By Q. Esiel. Linfield College.
You should be aware of whether the patient is syndromic or not (those with a “syndrome” typically have more sutures in need of repair discount levitra super active 40mg on-line, and might well have other problems) discount levitra super active 20mg without prescription, and the extent of the repair. Because of the large blood loss, they typically receive quite a bit of fluid intra-operatively as well as post-operatively. Each member of the team brings unique knowledge and perspective to the care of the patient and recognizing and integrating all members of the team in the ongoing care of the patient is essential in providing optimal care for these patients. The presence of trainees from medicine, nursing, respiratory therapy, or other disciplines adds to the size and complexity of the team caring for the patient, and the roles and responsibilities of these individuals must be explicitly acknowledged. Perioperative care encompasses both pre and post operative care of the patient with congenital heart disease. Although many infants and children with congenital heart defects are managed as outpatients until their repairs, some infants or older children with severely abnormal physiology require stabilization and critical care prior to surgery. Many of the basic principles of cardiac intensive care apply to both pre and post operative care and will be considered in this chapter. In addition to supportive care and stabilization, pre operative management includes thorough evaluation of the anatomy and physiology of the heart and the physiologic status of the patient as a whole so that appropriately planned and timed surgery can take place. Basic principles of pediatric critical medical and nursing care remain relevant in the pediatric congenital cardiac patient. Pediatric cardiac patients are cared for in specialized cardiac intensive care units and in multidisciplinary intensive care units. There is some data that institutions that perform more surgeries have improved outcomes (info here—based on surgeon, unit, hospital?? Regardless of the focus of the unit, a commitment to ongoing education and training, as well as a collaborative and supportive environment is essential. We feel strongly that a unit dedicated to the care of infants and children is best able to care for these patients (down on the adult units caring for kids). Oxygen delivery is therefore primarily dependent on systemic cardiac output, - 58 - hemoglobin concentration, and oxygen saturation. Stroke volume is in turn dependent on preload, afterload, and myocardial contractility. Both pulmonary blood flow (Qp) and systemic blood flow (Qs) are determined by these fundamental forces. In the patient with two ventricles, ventricular interdependence, or the affect of one ventricle on the other, may play a role in pulmonary or systemic blood flow. In some situations, including the post operative state, the pericardium and restriction due to the pericardial space may also play a role in ventricular output. When evaluating the loading conditions of the heart and myocardial contractility, it is important to consider the two ventricles independently as well as their affect on one another. In previously healthy pediatric patients without heart disease, right atrial filling pressures are commonly assumed to reflect the loading conditions of the left as well as the right ventricle. Pre-existing lesions and the affects of surgery may affect the two ventricles differently. For example, the presence of a right ventricular outflow tract obstruction will lead to hypertrophy of the right ventricle. That right ventricle will be non-compliant, and the right atrial pressure may therefore not accurately reflect the adequacy of left ventricular filling. Oxygen content (CaO2) is primarily a function of hemoglobin concentration and arterial oxygen saturation. Thus, patients who are cyanotic can achieve adequate oxygen delivery by maintaining a high hemoglobin concentration. Arterial oxygen saturation is commonly affected by inspired oxygen content, by mixed venous oxygen content of blood, by pulmonary abnormalities, and by the presence of a R to L intracardiac shunt. Arterial oxygen content in the patient with a single ventricle and parallel pulmonary and systemic circulations will depend on the relative balance between the circulations as well. In the patient with intracardiac shunt or the single ventricle patient, arterial oxygen content is also affected by the relative resistances of the pulmonary and systemic circuits, as this determines how much blood flows through the lungs relative to the systemic output. Low mixed venous oxygen content contributes to desaturation and suggests increased oxygen extraction due to inadequate oxygen delivery, which in turn is either due to inadequate systemic cardiac output or inadequate hemoglobin concentration. A thorough understanding of these fundamental principles of cardiac output and oxygen delivery is essential for the perioperative care of the patient with congenital heart disease. General Principles of Anatomy and Pathophysiology Affecting Pre-operative and Post- operative Management An understanding of the anatomy and pathophysiology of the congenital cardiac lesion under consideration allows one to determine the pre-operative care or resuscitation needed and to predict the expected post-operative recovery. Acyanotic Heart Disease Children with acyanotic heart disease may have one (or more) of three basic defects: 1) left-to-right shunts (e.
Proteins have long been recognized as fundamental structural elements of every cell of the body levitra super active 20 mg sale. Specific proteins and protein derivatives have been recognized as functional elements in certain specialized cells glandular secretion buy cheap levitra super active 20 mg online, enzymes and hormones. Proteins in natural foods differ widely in the number and the proportion of the 22 or more amino acids. A good quality or a complete protein is the one that supplies all the essential amino acids in sufficient quantities and in proper ratio for normal growth and maintenance. In general all proteins from animal source, such as meat, poultry, fish, eggs, milk and milk products provide good quality proteins. They are listed as meat alternates in the four-food group chart because they provide one of the better quality plant proteins. Digestion and absorption of protein The digestion of protein in the alimentary tract is accomplished by the action of several proteolytic enzymes in the gastric, pancreatic and intestinal juices. Any of these enzymes that have the power to attack native proteins must be secreted in an inactive form to prevent damage to the tissues where they are formed. Types of enzymes Pepsinogen is secreted by the gastric juice and activated by the Hydrochloric acid Trypsinogen is secreted by pancreatic juice and activated by entropeptidase 20 Nutrition Chemotrypsinogen is secreted by pancreatic juice and activated by the active tripsin Peptidase intestinal juice Table 3 Summary of protein digestion Site of action Protein Enzyme End – Product Stomach Protein Pepsin in acid Large peptide polypeptides Trypsin chemotrypsin poly peptides Peptidase (secreted Polypeptide by mucosal cells of - Small dipeptides small intestine Polypeptides intestine Dipepetides Amino acids Enter portal blood Liver Peptides Amino acids Body tissues Portal 21 Nutrition The Amino Acid Pool The amino acids from the food or from the body tissues enter a common pool, which is drawn upon for the synthesis of proteins, hormones, enzymes, blood protein and nucleic acids, or some of the amino acids are degraded for energy needs. If carbohydrates and fats are not meeting the energy needs of the body, amino acids can be used to provide energy. Danger of the weaning period The weaning period is fraught with dangers for a large proportion of the world’s children and nutritional disorders are common at this time of life. In the West a general awareness of the nutritional needs of the weanling, together with the ability of the average family to provide the necessary foods, have helped to remove most of the dangers of the weaning period. In the peasant society of developing countries, however, parents are generally are unaware of the dietary needs of children, and several customs associated with weaning are likely to give rise to nutritional deficiencies. There are superstitions and beliefs concerning the effects of another pregnancy on the quality of the breast milk. They also think that the baby in the womb is jealous of the older sibling on the breast. It is therefore considered urgent that the child should be taken off the breast immediately. The mother may apply potions (bitter material) to the nipples so that when the child takes the breast the sharp bitter taste makes him/her give up suckling. The child has very close relationship with the mother, the mother takes him/her back wherever and whenever she goes to fetch water or to bring firewood, the child has also access to breast milk on demand. The child sleeps on her back, but this intimacy will be interrupted when the mother knows that she is pregnant for the subsequent child. This is a psychological blow for the child and causes poor appetite and as the result the child can develop protein energy malnutrition. The diseases occur mostly in children between one and three years of age, after they have been taken of the breast. Therefore, all factors that could possibly contribute to the child malnutrition in general should be avoided. These include: Seasonal food shortage Unfavorable family condition, Inadequate water supply and sanitary facilities, Certain traditional attitudes during pregnancy, prenatal period, breast-feeding and weaning periods, and All infectious diseases, which generally reduce immunity. Other diseases may sometime play an important role in precipitating the onset of kwashiorkor in already malnourished child. Severe: superficial ulceration, bleeding Hair changes Hair changes are classified into three categories Mild: beginning of visible color and structural changes Moderate: color and structural changes, loss of hair Severe: loss of hair together with ulceration of head Physiological functions of the various systems are markedly disturbed with Diarrhea Electrolyte disturbance Circulatory insufficiency Metabolic imbalance Poor renal functions Hence the child with kwashiorkor should be thought of as an emergency in need of referral to the nearest health facility. Child status after discharge from hospital Mental state has improved as shown by smiling, response to stimuli, awareness, and interest in the surroundings Appetite has returned and he/she is eating well Shows physical activity Temperature is normal No vomiting or diarrhea No edema Starting to gain weight. Lipids Are the form of stored energy in animals Have high energy value 9 kcal/gm of fat Act as carriers for fat soluble vitamins Are palatable giving good taste and satiety Serve as insulator preventing heat loss from the body Lubricate the gastrointestinal tract Protect the delicate organs such as Kidney, Eyes, heart and the like. Phospholipids, sterols and lipoproteins Phospholipids are structural compounds found in cell membranes. They are essential components of enzyme systems and are involved in the transport of lipids in plasma. Sterols These are precursors of vitamin D, which are found both in plants and animals.