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care will be oriented to avoid complications such as accidental decannulation and cannula obstruction by a mucus plug.

Some of this care are:
1.cura every 12 hours so will clean the stoma thus preventing maceration and infection:
-observe the appearance of the stoma
watching for signs of infection, clean the area with saline

-dry thoroughly with a disinfectant-impregnated
-cover the area with a small pair bib to protect from moisture and tracheal secretions
-change attachment straps; the tape know that it is fair enough if we can pass a finger between the tape and neck
-neck to keep the tape clean and dry to avoid infection and irritation

2.Change cannula once a week:
-first secretions aspire
-hyperextending the patient's neck using a runner below the shoulders to better expose the tracheostomy.
-a person holding the cannula while another cuts the ribbon
-lubricate the cannula
-spray lubricant used to remove the tube and enter the new softly, without pushing hard, but once placed
-check the status of the patient: color, air intake ..
-tie fastening tape and place a protective dressing, while the other person holds the cannula.


Recommendations:

1.Siempre we have a patient with a tracheostomy will have material prepared for emergencies in an accessible and close to the patient, this material would be:
-cannulas replacement of the same number of carrying and a lower number.
-scissors to cut the ribbons.
-tube endotracheal tube smaller than the suction-

2.Es important that whenever you switch the cannula is made between two people. 3.The
cannula change is usually done every 7 days although sometimes may require fewer days. 4.Siempre
should we believe we will make the cure.

Rs232 To Rs422 Connection Diagram

Tracheostomy Care of Congestive Heart Failure

Introduction The heart is considered the most important central body for life, many people did not seem so serious a disease suffer or have gallbladder neck fractures, femur, and heart disease. Diagnosis of Heart Failure causes fear and anxiety in many people. It is clear that remarkable progress has been made in treating heart failure.
The diagnosis is based on the assessment Clinical manifestations of pulmonary congestion, nursing assessment focuses on the search for signs and symptoms of pulmonary and systemic overload of fluids as inferred from a wealth of knowledge and professional preparation. Due to the increase in the tendency to reduce hospitalization and increase the use of consultancy services, it is becoming much more the need to update the nursing staff in action with patients who have heart failure.

CONGESTIVE HEART FAILURE

is the heart's ability to push enough blood to meet the needs of oxygen and nutrients to the tissues, this includes the right heart failure and left, which cusa the signs and symptoms from the circulatory disorder.
Heart failure can define from 3 views.
report: syndrome accompanied by signs and symptoms secondary to failure of the heart as a pump. Hemodynamic

: pathophysiological state in which the heart is unable to maintain the volume / min appropriate to the needs of the tissues with the values \u200b\u200bof filling pressure of increased cavities, left atrial pressure above 12 mn hg, return venous blood volume also increased.
Biochemical metabolic: Impotence of the heart to transform chemical energy into mechanical.

PATHOPHYSIOLOGY

The mechanism involves reduction in the contractile properties of the heart which reduces the normal cost. The primary problem is the damage and inhibition of myocardial muscle fibers, stroke volume is poor and can not maintain a normal cardiac output. Stroke volume, which drives the heart with each contraction, depends on three factors: preload, contractility and poscarga.2


ETIOLOGY 1. Coronary atherosclerosis.
2. Systemic or pulmonary hypertension.
3. Rheumatic fever.
4. Cor lung.
5. Constrictive pericarditis.
6. Valve stenosis.
7. Hyperthyroidism.

Pathogenic Classification

1-Primary: correspond to myocardial failure.
a) Coronary artery disease.
b) IMA H
c) Ventricular remodeling after AMI
d) Hypertensive heart disease.
e) My heart.
f) metabolic disorders.

2. Secondary: correspond to overload.
a) Diastolic.
b) systole.


Clinical Manifestations.
The hallmark is the increased intravascular volume. By reducing spending on the heart increasingly inadequate arterial and venous pressures. Increased pulmonary venous pressure allows the passage of fluid from the capillaries into the alveoli (pulmonary edema) that occurs with coughing and dyspnea, most often systemic venous pressure and increased peripheral edema ponderal.1

Insufficient hemicardio left. Here

predominant visceral congestion and peripheral tissues. This is because the attack right can not properly push blood volume and thus does not accommodate all hematic fluid reaches the venous circulation.
The table includes lower extremity edema, weight gain, hepatomegaly, neck vein distention, ascites, anorexia, nausea, nocturia and weak.
Edema begins in feet and ankles, slowly climbs up the legs and thighs and external genitalia and final portion covers lower trunk. It suddenly. Sacral edema frequently in people who lie in bed.
Hepatomegaly is caused by venous engorgement and tenderness in the right upper quadrant abdomen of the patient complains of pain, this process reaches a level known as ascites.
Anorexia and nausea are the result of venous engorgement and stasis of abdominal organs.
Nocturia or wetting, because the rest appears to increase the risk prone venal blood, which occurs diuresis, which is more common at night because the physical rest improves cardiac output.
accompanying weakness of right heart failure depends on the lower cardiac output.

examinations.
We refer to these complementary studies that help us to confirm the diagnosis
IC 1. Chest X-ray: cardiomegaly were found in the absence of this does not rule out IC as in diastolic dysfunction.
2. Electrocardiogram is useful for information about the underlying heart disease such signs of LV hypertrophy, ischemic changes of ST segment or T wave, or the presence of the Q wave of necrosis with signs that speak of a hypertensive heart disease.
3. Laboratory analysis.
4. Echocardiogram: This test is a priority to evaluate the patient. TREATMENT

The main objectives of treatment of individuals with impaired are:
1. Improve sleep to lessen the workload of the heart.
2. Improve the strength and efficiency of myocardial contraction through drugs.
3. Remove the excess volume or diabetic, diet and rest. PHARMACOTHERAPY

1-Cardiac glycosides. Digitalis
: These drugs improve the force of myocardial contraction and slow the frequency of it. Exert various effects:
Increased cardiac output, decreased venous pressure and blood volume, increased diuresis, which relieves pain.
digitalis poisoning: Anorexia, nausea and vomiting. Heart rhythm disturbances, bradycardia, premature ventricular contractions, ventricular bigeminy, blurred vision, weakness, and others.
. Prior to administration should be measured heart rate in the area espical if you notice excessive deceleration or change in the rhythm, not given the drug and medical alerts.
. If the clinician ordering the use of digitalis, it is necessary to measure its concentration in serum before administration.
. Managing diabetes in the early hours of the morning so that does not interfere with sleep.
. Weigh the patient daily, at the same time and swelling of the leg examined.

2-Vasodilators:
Used to reduce the resistance to expulsion of blood from the left ventricle. Its action is accompanied by a more complete ventricular emptying and venous capacity improvement. Sodium nitroprusside
: via intravenous drip in perfectly calibrated and monitored. It monitors the patient mediation of the pulmonary artery pressure and cardiac output. Another vasodilator is nitroglycerin.

3-Dietoterapia: consists in providing nourishment to the heart to develop a minimum of effort and muscular work, while the nutritional status remains within satisfactory limits.
calorie diet is that overweight and increases the heart's workload increases, decrease alcohol consumption, and to reduce salt intake in patients with mild IC. In IC must strictly control the salt used diuretics but not exceed l0 grams daily.
4 - Delete the habit of smoking.
Nicotine increases heart rate and therefore the consumption of O2 and carbon monoxide causes tissue hypoxia and infarction.

Do Maryjbligewearwigs

Nursing Care for patients with lymphedema Neoplastic Disorders

· DEFINITION: Accumulated

progressive lymph in the interstitial spaces of the subcutaneous tissue, accompanied by retention water.
is a high protein accumulation, which contributes to increased fibrosis and edema own establishment.

· OBJECTIVE: Reduce

now that the introduction of malignancy can cause lymphedema, seeking a reduction of the edema.

· CAUSE:

neoplastic Lymphedema is caused by a blockage of circulation in the lymph collectors.


· DEMONSTRATION:

is common in cancers of the female genital tract of slow evolution. The edema in these cases are occurring very slowly, is located at the root of the limb and is often hard consistency and without fovea.
When lymphedema is due to the axillary or inguinal venous obstruction by thrombi produced by the same tumor progression is mixed edema, lymphatic and venous.


· NURSING CARE:

Skincare:

skin should be kept clean to avoid cuts, scratches, etc.. If this happens, wash the area, apply a local antiseptic such as povidone-iodine and monitor the possible onset of local infection.

meticulous care in cutting nails and toes, it is best to use clippers that the use of scissors.

body wash with water not too hot. Thorough drying of the skin, with emphasis on the folds and interdigital spaces.
Applying lotions or moisturizers, should be non-perfumed or alcohol based, as they tend to irritate.

do not recommend prolonged sun exposure of the affected limb, and solar dermatitis avoid only aggravate the skin condition. Place

compresses on the affected limb if we observe that there is excessive exudation of lymph, changing them whenever they are wet.

Avoid wearing clothes too tight, the clip in the case of women it will not tighten or chest, or shoulder.

nursing staff should avoid performing invasive procedures on the affected limb:
· Extraction of blood.
· Determination of capillary blood glucose levels by pricking the heel of your fingers.
· Manage drugs or vaccines administered intradermally, subcutaneously or intramuscularly.
• Take your blood pressure.

Exercise:
The movement is essential to have a good lymphatic flow, and muscle contraction stimulating massage makes this flow.
should be viewed as a moderate and preferably continuous but led by a physiotherapist.

manual lymphatic drainage and massage:

are movements on the skin in order to stimulate lymphatic circulation, so that excess lymph enter the lymphatic system.
should be soft but firm, 20 to 30 minutes. It should start from the healthy to the edematous area, and from the distal to proximal draining lymph previous nodes also massaged. This provides an increased flow of surface and during the massage the distal drain more easily.
measures are recommended after compression. Measures compressive

:
are important when there is no scarring and assists circulation of interstitial fluid into the lymphatic system.
These measures are aimed at reducing edema, lymph is formed by limiting the pressure on the skin and subcutaneous tissue. Dressing

or compressive elastic bandage 10 cm wide from fingertip to the root of the limb. Effective if the swelling does not exceed the root of the limb.

or compression stockings and gloves, since the lifting of the patient. During the rest will raise the affected limb.

or intermittent pneumatic compression, useful in the cases had severe lymphedema fingers and constant pain.

contraindicated if infection, venous thrombosis, or metastasis, to prevent its extension. And if you are undergoing radiation therapy.

These measures, together with the exercise carried out consistently allowed:
§ Limit the accumulation of lymph in the limb. §
promote venous return and lymph to the origin of the limb. §
stimulate muscle action.

Distance From Velachery To Stella Marys College

BRAIN TUMORS

• Brain tumors represent a large and heterogeneous group of diseases involving the brain and related structures. The variability of these is very large, ranging from benign and curable tumors without major complications until very aggressive and malignant processes, difficult to treat and produce serious sequelae and high mortality.

risk factors in the formation of brain tumors

-Hereditary Genetic Factors
In diseases such as neurofibromatosis or Von Recklinhausen disease have been observed acoustic neuromas and a variety of gliomas. The optic nerve glioma is rare.
• Tuberous sclerosis, disease-Lindau Von Hipel and Sturge-Weber syndrome is a disease associated with the presence of CNS tumors. Approximately 16% of patients with brain tumors have a family history of cancer.

Environmental Factors:
• have been related to the presence of CNS tumors, radiation, trauma, occupational factors and infectious factors. Radiation


• It has been reported an association between risk of glioma and meningioma and a history of repeated X-ray exposures. Injuries


• It has been reported a higher incidence of meningioma in patients who complain of severe traumatic brain injury several years before diagnosis. Hormonal Factors


• The prevalence of meningiomas in women, or their growth during pregnancy, suggesting a hormonal factor.

Immunosuppression:
• The patients with AIDS and medically immunosuppressed are at increased risk of developing primary brain lymphoma.
• However, little is known about the etiology of CNS tumors and is not yet possible to take timely preventive measures. Classification

• A wide variety of brain tumors, dependent on their genesis of different cell types found in the brain and its surroundings. Thus we have the same cell tumors that form the brain and nerves:
• gliomas (the most common tumors, "primary")
• neurocytoma
• Schwannomas or neurinomas
• Tumors of the membranes covering the brain or meninges (meningiomas)
• Tumor-related bony structures or cysts pseudotumors
•
• gland tumors that have associated (tumors of the pituitary gland)
• Tumors Embryonal and early
• Tumors associated with blood vessels, etc.
• Another important group is made up of brain metastases or tumors "side" who have traveled from another body which has a primary tumor or cancer and has been installed in the brain, where they grow back like a tumor.

Symptoms:
• Symptoms vary, depending on size and location of the tumor. A growing tumor is often associated with fluid accumulation, because it exerts pressure on the brain. Symptoms may develop gradually or rapidly.
• Symptoms may include:
• Headache. The vast majority of headaches are not caused by brain tumors. The headaches associated with brain tumors have the following features:
-get progressively worse over a period of months or weeks
-Worse in the morning or cause you to wake during the night
-are different from the common headaches
-Worsens with change of posture, straining or coughing

• Seizures • Nausea or
vomiting • Weakness in arms and / or legs
• Loss of sensation in the arms and / or legs

• Difficulty walking • Vision changes • Problems with language


• Drowsiness • Memory problems
• Personality changes

Clinical manifestations:
• Despite their diversity pathological, clinical effects of brain tumors depend on a number of pathophysiological mechanisms relatively scarce. One of the most important concepts regarding the pathophysiology of brain tumors that grow within the limits of the rigid and inflexible skull. As the volume of the cranial cavity is constant, any expansion process will necessarily produce a proportional rise in intracranial pressure (ICP). Once they pass the compensation mechanisms, will be continued growth at the expense of volumetric brain needs a critical event that results in distortion and herniation of the brain and ultimately end in death. Initially, the brain shows a remarkable tolerance to the effects comprehensive and invasive brain tumors, so early symptoms can be scarce.

• Eventually, all brain tumors cause symptoms by one or more of the following mechanisms
1) Increase in ICP caused by the mass of the tumor, brain swelling or obstruction of the flow of cerebrospinal fluid (CSF )
2) destruction, local compression or distortion of brain tissue, resulting in specific neurological deficits
3) compression or distortion of cranial nerves, resulting in paralysis characteristics of these
4) local electrochemical instability seizures.


• Symptoms of brain tumors are of two basic types:
-no focus, related to the overall effect of increased ICP
-focal-specific localization and functional changes attributable to the area of \u200b\u200bbrain tissue affected.
- The elevations of ICP are responsible for many of the nonspecific symptoms caused by brain tumors.
- Headache is one symptom that most often accompanies brain tumors. When due to a carcinoma, tends to show some special features. Thus, usually a type headache "pressure" of moderate intensity, typically generalized or retroorbital more intense in the early morning, these headaches tend to worsen with coughing, exertion, leaning forward or any other type Valsalva maneuver is due to irritation of the pain-sensitive structures (dura or blood vessels), often accompanied by nausea and vomiting, the latter sometimes described as the "shotgun", especially in children.
-The effects of raised ICP in the optic nerve cause blurred vision, expansion of the blind spot and papilledema. The sixth cranial nerve, because of its long intracranial course, is very sensitive to elevations in ICP and functional impairment resulting in lateral rectus weakness, and diplopia. Finally, in young children, increases in ICP may lead to diastasis of cranial sutures, with growth in head circumference.

• The focal symptoms are location-specific variables as dependent neuroanatomical structures affected, and are characterized by gradual and progressive loss of neurologic functions.
• Injuries affecting the motor cortex produce a contralateral hemiparesis.
• Involvement of the sensory cortex alters one or more sensory functions.
• The impairment of memory, trial and personality is typical of the lesions of frontal and temporal lobes.
• Injuries to the dominant frontal and temporal hemispheres can result in various deficiencies of language.
• occipital lesions produce contralateral hemianopsia homonymous visual defects.
• The posterior fossa tumors tend to alterations of functions of the cerebellum, ipsilateral loss of coordination (cerebellum) and ataxia (cerebellar vermis). Tumors in the region of the hypothalamus and pituitary gland can produce a wide variety of systemic endocrine disruption.

• When brain tumors affect the cranial nerves, leading to a wide variety of symptoms that have great value in the study of localization: the base lesions of the anterior fossa cause anosmia (cranial nerve I).
• paraselares neoplasms affecting the nerve and chiasm produce characteristic patterns of loss of vision. The optic nerve compression monoocular usually cause loss of vision, while compression of the chiasm is associated with a bitemporal hemianopsia.
• Lesions involving the cavernous sinus producing paralysis of cranial nerves that pass through it (III, IV, V and VI). Tumors posterior fossa may lead to facial anesthesia (par V), facial weakness (even Vll), hearing impairment (VIII pair) and difficulty swallowing (cranial nerves IX, X).

• Finally, brain tumors can cause a partial or generalized seizure activity. In fact, the recent convulsions in an adult should be considered secondary to space occupying lesion until proven otherwise. Although seizure activity may occur in the context of any structural abnormality supratentorial (neoplastic or not), its association with brain tumors is usually caused by prolonged compression or irritation of the brain tissue immediately adjacent to the tumor. Epileptogenic capacity as compressed or infiltrated brain is a phenomenon that develops over time, seizures of long duration usually indicate tumor biological evolution.


OVERVIEW OF TREATMENT OPTIONS

treatment of brain tumors in adults:
• There are treatments for all patients with brain tumors. Using three kinds of treatment: surgery

• • radiotherapy • chemotherapy

• Surgery is the most common treatment for brain tumors in adults.
• To remove the cancer brain, will cut a section of skull bone to reach the brain, craniotomy. After the bone is put back in place or put a piece of metal or cloth to cover the opening in the skull.
• Radiation therapy is the use of X-rays produced by a linear accelerator or cobalt machine and its purpose is to eliminate cancer cells from the outside and shrink tumors (EBRT). Radiation therapy can also be used by putting materials that produce radiation in the tumor (radioisotopes) to kill cancer cells from the inside (internal radiation therapy).
• Chemotherapy the use of drugs to kill cancer cells.
• Clinical trials are ongoing with biological therapy to treat the body that fight cancer. In this therapy uses materials made by the body or made in a laboratory to boost, direct or restore the body's natural defenses against disease. Biological therapy is also known as therapy biological response modifier or immunotherapy.

Surgery
• Surgical removal is the most important initial therapeutic approach in virtually all primary brain tumors. Fulfills three essential and immediate objectives: NEstablece

histological diagnosis quickly nAlivia intracranial pressure and mass effect, thus improving neurological function
nLogra cancer cytoreduction may prolong life, improve the effectiveness and safety of adjunctive treatments such as radiotherapy, or both things.
• The technological and conceptual advances of neurosurgery are continuous and have allowed the design of safer and more effective forms of treatment. Tumors previously considered inaccessible, such as those located in deep regions can be addressed safely using a surgical microscope, microinstrumentación and microsurgery.
• Son Few intracranial tumors beyond the direct surgical access achieved by the current neurosurgical technology, laser, ultrasonic aspirators, ultrasounds, stereotactic surgery procedures and neuronavigation.

• In the majority of benign extra-axial lesions (meningiomas and acoustic neuromas), the goal of surgery is complete removal with healing potential. In these cases, the challenge is to remove the tumor as completely as possible, while reducing surgical trauma to adjacent nerve structures. This can be achieved, especially with the use of monitoring techniques electrofisiológica intraoperatoria, que pueden alertar al cirujano acerca del riesgo que corren las estructuras nerviosas vulnerables durante la extirpación del tumor.
•En los tumores malignos infiltrantes intraaxiales, de origen glial en su mayoría, la cirugía permite llegar al diagnóstico histológico y constituye una medida de control temporal, pues reduce el efecto de masa y la PIC. Debido a su naturaleza localmente agresiva, los tumores cerebrales malignos no son susceptibles de curación en la actualidad y su control requiere acudir a estrategias multimodales. Aunque existe cierta discusión sobre cuál debe ser la misión de la cirugía agresiva en el tratamiento de estas lesiones, la mayor parte de los neuro-oncólogos agree that the "debulking" and elimination of tumor surgical goals are reasonable, provided that we achieve without causing neurological deficits.
• Morbidity and mortality of cranial operations have decreased dramatically in recent decades. Mortality rates at 30 days after the extirpation of brain tumors are generally less than 3% in recent series. The rate of complications depends on the nature of the tumor and its location. Severe complications (bleeding at the site of surgery, infection and permanent neurological damage) together, affect < 10% de los pacientes.

Corticosteroids and cerebral edema
• By mechanisms not yet clarified, it is common for brain tumors, both benign and malignant, causing vasogenic edema in the peritumoral brain tissue. Sometimes can be massive brain swelling, which contributes significantly to the overall mass and accelerated neurological deficits clinically all caused by the tumor itself.
• Corticosteroids have become an important therapeutic role antiiflamatorios agents capable of rapid and effective reduction of peritumoral edema. The fact that these agents may occur often on their own, immediate and dramatic improvement of the state clinical and neurological function, frames the pathophysiological contribution of cerebral edema secondary to the overall deterioration of neoplasia.
• In general, steroids are administered in the perioperative period and their doses are reduced gradually after the removal of the tumor. Also serve a palliative function in patients with progressive and recurrent malignant tumors, where they can enhance residual neurological function, at least temporarily. Radiotherapy


• It has demonstrated the efficacy of radiotherapy in the majority of malignant brain tumors. Once the pathologic diagnosis de neoplasia maligna encefálica y realizada la máxima extirpación quirúrgica, lo habitual es que la radioterapia esté indicada. Aunque las distintas entidades histológicas muestran diferencias individuales en cuanto a su sensibilidad a la radiación, la mejoría de la supervivencia a corto plazo (1-5 años) que se consigue con ella hace incuestionable su uso en la mayoría de los tumores del SNC. El principal factor limitante de sus efectos a largo plazo es el nivel de las dosis de radiación tumoricida, que suele superar los umbrales de tolerancia del SNC. Incluso cuando se prescriben dosis de radiación situadas dentro de los niveles de tolerancia establecidos (40-60 Gy), el encéfalo es vulnerable a distintos efectos toxic.
• Acute reactions that occur during or immediately after radiation, are the result of acute brain swelling and is manifested by increased neurological deficits. Fortunately, these reactions respond well to steroids and generally are reversible, from 1 to 3 months after radiation syndrome usually appears similar but delayed, also reversible with steroids. Brain's reaction less common but more serious and irreversible, is known as radiation necrosis, which can appear months or years after radiation therapy. It is a progressive brain reaction presumably due to direct toxicity to the brain and its microvasculature.

• Affected patients suffer from an insidious and progressive deterioration, focal neurologic signs and dementia. Radiation necrosis may be difficult to distinguish from tumor recurrence, and both show the clinical and imaging characteristics similar. In these circumstances, treatment may include steroids or rescue decompressive intervention. However, many patients are often in terminal stages of their disease, so the most appropriate treatment is, in most cases, conservative and palliative.
• As the survival of patients with CNS tumors is prolonged, additional complications appear different long-term radiation aroused increasing concern. These include hypopituitarism, occlusive disease of the arteries and radiation-induced oncogenesis. The radiation-associated tumors (meningiomas, sarcomas and gliomas) are a rare late complication that usually occurs decades after cranial radiation. More worrisome are the risks of radiation in young children, such as learning disorders, pituitary insufficiency, the myelopathy and spinal deformities, in addition to the adverse effects mentioned above. As a CNS myelination usually completed towards the 2 to 3 years of age, radiation therapy prior to these dates is especially dangerous and generally should be avoided. Chemotherapy


• Despite periodic episodes cause short-term optimism, chemotherapy has not yet produced significant impact on the treatment of malignant brain tumors. Virtually all anticancer agents available for treatment of hematologic malignancies and systemic also have been studied in brain tumors. Except for some recent successes in certain childhood tumors such as germinoma and medulloblastoma, the therapeutic modality has not provided consistent benefit to most patients. • In purely
cancer, brain tumors, with highly localized position, relatively small tumor mass and metastatic nature should respond well to chemotherapy, however, these factors are offset by the peculiar complexity of the CNS, hamatoencefálica barrier which severely limit access to most antitumor agents. Although farmacolofisiológica integrity of this barrier is altered in varying degrees among different brain tumors, the penetration of most chemotherapeutic agents remains limited.
• However, a small number of non-polar soluble compounds and low molecular weight able to freely cross the blood brain barrier intact. These include the nitrosoureas, the hydroxyureas and diazoquinona (AZQ).
• Access from other less permeable agents (methotrexate, vincristine, cisplatin) can sometimes be facilitated by breaking the osmotic blood-brain barrier, or by intrathecal and intraarterial administration. Of these six agents, the nitrosoureas and hydroxyureas are the best studied. In a recent analysis of prospective randomized studies conducted in the last decade, has shown that chemotherapy given after surgery and radiation for malignant gliomas, provides a modest increase in survival.
• The average survival rate at 24 months was 23.4% in the group receiving chemotherapy and 15.9% in those treated with surgery and radiotherapy. However, this gain is small but statistically significant, it can often be masked by other variables such as age and functional status at the time that expresses the tumor.

Other adjunctive treatments

• Almost without exception, virtually all patients with malignant brain tumors eventually develop local recurrence, although the treatment has been aggressive and multimodal (surgery, radiotherapy and chemotherapy). In the last decade has significantly defined adjuvant strategies to control local tumor growth, among which are alternative methods of administration of radiation and immunotherapy. Of these, interstitial brachytherapy and stereotactic radiosurgery are gradually gaining acceptance, although immunotherapy also get some minor results in certain patients. All these modalities are options that can be offered.

CRANIOTOMY:

• Definition: Surgery is performed to treat brain injuries and its surrounding structures through an incision in the skull (craniotomy).

Description:
• The scalp is partially shaved, cleaned and prepared for surgery, an incision through the scalp and the skull is punctured. While doing brain surgery involves removing a portion of cranial bone (usually temporarily) which is then replaced and secured in place.

Directions:
• The brain surgery may be needed to treat: brain tumors

• • bleeding (hemorrhage) or blood clots (Hematomas) from injuries (subdural or epidural hematomas)
• weakness of blood vessels (cerebral aneurysms)
• arteriovenous malformations (AVM, abnormal blood vessels)
• damage to the lining of the brain (dura)
• accumulations infection in the brain (brain abscesses)
• severe facial neuralgia or pain (such as trigeminal neuralgia or tic douloureux)
• head injury and skull fracture repair

Risks:
• The risks for any procedure with anesthesia are:
•
drug reactions • problems respiratory
• The risks for any surgery are: bleeding

• • •
infections Additional risks of brain surgery are:
• cerebral tissue injury
• blood vessel damage
• paralysis or muscle weakness or nervous
• loss of mental functions (memory, speech, understanding)
Expectations after surgery
• The results depend largely on the underlying disease being treated, the patient's general health, the extent of the procedure and surgical techniques employed. Convalescence


• Recovery time ranges from 1 to 4 weeks and full recovery can take up to 8 weeks.
• Brain (brain) is located inside the skull, which is formed by a series of bones. The skull protects and supports the brain.

• Brain surgery is performed to treat: brain tumors

• • Bleeding (hemorrhage) or blood clots from injuries (subdural hematoma or epidural)
• Weakness of blood vessels (cerebral aneurysm)
• Damage to tissues covering the brain (dura)
• pockets of infection in the brain (abscesses brain)
• Severe pain or facial nerve (trigeminal neuralgia or tic douloureux)


• Epilepsy • The craniotomy is a surgical procedure that can enter the brain through the skull. Shaving the scalp for an incision and then make a hole through the skull. He takes a piece of the skull while the brain is operated and is put back before suturing the scalp.
• The results depend on the origin, severity and location of the problem.

herniated nucleus pulposus (HNP)

Alternative Names: Cervical Radiculopathy, Herniated Disk, Herniated Disk intervertebral Radiculopathy lumbar intervertebral disc prolapse, ruptured disc, herniated disc
Definition:
• A herniated disc is a herniated disc or dislocated disk along the spinal cord. The condition occurs when all or part of the soft center of a spinal disk is forced to pass through a weakened part of the disc.

Causes and risk factors:
• The bones of the spine or vertebrae running down the back, connecting the skull to the pelvis. These bones protect nerves that come out of the brain, down the back and then travel from there throughout the body. The spinal vertebrae are separated by discs filled with a soft, gelatinous substance, which provide cushioning to the spine. These disks may herniate (move out of place) or rupture from trauma or strain.
• The spine is divided into several segments: the cervical spine (neck), thoracic spine (part of the back behind the chest), lumbar spine (lower back) and sacral spine (the part connected to the pelvis).
• The Radiculopathy refers to any disease affecting the spinal nerve roots. A herniated disk is one cause of radiculopathy (sciatica).
• Most hernias occur in the bottom back or lumbar spine area. Lumbar disk herniation occurs 15 times more frequently than cervical disc herniation (neck) and is one of the most common causes of back pain. For its part, the cervical discs are affected 8% of cases, while discs of mid-back (thoracic) in only 1 to 2%.
• Nerve roots (large nerves that branch off the spinal cord) may become compressed resulting in neurological symptoms such as sensory or motor changes.
• Disk herniation occurs more frequently in middle-aged men and elderly, especially those involved in physical activities vigorous. Other risk factors include any congenital conditions that affect the size of the lumbar canal.

How does it occur?
• The fissure, protrusion or herniated disc occurs when pressure inside the disc is greater than the resistance of the fibrous. As the fibrous is third thicker in its anterior wall in the back, most of the cracks, protrusions and herniations occur in the latter.
• The typical mechanism consists of the following movement sequence:
• Bending the spine forward: When you do the wheel is more load on the front. When jelly- the nucleus pulposus is compressed against the back wall of the fibrous. • Load weight
important: When do you tend to be compressed a vertebra against the other, increasing the pressure within the disc.
• Extension of the spine with the weight loaded: In doing so, the increased pressure load disc that carries the weight is "squeezing" the nucleus pulposus back harder. If the pressure against the back wall of the fibrous enough, the envelope tears (fissures disk), bulges (prorusión disk) or part (herniated disk).
• A similar effect can be achieved by repeated flexion and extension movements with a smaller load or no load. Each time you generate small impacts against the rear wall of the fibrous.
• These mechanisms occur more readily when the muscles of the back are not very powerful. If they are sufficiently developed, these muscles protect the disc by several mechanisms. Symptoms



HERNIA SYMPTOMS OF LUMBAR DISK severe


• Lumbago • Pain that radiates to the buttocks, legs and feet
• Pain that worsens with coughing, straining, or laughing
• Tingling or numbness in the
legs or feet • muscle weakness or atrophy in stages Advanced • Muscle spasm


CERVICAL DISK HERNIA SYMPTOMS:

• Neck pain, especially in the back and sides
• Deep pain near or over the scapula on the affected side
• Pain radiating to the shoulder, upper arm, forearm, and rarely the hand, fingers or chest
• Worsening pain when coughing, straining, or laughing
• Increased pain when bending the neck or turning head to one side
• Spasm of cervical muscles
• Weak arm muscles


Signs and tests • A physical examination and the history of pain may be sufficient to diagnose a herniated disk. The doctor perform a neurological exam to evaluate muscle reflexes, sensation and muscle strength. Often, examination of the spine revealed a decrease in the curvature of the spine in the affected area.
• leg pain that occurs when a person sits on the exam table and lift your leg straight up usually suggests a herniated lumbar disc.
• "foraminal compression test of Spurling" is done to diagnose cervical radiculopathy. For this test, you will bend your head forward and sideways, while the doctor slight downward pressure applied on the top of the head. In general, increased pain or numbness during this test is indicative of cervical radiculopathy.

DIAGNOSTIC TESTS:

• You can take a spine radiograph to rule out other causes of back or neck pain. However, it is not possible to diagnosis herniated disk by a radiograph of the spine.
• Spine MRI or spine CT will reveal the spinal canal compression by the herniated disc.
• myelogram may be done to determine the size and location of the hernia disc.
• You can take an EMG to determine exactly what the involved nerve root.
• You can also conduct a test of nerve conduction velocity.

Treatment:

• The main treatment for a slipped disc is a short period of rest with pain followed by physical therapy and anti-inflammatory. Over 95% of people who follow these treatments will recover and return to normal activities. A small percentage of people need additional treatment may include steroid injections or surgery.

DRUGS:

• For people with sudden herniated disk caused by some type of trauma (like a car accident or lifting a heavy object), immediately followed by acute back pain and leg pain are prescribed narcotics and anti-inflammatory drugs (NSAIDs .)
• If the patient has back spasms, muscle relaxants are usually given, and on rare occasions, steroids may be given either by pill or directly into the bloodstream through an intravenous (IV).
• NSAIDs are used to control prolonged pain, but narcotics may be given if the pain does not respond to anti-inflammatory drugs.

LIFESTYLE CHANGES:

• Any extra weight being carried by an individual, especially in the top front of the abdomen, worsen any back pain. Exercise and diet are crucial to improving back pain in overweight patients.
• Physical therapy is important for nearly everyone with disk disease. The therapists provide advice on how to properly lift, walk, dress and perform other activities. They will also work on strengthening the muscles of the abdomen and lower back to help support the spine. The flexibility of the spine and legs is taught in many programs therapeutic.
• Some recommend the use of braces (brace) for the back to help support the spine. However, overuse of these devices can weaken the abdominal muscles and back, causing a worsening of the problem. Special Belts for weight lifting can be helpful in preventing injuries in those whose work involves heavy lifting.

SURGERY:

• For the few patients whose symptoms persist despite the above interventions, surgery may be a good choice.
• discectomy is a procedure that requires general anesthesia to remove a protruding disc. The hospital stay is 2 to 3 days. The patient is encouraged to walk the first day after surgery to reduce the risk deTVP.
• Full recovery takes several weeks. If it is necessary to remove more than one disk, or if other problems in the back besides a herniated disk, may be required more extensive surgery, which may require a recovery period much longer.
• Other surgical options include microdiscectomy, a procedure removing fragments of nucleated disk through a very small incision.
• Chemonucleolysis involves the injection of an enzyme (called chymopapain) into the herniated disk to dissolve the protruding gelatinous substance. This procedure may be an alternative to diskectomy in certain situations.

Expectations (prognosis):

• Most people improve with conservative treatment and only a small percentage continues to suffer from chronic back pain even after treatment.
• It may take several months to a year or more for the patient can resume all activities without pain or tightness in the back. It is possible that people with certain occupations that involve heavy lifting or straining your back have to change job activities to prevent recurrent back injury.


Complications • Chronic back pain
• Permanent injury to the spinal cord (rare)
-loss of movement or sensation in the feet or legs
-loss of function of the bladder and bowel Prevention


• Safe practices at work and play, the proper techniques for lifting and weight control can help prevent back injuries in some people.

HYDROCEPHALUS:

• SPACE Cerebrospinal Fluid
• Cerebrospinal fluid normally circulates through the ventricular system, which encloses the inner space and the subarachnoid space, outer space, through the holes of Luschka and Magendie. The fluid is produced by the choroid plexus and partly reabsorbed by the villi of Pacchioni. In adults, usually amounting to about 150 ml, of which about a quarter are located in the ventricular system. Normally produce and reabsorb about 20 milliliters per hour, about 500 ml per day.

CONCEPT AND METHODS OF HYDROCEPHALUS
• Hydrocephalus is essentially a pathological increase of cerebrospinal fluid which especially in children leads to increased brain volume and head. Dilation of the ventricular system causes a pressure atrophy. The atrophy may be so strong that the brain walls are reduced to a millimeter thick. • distinguish
pathogenetic communicating hydrocephalus and noncommunicating.
• In the first form the liquid flows freely through the internal and external spaces. This is an increase in fluid reabsorption by decreasing or overproduction. The most common form is the first condition. This is caused by blockage of the hairs usually Pacchioni fibrosis. The fibrosis may be a sequel to meningitis or meningeal hemorrhage. Hydrocephalus caused by overproduction is rare and may occur in cases of choroid plexus papilloma.
• In noncommunicating hydrocephalus there is a blockage in the flow of fluid located between the sites of production and resorption. The most common site is in the aqueduct, where the obstruction can be caused by a malformation with branching and stenosis, and inflammation or tumors. Less commonly the blockage is in the holes of Luschka and Magendie, caused by fibrosis as a consequence of inflammation or bleeding.

• Causes of hydrocephalus:

• There are many causes within the most frequent are: tumors that obstruct the normal circulation, bleeding, head trauma, infections (meningitis), stroke in certain areas, hematoma, parasitic diseases in the nervous system (such as neuro-cysticercosis ), some obstructions and congenital malformations of the nervous system (brain and spinal or vertebral column). There are also called primary hydrocephalus, where there is no clear causal for the genesis of hydrocephalus.

Symptoms:

• The symptoms usually are due to increased pressure inside the skull or intracranial hypertension due to abnormal accumulation of cerebrospinal fluid. These consist of severe headache and increasing (more commonly in the morning), vomiting, impaired consciousness (drowsiness, somnolence), changes in vision and the gaze, difficulty walking, impaired breathing, among others. In the long term, untreated hydrocephalus can time serious intellectual sequelae in patients, especially children (delays).
• In young children, when the skull has not closed yet, you can see an abnormal increase in head size and a protrusion at the level of Fontanellas or soft spots. Symptoms, especially in hydrocephalus acute patient can lead to coma and even death without appropriate treatment.

• Acute Hydrocephalus
• hydrocephalus is a type of violent onset that quickly leads to a syndrome of intracranial hypertension and can cause death if not resolved. The patient moves from normal to eat quickly, and there is usually a history of trauma, bleeding, stroke, an infection of the nervous system, brain tumors that have complicated and others. This table often occurs in patients previously operated for hydrocephalus in which the fluid diverter valve that is installed can be covered or dysfunction.

• What normo-tensive hydrocephalus or hydrocephalus in adults?

• A special type of hydrocephalus where the pressure of cerebrospinal fluid is normal or slightly increased (hence the name), which usually occurs in older adults with impaired fluid absorption is not caused by disease specific (primary) and it causes very characteristic symptoms: impaired consciousness (memory and other skills), a particular imbalance in walking and loss of sphincter control. This triad (3 symptoms) feature can occur in elderly patients for many other reasons (dementia, Alzheimer's, Parkinson's disease, genital prolapse, multiple strokes, etc.) so that the diagnosis of this type of hydrocephalus is particularly difficult and requires a careful medical assessment, special tests and testing times serial therapeutic lumbar punctures.

Diagnosis:
is diagnosed based on a rigorous assessment specialist with the support of imaging tests like magnetic resonance scanner, which will increase the size of the cerebral ventricles. In the case of normo-tensive hydrocephalus are also requested a special study of the circulation fluid called radio-isotope cisternography, where a measurable isotope is introduced into the cerebrospinal fluid to determine its absorption.
• In the case of a patient previously operated and suspected a malfunction of the valve, but that is not fully clarified by the initial images and when it is not an absolute emergency, you may also do a valvulografía where determine a possible obstruction of the valve and the latter's position.

Treatment:

• When hydrocephalus diagnosed with certainty, the procedures are designed to remove excess fluid puts pressure in the nervous system. For this there are drainage systems (internal and external) and neuro-endoscopy.
• Internal systems are valves that can be ventriculo-peritoneal (the most often used to draw fluid from the cerebral ventricles to the peritoneum in the abdomen where it is reabsorbed) ventriculo-atrial (from the ventricles into a cavity of the heart, reserved for special cases); valves lumbo-peritoneal (from fluid in the lumbar region into the peritoneum in the abdomen), among the most used. Systems operate at different pressures and pressure valves Adjustable to be used depending on the case.
• The external drainage of cerebrospinal fluid are temporary and serve to pass an emergency where the cause of hydrocephalus is not supposed to be permanent, or when an infection can not be for some time to install a valve definitive risk of contamination. These systems are introduced into the ventricles and fluid accumulates in a reservoir bag or sterile. In some cases the catheter can drain the fluid from the area of \u200b\u200bthe spine to an external reservoir (in some cases of communicating hydrocephalus).
• The neuro-endoscopy is a breakthrough in the treatment of hydrocephalus type non-communicating or obstructive. This procedure makes a small hole in the base of the brain that produces a by-pass bridge that bypasses the site of the blockage in certain types of hydrocephalus. This allows not stop valves. However, you can only put this procedure in a group of patients, usually in pediatric patients.


Forecast and possible sequelae of hydrocephalus
• This is very variable and depends heavily on other diseases of the patient, such as hydrocephalus and early diagnosis and treatment. If the cause of hydrocephalus manages to be treated, and it is managed and compensated hydrocephalus, evolution can be successful and you can choose to optimal quality of life. A patient with a bypass valve can perform a completely normal life. The most common complications of these valves are possible infections and obstructions

• Cerebrospinal fluid (CSF) bathes the brain and spinal cord. The highest concentration of this fluid is located in the ventricles of the brain, which are large cavities that produce and reabsorb the CSF.

• In cases of hydrocephalus, the ventricles of the brain increase in size the effect of cerebrospinal fluid. This causes the brain tissue is compressed against the skull and cause serious neurological problems, so it is necessary to place a shunt, also called ventriculoperitoneal shunt to drain excess fluid and relieve pressure on the brain. This procedure should be performed as soon as hydrocephalus is diagnosed, to offer the child the best neurological perspectives.
• A flap is cut in the scalp to drill a small hole in the skull, while the patient is in the operating room under general anesthesia.
• A small catheter is inserted into one of the ventricles of the brain and you connect a pump to keep the fluid away from the brain. Another catheter is connected to the pump and placed in a tunnel (under the skin) behind the ear, that goes down the neck and chest. The catheter should reach the peritoneal cavity or abdominal cavity, where the fluid is absorbed.

• Often, ventricular peritoneal shunt is crucial to prevent and avoid serious brain damage in children with hydrocephalus. Common problems associated with ventriculo peritoneal include the same malfunction and shunt infection.
• However, when there is no problem, they often leave the derivation for many years.

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Neurosurgical emergency venous access

Quite often the management of patients in the ED requires the establishment of intravenous access for acute resuscitation, hydration, pain control, patient monitoring, blood transfusion and blood sample collection. Although there are various techniques for achieving these objectives, the inclusion of a peripheral venous catheter is the first choice, being a simple, fast and with minimal complications for the patient when performed by staff with a good level of training and skill . This guide explains broadly the use of peripheral venous catheter and briefly describes other techniques para el acceso venoso.

Catéteres venosos centrales: es un procedimiento programado, que requiere estabilidad del paciente, tiempo y condiciones más exigentes en la técnica aséptica, por lo tanto, su inserción en urgencias no resulta práctica.
Sin embargo, la enfermera debe conocer su manejo, puesto que cuando el paciente llega a urgencias con el catéter instaurado está indicado su uso y no la inserción de un catéter venoso periférico.

Infusión intraósea: se utiliza para la administración de líquidos y medicamentos en niños menores de ocho años cuando los intentos por obtener un acceso venoso no han tenido éxito and in front of a revival.
is a temporary measure and should be replaced by venous access as soon as possible. The puncture is performed with spinal needle with stylet or Ga 16-18 gauge hypodermic needle attached to a syringe in the anteromedial aspect of proximal tibia. This procedure is contraindicated in patients over eight years, split, bone disorders and use of toxic drugs for the bone marrow. This procedure must be performed by a physician.

Venodiseción: is addressing a vein through the incision of the skin, subcutaneous tissue and direct insertion of a catheter into the vein. Is indicated in situations in which it was impossible for percutaneous puncture. Its use is increasingly restricted, as reports indicate an increased incidence of infections due to tissue manipulation, requires trained personnel, equipment and longer dissection surgery. It is performed most often in children.
In patients with multiple trauma site of choice is a saphenous vein at ankle level, making the front and cut 2 cm above the medial malleolus and tibial. Followed by the median basilic vein in the antecubital region, 2.5 cm lateral to the medial epicondyle of humerus in flexion crease elbow. In urgent cases we recommend dissection of the vein more easily identified, however, certain factors may influence this election, an example is the external jugular vein, easily accessible by very superficial, but the result is unsightly.

peripheral venous catheter: the use of peripheral intravenous catheters in patients with ED is a high frequency.
Like any invasive procedure has risks and complications, including phlebitis and thrombosis, in some cases altering the patient's progress and prolong hospital stay with a corresponding increase in the cost of care.
The progress in the last twenty years has been marked by introducing materials that cause less local reaction, reduce bacterial colonization and marked reduction in the caliber of the peripheral cannula. Despite the progress made has not been able to establish a protocol for management of peripheral venous catheters to provide security in reducing complications when placing a peripheral catheter, the only thing that is certain is that strict application of aseptic technique performing the procedure reduces complications. Other measures, such as placement of gauze versus transparent dressings, catheter periodic change and cure 24 hours after insertion, not ensure the absence of phlebitis and reactions at the insertion site. It all depends on the duration of intravenous therapy, the patient's activity level, skin conditions and the number of insertions already performed. INDICATIONS


• Fluid and electrolytes.
• Administration of intravenous medications.
• Transfusion of blood and its derivatives.
• Collection of blood samples.
• Maintain intravenous permeble emergency.
• Performing diagnostic studies.

PROCEDURE

1. Explain to the patient the procedure.

2. Patient's location so that the tip remains in a firm, flat surface.

3. Hand washing and placement of clean gloves.

4. Puncture site selection: assessing size, condition of the vein, the presence of twists and bruises, an indication of the catheter.

5. Tourniquet application: to feel and see the veins. Do not stress too much, since blood flow is obstructed, it can be seen to feel the pulse.

6. If an elder or a child to apply the tourniquet too soft, or use your fingers like this otherwise you may damage the vein at the time of needle insertion.

7. Palpation of the vein, use the index and middle fingers of the nondominant hand to feel the vein, they have greater sensitivity than the dominant hand, a healthy vein is palpable soft, supple, durable and without a pulse. Palpation is the technique of greater value if you can see, locate and define the path of the vein catheter insertion will be successful. If not feel or see the vein attempt the following operations: placing a warm compress along arm or insertion site 10 minutes before tourniquet application, perform massage in the direction of blood flow and indicate the patient to open and close the hand.

8. Skin preparation with antiseptic solution may be alcohol 70% to 10% povidone iodine or 2%. Rub the insertion site of the center to the periphery for a period of 60 seconds and let the solution sit for two minutes, after which the excess is removed. Do not use alcohol after applying iodine solution because it prevents the residual antiseptic activity of iodine.

9. Fixing the vein, without contact with the area ready for puncture, using the index finger and thumb of the nondominant hand stretching the skin.

10. puncture technique: direct the needle at an angle of 10-30 ° with the bevel up to penetrate the skin, then reduce the angle to avoid crossing the posterior wall of the vein. To obtain blood return to the chamber of the needle, the tourniquet is removed and the catheter is advanced and simultaneously withdrawn the guide wire, is occluded for a moment the flow pressure with the thumb on the vein at the site of locates the catheter tip, and discarded once the needle into a provided for this purpose.

11. Connect the equipment with the solution to be infused or adapter (plug heparinized) and adjust the infusion rate at an appropriate pace.

12. For the introduction of a catheter with the catheter cap is washed with 1 mL of saline haparinizada (100 IU / mL).

13. Check that the liquid flows freely, cover with dressing and secure the catheter.

14. Venipuncture mark the date, time and size of the catheter. Mark infusion to date.

15. Register in history the procedure, complications and patient response.

16. Assessed at least once per shift the site of venipuncture and the solutions are infused.

17. Make healing insertion site every 48 hours, or sooner if the dressing gets wet or in poor condition.

18. Change venipuncture every 72 hours, or sooner if there is pain, cold, pale skin, redness or swelling at the puncture site.

19. Explain to the patient's signs and symptoms of phlebitis and extravasation to timely report his presence.

RECOMMENDATIONS SET

- The health professional must have extensive knowledge of the procedure and its aim to select the type of catheter and vein to be used.

- Use the catheter shorter and smaller gauge that fits the prescribed treatment and select the vein that matches the size and length of the catheter.

- Use small-bore catheters and length for the administration of antibiotics and fluid maintenance.

- For blood, a catheter 18 gauge or higher Ga.

- If a patient receives Irritating drugs using 24-22 gauge catheter Ga and place in a large vein to facilitate the hemodilution and reduce irritation of the vein.

- A venipuncture in the hand is suitable for small-caliber catheters such as Ga 22 and 24, larger-caliber catheters are indicated in the forearm and arm.

- The cephalic vein, intermediate cephalic or basilica are ideal.

- Avoid if possible place the catheter in the dominant arm.

- Avoiding the following sites flexion (bending the wrist or elbow) to reduce risk of extravasation. If necessary, apply a restraint.

- Do not try to puncture a vein more than twice because of lack of experience, state of the patient or vein. Seek help from another person.

- Do not use a peripheral to the infusion of irritants or hyperosmolar (osmolality greater than 500 mOs / mL) and parenteral nutrition and 50% dextrose.

- Avoid using veins that have submitted phlebitis.

- Avoid puncturing the veins of the arm on the side of a mastectomy or lymph node.

- A general principle is to start from the distal to proximal.

- Do not shave the puncture site; microabrasion occur that increase the risk of infection if it is necessary to cut hair.

- Do not palpate the insertion site after cleaning the skin with antiseptic solution.

- Do not choose a sclerotic vein, which seems to feel it a string and moves with ease.

- Avoid a vein painful, swollen or near areas of extravasation or phlebitis.

- No choice veins in areas of sensitivity disorders, since the patient did not show alterations early.

- No members paretic perform venipuncture.

- Do not use lower-limb veins for the high risk of thrombophlebitis.

- Avoid puncturing the veins of the anterior aspect of the wrist, because the risk of nerve and tendon injury during the procedure or infused fluid extravasation.
not puncture the skin sites where there is injury (fungi, abrasions, etc.).. COMPLICATIONS

• Phlebitis: involves inflammation of a vein due to an alteration endothelium. Platelets migrate to the injured area and around the tip of the catheter begins the formation of a thrombus. Platelet aggregation causes histamine release, increasing blood flow by vasodilation in the area. The signosy characteristic symptoms are: mild pain, redness of the area or the venous route, local heat, to feel the vein has the appearance of lace, fever may occur. Its incidence is 30-35%. Phlebitis are presented for three types of causes: bacterial, chemical and mechanical.
Phlebitis is presented bacterial microorganisms in the solution, equipment contamination during insertion, technical deficiency Aseptic (hand washing and skin preparation) and absence or poor placement of the dressing. Chemical phlebitis caused by irritation of the vein by acids, alkalines or hypertonic. Mechanical phlebitis associated with slow infusion, inadequate fixation of the catheter insertion site (flex zones, tortuosity of the vein) catheter size larger than the size of the vein and the vein punctured injury.
The following drugs or groups have been identified as causative agents of phlebitis: antibiotics (63% of cases), antivirals, anticonvulsants (phenytoin, phenobarbital), benzodiazepines (diazepam and midazolam), adrenergic (dobutamine, dopamine, norepinephrine), local anesthetics (lidocaine), antiarrhythmics (amiodarone), calcium antagonists (nimodipine), antiulcer (omeprazole) and electrolyte solutions (potassium).

Prevention of phlebitis: identification and control of risk factors are the basis for prevention. There should be a guide to peripheral venous catheter insertion and monitoring program of the catheters to verify compliance with defined estánderes and early identification of complications.
chemical phlebitis is prevented by the use of veins with good venous flow to facilitate hemodilution, diluting the drug in 30-60 mL of solution and infused into a time of 30-60 minutes.

• Extravasation: is the infusion of fluid outside the blood vessel in the tissue surrounding the vein. Signs and symptoms include pain, local erythema, burning sensation and absence of venous return. Then formed a blister that turns into ulcer damage to cells caused by drug extravasation.
is important to prevent this complication, for irreversible tissue damage, which depends on the characteristics of the liquid: hyperosmolar solutions (calcium, potassium and glucose), diagnostic agents, adrenergic (adrenaline, dopamine, dobutamine and noradrenaline) irritant solutions at basic pH (phenytoin, sodium bicarbonate, acetazolamide, acyclovir, and thiopental) and others (amphotericin, diazepam, diazoxide , doxapram, phenobarbital, gamciclovir, methocarbamol, sodium nitroprusside, pentamidine, promethazine, rifampin, tetracycline and vancomycin).
knowledge of drugs capable of irritant or vesicant allows accurate selection of venipuncture site (ideally in the forearm and to prevent lower limb veins of the wrist and back of the hand, small vessel diameter, enlarged or sclerotic).
Management General measures consist of extravasation stop infusion, aspirate 5 mL of blood, administer 5-10 ml of solvent, remove the catheter, mark the edges of the affected area, elevate the limb and monitor progress.
Specific measures include physical means (heat to promote drainage of the drug or cold when an antidote is injected locally) pharmacological measures by the administration of antidotes for topical or systemic and surgical treatment.