By T. Urkrass. Idaho State University.
Further more it has been shown that the resistive index significantly reduces if diclofenac is administered order toradol 10 mg with mastercard pain medication for glaucoma in dogs. Level 4 evidence suggests that (34) (35) (36) hydromorphine might be helpful purchase 10 mg toradol otc pacific pain treatment center victoria bc, however there is a significant risk of vomiting Diclofenac can affect renal function in patients with already reduced function. Studies indicate that the incidence of (38) recurrent renal colic decreases with administration of diclofenac sodium. When the pain is unremitting the treating urologist should think of alternative measures such as drainage by stenting or percutaneous nephrostomy or even removal of the stone. The prerequisite for this approach is that the patient should be comfortable this approach. Studies indicate that alpha blockers facilitate ureteral passage ,while nifedipine provides marginal benefit. Patients who opt for Medical expulsion therapy should have well controlled pain, no evidence of sepsis, and adequate functional reserve, such patients should be periodically observed for stone position and assessment of hydronephrosis. Anomalous kidneys These group of patients include those patients with stones in ectopic, horseshoe or kidneys with fusion anomalies. The factors to be taken into consideration are the stone bulk, the location of the stone, the vascular and the anatomy of the pelvicalyceal system. Ultrasound helps in gaining access in ectopic kidney apart from being a diagnostic tool. Flexible ureteroscopy will be useful tool in stones small burden stones in size with the availability of smaller flexible ureteroscopes, and access sheaths. However the surgeon should consider complete “on table” clearance in these patients as the drainage is likely to be impaired. Who does what/ and timeline Doctor 32 The treating doctor ideally should be an Urologist or a surgeon trained in Urology. He is responsible for the initial workup of the patient and subsequent management of the patient. He is responsible for counseling the patient regarding the success rates, complications and possible outcome of any given procedure. All possible treatment options in a given clinical situation should be discussed with the patient. The patient on discharge should be given instructions for follow up and measures (dietary and pharmacologic) to prevent stone recurrence. Nursing and technical staff:-The nursing staff should be trained in the aspect of maintenance and use of endourologic equipment, considering the fragility and cost of these equipments. The technical/nursing staff prepares the trolley and assists the surgeon during the procedure. Referral criteria:- The criterion for referral remains, lack of appropriate infrastructure and expertise at primary level. The indications for referral to tertiary care centre in managing stones disease are:-! The treatment of small non obstructing calyceal calculi in patients with symptoms. The role of ureteral stent placement in the Prevention of steinstrasse J Endourol 1999;13(3):151-5. A prospective multivariate analysis of factors predicting stone disintegration by extracorporeal shock wave lithotripsy: The value of high resolution non contrast computed tomography Eur Urol 2007; 51(6):1688-93. Air pockets trapped during routine coupling in dry head lithotripsy can significantly decrease the delivery of shock wave energy. Lower pole I A prospective randomized trial of extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy for lower pole nephrolithiassis-initial results J Urol 2001;166(6):2072-80. Perioperative antibiotic prophylaxis in ureteroscopic stone removal Eur Urol 2003; 44(1):115-8. Flexible ureterorenoscopy for the treatment of lower pole calyx stones; influence of different lithotripsy probes and stone extraction tools on scope deflection 37 and irrigation flow. Ureteroscopic management Of ureteral calculi:Electrohydraulic versus holmium Yag lithotripsy J Urol 1997;158(4):1357-61.
Metabolic: Increased hepatic glycogenolysis purchase 10 mg toradol free shipping pain treatment center new paltz; decreased peripheral glucose intake discount toradol 10 mg online pain treatment laser; increased free fatty acids in the blood (lipolysis) 6. Skeletal muscle: facilitation of neuromuscular transmission and vasodilatation Drugs Acting on the Adrenergic Receptor Subtypes α1 α2 β1 β2 Agonist Phenylephrine Clonidine Dobutamine Salbutamol Methoxamine Oxymetazoline Isoproterenol Terbutaline Terbutaline Isoetharine Antagonist Prazosin Yohimbine Propranolol Propranolol Phentolamine Phentolamine Pindolol Pindolol Phenoxybenzamine Phenoxybenzamine Atenolol Butoxamine Metoprolol Timolol Timolol Adrenaline stimulates all the four receptor subtypes. Noradrenaline stimulates both alpha receptors and beta1 but has very poor affinity for beta2 receptors. It is therefore ineffective when given orally and should be given intramuscularly or subcutaneous. Intravenous injection is highly dangerous and is likely to precipitate ventricular fibrillation. The drug may how ever, be given by nebulizer for inhalation when its relaxing effect on the bronchi is desired or it may be applied topically to mucus membranes to produce vasoconstriction. Because of the extensive metabolism of the drug in liver, little is excreted unchanged in the urine. Pharmacodynamics Adrenaline directly stimulates all the adrenergic receptors both and brings about effects of sympathetic nerve stimulation. Its action may be divided in to two, depending on the type of receptor stimulated. The α effects consist of vasoconstriction in skin and viscera, mydriasis, platelet aggregation and some increase in blood glucose. The ß effects consists of increased contractility and rate of heart with a decreased refractory period (ß1), vasodilatation in muscles and coronary vessels (ß2), bronchial relaxation (ß2) uterine relaxation (ß2), hyperglycemia, lactic acidemia and increased circulating free fatty acids. Pharmacokinetics Like adrenaline, noradrenaline is ineffective orally so it has to be given intravenously with caution. It is not given subcutaneous or intramuscularly because of its strong vasoconstrictor effect producing necrosis and sloughing. The metabolism is similar to adrenaline; only a little is excreted unchanged in urine. Pharmacodynamics Nor adrenaline is a predominantly α receptor agonist with relatively less β agonist action when compared to adrenaline. Adverse effects include: - Anxiety, headache, bradycardia are common side effects - Severe Hypertension in sensitive individuals - Extravasation of the drug causes necrosis and sloughing. These are the other catecholamines which have similar properties to adrenaline and noradrenaline. These drugs have advantage over the others because they are 45 more selective in their action so that they have fewer side effects than adrenaline and nor adrenaline. It has a good distribution through out the body and is resistant to hydrolysis by the liver enzymes. Because of its stability to metabolism it has long duration of action than the catecholamines. This effect is partly by a direct action on the receptors and partly indirectly by releasing noradrenaline from its tissue stores the effect of the drug to various organs and systems is similar to that of adrenaline. Nocturnal enuresis Side effects The side effects are similar to those of adrenaline; but in addition it may produce insomnia and retention of urine. Based on their selectivity to specific receptors the rest of the catecholamines, are classified but it is very difficult to exhaust all the drugs. More over their effect and pharmacology is discussed where they are clinically indicated. Drugs blocking theβ Adrenergic receptor These drugs prevent the response of effectors organs to adrenaline, noradrenaline and other sympathomimetic amines whether released in the body or injected. Circulating catecholamines are antagonized more readily than are the effects of sympathetic nerve stimulation. The drugs act by competing with the catechoamines for α or β receptors on the effectors organs. Irreversible antagonists tightly bind to the receptor so that their effects may persist long after the drug has been cleared from the plasma e. Hence, postural hypotension and reflex tachycardia are common during the use of these drugs. It has high affinity for alpha1 receptor and relatively low affinity for the alpha2 receptor.
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