripheral Nerve Blocks 1741 two thirds and lateral one third along this line. This site is well away from the femoral artery, which is useful for patients in whom femoral artery puncture is contraindicated. Ultrasound can also be used to visualize the two fascial layers and spread of local anesthetic behind the fascia iliaca. Side Effects and Complications Intravascular injection and hematoma are possible because of the proximity of the femoral artery. Anatomically, the nerve and artery are located in separate sheaths approximately 1 cm apart. In most patients with normal anatomy, the femoral artery can be easily palpated, allowing correct, safe needle positioning lateral to the pulsation. The presence of femoral vascular grafts is a relative contraindication to these techniques. Several approaches to the saphenous nerve block have been described using both a transsartorial (above the knee) and paravenous (below the knee) approach. The saphenous nerve can also be blocked at the level of the ankle and will be described as part of the ankle block. Anatomy the saphenous nerve is a cutaneous sensory branch off the posterior division of the femoral nerve. The nerve emerges and divides at the level of the knee before continuing distally along the medial border of the tibia, posterior to the great saphenous vein. The saphenous nerve is located approximately 1 cm medial and 1 cm posterior to the saphenous vein at the level of the tibial tuberosity. It descends under the iliac fascia to enter the thigh deep to the inguinal ligament 1 to 2 cm medial to the anterior superior iliac spine. The nerve emerges from the fascia lata 7 to 10 cm below the spine and divides into anterior and posterior branches. The skin of the lateral portion of the thigh from the hip to midthigh is supplied by the posterior branch; the anterior branch supplies the anterolateral thigh to the knee. Technique the saphenous nerve is purely sensory; therefore, a field block technique is most common. Ultrasound guidance can also be used to identify the neural and vascular structures. At the level of the tibial tuberosity, approximately 5 to 10 mL of local anesthetic is infiltrated deep to the great saphenous vein. Approximately 5 to 10 mL of local anesthetic may be infiltrated from the medial condyle of the tibia anteriorly to the tibial tuberosity and posteriorly to the medial head of the gastrocnemius muscle. The sartorius muscle is palpated on the medial side of the leg, just cephalad to the patella. At the upper pole of the patella, a 22-gauge, 5-cm needle is advanced 45 degrees from the coronal plane, through the muscle belly of the sartorius until a fascial pop is noted. Ultrasound-guided saphenous nerve block can be performed either above or below the knee. For the transsartorial technique, the nerve can be found lying medial to the vastus medialis muscle within the fascia. Clinical Applications the lateral femoral cutaneous nerve block is useful for skin graft harvesting and can be used in concert with other peripheral nerve blocks for complete anesthesia of the lower extremity. Technique A point is marked 2 cm medial and 2 cm caudad to the anterior superior iliac spine. A 22-gauge, 4-cm needle is advanced perpendicular to the skin entry site until a sudden release indicates passage through the fascia lata. As the needle is moved in a fanlike pattern laterally and medially, 10 to 15 mL of solution is injected, depositing local anesthetic above and below the fascia. Although a sensory nerve, the lateral femoral cutaneous nerve can be localized using a nerve stimulator technique by seeking pulsatile tingling in the distribution of the nerve. Side Effects and Complications the risks of complications with this block are low, although the same theoretical risks all regional anesthetic techniques apply to this block. Given that the great saphenous vein is used as a landmark for the field block technique, minor hematoma formation is not uncommon.

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Neuropathies may involve all components of the nerve hair loss cancer discount finpecia 1mg with amex, thereby producing sensory hair loss in men gymnastics discount 1mg finpecia fast delivery, motor hair loss 45 women cheap 1mg finpecia, and autonomic dysfunction fitoval shampoo anti-hair loss purchase finpecia cheap, or only one component. Myasthenia gravis is a disorder of the muscular system caused by partial blockade or destruction of nicotinic acetylcholine receptors by IgG antibodies (see also Chapters 34, 38, and 80). The severity of the disease correlates with the ability of antibodies to decrease the number of available acetylcholine receptors. Because much of the care of patients with myasthenia gravis involves tailoring the amount of anticholinesterase medication to the maximal muscle strength of the patient, derangement of the course of the patient during the surgical procedure could necessitate Chapter 39: Anesthetic Implications of Concurrent Diseases 1201 reassessment of the drug dosage. For that reason, all anticholinergic drugs may be withheld for 6 hours preoperatively, and medication should be reinstituted postoperatively with extreme caution because the sensitivity of these patients to such drugs may have changed. Small doses of succinylcholine can be used to facilitate endotracheal intubation; extremely small doses of nondepolarizing drugs can be used for intraoperative relaxation not achieved by regional anesthesia or volatile anesthetics. Of prime importance is monitoring neuromuscular blockade as the guide for muscle relaxant administration and their reversal (see Chapter 53). Although controlled ventilation was frequently required for at least 24 to 48 hours postoperatively, immediate extubation has become more common. Lambert-Eaton syndrome (myasthenic syndrome) is characterized by proximal limb muscle weakness and is associated with antibodies directed against the voltagegated calcium channels in presynaptic nerve terminals. Affected patients exhibit decreased release of acetylcholine at the neuromuscular junction. Guanidine therapy enhances the release of acetylcholine from nerve terminals and improves strength. Men with this syndrome generally have small cell carcinoma of the lung or other malignant disease, whereas women often have malignant disease, sarcoidosis, thyroiditis, or a collagen-related vascular disease. In addition, these patients have increased sensitivity to both depolarizing and nondepolarizing muscle relaxants. Dermatomyositis and polymyositis are characterized by proximal limb muscle weakness with dysphagia. These conditions are associated with malignant disease or collagen-related vascular disease and often involve respiratory and cardiac muscle. Periodic paralysis is another disease in which sensitivity to muscle relaxants increases. Periodic weakness starts in childhood or adolescence and is precipitated by rest after exercise, sleep, cold, surgery, or pregnancy. Hypokalemic and hyperkalemic forms exist and are associated with cardiac arrhythmias. Like thyrotoxic periodic paralysis, these hypokalemic and hyperkalemic forms usually spare the respiratory muscles. Anesthetic management consists of minimizing stress and maintaining normal fluid and electrolyte status and body temperature. Because the disease involves the muscles themselves and not their innervation, conduction anesthesia cannot produce adequate relaxation of tonic muscles. As with the other forms of muscular dystrophy, most problems in myotonic dystrophy arise from cardiac arrhythmias and inadequacy of the respiratory muscles. Malignant hyperthermia in the patient or in a relative of the patient merits careful history taking and at least consideration of performing a test for susceptibility to the condition (see also Chapter 43). In some cases, malignant hyperthermia has been associated with recognizable musculoskeletal abnormalities such as strabismus, ptosis, myotonic dystrophy, hernias, kyphoscoliosis, muscular dystrophy, central core disease, and marfanoid syndrome. Appropriate preparation for a patient with previous masseter spasm, or trismus, is a matter of considerable debate. Malignant hyperthermia occurs most frequently in children and adolescents; the incidence is 1 in 14,000 administrations of anesthesia. The incidence increases to 1 in 2500 patients requiring strabismus (squint) surgery. It is associated with congenital cardiac lesions such as endocardial cushion defects (40%), ventricular septal defects (27%), patent ductus arteriosus (12%), and tetralogy of Fallot (8%). Down syndrome is also associated with upper respiratory infections, with atlanto-occipital instability (in 15% of patients,315-318 in whom it is asymptomatic in most cases, but all patients should be treated as though they have atlanto-occipital instability) and laxity of other joints, with thyroid hypofunction (50%), with an increased incidence of subglottic stenosis, and with enlargement of the tongue (or a decreased oral cavity size for a normal-sized tongue). A reported sensitivity to atropine has been disproved, although administration of atropine to any patient receiving digoxin for atrial fibrillation should be done with care. These patients may benefit from preoperative treatment or anesthetic management that assumes this possibility (see also Chapter 70). The linking of renal failure to electrolyte disorders is more obvious: the kidney is the primary organ for regulating body osmolality and fluid volume and has a major role in excretion of the end products of metabolism. In performing these functions, the kidney becomes intimately involved in the excretion of electrolytes. A patient with renal insufficiency whose own kidneys are still functioning is distinct not only from a patient with end-stage renal disease whose renal functions are provided by dialysis but also from a patient who has a transplanted kidney. In addition, acute changes in renal function present quite a different problem than do chronic alterations in function. Certain renal diseases require different preoperative preparation than others, but generally, renal disease of any origin presents the same preoperative problems (see also Chapters 23, 38, and 52). The soundness of tubular function is an important consideration because tubular dysfunction with attendant uremia presents problems quite different from those presented by glomerular disease with only nephrotic syndrome. This is not to minimize the adverse effects of glomerular disease; nephrotic syndrome consists of massive proteinuria and consequent hypoalbuminemia.

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Their heart failure is due to diastolic dysfunction: abnormal diastolic relaxation and filling hair loss zetia order finpecia online now. At slower heart rates hair loss gastric sleeve purchase finpecia 1 mg mastercard, these two waves are separated by a period of relatively little flow (diastasis) hair loss 12 months postpartum purchase finpecia 1mg with visa. Three severities of diastolic dysfunction are diagnosed by the combination of flow patterns in the mitral valve and pulmonary veins hair loss 2015 buy discount finpecia 1mg on-line. In impaired relaxation, left atrial pressure is normal, and therefore so is the pattern of pulmonary venous flow-the S wave is greater than the D wave. The second and more severe degree of diastolic dysfunction is termed pseudonormal and is characterized by the return of the normal E:A ratio because of a pathologic increase in left atrial pressure that results in abnormal pulmonary venous flow-the D wave is greater than the S wave. One simple way to confirm that the mitral flow pattern is pseudonormal and not normal is to reduce left atrial filling transiently with a Valsalva maneuver. If diastolic function is pseudonormal, then the E:A ratio will transiently reverse, with A being greater than E. If diastolic function is normal, then the normal ratio of E greater than A will persist and both waves will decrease in size. The third and most severe degree of diastolic dysfunction is termed restrictive and is characterized by an extremely high E-wave velocity, short deceleration time, and low A-wave velocity. In restrictive diastolic function, left atrial pressure is very high and results in an extremely small S wave and large D wave in the pulmonary veins. Patients with this pattern have a poor prognosis and suffer symptoms of congestive heart failure, regardless of their systolic function. From the start of the line at the inflection point of the E wave until its intercept at the base line is the deceleration time. This time is depicted in each of the mitral velocity drawings by the black arrows. An experienced observer can differentiate severe ventricular dysfunction from other life-threatening causes of hypotension. Hypovolemia is easily recognized as a clear decrease in ventricular filling and a distinctive increase in ejection. Physiologic changes produced by tamponade results when a pericardial effusion or other compression of the heart causes cardiac chamber pressures to be higher than filling pressures, resulting in the collapse of the chamber(s) and rapid deterioration of the cardiac output. When an area of the myocardium is clearly in view, segmental contraction can be difficult to evaluate if the heart significantly rotates or translates during systole or if discoordinated contraction occurs because of bundle branch block or ventricular pacing. A noticeable worsening of segmental wall motion and wall thickening (in the absence of similar global changes) is required to make the diagnosis of ischemia; even experts do not consistently interpret less pronounced changes. In coronary surgery, differentiating infarction, stunning, and ischemia is vitally important. Restoring intraoperative blood pressure with phenylephrine to preoperative levels improves the concordance between preoperative and intraoperative assessment of mitral regurgitation, but discrepancies remain. To limit the time to surgery further, one center uses a regional strategy of direct admission to the operating room for patients with diagnosed or suspected acute aortic dissections. These guidelines detail the clinical application of epiaortic scanning during heart surgery to evaluate the atherosclerotic disease burden in the ascending aorta and arch to guide proper cannulation strategies that may decrease the incidence of perioperative stroke. In a different study, 437 patients underwent mitral valve repair by a variety of techniques. Although moderate or severe periprosthetic leaks should almost always undergo immediate repair, almost half of the small leaks resolve with the administration of protamine. In a study of 417 patients undergoing valve replacement, immediate surgical correction was required in 15 patients (3. With color Doppler positioned over the leaflets and outflow track, Chapter 46: Perioperative Echocardiography 1423 Figure 46-33. At the top of the echocardiogram is a still-frame image of the two-dimensional cross section used to position the Doppler sample cursor (diagonal white line). Two-dimensional imaging reveals thickened leaflets that dome toward the left ventricle and open poorly. Color Doppler reveals laminar flow acceleration into the stenotic orifice and a turbulent jet emerging into the ventricle (Figure 46-34). Mathematical calculation from these traces, such as pressure half time, are the most precise methods to assess the severity of mitral stenosis; and formulas for these evaluations are built into the software of virtually every ultrasonograph. Pulmonary and tricuspid valve pathologic assessment are conducted in a fashion analogous to that described for the aortic and mitral valves (see Tables 46-6 and 46-7). Spontaneous contrast is a swirling, smokelike appearance of 1-to 2-mm densities not attributable to exogenously administered contrast agents but to the aggregation of red cells in areas of low flow. Whenever left atrial enlargement and spontaneous contrast are noted, thrombus in the left atrium and, in particular, the left atrial appendage should be suspected and carefully examined. The presence and severity of mitral regurgitation are evaluated from the same cross sections used for evaluation of mitral stenosis and with the same grading strategy used for aortic regurgitation (Table 46-7). Mild regurgitation is characterized by a narrow-based, systolic color jet (<2 mm at its origin in the valve) that occupies less than 25% of the left atrial cross-sectional area and extends less than one half of the distance to the posterior wall of the left atrium. Moderate regurgitation is a broad-based, systolic color jet (3 to 5 mm at its origin in the valve), occupying less than 50% of the left atrial cross-sectional area and extending 50% to 90% of the distance to the posterior wall of the left atrium. Severe regurgitation is a broadbased, systolic color jet (>5 mm), occupying most of the left atrium and extending into the pulmonary veins and left atrial appendage (Figure 46-36). Eccentrically-directed jets of mitral regurgitation that hug the wall of the atrium are generally associated with more severe valvular regurgitation than their cross-sectional area might suggest (see Figure 46-36). Moreover, eccentric-directed jets usually point away from the defective leaflet; that is, lateraldirected jets are usually associated with anterior leaflet defects and medial-directed jets are usually associated with posterior leaflet defects, provided the mechanism of regurgitation is leaflet prolapse or flail. After bypass, surgical management changed in 10 patients including graft evaluation or revision and mitral repair (also see Chapter 67).

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The term airway management refers to this practice and is a cornerstone of anesthesia hair loss 7 year old daughter cheap finpecia 1mg without prescription. The anesthesia practitioner should become proficient with techniques for transtracheal jet ventilation and cricothyrotomy hair loss cure genetic purchase finpecia discount. The plan for an extubation of the trachea must be preemptively formulated and includes a strategy for reintubation of the trachea should the patient be unable to maintain an adequate airway after extubation hair loss cure knee cheap finpecia 1mg free shipping. Therefore one of the fundamental responsibilities of the anesthesiologist is to establish airway patency and to ensure adequate ventilation and oxygenation hair loss cure news 2012 finpecia 1mg otc. The term airway management refers to the practice of establishing and securing a patent airway and is a cornerstone of anesthetic practice. Because failure to secure a patent airway can result in hypoxic brain injury or death in only a few minutes, difficulty with airway management has potentially grave implications. As with any manual skill, continued practice improves performance and may reduce the likelihood of complications. New airway devices are continually being introduced into the clinical arena, each with unique properties that may be advantageous in certain situations. Becoming familiar with new devices under controlled conditions is important for the anesthesia practitioner-the difficult airway is not an appropriate setting during which to experiment with a new technique. Knowledge of normal anatomy and anatomic variations that may render airway management more difficult helps with the formulation of an airway management plan. Because some critical anatomic structures may be obscured during airway management, the anesthesiologist must be familiar with the interrelationship between different airway structures. The airway can be divided into the upper airway, which includes the nasal cavity, the oral cavity, the pharynx, and the larynx; and the lower airway, which consists of the tracheobronchial tree. The nasal cavity is divided into the right and left nasal passages (or fossae) by the nasal septum, which forms the medial wall of each passage. The septum is formed by the septal cartilage anteriorly and by two bones posteriorly-the ethmoid (superiorly) and the vomer (inferiorly). Nasal septal deviation is common in the adult population6; therefore the more patent side should be determined before passing instrumentation through the nasal passages. The lateral wall of the nasal passages is characterized by the presence of three turbinates (or conchae) that divide the nasal passage into three scroll-shaped meatuses (Figure 55-2). The inferior meatus, between the inferior turbinate and the floor of the nasal cavity, is the preferred pathway for passage of nasal airway devices7; improper placement of objects in the nose can result in avulsion of a turbinate. This fragile structure, if fractured, can result in communication between the nasal and intracranial cavities and a resultant leakage of cerebrospinal fluid. Because the mucosal lining of the nasal cavity is highly vascular, vasoconstrictor should be applied, usually topically, before instrumentation of the nose to avoid epistaxis. The posterior openings of the nasal passages are the choanae, which lead into the nasopharynx. Actively pursue opportunities to deliver supplemental oxygen throughout the process of difficult airway management. Develop primary and alternative strategies: Awake intubation Airway approached by noninvasive intubation Succeed* Fail Consider feasibility of other options(a) Invasive airway access(b)* Invasive airway access(b)* 1649 Intubation after induction of general anesthesia Initial intubation attempts successful* Initial intubation attempts unsuccessful From this point onward, consider: 1. Pursuit of these options usually implies that mask ventilation will not be problematic. Therefore these options may be of limited value if this step in the algorithm has been reached via the Emergency Pathway. Invasive airway access includes surgical or percutaneous airway, jet ventilation, and retrograde intubation. Consider re-preparation of the patient for awake intubation or cancelling surgery. The tongue is anchored to various structures by its extrinsic musculature; of these, the most clinically relevant to the anesthesiologist is the genioglossus, which connects the tongue to the mandible. Cellulitis (Ludwig angina) or hematoma formation in these spaces can cause elevation and posterior displacement of the tongue and resultant airway obstruction. Sagittal section through the head and neck showing the subdivisions of the pharynx. The posterior wall of the pharynx is made up of the buccopharyngeal fascia, which separates the pharynx from the retropharyngeal space. Improper placement of a gastric or tracheal tube can result in laceration of this fascia and the formation of a retropharyngeal dissection. Along the superior and posterior walls of the nasopharynx are the adenoid tonsils, which can cause chronic nasal obstruction and, when enlarged, can cause difficulty passaging airway devices. The nasopharynx ends at the soft palate; this region is termed the velopharynx and is a common site of airway obstruction in both awake and anesthetized patients. The lateral walls contain the palatoglossal folds and the palatopharyngeal folds, also termed the anterior and posterior faucial (tonsillar) pillars, respectively; these Palatoglossal fold (anterior pillar) Tonsil Figure 55-4. The base of the tongue lies in the anterior aspect of the oropharynx, connected to the epiglottis by the glossoepiglottic folds, which bound paired spaces known as the valleculae (although these are frequently referred to as a single space called the vallecula). The hypopharynx begins at the level of the epiglottis and terminates at the level of the cricoid cartilage, where it is continuous with the esophagus. The larynx protrudes into the hypopharynx, creating two piriform recesses on either side (Figure 55-5). The arytenoid cartilages articulate with the posterior cricoid and are the posterior attachments for the vocal cords. It functions to divert food away from the larynx during the act of swallowing, although its role in this regard is not essential to prevent tracheal aspiration.

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Intraoperative cardiac arrest occurred most frequently in patients younger than 1 year of age (4 in 2901 procedures) hair loss cure within 2 years order finpecia with visa. Postoperatively hair loss cure columbia effective finpecia 1 mg, minor events such as nausea and vomiting were more common in older children hair loss pcos discount finpecia 1 mg fast delivery, whereas respiratory events were more common in infants and younger children (Table 37-15) himalaya hair loss cream buy 1mg finpecia otc. When compared with adult patients, children experienced different complications, which frequently extended well into the postoperative period. In a comparison of 2-year periods between 1982 and 1987, rates of intraoperative events were found to be stable, and the rate of postoperative complications decreased. The incidence of deaths related to anesthesia was far lower, occurring at a rate of 1 in 10,188 or 0. In all of the 10 anesthetic-related deaths that the authors observed, preexisting medical conditions were assessed to have been a significant contributing factor. Includes nausea and vomiting, sore throat, muscle pain, headache, dental conditions, positional conditions, conditions involving extremities, eye conditions, croup, temperature, behavioral problems, thrombophlebitis, arterial line problem, awareness, and "other" problems. Includes "other respiratory" conditions, cardiovascular disorders, nerve palsy, hepatic disorders, renal disorders, seizures, surgical complications, and death. A total of 92,881 anesthetics were administered during the study period, 4242 (5%) of which were for the repair of congenital heart malformations. The incidence of cardiac arrest and mortality was highest in neonates (0 to 30 days of life) undergoing cardiac procedures (incidence, 435 per 10,000; mortality, 389 per 10,000). Efforts to understand the causes and outcomes of cardiac arrest in pediatric anesthesia patients have been aided by the development of large-scale clinical registries for research and quality improvement. Institutions included in the registry submitted standardized data from each cardiac arrest occurring in an anesthetized child 18 years of age or younger. A total of 289 cardiac arrests occurred in the 63 institutions in the database during the first 4 years of the registry, 150 of which were judged to be related to anesthesia (1. Medication-related causes and cardiovascular causes of cardiac arrest were most common. Anesthesia-related cardiac arrest occurred most often in patients younger than age 1 year and in patients with severe underlying disease. The goal of the registry is similar to that of the closed claims studies-to identify the causes in this unique population and thereby formulate preventive strategies. Cardiovascular causes of cardiac arrest (41%) were the most common, with hypovolemia from blood loss and hyperkalemia from transfusion of stored blood being the most common identifiable cardiovascular causes. Among respiratory causes of arrest (27%), airway obstruction from laryngospasm was the most common. Vascular injury incurred during placement of central venous catheters was the most frequent equipment-related cause of arrest. Cardiovascular and respiratory causes occurred most commonly in the surgical and postsurgical phases, respectively. A key issue in research on the safety of surgery and anesthesia among older adults is the determination of what constitutes old age from the perspective of perioperative risk. Multiple definitions have been used for advanced age, including age older than 65, 70, 80, or 90 years. For example, Denney and Denson142 evaluated risk associated with surgery in patients older than 90 years of age. They reported 272 patients undergoing 301 operations at the University of Southern California Medical Center, finding a high perioperative mortality rate among older patients with serious bowel obstruction (63%). Taking a slightly different approach, Djokovic and HedleyWhyte143 studied outcome after surgery in 500 patients older than 80 years of age. Del Guercio and Cohn144 investigated the value of preoperative invasive monitoring in obtaining hemodynamic and cardiopulmonary variables for predicting operative risk in the older adult. Advanced and uncorrectable functional deficits were found in 63% of patients, and all in this group who underwent the planned surgery died. More recently, a growing body of literature has focused on the importance of functional disability and chronic geriatric syndromes, such as frailty and dementia, as determinants of postoperative outcomes among older individuals. Robinson and colleagues examined a cohort of 110 surgical patients with a mean age of 74 years, finding a 15% 6-month rate of mortality. Statistically significant predictors of 6-month mortality included impaired cognition, a recent fall, hypoalbuminemia, anemia, functional dependence, and comorbidity. Four or more markers in any one patient effectively predicted 6-month mortality (sensitivity, 81%; specificity, 86%). Most recently, Finlayson and colleagues examined 6822 older nursing home residents undergoing intestinal resections for colon cancer, noting a 53% 1-year mortality rate and a 24% rate of sustained decline in functional independence in activities of daily living among survivors. In multivariate regression, age older than 80 years, hospital readmission after surgical discharge, surgical complications, and functional decline before surgery all predicted functional decline at 1 year. From a global perspective, there does not appear to be a single best anesthesia technique for a particular surgery or group of surgeries. In a multivariate analysis by Cohen and co-workers96 of 100,000 anesthesia procedures performed in Canada, the choice of drug did not provide any additional prognostic information for predicting mortality beyond that of patient disease and the surgical procedure. In univariate analysis, monitored anesthesia care appeared to be associated with worse outcomes; however, this association was attributable to the use of monitored anesthesia in sicker patients (see Table 37-12). One question that has persisted within the anesthesia literature is the issue of whether anesthetic medications carry inherent toxicity (also see Chapter 26). For example, numerous recent discussions have focused on the potential toxicity of halothane and sevoflurane. In the case of halothane, concern focused on the potential for fulminant, potentially fatal, hepatic necrosis with this medication. After several case reports of hepatic necrosis after halothane anesthesia, a large retrospective study of 856,500 anesthesia procedures at 34 institutions was undertaken.

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