Keep the Serum Potassium at High or Normal Levels When Attempting to Correct a M
ساعت ٤:٢٢ ‎ب.ظ روز ۱۳۸٩/٦/٢۸   کلمات کلیدی: serum potassium ،metabolic alkalosis

در درمان آلکالوز متابولیک بهتر است سطح پتاسیم سرم در سطوح نرمال یا حتی بالاتر حفظ شود:


اهمیت آنژیو گرافی در ترومای بلانت ارگانهای سخت
ساعت ٤:۱٦ ‎ب.ظ روز ۱۳۸٩/٦/٢۸   کلمات کلیدی: blunt solid-organ injury ،angiography
این مطلب اختصاصاً مربوط به پرستاری نیست ولی عواقب عدم توجه به آن بارها و بارها پرستاران را با مشکلات عدیده در مراقبتهای پرستاری مواجه کرده است:
Consider Angiography for Blunt Solid-Organ Injury
Suneel Khetarpal MD
Barbara Haas MD
The ability to manage the majority of solid-organ injuries nonoperatively has become a cornerstone in the optimal approach to blunt trauma. Both diagnostic and therapeutic angiography is gaining increasing prominence as a technique by which this goal can be achieved.
The spleen is the most frequently injured organ following blunt abdominal trauma, with splenic injuries being present in 25% to 30% of cases. Liver injury is less frequent (15% to 20% of patients), and renal trauma is present in approximately 10% of patients. Although the circumstances in which angiography can be used in the management of these injuries are constantly evolving, a number of reports have demonstrated its value as an adjunct that can increase overall organ salvage and decrease the need for surgical intervention.
All grades of splenic injury have been successfully managed nonoperatively in hemodynamically stable patients. However, increasing grade of injury, as well as contrast extravasation or blush on admission computed tomography (which MUST be performed with intravenous contrast), has been associated with increasing likelihood of nonoperative management failure. Angioembolization has been considered useful in avoiding surgery in this subset of patients, who are most likely to fail observation in the intensive care unit. In recently published reports, between 5% and 15% of patients with splenic injuries were successfully managed with angioembolization, with success rates greater than 90% reported. The indications and technique for angioembolization in splenic trauma have been evolving rapidly and are the subject of considerable debate. Advocates of proximal splenic artery embolization theorize that this approach decreases splenic blood pressure, which prevents delayed hemorrhage and accelerates splenic healing while maintaining splenic perfusion through collateral blood flow. Others use angioembolization at the level of more distal arteries to the spleen, which requires more time and manipulation but preserves blood flow to the spleen.
Watch Out For
It is important to note that approximately 8% to 10% of patients who initially appear to have been successfully managed nonoperatively are at
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risk for delayed complications requiring intervention. Complications include persistent hemorrhage, delayed splenic rupture due to expanding hematoma, and splenic artery pseudoaneurysm formation. Angioembolization should be considered in the treatment of these complications, given that patients who fail nonoperative management and require delayed operative intervention have significantly worse outcomes than both patients managed nonoperatively and patients managed surgically at initial presentation.
The use of angiography and arterial embolization for hepatic injury has also undergone considerable evolution. Initially introduced as a viable therapeutic modality for hemodynamically stable patients, the technique has been shown to be a successful alternative to surgery in patients who are hemodynamically stable only with ongoing resuscitation. These are generally patients with isolated liver injuries or liver injuries associated with concomitant intra-abdominal trauma not requiring emergent laparotomy. Moreover, emphasis has been placed on the use of angioembolization in patients with high grades of injury and evidence of ongoing arterial bleeding on computed tomography in the form of contrast blush. Historically, these patients are most likely to fail nonoperative management.
A separate group of patients who benefit from hepatic artery angioembolization are severely injured patients for whom the technique is a component of postoperative stabilization and resuscitation. In particular, patients with grade IV and grade V liver injuries appear to benefit from angioembolization, although the data supporting this approach combine patients with both blunt and penetrating mechanisms of injury. Finally, angioembolization has successfully been used in the management of delayed complications in patients with hepatic injuries. Specifically, up to 5% of patients managed nonoperatively subsequently develop delayed or recurrent hemorrhage, 1% to 2% develop vascular abnormalities, such as pseudoaneurysm, and 1% develop hemobilia. In most cases of delayed vascular complications, angioembolization is the primary treatment of choice.
Angioembolization has also been used with success in the management of blunt renal injuries, although there is less experience managing this type of injury with interventional radiology. Given that 85% of renal injuries are grade III or less, these injuries are less likely to require intervention. Successful angioembolization of renal vascular injuries in patients who are hemodynamically stable has been reported by a number of groups, with emphasis being placed on highly selective embolization to attempt maximum tissue preservation and thus preserve renal function.
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As with any intervention, angiography and subsequent embolization is not without risk. Angiography is associated with risk of hematoma, vessel thrombosis, and vascular injury, such as vessel dissection or pseudoaneurysm formation. Vessel embolization can be associated with tissue infarction and subsequent abscess formation, particularly when less selective techniques are used. Nevertheless, the utility of this technique in the successful nonoperative and operative management of blunt solid-organ injuries has been demonstrated in a variety of patient populations.
Suggested Readings
Haan JM, Biffl W, Knudson MM, et al. Western Trauma Association Multi-Institutional Trials Committee. Splenic embolization revisited: a multicenter review. J Trauma 2004;56(3):542–547.
Harbrecht BG. Is anything new in adult blunt splenic trauma? Am J Surg 2005; 190(2):273–278.

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ساعت ۸:٥۳ ‎ق.ظ روز ۱۳۸٩/٦/۱٦   کلمات کلیدی: abdominal compartment syndrome

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ساعت ۸:۳۸ ‎ق.ظ روز ۱۳۸٩/٦/۱٦   کلمات کلیدی:

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اشتباهات شایه در بخش آی سی یو 8
ساعت ٢:٥٠ ‎ق.ظ روز ۱۳۸٩/٦/۱٢   کلمات کلیدی: pulmonary embolism ،arterial blood gas

ABG چه جایگاهی در تشخیص آمبولی ریوی دارد ؟

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ساعت ۸:۱٢ ‎ق.ظ روز ۱۳۸٩/٦/٩   کلمات کلیدی: