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Carlos A. Guanche, MD

• Southern California Orthopedic Institute
• Van Nuys, California

Exclude analgesics administered during other procedures performed after delivery such as episiotomy or laceration repair erectile dysfunction treatment machine erectafil 20 mg without a prescription. If a patient receives a spinal with Duramorph for a C-section impotence clinics buy cheap erectafil 20mg on line, even if they were not in labor and were not experiencing any pain erectile dysfunction treatment cincinnati generic erectafil 20 mg free shipping, still code analgesia as “yes” in addition to “spinal anesthesia” erectile dysfunction causes anxiety purchase erectafil with american express. This category includes Morphine and Phenergan for sleep green tea causes erectile dysfunction purchase generic erectafil canada, Tylenol otc erectile dysfunction drugs walgreens buy erectafil 20mg online, Fentanyl used in epidurals. Anesthesia is a medication or other agent used to cause a loss of feeling (loss of sensation of pain). If a woman is induced it would be rare that she should also be coded as being augmented. Other reasons include facilitating placement of a scalp electrode, to check for meconium, to allow the head to descend, and because it”s going to happen eventually anyway. Race is self-reported, meaning the parent is considered to be whatever race they say they are, regardless of appearance. If the "Other", “American Indian", “Alaskan Native”, “Other Asian” or “Other Pacific Islander” category is selected; enter up to 2 specific nationalities or tribes. The place of residence during military duty or while attending college is considered a permanent residence and should be entered when applicable. Enter either the Post Office box number, city, state and zip code or the house number, street name, apartment number, city, state and zip code where the parent receives their mail. Each of the address segments are entered into separate fields: house number, street direction. Yes No Not required Mother / Father Mother / Mother Parent’s First Name: Parent’s Middle Name: Parent’s Current Last Name: Last Name on Parent’s Birth Certificate: Parent’s Name Suffix Social Security Number: nd – –. A 38 properly completed Acknowledgment of Paternity is also required if, at the time of birth, the mother is unmarried and was divorced or widowed before conception. A female may be listed as the second parent only if she is legally married to the birth mother. Therefore, a woman in a domestic partnership with the birth mother may not be entered on the birth certificate as the second parent. In the event that a male changes his last name at the time of marriage, the name on his birth certificate would be listed here. This may or may not be the same as his current name depending on whether his name was changed by marriage only or changed through a court proceeding resulting in an amendment to his birth certificate. If the Social Security number is unknown, enter all nines, if refused, enter all zeros. There is no set rule as to how many generations are to be taken into account in determining ancestry or ethnic origin. The response is to reflect what the person considers himself or herself to be, and is not based on percentages of ancestry. If the "Other", “American Indian", “Alaskan Native”, “Other Asian” or “Other Pacific Islander” category is selected, enter up to 2 specific nationalities or tribes. Examples of businesses or industries are government, retail store, farming, manufacturing, construction, insurance, chemical, etc. If the exact day is unknown, but the month and year are known, obtain an estimate of the day from the mother or her physician. Include only the visit to a private physician or to a clinic or outpatient department of a hospital in which the mother’s health history was taken and an initial physical examination for this pregnancy was performed. Include only a visit to a private provider or to a clinic or outpatient department of a hospital in which the mother received prenatal care. If an exact date is not available, try to get an estimate such as beginning, middle or end of the month. A prenatal visit includes all regular visits to a doctor or clinic and any other visits to a doctor, clinic or emergency room for treatment of a pregnancy related problem. For example, a pregnant woman may come to the hospital a few times near the end of her pregnancy, but have no prenatal care or very little at all. If the hospital visits are counted, it may look like the woman had several prenatal care visits when in fact she had none at all. For example, fetal deaths of less than 20 weeks gestation (under 5 months) should be entered in the space labeled Less than 20 Weeks. Code cases of molar pregnancies or blighted ovum as spontaneous terminations regardless of final mode of pregnancy completion. As "Other Pregnancy Outcomes”, these events are not included in the calculation of the live-birth order. If all previous set members were born dead or if this certificate is for the first set member, enter the month and year of the last delivery involving a live birth. Usually this will be the same date as the birth date of the child named on this certificate. So many people are on antidepressants these days that I would not code someone with mild, well-controlled depression as a serious other chronic illness. If she had a history of psychiatric hospitalizations, suicide attempts, or currently is undergoing regular psychotherapy, however, I would code it as a serious chronic illness. For example, in cases of multiples when coding for twin B do not code previous preterm birth if it is only in reference to twin A’s birth (E. This includes being referred for testing/consultation, or for transfer of care to a high risk provider. If a patient is referred to Maternal Fetal Medicine for an opinion and recommendation about an abnormal ultrasound or lab value, or about a particular diagnosis, that would count as a high-risk referral. Not every patient sent for an ultrasound is necessarily a high-risk referral; it would depend on the reason for being sent. For example, in cases of multiples when coding for twin B do not code previous low birth weight infant if it is only in reference to twin A (E. Infertility Treatment is any assisted reproduction technique used to initiate the pregnancy. Select this item if none of the items above are selected, even if other medical/obstetric risk factors exist. Do not code solely based on the fact that a woman is being preventively treated with Valtrex. Hep B & C can be chronic infections and do not have to have first occurred during pregnancy. Code any positive Hep B or C test as "Infection present or treated during pregnancy. Exclude positive skin test for tuberculosis without mention of treatment and/or diagnosis of active tuberculosis. Indicate the average number of cigarettes or packs of cigarettes she smoked per day in each of the time periods indicated. E-cigs and Hookahs are not included, but if a woman admits to hookah use ask her what she uses it for as it may indicate illegal drug use. If the mother has indicated that she may have had a few drinks from the time of conception to a positive pregnancy test consider that a positive response (yes). A ‘yes’ response will show that the woman did not receive adequate preconception care. A ‘yes’ response will show that the woman did not receive adequate pre-conception care. Includes MacDonald’s suture, Shirodkar procedure, and abdominal cerclage via laparotomy. This may include the administration of terbutaline which is used to inhibit contractions, however not when it is only used to inhibit contractions prior to a C-section scheduled for that day (T. If more than one test was done record the earlier date as entering a later date may imply that the test was not performed as required with the early pregnancy screening. Prenatal care includes visits to a doctor, nurse or other health care worker before your baby was born to get checkups and advice about pregnancy. Answer ‘yes’ if you made such visits for the pregnancy prior to admission for delivery. For each item, answer Yes if someone talked with you about it or answer No if no one talked with you about it. Please enter the number of times that you exercise, not counting routine daily activities such as walking to the store, lifting boxes at your place of employment, etc. Social Assessment refers to psychosocial, socioeconomic and other social issues that may affect a pregnancy. Examples include: on or need Medicaid and/or public assistance; unwed or baby’s father is not actively involved; under emotional or physical stress; recently felt depressed or hopeless; mother and /or her children in foster care, past or pregnant; thinking about adoption; want to see a social worker or public health nurse; housing, legal, transportation, safety or child care problems. If it was too late in the pregnancy for the test to be offered / done, please select “No, Too Late”. Enter the number of times the mother was hospitalized during this pregnancy for at least 24 hours or more, excluding the hospitalization for this delivery. If the mother was transferred to another unit in the hospital, use the date of discharge from the hospital (rather than the maternity unit). Unlike notarizing a document, witnessing a signature is just signing that you watched the individual sign. You do not need to verify that the person signing is who he says he is only that he signed in front of you. If the form is falsely signed, it is up the signatories or the person challenging the signatures to take the issue to the court system. We are not responsible for the veracity of the statements made by the mother and the putative father. If the form is ever challenged it could be determined that fraud was perpetrated by the signatories. If this becomes an issue after explanations are offered, allow the mother and the putative father to complete the form and process it as you normally would. In a rare situation where the signatories say that they signed in error and the form has not left the room, it can be destroyed in the presence of both witnesses. Once the form has been signed and has left the presence of the signatories it must be filed as stated. Either the mother or the father has the right to rescind the acknowledgement of paternity by petitioning the court to vacate the Acknowledgement of Paternity form within the earlier of 60 days of signing the form or the date of an administrative or judicial proceeding related to the child in which either signatory is a party. If the signatory is unsure of what that means you should contact your local child support agency. Be sure the signatory understands the importance of this legal document because after 60 days has passed since signing the form, proof of fraud, duress, or mistake-of-fact will be needed to challenge the acknowledgement of paternity in court. Please, note that the burden of proof is on the person challenging the acknowledgement of paternity. The paternity testing has to be court ordered as the courts have specific labs from which they will accept results. If the mother leaves the parent portion blank and she is still legally married, the ‘legal husband’ remains legally responsible for the baby/child. If the need arose the husband can be sought for child support and the child is eligible for all the rights given to the husband’s biological children. If your hospital does not have the video available you can find it on the Child Support web site. Feel free to give gentle counseling to the parents if they show signs of hesitation re: the form. What happens when a purported father calls the registrar to say that the name on the Birth Certificate is not his, that he never signed anything? It is, also, important to know that the father has the option to sign the form in front of two witnesses even if the mother is unwilling to sign and acknowledge that the man is the father of her child. In this case the father would need to self-file the form with the Office of Putative Paternity. Filing would not make him financially responsible for the child but could make the child eligible for a portion of his inheritance. It would also allow the father to be contacted if the mother sought to place the child up for adoption. Encourage them not to sign if they are not 100% sure that the info is correct, that once signed it is a legally binding form. The parents have 90 days in which they can add or st change the baby’s 1 and/or middle name (A Social Security number will not be executed unless there is a first and last name). The only acceptable wat to make a correction is with a single line through the error and the parents’ initials then the new info, always printed or typed in blue or black ink, and never any correction fluid. Our approach toward your care is to educate you and work together with you to make your pregnancy a wonderful and memorable experience. To help achieve this goal, please read the “Care and Treatment” information on our website It is a three-campus medical center with over 1,000 beds, serving Berkeley, Oakland, and surrounding communities. We admit to the Berkeley campus, or Alta Bates Medical Center, for inpatient Maternity and/or Gynecologic services and to the Oakland campus, or Summit Medical Center, for Gynecologic care. Messages can be left after hours with our answering service and phone calls will be returned on the next business day if not urgent. When you call, describe your problem and the physician on call will return your call as quickly as possible. Physicians on call are on duty for the entire practice therefore they may be in surgery or delivering a patient and may not be able to call back immediately. If you are in labor and unable to reach the on call physician in a timely manner, call Labor and Delivery at (510) 204-1572. If you need to go to labor and delivery or the emergency room and your call has not been returned, please do so. Please contact the office for all non-emergency concerns through the MyHealth Patient Portal so that your chart and medical history will be available:

Submaximal isometrics for shoulder internal/external rotators impotence hernia buy erectafil with a mastercard, flexors erectile dysfunction in middle age buy cheap erectafil 20mg on line, and abductors may begin at 3 to 4 weeks erectile dysfunction and heart disease buy genuine erectafil online. Care should be taken to ensure that exercises are performed in the scapular plane whenever possible erectile dysfunction medicine bangladesh generic 20mg erectafil with amex. Rhythmic stabilization of the scapulo thoracic and glenohumeral joints is incorporated later and progresses as tolerated to promote dynamic stabilization erectile dysfunction and pump discount erectafil 20mg. Strengthening typically progresses from supine to side-lying erectile dysfunction treatment options injections erectafil 20mg with mastercard, sitting, and Shoulder Impingement and Rotator Cuff Tears 335 standing. Isotonic exercises via small handheld weights or elastic tubing typically begins in 4 to 6 weeks. Further progression and rehabilitation should be based on the needs of the individual patient. With the patient sitting or standing, the examiner places one hand posteriorly over the scapula and grasps the patient’s elbow. With the patient’s scapula stabilized, the shoulder is maximally passively flexed overhead, compressing the greater tuberosity against the anteroinferior border of the acromion. Shoulder pain and apprehension indicate a positive sign—involvement most likely of the supraspinatus and possibly of the long head of the biceps tendon. With the patient sitting or standing and the upper extremities relaxed, the examiner forward flexes the shoulder to 90 degrees and then forcibly internally rotates the shoulder. This action pushes the supraspinatus tendon against the anterior surface of the coracoacromial arch. In the presence of a positive painful arc or pain with external rotation, the patient lies supine. The examiner pushes the humeral head inferiorly while simultaneously abducting and externally rotating the shoulder. The test is considered positive for mechanical impingement if the pain is decreased or abolished. With the patient seated, the examiner places one hand over the posterior aspect of the scapula to stabilize the trunk and with the other hand grasps the patient’s elbow. With the trunk stabilized, the examiner maximally adducts the shoulder horizontally. Superior shoulder pain indicates acromioclavicular joint pathology, whereas anterior shoulder pain may indicate subscapularis, supraspinatus, and/or long head of the biceps tendon pathology. Posterior shoulder pain may indicate pathology of the infraspinatus, teres minor, and/or posterior joint capsule. The most common range for a painful arc is 60 to 120 degrees of humeral elevation. The patient stands with both shoulders abducted to 90 degrees, in the scapular plane (horizontally adducted 30 degrees), and internally rotated in such a position that the thumbs point toward the floor. Pain and/or weakness indicates a tear of the supraspinatus or injury to the suprascapular nerve. With the patient standing or sitting, the examiner passively places the involved shoulder in 90 degrees of abduction, asking the patient to lower the arm slowly to the side. A positive sign, defined as inability to lower the arm slowly to the side or reproduction of significant pain, indicates a tear in the rotator cuff. Standing with the dorsum of the hand placed against the back pocket, the patient lifts the hand away from the back. Inability to perform this task or pain may indicate a lesion of the subscapularis. This maneuver also can produce abnormal scapular motion, indicating scapular instability, and is used to assess rhomboid muscle strength. The examiner places the patient’s arm in 90 degrees of elbow flexion, 90 degrees of abduction, and almost full external rotation. A drop or lag indicates infraspinatus attenuation or insufficiency related to weakness often related to tearing. The test is positive for supraspinatus or infraspinatus pathology if the patient cannot maintain the position. The hand is passively lifted off the back, and support is maintained on the elbow but released from the wrist. What are the sensitivity and specificity of the various tests for rotator cuff pathology? Test Sensitivity (%) Specificity (%) Neer impingement test 89 25 Hawkins-Kennedy impingement test 92 25 Cross-over test 82 28 Painful arc sign 33 81 Drop-arm test 8 97 Jobe 84 58 Lift-off sign 62 100 Internal rotation lag test 97 96 External rotation lag test 70 100 Drop sign 20 100 Yergason’s test 37 86 Speed’s test (palm-up test) 69 56 35. Large and massive rotator cuff tears result in approximately a 50% reduction in strength when compared to the noninvolved side (testing performed in 10 degrees of shoulder abduction with focus on the supraspinatus). How accurate is a clinical examination of the shoulder in predicting rotator cuff pathology? The sensitivity of a clinical exam of the shoulder (which includes the use of various shoulder special tests) is approximately 91% with a specificity of 75%. Data that assist in the specific diagnosis of a rotator cuff tear are age of the patient (>40 years), previous trauma (minor), and degenerative changes on radiologic examination. Thus a good clinical examination is accurate and more cost-effective than a battery of radiologic studies in diagnosing rotator cuff pathology. According to Murrell and Walton, three simple tests are highly predictive of rotator cuff tear: supraspinatus weakness, weakness in external rotation, and impingement sign. When all three of these clinical tests were positive, or if two tests were positive and the patient was aged 60 or older, the individual had a 98% chance of having a rotator cuff tear. Furthermore, the investigators reported that any patient with a positive drop-arm sign also has a 98% chance of rotator cuff tear. If none of the aforementioned clinical features are present, the chance of rotator cuff tear diminishes to only 5%. The predictive influence of clustering these three clinical tests is comparable to the best results for magnetic resonance imaging and ultrasonography, and as suggested by the investigators, easier to perform and more cost-effective. Which imaging study—plain radiographs, arthrography, or ultrasonography— is more accurate in diagnosing a rotator cuff tear? In addition, it has a sensitivity of 50% and specificity of 96% when used to evaluate full thickness rotator cuff tears. Other research has reported the arthrogram to have a 0 to 8% probability of a false negative. The diagnostic sensitivity (98%) and specificity (91%) of ultrasonography have been compared with surgical findings. They reported that subjects with rotator cuff tear demonstrate radiographic findings. They also noted that in patients with small to moderate rotator cuff tears, acromial morphology and spurring were not predictive of a full-thickness rotator cuff tear. Recent literature has reported 78% accuracy, 81% sensitivity, and 78% specificity in determining full-thickness rotator cuff tears. Other researchers have reported an accuracy of 80% and sensitivity and specificity values of 92% and 93%, 338 the Shoulder respectively. Early surgical intervention is recommended in patients with rotator cuff disease who have greater than 12 months’ duration of symptoms, severe functional impairment, or a confirmed rotator cuff tear greater than 1 cm. Of these patients, 76% can anticipate a good or excellent result in 6 to 12 months. Of patients with impingement syndrome without rotator cuff tear, 85% will experience a good or excellent result with conservative management of at least 18 months. Problems with analyzing outcomes after rotator cuff repair are due to variable accuracy in describing preoperative functional levels, extent and location of the tears, tissue quality, follow-up schedule, and postoperative functional status. Cofield’s investigations describing the outcomes of rotator cuff repair reported improvements in pain (averaging 87%) and patient overall satisfaction rates of 77%. At least 12 months is required to restore strength after rotator cuff repair; the most significant increases are noted 6 to 12 months after surgery. What percentage of patients undergoing rotator cuff repair have a favorable outcome? Favorable outcomes are achieved in more than 75% of patients undergoing rotator cuff repair. However, some studies have reported satisfactory results in upward of 90% of patients. What is the clinical outcome of a patient suffering structural failure of a rotator cuff repair? Fifty-five percent of the subjects reported that they were very satisfied, 30% were satisfied, and 15% were disappointed with the outcome. However, Hawkins has reported 87% satisfaction with open acromioplasty versus 40% satisfaction with arthroscopic technique. Although much of the literature seems to support both open and arthroscopic techniques, interpretation is difficult because not all patients begin with the same level of soft tissue involvement. Recent evidence supports the value of a supervised nonoperative strengthening program for chronic, full-thickness rotator cuff tears, although the range in improvement and overall satisfaction varies from 33% to 90%. However, an acute partial-thickness tear may progress if rehabilitation programs address rotator cuff strengthening too aggressively and in isolation. What are the options for management of an irreparable rotator cuff tear secondary to arthropathy? Because each patient has different levels of pain and functional disability, options for the manage ment of arthropathy vary. When developing an outcome measure for shoulder function, is the evaluation of strength of the opposite shoulder important to measure? Yes; the use of the contralateral limb as an internal control eliminates confounding variables such as age. Thus shoulder outcome tools should measure involved and uninvolved shoulder strength. What are some of the common physical therapy interventions for shoulder (rotator cuff) pain, and are they effective? According to a Cochrane Database Systematic Review, the following statements can be made regarding common physical therapy interventions for shoulder (rotator cuff) pain. Exercise (rotator cuff) is effective in the short-term recovery in rotator cuff disease. If a patient cannot attend formal physical therapy programs after surgical repair of the rotator cuff, is a standardized home program effective? The literature has indicated that a standardized home program (to include written and video instructions) for patients following rotator cuff repair resulted in favorable outcomes in regards to range of motion, strength, and patient-reported outcomes. Bibliography Bartolozzi A, Andreychik D, Ahmad S: Determinants of outcome in the treatment of rotator cuff disease, Clin Orthop Rel Res 308:90-97,1994. Hertel R et al: Lag signs in the diagnosis of rotator cuff rupture, J Shoulder Elbow Surg 5:307-313, 1996. Holtby R, Razmjou H: Validity of the supraspinatus test as a single clinical test in diagnosing patients with rotator cuff pathology, J Orthop Sports Phys Ther 32:194-200, 2002. Jost B et al: Clinical outcome after structural failure of rotator cuff repairs, J Bone Joint Surg 82A:304-314, 2000. Lashgari C, Yamaguchi K: Natural history and nonsurgical treatment of rotator cuff disorders. How do the size, shape, and orientation of the glenoid fossa affect gleno humeral joint stability? The glenoid cavity can be described as an irregularly shaped oval, much like an inverted comma. On the basis of studies conducted by Saha, the average height is 35 mm and the average width is 25 mm. Saha also demonstrated that in 75% of the specimens examined, the glenoid fossa was retroverted approximately 7 degrees. The glenoid is also tilted from superomedial to inferolateral an average of 15 degrees. The depth of the fossa is enhanced by the glenoid labrum, which can contribute up to 50% of the fossa’s depth. Passive stability is provided by the bony geometry, glenoid labrum, limited joint volume, negative intra-articular pressure, adhesion and cohesion, and capsuloligamentous structures. As long as the relative vacuum effect is maintained, limited joint volume does not allow the joint surfaces to be easily distracted or subluxated. The close match of the articular surfaces produces intermolecular forces of surface tension, cohesion, and adhesion, which provide continued coupling of the humerus to the glenoid. Adhesion refers to the attraction of unlike substances (joint fluid to bone), whereas cohesion refers to the attraction of like substances (joint fluid to joint fluid). In addition, the glenoid labrum deepens the fossa by 5 mm in an anteroposterior direction and by 9 mm in the superior and inferior direction. The superior, middle, and inferior glenohumeral ligaments provide anterior stability. With the arm in the adducted position, the superior glenohumeral and coracohumeral ligaments act in a suspensory role to resist inferior translation of the humeral head. As the arm is brought up into the mid range of abduction, the middle glenohumeral ligament provides more of a stabilizing role. In addition, as the arm is abducted to 45 degrees and beyond, the anterior and posterior portions of the inferior glenohumeral ligament complex become the stabilizers to resist inferior translation. Above 90 degrees of abduction, the inferior glenohumeral ligament becomes the primary stabilizing function. The anterior band of the inferior glenohumeral ligament complex is the primary restraint to anterior translation at 90 degrees of abduction. Posterior stabilization of the glenohumeral joint with the arm at 90 degrees of abduction is provided primarily by the posterior band of the inferior glenohumeral ligament complex.

The process is improved if information can be given Pain pathways in labour antenatally erectile dysfunction medication otc erectafil 20mg on-line. Tese somatic impulses travel primarily via the pudendal nerve to dorsal root ganglia of S2 to S4 erectile dysfunction causes depression purchase erectafil in india. The ideal labour epidural block should cover sensory loss from T10 – S5 dermatomes (with minimal motor block) to provide analgesia for The vertebral column the frst and second stages of labour treatment of erectile dysfunction using platelet-rich plasma buy discount erectafil 20mg online. Tere are fve lumbar vertebrae erectile dysfunction heart disease buy erectafil 20 mg on line, which have large vertebral Patient positioning for neuraxial blockade bodies for weight-bearing erectile dysfunction rings generic erectafil 20mg free shipping, increasing in size from L1 to L5 do erectile dysfunction pills work erectafil 20 mg amex. The vertebral bodies maternal comfort and compliance, as well as anaesthetist preference. Tree ligaments are pierced during epidural insertion: Equipment and Insertion Technique supraspinous, interspinous, and ligamentum favum (Figure 1). The basic equipment required for epidural Insertion is: The epidural space The epidural space is a ‘potential space’ that surrounds the dura. Scrub Pack: Hibiscrub, surgical hat, mask, gown, gloves mater and extends from the foramen magnum to the sacral hiatus at. Tere is a large variation in Single-shot spinal drugs/ doses currently used for test doses, with ranges of 3-20mg bupivacaine and 15-90mg lidocaine. Multiparous parturients are probably the breakthrough pain should be treated as a ‘test dose’ as catheters most suitable candidates for this technique due to rapid labour can migrate intrathecally and intravascularly, despite initially being progression. Contin Educ Anaesth Crit Single-shot spinal followed by epidural Care Pain 2005; 5(3): 98-100 5. The intercristal line determined by palpation is not a reliable anatomical landmark for neuraxial anesthesia. Comparative study between puncture with a spinal needle but without administering intrathecal ultrasound determination and clinical assessment of the lumbar interspinous drugs. M E J Anesth 2014; 22(4): 407-12 by intrathecal local anaesthetics and enhances labour analgesia 9. Which is a better position for insertion of intrathecal space; when there is a puncture in the dura the anaesthetic a high thoracic epidural catheter: sitting or lateral decubitus? Single-shot spinal block for labour analgesia An epidural test dose can identify inadvertent intrathecal or in multiparous parturients. Br J Anaesth 2012; 109(2): 144-54 (epinephrine) was used as a ‘test dose’: intrathecal lidocaine would 18. However, using adrenaline is unreliable (low sensitivity) because of confusion with transient tachycardia seen with contraction pains. Case 1 A 30-year-old primigravid patient, with prolonged frst stage, now fully dilated. She is in severe distress with pain, although it appears that she will tolerate sitting still for the procedure. Case 2 A 38-year-old multiparous patient, G3P2, had previous uneventful vaginal deliveries with epidurals. She is requesting an epidural but reports she cannot sit down due to sacral pressure or stay still due to pain. You manage to get her onto the bed, but despite this she is moving around the bed constantly. She is intermittently drowsy with medical nitrous oxide and oxygen gas mixture (50:50), which she will not stop using. Unrealistic patient expectations and low pain thresholds Subcutaneous placement of epidural catheters will result in complete continuous spinal analgesia7, or the catheter can be removed and re block failure. Insertion into the subdural space would imply Intravascular placement of an epidural catheter is a potentially life advancement beyond the epidural space, piercing the dura mater but threatening complication and can occur in up to 3-7% of placements not entering the subarachnoid space. This can be identifed if blood is aspirated can range from complete block failure, to a patchy asymmetric 8 6 via the epidural catheter, however there is a high false-negative rate. The intravascular catheter can either be withdrawn (1cm at a time Intrathecal catheter placement can occur after unintentional dural then fushed with saline and aspirated) until no more blood is be puncture with the needle or catheter. It is identifed by cerebrospinal aspirated, or it can be totally removed and replaced. Intrathecal placement can occur at the time advancing the needle or catheter during a contraction, limiting the of catheter insertion or due to migration from the epidural space. Pain thresholds and response immediately stop administering the epidural bolus and/or infusion to local anaesthesia can vary between individuals and also between and commence treatment with intravenous lipid emulsion diferent labour processes and fetal positions. Migration of the catheter An incomplete block can range from a missed segment, a patchy Migration of epidural catheters can occur despite correct placement block, a unilateral block, sacral sparing, not dense enough block, initially. Tere are a number of techniques that can be Migration of the catheter through the intervertebral foramina employed to rescue an inadequate block. Examination – check the position of the catheter (compare with The incidence of epidural catheter migration can be minimized by what was documented at the time of placement), check sensory/ leaving 5cm or less in the epidural space and attention to fxation motor block. Assess efectiveness of a bolus dose (if not already done) prior prevent migration. Subcutaneous migration of the catheter is more to catheter manipulation and/ or further boluses with increased likely to be seen if less than 3cm is left in the epidural space, and local anaesthetic concentration ± supplemental epidural narcotic unilateral analgesia is more likely if greater than 5cm of the catheter (fentanyl). Post-operative scarring and can be administered depending on whether spread or density is obliteration of the epidural space distorts normal anatomy and may required. A physician-administered bolus is efective in approximately interfere with normal loss of resistance and spread of local anaesthetic 13 70% of cases. Catheter manipulation Sacral sparing Epidural catheters can pass cranially, caudally, laterally or into the During labour, aferents innervating the vagina and perineum cause 11 anterior epidural space. The S2-4 nerve roots are covered fashion) and giving an additional dose of local anesthetic can improve with thick dura mater, have a large diameter and are further away 13 the block in 77% of patients. Tese factors in addition to the Epidural opioids normal propensity for local anaesthetic solution to travel cephalad Morphine, diamorphine, sufentanil and fentanyl can all be can reduce difusion to sacral nerve roots leading to sacral sparing administered epidurally. Fentanyl is the commonest opioid used for and failure of labour analgesia in the second stage. Epidural fentanyl can be administered as an initial loading dose Patient expectations and pain thresholds and/or for breakthrough pain (50-100mcg) to improve the quality Managing individual patient expectations are vital. Another potential rescue measure for asymmetrical blocks is to 2008; 1(2): 49-55 alternate the position of the parturient between the right and left 3. Complications of obstetric epidural analgesia and anaesthesia: a prospective analysis of 10,995 cases. Accidental subdural injection during attempted lumbar epidural block may present as a failed or inadequate block: radiographic evidence. Is continuous spinal analgesia via an epidural catheter adequate pain relief, maternal satisfaction and the ability to convert appropriate after accidental subarachnoid administration of 15 mL of labour analgesia to surgical anaesthesia if required for caesarean bupivacaine 0. Detection of intravascular epidural catheter placement: a The following criteria should be satisfed before topping-up a labour review. Tere is no suspicion of an intrathecal or intravascular catheter subdural injection: a complication of an epidural block. A systematic review of randomized resolution of pain from any intervention(s) performed, i. Epidural catheter tip position and distribution of injectate evaluated failure and conversion to general anaesthetic during caesarean section. Although a more involved procedure, a Treatment of incomplete analgesia after placement of an epidural catheter and administration of local anesthetic for women in labor. The site of action of epidural fentanyl infusions in the presence of local anesthetics: a minimum local analgesic concentration infusion study in nulliparous labor. Epidural catheter function during labor predicts anesthetic efcacy for subsequent cesarean delivery. She is in severe distress with pain, this she is moving around the bed constantly. This parturient is unlikely to tolerate labour without any She is a primip with a prolonged frst stage. A rapid second stage is form of neuraxial analgesia, however it can only be provided for her unlikely and she is at risk of an instrumental delivery. In addition, the labour and provide the option of anaesthesia for an assisted or operative anaesthetist needs to consider that a number of factors may impact the delivery if required. Focusing on breathing control improves the efectiveness of Nitrous oxide/oxygen and a calm explanation from the anaesthetist may help. Case 2 the patient may be more comfortable in the lateral position (especially if they are drowsy), but this needs to be balanced with the familiarity of A 38-year-old multiparous patient, G3P2, had previous uneventful the anaesthetist with this position. She went provide enough analgesia to calm the patient and allow a longer term into labour at home 2 hours ago. She is requesting an epidural but epidural to be established in a calm, safer environment. She is Case 4 unable to sit due to sacral pressure, likely from a low-lying fetal head. Performing the neuraxial procedure in the lateral position has a number A 32-year-old multiparous patient, G2P1, is 3 cm dilation. In view of gestational hypertension the platelet count should be she will need the epidural component, exposing her to unnecessary checked prior to epidural insertion and removal. The paediatricians must be informed of potential fetal be challenging in obese patients, therefore it is easier to place it in a respiratory depression. Intubation can also potentially Case 3 be more difcult in obese patients, therefore having a catheter in-situ and time to ensure it is functioning well, may avoid the need to perform A 24-year-old primigravid patient is 4cm dilation. You are requested urgently for stress response from labour, which can improve blood pressure control. On your arrival, the parturient is face down on the foor of the room, on her knees crying in pain. However, pain during childbirth is undertreated in variable resource environments Epidurals provide safe and efcient provision of anesthesia for unplanned or emergent cesarean delivery. This article will focus primarily on establishing an epidural service to provide labour analgesia and anesthesia for nonscheduled cesarean delivery. The development of a labour epidural service should encompass patients’ safety as its key tenant. Developing a high quality epidural service requires a well-trained, cooperative multidisciplinary team, an adequately equipped unit, and dedicated leadership whose role is to ensure the service maintains high standards. Ongoing monitoring and evaluation of the service will create the best environment for continued improvements and longevity of a means to strive towards provision of excellent care for parturients and their babies. However, one study estimated social and economic well-being of a community or that only 2. Acute pain during childbirth is undertreated public hospital received neuraxial labour analgesia. Pain associated this article will focus primarily on establishing an with labour and delivery is the most important Ronald B. George md, frcpc epidural service to provide labour analgesia and anesthetic-related concern for expectant mothers in Department of Women’s & 2 anaesthesia for non-scheduled caesarean delivery. Epidurals provide safe and efcient provision successful establishment of an epidural service, safety of anaesthesia for unplanned or emergent caesarean Andrew Kintu, mbchb, mmed considerations, and highlighting challenges within delivery. Every epidural provides analgesia; a managed low incidence of side efects or serious complications Department of Anaesthesia 6 epidural service provides analgesia, anaesthesia, to the parturient or fetus. Mulago Hospital and conveys a level of safety to women within the Makerere University College In the year 1900, subarachnoid injection of cocaine service. The development of a labour epidural service of Health Sciences was described with the result of total lower body should encompass patients’ safety as its key tenant. Adapted from Report of Best practice in the management of epidural analgesia in the hospital setting. Epidural analgesia is a technical They suggest that patient preference is all that is necessary for an procedure, performed under aseptic technique, where medication indication to provide labour analgesia; “Labour causes severe pain for is injected into the epidural space with the intention of providing many women. Tere is no other circumstance where it is considered analgesia to a specifc region of sensory dermatomes. Table 1 and other cardiac conditions, that would beneft haemodynamically highlights several key diferences between these neuraxial procedures. Patients with stenotic valvulopathies do All three of these neuraxial techniques share the beneft of avoiding not tolerate the tachycardia that may accompany labour pain. By maternal sedation, which may occur with labour analgesia provided 15 providing analgesia via epidural, the increase in heart rate secondary via parenteral opioids or inhaled nitrous oxide. Resuscitative equipment and medication must be available lack of necessary medications and equipment, coagulopathy in the event of hypotension, high or total spinal anaesthesia, local (including ongoing use of anticoagulant medication), and anaesthetic toxicity or cardiopulmonary arrest. Tere are a variety of prepackaged epidural and spinal 17 for cardiopulmonary resuscitation. Tese guidelines should be anaesthesia kits that contain all the required procedural equipment. Table 4 lists this can reduce costs but this generally requires continuous demand equipment and drugs that should be available, at minimum, in order to become cost efcient. The procedural equipment (listed in Table 3) can be acquired individually Consideration should be given to institutional infrastructure. It would be unrealistic to expect that all facilities ofering obstetrical care would also have neurosurgical capabilities. Adapted from Kodali et 12 there should be a policy in place to obtain appropriate imaging and al. Epidural or spinal needles (disposable or reusable, as long as sterility Another aspect of institutional infrastructure concerns personnel. Loss of resistance syringe (if using loss of resistance technique) Finally, continuous quality improvement protocols should be Local anesthetic established and followed. Continuous quality improvement is an integral aspect of patient safety and will allow for identifcation of Lipophilic opioid (optional) problems that could contribute to increased morbidity and mortality.

In a deeper location impotence of organic origin meaning order erectafil 20 mg, the metacarpal ment of the focal zone should be obtained for their bones are imaged as bright hyperechoic oval struc accurate evaluation online erectile dysfunction drugs reviews erectafil 20mg line. In the palm erectile dysfunction injection device discount erectafil 20 mg without prescription, the two arte as a round hyperechoic structure embedded within rial arches erectile dysfunction muse purchase erectafil 20mg fast delivery, superficial and deep erectile dysfunction treatment old age generic erectafil 20 mg line, can be imaged with the hypoechoic bellies of this muscle (Fig erectile dysfunction treatment clinics cheap erectafil 20mg otc. The superficial arch lies superficial to the flexor It may be surrounded by a thin anechoic rim due tendons; the deep one can be identified between to a film of fluid contained in the tendon sheath. For allows these nerves to be followed from the divi each digit, the two contiguous tendons are approxi sion of the median nerve at the distal edge of the mately the same size. Among the flexor tendons transverse carpal ligament to the bases of the fin of adjacent fingers, the lumbrical muscles can be gers. The deep motor branch of the ulnar nerve can demonstrated arising from the flexor digitorum be seen ending in the hypothenar muscles while the profundus (Figs. The palmar middle superficial sensory branch follows the ulnar artery fascia separates the lumbrical muscles from the to reach the last two fingers. On the longitudinal image, the tendon sheath appears as a thin hyperechoic line (arrowheads) separated from the tendon by a thin hypoechoic rim. Dynamic scanning during movements of the interphalangeal joint allows an easier differentiation between these structures. The dorsal aspect of the interpha langeal joints is not clearly visualized by means 11. Only the proximal synovial Dorsal Aspect recess can be detected if distended by a patho logic effusion. Accurate assessment of joints basi At the level of the metacarpal heads, the sagit cally relies on longitudinal images. These visualize tal bands maintain the extensor tendons in the the extensor tendon running in the subcutaneous midline of the metacarpals during flexion and tissue over the hyperechoic bony cortex and the extension of the fingers. Disruption of the sagit In normal conditions, intra-articular fluid is not tal bands can result in instability of the extensor detected at the level of the dorsal synovial pouch tendon, which is then free to sublux on the sides that extends proximally under the extensor tendon. At the metacarpal head level, the extensor tendon appears as an oval hyperechoic structure (arrow) covered by the sagittal band (arrowheads). The tendon of the first dorsal interosseous muscle (arrowheads) is visualized overlying the ligament. Observe the fascicles of the nerve that appear as hypoechoic spots embedded in the hyperechoic epineurium. Using thin anisotropic bands covering the flexor tendons high-resolution probes, the A1, A2 and A4 pulleys (Martinoli et al. Transverse planes are the can be demonstrated in virtually all normal subjects best for depicting them. Saline was injected inside the ft tendon sheath and in the subcutaneous ft tissue located just superficial to it. Bianchi throughout the hand, whereas tears in patients with depends on the amount of tension force applied at rheumatoid arthritis are far more common at the the moment of injury. The patient presents with local essential for assessing tendon continuity and for dif swelling and tenderness over the dorsal aspect of ferentiating between partial and complete ruptures. The finger may assume a bent-down distal insertion of the tendon into the base of the position, commonly known as “boutonnière” defor distal phalanx. This often occurs joint demonstrate lack of tendon echoes inserting when the distal interphalangeal joint has abruptly to the base of the middle phalanx, whereas the late been forced into extreme flexion. In some cases, a ral tendons are best demonstrated at both sides of piece of bone may be pulled off by the tendon. This len, hypoechoic and jammed over the dorsal aspect lesion is commonly referred to as “mallet finger,” of the proximal interphalangeal joint (Fig. In some cases, ture is usually demonstrated over the distal shaft of surgical repair is needed, especially in intrasubstace the middle phalanx, indicating the retracted tendon tears. Bianchi only changes in the para-articular soft tissues and an nique is required not to miss mild fluid effusions intermittent tendon dislocation could go unnoticed. The identification of sheath fluid is easier over the metacarpal heads due to the more superficial course of the flexor tendons, and in the fingers, where it 11. In subacute and chronic teno limited number of normal subjects, a thin regular synovitis, a thickened synovial sheath can be an hypoechoic rim <0. Serous tenosynovitis can result rounding the flexor digitorum tendons in the palm from chronic microtrauma, such as in trigger finger or the fingers, just proximal to the A1 and A2 pulleys. In this is a normal finding and should not be misin psoriatic arthritis, there may be a diffusely swollen terpreted as a sign of tenosynovitis. In the hand, finger, commonly known as “sausage finger,” related tenosynovitis of the flexor digitorum tendons may to either a flexor tendon tenosynovitis or simultane depend on their involvement by systemic disorders, ous inflammatory involvement of all the three finger such as rheumatoid arthritis and other inflamma joints. Similar to other sites in the body, the tial diagnosis is important because in tenosynovitis hallmark of acute tenosynovitis of flexor tendons a single steroid injection inside the synovial sheath is an increased amount of synovial fluid that typi is curative whereas multiple injections within the cally appears as a hypo or anechoic collection dis different joints are required in the latter situation. Clinically, the inflamed an expression of systemic arthritides, such as rheu finger swells and its movements become painful. Fluid distention (asterisk) of the common synovial sheath of the flexor digitorum superficialis (s) and profundus (p) tendons for the index finger is observed. In the midpalm, careful scanning technique is needed to avoid confusing the sheath fluid with adjacent hypoechoic lumbrical muscles (L). The fluid is located anteriorly to the tendons and assumes a lobulated appearance created by the discontinuity of the annular pulleys. Note the absence of synovial distension at the sites of the A1, A2, A3 and A4 pulleys (white arrowheads). This primarily depends on the constrictive action of the pulleys on the synovial sheath. Then, the sheath fluid may also cover part of the pulleys spreading over them from their proximal and distal edges (open arrowheads). The insert at the bottom left side of the figure indicates probe positioning mechanical tendinitis and infectious disease. In mode rate hyperplasia, the synovium can be observed projecting inside the effusion from the parietal and visceral layers. In more advanced cases or in severe disease, the synovium can completely fill the tendon sheath (Grassi et al. In the acute phases of inflammation, color and power Doppler imaging demonstrate hyperemic flow within the synovial folds and the tendon substance. In these settings, it may help to differentiate synovial pannus from effusion (Newman et al. In addition, a consistent decrease in synovial hyperemia can be observed as a response to medical therapy and can Fig. Schematic drawing of a palmar view of the hand demonstrates be regarded as an indicator to monitor the effects of the continuity of the carpal synovial sheath of flexor tendons therapy (Breidahl et al. The flexor tendons In hand wounds, foreign bodies are a common for the index, middle and ring fingers have isolated sheaths cause of infection of the flexor tendon sheath. In (yellow) extending from the metacarpal neck down to a level infectious tenosynovitis, detection of an echogenic just proximal to the insertion of the flexor digitorum profun dus on the distal phalanx. The carpal sheath of the flexor pol effusion can allow an early diagnosis in the proper licis longus tendon (blue) is separated from the carpal synovial clinical setting (Schechter et al. Bianchi penetrating wounds involving the palmar aspect of the finger distal to the A2 pulley, the flexor digito * rum profundus is more frequently torn because it * lies in a more superficial position than the two slips ft of the flexor digitorum superficialis (see Fig. Closed trauma with avulsion of the flexor digitorum * * profundus from its distal insertion can also occur a as a result of a forced passive hyperextension injury on an actively flexed finger. Standard radiographs must be performed to obtain full depiction of the avulsed bone. Infectious tenosynovitis of the flexor tendons obtained during passive and active movements of in a patient with a previous penetrating injury in the soft the finger and during contraction against resistance tissues of the middle finger. Partial tendon tear thickening of the visceral layer (arrowheads) of the tendon presents as a fusiform hypoechoic swelling of the sheath. Correlation with the fluid revealed purulent material the clinical history is essential for this purpose. The amount of proximal retraction depends body is found lying inside the tendon sheath. Due to on the size of the muscle and mechanism of the the anatomic configuration of the synovial sheaths, injury (Fig. In general, the proximal tendon infection of the thumb and little finger is more likely end cannot be palpated. Its imaging detection is, to spread upstream to reach the common flexor therefore, essential for planning a correct surgical synovial sheath in the palm and wrist than are infec incision. In acute lesions, an effusion in the tendon tions affecting the three central fingers (Fig. The location of a flexor tendon Flexor Digitorum Tendon Tears tear has surgical and prognostic implications and should be detailed in the report. Surgi single finger or more tendons in adjacent fingers cal stitches appear as tiny echogenic spots located when extensive sharp injuries across the palm or the inside the repaired tendons that follow the tendon ventral aspect of the fingers occur. Note the empty sheath (white arrows) and the marked cranial retraction of the tendon end which migrated proximal to the level of the metacarpophalangeal joint. In combined A3 and A4 pulley tears, an the bowstringing is observed over the middle pha even greater tendon-to-bone distance was observed lanx (Fig. The difference between isolated A2 pulley active forced flexion may enhance the subluxation of and combined A2 and A3 pulley tears was statisti tendons. An anechoic effusion (asterisks) is also intervening between the flexor tendons (ft) and bone. A different location of fluid exists: in tenosynovitis, the fluid expands mainly anteriorly to the flexor tendons because these tendons are fixed very tightly to the bone surface by the pulleys; in pulley tears, the fluid collects posteriorly to the flexor tendon because of the free space left over the bone. As an alterna palmar plate within which a hypoechoic cleft can be tive, a slip of the flexor digitorum superficialis can appreciated as a sign of rupture (Fig. Treat be rerouted over the palmar surface of the flexor ment of these lesions depends on the stability of the digitorum profundus. If clinical assessment shows a stable joint then Apart from the traumatic setting, loosening of conservative treatment is indicated, while unstable the pulleys may be secondary to inflammatory or metacarpophalangeal joints require surgical correc infectious tenosynovitis. A typical case of pulley involvement occurs in patients with rheumatoid arthritis due to 11. It has a prevalence of approximately 1–2% at the volar aspect of the finger joints and deep to and may present bilaterally in up to 60% of cases the flexor tendons. Palmar progress to form fibrous cords or bands beneath the plates injuries are mostly secondary to hyperexten skin that stretch from the palm into the fingers lead sion trauma of the joint. In the first, the stress force does not cause disease is more common in diabetic patients and a palmar plate tear but detaches a bony fragment can be associated with fibromatosis in other areas, from the base of the phalanx, caudal to the joint line. Tears Peyronie disease) leading to deviation of the erect within the substance of the palmar plates are rarer penis. In Dupuytren disease, the ulnar aspect of the and cannot be detected on plain films. They are usu fascia is more commonly involved near the distal ally observed at the metacarpophalangeal joint of the crease of the hand and the bases of the ring finger. Associated intra-articular fluid (asterisk) in the fpl metacarpophalangeal joint is evident. Therefore, the presence of fluid must be always correlated with the clinical findings. The procedure of needle place ment is not only more accurate but also less painful 11. Effu of intra-articular calcific fragments relies on their sions appear as anechoic fluid collections located typical osseous appearance with posterior acou inside the synovial recesses (Fig. Metacarpo stic attenuation and their position inside the joint phalangeal joint and interphalangeal joint effusions cavity. When loose bodies are located on the palmar are easily detected by means of a dorsal or palmar aspect of the finger, one should be careful not to approach using longitudinal images. Differential diagno images should also be performed routinely because sis is based on the location of the fragment inside they can show small amounts of fluid that are pos or outside the synovial space. Irregularities in the sibly displaced at the medial and lateral sides of the shape of the articular bony surfaces and osteophytes recesses and that can go unnoticed in longitudinal can also be appreciated (Fig. Fluid distension In rheumatoid arthritis, chronic synovitis leads of the palmar recess occurs proximal to the level to hypertrophy and hyperplasia of the synovium of the joint line, over the metacarpal or phalangeal (pannus), progressive thinning of the articular car necks. This is due to the constraining action of the tilage and exposure of the subchondral bone. Note the relationship of this recess with the palmar plate (asterisk), the flexor tendons (ft) and the edge of the head of the proximal phalanx (star). Dynamic study of the proximal interphalangeal joint in a patient with intra-articular effusion. Slight flexion squeezes the posterior recesses moving the intra-articular fluid into the volar recess (arrowheads) of the proximal interphalangeal joint. The metallic prosthesis appears as a regular bright curved line (arrow) with posterior reverberation arti fact (white arrowhead). Hyperemia (open arrowheads) due to active pannus is identified in the volar synovial recess at color Doppler imaging. At these radiographs and a variety of complementary projec sites, the cartilage layer is interrupted at some dis tions in an attempt to increase the sensitivity of this tance from the capsule insertion leading to the so modality for identifying disease-related changes. Bare areas demineralization and para-articular soft-tissue swel are characteristic sites of bony erosions in early ling, are nonspecific findings and marginal erosions rheumatoid arthritis. In ligament structures are weakened from the destruc recent years, the introduction of new disease-modi tive action of the pannus and progressively fail to fying antirheumatic drugs, has led to preventing retain the joint in the correct position. In severe progression of joint destruction and long-term disa longstanding disease, complete disintegration of the bility. Nevertheless, these powerful drugs are very joint occurs as the ultimate result of these pathologic expensive and, most importantly, have some serious changes, leading to typical finger deformities, such side-effects that restrict their use to aggressive rheu as the ulnar deviation of the fingers due to instability matoid arthritis. Accordingly, clinicians ask for ima of the metacarpophalangeal joints with secondary ging modalities able to demonstrate early changes volar subluxation and ulnar deviation of the proxi which can correlate with a more aggressive pattern mal phalanges, the swan-neck flexion deformity of disease. A characteristic finding para-articular involvement and especially tendon is sparing the distal interphalangeal joints.

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