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Between the two layers cheap 500 mg chloramphenicol with mastercard antibiotics for acne and pregnancy, within the pericardial sac discount chloramphenicol online amex virus gear, serous pericardial fluid (≤25 mL in adults) serves to lubricate the heart and allow its relatively friction-free movement within the chest discount chloramphenicol 250 mg online antibiotics and weed. In addition purchase 250mg chloramphenicol with amex bacteria zombie, the parietal pericardium limits the diastolic dimensions of the heart. Parietal Pericardium The parietal pericardium represents a tough, flask-shaped sac that surrounds the heart and attaches along the great vessels, such that the ascending aorta and main pulmonary artery are intrapericardial (Fig. Similarly, the terminal 2 to 4 cm of the superior vena cava are also located within the pericardial sac, as are shorter lengths of the pulmonary veins and the inferior vena cava. For patients with total anomalous pulmonary venous connection, the confluence of pulmonary veins is located within the pericardial sac behind the heart. In contrast, the right and left pulmonary arteries and the ductus arteriosus are extrapericardial structures, and surgical procedures restricted to these vessels do not require a pericardial incision. The parietal pericardium consists of an outer fibrous layer and an inner serous layer of mesothelial cells. Its outer surface also normally contains variable amounts of adipose tissue, especially near the diaphragm, that can cause apparent thickening of the pericardium, and contributes to the cardiac silhouette radiographically. Because the fibrous pericardium contains little elastic tissue, it cannot distend acutely. Consequently, the rapid accumulation of as little as 200 mL of pericardial fluid in adults generally produces hemodynamic features of cardiac tamponade. However, in the setting of chronic enlargement of the heart, as occurs with normal body growth or with cardiac dilation, stretching and growth of the P. A: With the anterior aspect of the parietal pericardium removed, the intrapericardial position of the great vessels is apparent. B: With most of the parietal pericardium excised, the pericardial reflection can be identified (arrows), as can the ligament of Marshall (arrowheads) and the transverse sinus (asterisk) (left lateral view). It consists of a delicate lining of mesothelial cells and the subjacent adipose tissue, coronary vessels, and nerves along the surface of the heart. Prominent tags of fat cover the origins of the coronary arteries between the aorta and the atrial appendages. With increasing age, epicardial fat increases in amount and may infiltrate into the atrial septum, particularly within the limbus of the fossa ovalis. Because the heart must be compliant enough to enlarge during ventricular diastole and to contract during systole, the normal visceral pericardium has no dense fibrous component. Even so, it does have appreciable mechanical strength, as evidenced by the fact that following coronary interventions complicated by arterial perforation, the overlying epicardium readily withstands coronary blood pressure and thereby deters rupture into the pericardial sac. Pericardial Reflection The junction between the parietal and visceral layers occurs along the great vessels and is known as the pericardial reflection. That portion involving the great veins forms the oblique sinus, a cul-de-sac (shaped like an inverted U) along the posterior aspect of the left atrium. Between the great arteries anterosuperiorly and the atrial walls, posteroinferiorly, is a tunnel-shaped structure, the transverse sinus (Fig. Nearby, the ligament of Marshall represents the embryonic remnant of a left superior vena cava. Intraoperatively, in the setting of pulmonary atresia, if a remnant of the hypoplastic or atretic main pulmonary artery exists, it will be found along the ascending aorta, anterosuperior to the transverse sinus. Conversely, a persistent left superior vena cava will abut the left pulmonary artery posterior to the transverse sinus.

The ante- losal and cingulate buy chloramphenicol 500 mg on-line bacteria 4th grade science, and the vertically oriented rior and posterior walls of the central sulcus are parieto-occipital sulcus generic chloramphenicol 500 mg with visa infection hair follicle. The callosal sulcus is formed by the precentral and postcentral gyri discount chloramphenicol master card virus worse than ebola, dorsal to the corpus callosum cheapest generic chloramphenicol uk antibiotics used to treat bronchitis, the huge mass of respectively. The frontal lobe extends anteriorly from the The cingulate sulcus encircles the cingulate gyrus, central sulcus to the anterior tip of the hemi- which is dorsal to the callosal sulcus. The parietal lobe occipital sulcus, located a short distance posterior is superior to the lateral fssure and behind the to the corpus callosum, separates the parietal and central sulcus. It is shaped like the thumb medial surface of the hemisphere in the posterior Central sulcus Frontal lobe Parieto-occipital sulcus Frontal pole Occipital pole Occipital Lateral fissure lobe Temporal lobe Temporal pole Preoccipital notch Figure 4-4 Lateral view of left hemisphere. Between the para- nucleus, which is lateral to the external medul- central lobule and the parieto-occipital sulcus is lary lamina. In the mid- and the underlying rostral part of the cerebral line, from ventral to dorsal, are the hypotha- peduncle (Fig. The level also includes parts lamic area between the mamillary bodies, the of the cerebral hemisphere: the corpus callosum, third ventricle, the interthalamic adhesion, lateral ventricles, and the caudate and lentiform and the corpus callosum. The caudate and lentiform nuclei are tel- ventricle are formed by the hypothalamus ven- encephalic nuclei. The thalamus As found in the midbrain sections, the mid- extends laterally to the internal capsule, a huge brain here also comprises, from anterior to pos- mass of hemispheric white matter or nerve terior, the cerebral crus, substantia nigra, and fbers. The most prominent thalamic nuclei are the hypothalamus medially, the thalamus dorsally, round, centrally located centromedian nucleus in the internal capsule laterally, and the cerebral the internal medullary lamina and the ventral crus ventrally is the subthalamus. The caudate nucleus the medial dorsal, lateral posterior, and reticular is found in the lateral wall of the lateral ventricle. More ventrally, lateral to the internal capsule, is the lentiform nucleus, which comprises two more Chapter Review medial segments, the globus pallidus, and a lateral Questions segment—the putamen. Which cranial nerves attach to the The tuberal level is at the anterior part of the forebrain, which to the midbrain, and thalamus and the surrounding cerebral hemi- which to the hindbrain? In which divisions of the brain are the thalamus, the third ventricle, and the corpus various parts of the ventricular system callosum. When are the terms “anterior or ventral” pended from the corpus callosum by the septum and “posterior or dorsal” synonymous in pellucidum. The most uniform and prominent landmark thalamus on the lateral surface of the cerebral e. The left nasolabial groove was smoothed out, and his lips were drawn toward the right side. He was unable to retract the left corner of his mouth or to pucker his lips as in whistling. Frowning and raising his eyebrow on the left were impossible, and he was unable to close the left eye tightly. During the pathways whose integrated activity allows nor- execution of the movement, muscle receptors mal movements to occur. All of cerebellum with the motor cortex and the these participate in the sequence of events that brainstem motor centers, both of which infu- occurs when a voluntary movement is desired. It should be remembered that The idea or desire to perform the movement even though the fve subdivisions are described occurs in association areas of the cerebral cor- separately, all participate in commanded move- tex. Impulses from these areas pass to the basal ments and all must be intact for normal volun- ganglia and cerebellum.

In spite of the seri- Collett and Edwards4 have classifed truncus arteriosus accord- ous challenges presented by the child with truncus arterio- ing to the origin of the pulmonary arteries from the truncus buy chloramphenicol 250mg mastercard antibiotics causing c diff. It has been our obser- Truncus arteriosus results from malseptation of the conotrun- vation that the most common form of truncus lies somewhere cus purchase chloramphenicol 250mg without a prescription antimicrobial lock solutions. An interesting observation is that the ductus arteriosus is An alternative and simplifed method for categorization of rarely present when the aortic arch is intact discount chloramphenicol express bacteria class 8. The authors defned either aortic or pulmonary there being only a tiny conotruncal septum separating the dominance which they found in 20 and 8 specimens buy chloramphenicol with a visa antibiotics for stress acne, respec- aortic and pulmonary valves. Pulmonary dominance was found only when the aortic absent and the aortic and pulmonary valves fuse, there is a component of the trunk was hypoplastic and the ductus sup- single semilunar (truncal) valve and the pulmonary arteries plied the majority of fow to the descending aorta. However, as pulmonary resis- The truncal valve has a variable number of leafets and vari- tance falls in the frst days and weeks of life, there will be able morphology. There may be as few as two or as many an increasing amount of pulmonary blood fow and the child as six leafets, although it is very rare to fnd more than four is likely to develop signs of congestive heart failure. Therefore, there is competition lets tend to be somewhat myxomatous and thickened and can between the coronary and pulmonary beds for diastolic fow. It is rare for a truncal valve to be structur- ing diastole stealing blood fow from the hepatic, renal, and ally stenotic. Retrograde fow and potential for coronary insuffciency is further exacerbated by the presence of truncal valve regur- Ventricular sePtal Defect gitation. The degree of cyanosis is infuenced by the total pulmonary blood coronary arteries fow which, as mentioned above, is usually increased. Thus, truncus is like transposition in that it is a cyanotic anomaly, Although the distal branching of the coronary arteries is usu- but pulmonary blood fow is increased. However, the degree ally normal, it is not uncommon for one or both ostia to be 8,9 of cyanosis in truncus is usually much less severe than with abnormally positioned. The massively increased pulmonary blood be extremely close to the takeoff of the right or more com- 2,6 fow and exposure of the pulmonary arteries to both systolic monly the left pulmonary artery. As with tetralogy, there and diastolic systemic arterial pressure results in acceler- may be an anomalous anterior descending coronary artery ated development of pulmonary vascular disease. However, in 10–15% of patients, Generally, a murmur is detected shortly after birth. A chest the aorta is interrupted, either between the left carotid and X-ray will demonstrate evidence of increased pulmonary left subclavian or beyond the left subclavian11,12 and the blood fow, although arterial blood gases reveal at least mild descending aorta gives the appearance of being a direct con- cyanosis. Cardiac catheterization is rarely if ever indicated in communication) that the ductus under these circumstances the neonatal period. If a child presents beyond 2 or 3 months rarely closes and rarely requires a prostaglandin infusion to of age, cardiac catheterization may be necessary to assess maintain patency. Even when interrupted aortic arch is present, it is rare for 20 cular obstructive disease. Generally symptoms and signs recommended elective neonatal repair with encouraging of congestive heart failure appear gradually over the frst 15,21 results. The availability of cryopreserved valved allografts weeks of life as pulmonary resistance falls. It is only in the in the United States in the mid-1980s including very small rare circumstance that a child has been allowed to lapse into sizes, such as 7 and 8 mm, allowed primary repair even in the a severe degree of failure that aggressive medical stabiliza- youngest and smallest infants. In general, however, no attempt should be made to manage truncus medically for any extended period of time, but only in the immediate preop- tecHnical consiDerations erative period perhaps for a few days to optimize the child’s Anesthesia status before surgery. This should hold true even when the 14 Precardiopulmonary Bypass child is born prematurely. In the past, deferral of surgery with aggressive medical Routine anesthesia and monitoring procedures are described management led to a high risk of problems with pulmonary in detail in Chapter 3, Anesthesia for Congenital Heart hypertension, including pulmonary hypertensive crises in the Surgery, while anesthetic considerations specifc to patients early postoperative period.

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