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Cycle tests are most appropriate because there are expected VO2 values as a function of Watts (see ing for body weight would yield values of 60 and 45 torsemide 20 mg otc. If person one weighed 70 kg nonexercise data can also be used to estimate VO2max 20mg torsemide with amex. DETERMINANTS OF AND FACTORS AFFECTING VO2MAX TESTING FOR MAXIMAL AEROBIC POWER Intrinsic and extrinsic factors: Intrinsic factors The best tests for measuring VO2max are incremental affecting VO2max include genetics order 20 mg torsemide, gender cheap torsemide 20mg online, body com- tests order torsemide 10mg with mastercard. A number of issues and concepts are important position/muscle mass, age, and existing pathologies. In addi- Determinants: All systems serving a role in the deliv- tion, the test conditions should be standardized and the ery of O2 can affect VO2max. Central factors include car- diac output, pulmonary ventilation, arterial pressure, test should be tolerated by most people. Motivation hemoglobin (Hb) content, O2 diffusion into and through should not be a major factor, and little to no skill should the lungs, the alveolar ventilation: perfusion ratio, and be required. The primary ways to assess aerobic power are by treadmill walking/running, cycle or arm ergom- etry, and step tests. The test protocol should be incre- mental or progressively increasing work so a true TABLE 8-5 Expected VO2 Values at Designated Power Outputs Between 1 and 3 Min with Cycle Ergometry VO2max is achieved. Different values will be obtained when the mode of exercise changes, and the absolute POWER (W) OXYGEN UPTAKE (L/MIN) value will reflect the muscle mass involved. The leveling off or plateauing effect CHAPTER 8 BASICS IN EXERCISE PHYSIOLOGY 43 Hb-O2 affinity. Peripheral determinants include Onset of blood lactate accumulation: At specific muscle blood flow, capillary density, O2 diffusion to exercise intensity, muscle lactate production exceeds and extraction by muscle cells, Hb-O2 affinity, and utilization and blood lactate begins to accumulate skeletal muscle fiber profiles. Wa, MLSS, and onset of blood lactate accumulation (OBLA) may all demarcate the transition between the heavy and severe exercise domains. AEROBIC AND ANAEROBIC EXERCISE Steady state exercise: When rate of lactate produc- tion is balanced by the rate of oxidative removal and EXERCISE DOMAINS VO2 is stabilized within 3 to 6 min. As such, cardiac Three specific exercise domains were reported by output, HR, and pulmonary gas exchange are in a Gaesser and Poole (1996). Graphical presentations of steady state and exercise can continue for an extended the domains (moderate, heavy, and severe) are pre- period of time. In panel in VO2 beyond the 3rd min is observed when exercise is one, the lactate threshold (TLac) represents the bound- above the lactate threshold. The upper boundary of the heavy gradually increases until it reaches a steady state. TLac represents the lactate threshold and Wa represents critical power or work rate where maximal lactate at steady state occurs. This term, O2 debt, was coined lifted, and is expressed as a percent of the maximum by AV Hill in the early 1900s, but is transitioning to weight (1RM). If the 1RM for a particular exercise excess postexercise oxygen consumption (see is 80 kg, then a weight of 40 kg would be a 50% and below). It is The specificity principle states that physiological, neu- highly correlated with exercise intensity, and the fast rological, and psychological adaptations to training are portion may reflect resynthesis of stored PC and specific to the “imposed demand. The slow develop speed, power, and specific metabolic path- component may reflect elevated body temperature, ways, the imposed demand must target those specific catecholamines, accelerated metabolism (conversion areas. Low numbers of repetitions (6–10 RM) are associated with increases in strength and high num- Resistance exercise is used to improve muscular fit- bers (20–100 RM) are associated with increases in ness, which is a combination of strength, endurance, endurance. Strength is the greatest force a muscle can tion from strength to endurance. The primary components to muscle hypertrophy include a neural response, followed by an upregulation WEIGHT TRAINING PARAMETERS of second messenger systems to activate the family of W hen training with weights, the magnitudes of immediate early genes that dictate the responses of increase in muscle strength and endurance depend on contractile protein genes, and message passing down the specific training parameters: repetitions, sets, to alter protein expression. The Repetition maximum: The amount of force a subject new contractile proteins appear to be incorporated can lift a given number of repetitions defines repeti- into existing myofibrils and there may be a limit to tion maximum (RM). For example, 1RM is the maxi- how large a myofibril can become: they may split at mal force a subject can lift with one repetition and some point. Hypertrophy results primarily from 5RM would be the maximal force someone could lift growth of each muscle cell, rather than an increase in five times. For examples, repetitions could be 5, 10, Physiologic adaptations and performance are linked 12, 25, or 50. For BIOMECHANICAL FACTORS IN MUSCLE STRENGTH example, a training session could consist of three sets Neural control, muscle cross-sectional area, arrange- of 12 repetitions. For example, if the ity, strength-to-mass ratio, body size, joint motion session was three sets of 12 repetitions, the volume (joint mobility, dexterity, flexibility, limberness, and would be 3 × 12 or 36 repetitions.

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Modern burn care now depends on the coordinated effort of a multidiscipli- nary team effective 10mg torsemide. This approach is most effectively accomplished in specialized burn centers that bring together surgeons cheap torsemide 20 mg overnight delivery, intensive care specialists torsemide 10 mg mastercard, nurse clinicians buy torsemide 20mg low price, nutritionists order torsemide 20mg amex, rehabilitation therapists, pulmonary care therapists, and anesthesia providers. Anesthetic management is an important part of this multidisciplinary approach. Early excision and grafting of burn wounds limit systemic inflamma- 103 104 Woodson tory activity, speed healing of injuries, and reduce sepsis. However, with this technique burn patients come to surgery so soon after injury that anesthetic care may include management of the initial resuscitation. Skills and experience of anesthesia providers also have value in burn intensive care units where airway management, vascular access, pulmonary care, fluid and electrolyte management, and pharmacological support of the circulation are central issues. Rational and effective anesthetic management of acute burn patients requires an understanding of the multidisciplinary approach so that perioperative care is compatible with the overall treatment goals for the patient. It is important to keep these goals in mind when making perioperative decisions so that overall care is not sacrificed for short-term benefit in the operating room. The anesthetist becomes one of the burn care team when the anesthetic care in the operating room is coordinated with the patient’s care in the burn intensive care unit (ICU). Major burn injuries result in pathophysiological changes in virtually all organ systems. As a result, the anesthetist is faced with multiple challenges in the care of severely burned patients (Table 1). The challenges are both technical (airway management and vascular access) and cognitive (e. Challenges in the anesthetic management of burn patients do not end when the acute wounds are healed. With improved survival from burn injuries more TABLE 1 Challenges in Management of the Acute Burn Patient – Airway compromise – Pulmonary insufficiency – Impaired Circulation due to: Hypovolemia Decrease myocardial contractility Anemia Compartment syndrome – Difficult vascular assess due to: Burn wounds at access site Edema distorting/concealing landmarks – Monitoring with cutaneous sensors difficult Pulse oximetry, ECG difficult over burn wounds ECG – Rapid blood loss – Altered drug response – Renal insufficiency – Infection/sepsis – Impaired temperature regulation – Associated injuries Anesthesia 105 patients will present for reconstructive correction of extensive deformities. Pa- tients who have survived major burn injuries often require surgical reconstructive care for years after the initial injury in order to correct functional and cosmetic sequelae. These patients present their own unique challenges, both technical and otherwise. Airway management and vascular access can be very difficult in pa- tients with extensive burn scar deformities. Altered response to anesthetic drugs and reduced pain tolerance are also central issues for these patients. This chapter, however, will focus on anesthetic management during the acute phase of burn injury. PREOPERATIVE EVALUATION Preoperative evaluation of acutely burned patients requires knowledge of the continuum of pathophysiological changes that occur in burn patients from the initial period after injury through the time that all wounds have healed. The dramatic changes that occur in virtually all organ systems directly affect anesthetic management. In addition to the routine features of the preoperative evaluation, evaluation of the acute burn patient requires special attention to airway manage- ment, pulmonary support, vascular access, adequacy of resuscitation, and associ- ated injuries. The current standard of burn care calls for early excision and grafting of nonviable burn wounds. These wounds harbor pathogens and produce inflamma- tory mediators with systemic effects resulting in cardiopulmonary compromise. After major burn injury, the systemic effects of inflammatory mediators on metabolism and cardiopulmonary function reduce physiological reserve and patients’ tolerance to the stress of surgery deteriorates with time. Assuming that the patient has adequate TABLE 2 Specific Concerns for Preoperative Evaluation – Patient age – Extent of injuries (% total body surface area) – Burn depth and distribution (superficial or full-thickness) – Mechanism of injury (flame, explosion, electrical, chemical, scald) – Airway compromise – Presence of inhalation injury – Time elapsed since injury – Adequacy of resuscitation – Associated injuries – Coexisting diseases – Surgical plan 106 Woodson resuscitation, extensive surgery is best tolerated soon after the injury when the patient is most fit. Nevertheless, it must be recognized that resuscitation of burn injuries involves large fluid and electrolyte shifts and may be associated with hemodynamic instability and respiratory insufficiency. Effective anesthetic man- agement of patients with extensive burn injuries requires an understanding of the pathophysiological changes that result from major burn and inhalation injuries. This is required in order to assess resuscitation accurately prior to surgery and to provide appropriate resuscitation intraoperatively. In fact, anesthesia for major burn surgery involves resuscitation from the initial injury and/or the effects of the burn wound excision. Preoperative evaluation must be performed within the context of the planned surgical procedure, which will depend on the distribution and depth of burn wounds, time after injury, presence of infection, and existence of suitable donor sites for grafts. An anesthetic plan requires understanding of both the patient’s physiological status and the surgeon’s plan. The patient’s physiological status is revealed by results of physical examination and review of the medical record.

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PSYCHOLOGICAL INTERVENTIONS FOR ACUTE PAIN 259 ing EMLA versus those receiving placebo cream torsemide 20 mg overnight delivery, suggesting no additive benefit of EMLA beyond distraction (Lal cheap torsemide 10mg on-line, McClelland order 10mg torsemide with mastercard, Phillips 10mg torsemide visa, Taub buy 20 mg torsemide, & Beat- tie, 2001). Lack of statistical power does not account for the differences be- tween these studies, as the study with the largest sample size (n = 180) re- ported the most negative results (Arts et al. These studies do not indicate whether other psychological strategies, such as brief relaxation or imagery, may have been more effective than distraction relative to the pharmacological approach. However, these studies suggest that for brief, low-intensity procedures in which simple pharmacological interventions with minimal side effects (e. Several of the most methodologically sound controlled trials, all con- ducted in children, comparing psychological interventions with a pharma- cological intervention have been reported by Jay and colleagues (1987, 1991, 1995). Results indicated that the psychological intervention re- sulted in lower pain, distress, and physiological arousal than either the Val- ium or control conditions (Jay et al. A similar follow-up RCT by these researchers revealed identical effects on pain and arousal whether patients received a psychological intervention alone or in combination with Valium (Jay et al. Results indicated that general anesthesia was associated with less procedural distress, but no dif- ferences between interventions were observed regarding self-ratings of pain provided postprocedure. Subjects, all of whom received both types of pain intervention in the within-subject design, did not indicate a significant preference for one versus the other type of intervention, and it was noted that the psychological intervention required less time (Jay et al. As a whole, results of these well-controlled studies indicate that psychological interventions are of at least comparable efficacy to standard pharmacologi- cal approaches for management of the pain associated with bone-marrow aspiration in children. It is important to note that such findings are not likely to generalize to all types of clinical acute pain. Clearly, procedures associated with more in- tense acute pain, such as even “minor” surgery, require pharmacological analgesia. However, the results reported earlier indicate that combining psychological and pharmacological approaches may have significant bene- 260 BRUEHL AND CHUNG fits to patients. MODERATORS OF RESPONSES TO PSYCHOLOGICAL INTERVENTIONS Spontaneous Coping Strategies Many individuals implement their own spontaneous pain coping strategies when faced with acute pain (Spanos et al. The possibility that externally imposed interventions may interfere with pa- tients’ implementation of effective pain control strategies already in their behavioral repertoire cannot be ruled out. Although some studies suggest that these spontaneous coping strategies may be effective for pain reduc- tion (Spanos et al. Coping Style Patients’ preferred style of coping with stress, whether Monitoring or Blunting in character, may be relevant to understanding the efficacy of spe- cific psychological acute pain interventions. Monitors, also referred to as Sensitizers or Vigilants, prefer to cope with stressful situations by seeking out information about the stimulus, and by monitoring and trying to miti- gate their responses to the stimulus (Schultheis, Peterson, & Selby, 1987). Blunters, also termed Repressors, Avoiders, Distractors, or Deniers, prefer to cope with stressful situations through avoidance and by denial of the stressor (Schultheis et al. A number of studies have hypothesized that psychological acute pain in- terventions work best if they match an individual’s naturally preferred cop- ing style. For example, providing a sensory focus intervention to a Blunter would be considered a mismatched intervention, whereas a relaxing imag- ery strategy would be considered a matched intervention for such an indi- vidual (Fanurick et al. Laboratory acute pain studies have provided some evidence indicating that interventions matched to preferred coping style result in more effective reductions in acute pain responsiveness (e. PSYCHOLOGICAL INTERVENTIONS FOR ACUTE PAIN 261 Clinical studies regarding this issue are mixed, but generally negative. Although there were no interaction ef- fects regarding pain experienced during the procedures, Monitors were found to experience less distress in the information provision condition whereas Blunters experienced greater distress (Shipley et al. Studies performed in the context of more severe acute clinical pain, on the other hand, are more negative. In a study of general surgery patients, efficacy of information pro- vision, relaxation, and no intervention was compared as a function of Moni- toring and Blunting coping styles (Scott & Clum, 1984). Blunters reported less pain and used less analgesics when provided with no intervention, which appear at least not inconsistent with the matching hypothesis. How- ever, contrary to the matching hypothesis, Monitors appeared to do best with breathing relaxation as opposed to information provision (Scott & Clum, 1984). Work by Wilson (1981) also in general surgery patients found that Blunters did not experience exacerbated pain following an information provision intervention, again failing to support the matching hypothesis.

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Although the lesion reflective areas with a little acoustic shadowing may contain “solid” echoes buy torsemide 20 mg, it is well circumscribed behind buy discount torsemide 20 mg on line. A sinus may be seen as a low most common buy 20 mg torsemide fast delivery, US is also the easiest imaging to echo track between areas of abnormal tissue cheap torsemide 10 mg mastercard. There are approximately 100 benign lesions patient has an MRI examination as the patient is to 1 malignant lesion torsemide 20 mg online. The most common soft tissue placed in the supine position and the lump disap- sarcoma is the rhabdomyosarcoma, and second is pears. They are derived from author has even had patients whose lumps are only primitive mesenchymal tissue which probably has visible on standing after a run just prior to the US an association with skeletal muscle embryogenesis. There is great relief to both the Synovial sarcoma, despite its name, is unrelated to family and patient when a definite diagnosis can the synovium of joints and can be found anywhere in be made, and for this problem only US will give the body, but most commonly in the lower extremi- the answer! The bone lesion that can invasion but will not be as useful as MR in pro- cause soft tissue swelling is the soft tissue extension viding local staging which is essential for surgical of a Ewing’s sarcoma. US is used in the assessment of the carti- peripheral nerve sheath tumours are rare. When dence of abnormal vascularity alone cannot deter- the cartilage cap is greater than 3 cm in a child then mine whether a lesion is benign or malignant. They there is an increased suspicion of malignant trans- are solid lesions and therefore have a mixed echo formation into a chondrosarcoma. They may contain calcification and then US can be used to biopsy such a lesion, but once the they have “bright” echoes within them. This is not only possible also have “cystic” areas which are due to necrosis. Soft Tissue Tumours in Children 81 Liposarcoma is a rare lesion in childhood. They are there is soft tissue extension or a cortical defect, US surprisingly avascular on imaging. A neurofibroma is a lesion of low echo- size, causes pain, invades muscle or is heterogeneous, genicity. It may have a characteristic “ring” or target then malignancy should be suspected. Any large lesion sign with an area of higher echogenicity within the lower on US that does not fulfil all the criteria given in the echogenicity of the outer ring due to the interface lipoma section above should be imaged with MR and a of the hypoechoic tumour and the hyperechoic nerve biopsy guided by US should be undertaken. The excellent resolution of US can define Metastasis from endocrine neuroblastoma and the nerve from which these lesions arise. If the gain set- renal nephroblastoma (Wilms’ tumours) are most tings are too low a neural tumour may look like a cyst common. They are usually in bone but they may (with acoustic enhancement behind). Their appearance vary setting the gain on an area of known fluid as described and there may be no discriminating features. Allen Schwannomas can be very large and then show response to chemotherapy, so perhaps this could be areas of “cystic” degeneration which are evident on used to assess chemotherapy preoperatively. These are less common in children than adults The follow-up of sarcomas and lymph node and again are associated with neurofibromatosis involvement has always been difficult. This chapter illustrates a vari- ety of lesions that may be assessed and analysed by References and Further Reading imaging and where US has an important role. AbiEzzi SS, Miller LS (1995) The use of ultrasound for diagnoses that may benefit from US assessment that the diagnosis of soft-tissue masses in children. The same principles Orthop 15(5):566–573 apply and the above descriptions should assist the 2. Laffan EE, O’Connor R, Ryan SP, et al (2004) Whole-body examiner who is confronted by an unusual disease. Pediatr Radiol 34(6):472–480 For details of such disorders the reader is referred 3. Stramare R, Tregnaghi A, Fitta C, et al (2004) High-sensi- to texts on soft tissue tumours. An algorithm tivity power Doppler imaging of normal superficial lymph for the diagnostic imaging of a soft tissue lump in a nodes.

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