By: John Hunter Peel Alexander, MD
There is no exact method to consider all the Elderly patients generally do poorly with surgery for mitral relevant factors to identify high and low risk patients buy yogut 1 mg on-line. Mitral valve surgery has been documented to be per medical management, and the mortality and morbidity associ formed with acceptable early and midterm outcomes if repair is ated with surgery. There is limited indication for surgery are generally used in the elderly, but consideration must always in an attempt to preserve ventricular function because the aim be given to match durability of bioprostheses and longevity of of surgery in the elderly is to improve quality of life, not to pro the patient to avoid the need for late reoperation. Extreme calcification may necessitate aortic root replacement Impact of small prosthetic valve size on operative mortality in elderly and in this situation a stentless porcine root prosthesis would patients after aortic valve replacement for aortic stenosis: Does gender be advised rather than a mechanical valved conduit, to avoid matter J Am Coll Cardiol possible enlargement of the annulus to implant a satisfactory 2000;35:731-8. Effect of gender and coronary artery disease on operative either porcine or pericardial. Aortic valve replacement in Guidelines for the management of patients with valvular heart elderly patients: Influence of concomitant coronary grafting on late disease. Ann Thorac Surg Porcine bioprosthesis in the elderly: clinical performance by age 1995;60(Suppl 2):S443-6. Mitral valve surgery in deterioration in elderly patient populations with the Carpentier Edwards standard and supra-annular porcine bioprostheses: the elderly. Circulation Porcine bioprostheses in the elderly: Clinical performance by age 1989;80:I49-56. Aortic valve replacement in patients aged eighty years and older: Early and long-term results. Outcomes 15 years after valve bypass grafting and/or aortic or mitral valve operation in patients replacement with a mechanical versus a bioprosthetic valve: > or = 90 years of age. Increasing numbers of women with heart mined by this retrospective study has been assessed in a disease will be contemplating pregnancy as a result of advances prospective multicentre study of pregnancy outcomes in in the diagnosis and treatment of heart disease during child women with heart disease (16. Most studies are case series and there are few large greater than 30 mmHg by echocardiography), and reduced sys cohort studies. There is a need for large prospective observa temic ventricular systolic function (ejection fraction less than tional studies and randomized clinical trials. The predictors of primary cardiac events were incorpo rated into a revised risk index in which each pregnancy was assigned one point for each predictor when present. The esti Physiological changes during pregnancy mated risk of a cardiac event in pregnancies with zero, one and the changes in circulatory physiology during pregnancy are greater than one points was determined at 5%, 27% and 75%, well delineated and place increasing demands on the cardio respectively. The evaluation and management of Poor maternal functional class or cyanosis has been known valvular heart disease in pregnancy demands an understanding to also be predictive of adverse neonatal events (15,17. In the of these normal physiological changes associated with gesta prospective study, the five predictors of neonatal events were tion, labour, delivery and the early postpartum period. The fetal or neonatal death rate with none of the constant through the remainder of the pregnancy. There are decreases in peripheral vascular both neonatal and cardiovascular complications (18-20. During labour and delivery, pain maternal cardiac status and risk of cardiac complications dur and uterine contractions result in additional increases in car ing pregnancy have been classified as low risk, intermediate diac output and blood pressure.
The dos ing of naloxone varies depending on whether the patient is known to be opioid dependent as well as on the extent of respiratory depression discount 1 mg yogut with mastercard. The lower dose is used for opioid-dependent individuals, who will show withdrawal symptoms within minutes of be ing given the medication (129. For any person who presents with significant respiratory de pression, the initial suggested dose is 2. If no response is observed after administration of the 10 mg of naloxone, the diagnosis of opioid overdose should be reconsidered. Because naloxone is rap idly absorbed by the brain and then quickly redistributed and eliminated from the body, its activity in the brain is short-lived (126, 130. Thus, further monitoring and infusion of ad ditional naloxone are needed to continue antagonizing the effects of severe opioid overdose, particularly if longer-acting opioids have been ingested (128, 131. Monitoring for opioid withdrawal symptoms is also indicated because patients may experience significant distress that can last for several hours after reversal of an opioid overdose with an antagonist (129. Acute sedative-hypnotic overdose is recognizable by slurred speech, loss of coordination, and confusion and, in a severe overdose, stupor, respiratory depression, and coma. Like naloxone, flumazenil has poor bioavailability and a brief duration of activity and is administered by repeated boluses or through continuous in travenous infusion. Flumazenil can also affect cerebral hemodynamics and is not recom mended for situations in which intracranial pressure may already be increased (e. For these reasons, as well as cost, flumazenil is not recommended for uncomplicated benzodiazepine overdose that can be successfully managed by supportive ven tilation therapies. Medications to treat withdrawal syndromes Patients who develop tolerance to a particular substance also develop cross-tolerance to other substances in the same pharmacological class. Physicians can take advantage of cross-tolerance in the treatment of withdrawal states by replacing the abused substance with a medication that is in the same pharmacological class. For example, clonidine is an 2-adrenergic agonist that is useful in treating opioid withdrawal symptoms as well as anxiety syndromes (129, 142. Nonspecific symptoms of withdrawal such as headache and stomach upset may also require treatment using medications such as acetaminophen and histamine2-receptor antagonists, respectively. Agonist maintenance therapies Opioid agonist maintenance therapy may be the primary tool available to engage an opioid dependent individual in treatment because it relieves unpleasant withdrawal syndromes and craving associated with abstinence. The central and subjective effects of agonist therapies ren der these agents more acceptable to opioid-dependent patients than antagonist therapies, and adherence with treatment with agonist therapies is greater than with antagonist therapies. Opioid agonist maintenance therapies (described further below) include methadone, a long acting potent agonist at the mu opiate receptor sites (126), and buprenorphine, a potent long acting compound that acts as a partial opioid agonist at mu receptor sites (126) and that is pre scribed alone or with naloxone (in a combination tablet. Antagonist therapies Antagonist therapies are used to block or otherwise counteract the physiological and/or subjec tive reinforcing effects of substances. The narcotic antagonist naltrexone blocks the subjective and physiological effects of subsequently administered opioid drugs (e. Compared with naloxone, naltrexone has good oral bioavailability (126) and a relatively long half-life; it is also available in a long-acting injectable preparation that may improve treatment adherence. Mecamylamine, a nicotine antagonist, has also been studied, but its effectiveness remains unclear (146, 147.
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