Oral Roberts University. W. Sebastian, MD: "Buy online Atorlip-10 cheap no RX - Safe Atorlip-10 online OTC".
Retroperitoneal approaches require a flank incision and lateral decubitus positioning with flank extension (Fig buy 10 mg atorlip-10 visa cholesterol side effects. This approach has obvious advantages for treatment of infection but also simplifies procedures in those with prior abdominal surgery or obesity cheap atorlip-10 10 mg with visa cholesterol levels ratio canada. Difficulties with the retroperitoneal approach include access to the vena cava generic 10mg atorlip-10 mastercard cholesterol tester, risk of unintentional pneumothorax, and the adverse effects of lateral decubitus position and flank extension on respiratory vital capacity, which can be reduced up to 20% (see Chapter 29). Anterior approaches to nephrectomy involve supine positioning and breach of the peritoneal cavity through midline, subcostal, or thoracoabdominal incisions that provide direct access to both the kidney and major vascular structures. Although transperitoneal approaches add the risk of visceral injury and peritonitis, they improve access to the renal pedicle (e. The thoracoabdominal approach enters both the peritoneal and pleural spaces and rarely may require single-lung ventilation. In recent years, laparoscopic retro- and transperitoneal approaches to nephrectomy have surpassed their open equivalents in popularity, particularly for simple and donor procedures, but these techniques are even being used for nephron-sparing partial nephrectomy. Other recent innovations include robotic-assisted, single-port laparoscopic, and even transvaginal minimally invasive nephrectomies. Preoperative Considerations Recruits for donor nephrectomy surgery are typically healthy individuals; however, perioperative risk for other nephrectomy procedures often relates to the indication for surgery. Hence, protocols for assessment and management of perioperative cardiac risk are particularly relevant to nephrectomy surgery. Elective procedures involve irreversible kidney damage due to chronic pyelonephritis (e. Figure 50-7 Common positioning options for urologic surgery include right lateral decubitus with waist extension (A), lithotomy (B), supine with steep (30 to 45 degrees) Trendelenburg (C), and exaggerated lithotomy (D). Ten to forty percent of patients presenting with renal cancer have associated paraneoplastic syndromes. Renal tumors may also be associated with a hypercoagulable state; sudden intraoperative clot formation has been reported. Urologic surgery patients often present with additional disease workup that can provide a wealth of information beyond routine studies and assessment of their urinary tract. Standard recommended preoperative management of chronic drug therapies is all that is necessary for most nephrectomy procedures, although dose adjustment may be considered if significant changes in renal function are anticipated. Intraoperative Considerations Preparation for even the most straightforward nephrectomy surgery demands sufficient monitoring and vascular access to respond to complications, most notably significant hemorrhage, an uncommon but ever-present risk in such procedures. Although central venous line placement is not essential for most nephrectomy surgeries, patient and procedural factors such as comorbidities (e. If placement of a central venous catheter is deemed necessary, selection of the side ipsilateral to the nephrectomy surgery for subclavian or internal jugular central venous puncture should be considered to minimize the risk of bilateral pneumothorax. Assessment of infection, bony metastases, and bleeding risk may influence the decision to include neuraxial procedures in the anesthesia plan. If a lumbar or thoracic epidural catheter is placed, this is usually done prior to anesthesia induction to allow for a meaningful test dose sequence and to facilitate preincision administration of epidural opiates. Varied opinions regarding intraoperative local anesthetic dosing of the epidural catheter involve concerns over hemodynamic stability and the likelihood of significant blood loss during the procedure. Bladder catheter placement is essential for all nephrectomy procedures; urinary output monitoring provides information on intravascular volume status in the absence of central venous pressure monitoring, avoids the possibility of urinary retention, and also provides valuable information postoperatively regarding renal function, bleeding sources, and the possibility of clot-related urinary tract obstruction. Standard preanesthesia induction considerations include postoperative planning (e. Plans for postoperative analgesia strategy may dictate disposition particularly to involve a care team capable of recognizing and treating potential complications of the various analgesia strategies. Intraoperative and postoperative pain management can be accomplished by intravenous or other opioid therapies such as patient- controlled analgesia or neuraxial analgesia. Continuous epidural analgesia attenuates the neuroendocrine response but may also improve postoperative ventilatory mechanics and resolve ileus sooner, and has been associated with improved survival in intermediate- to high-risk noncardiac surgery. Complications associated with hemorrhage during nephrectomy are uncommon but mandate preparatory steps beyond monitoring and generous intravenous access. Confirmation that blood products are present or readily available should occur immediately prior to surgery. Routine fluid and patient warming technology, availability of colloid volume expanders, and even a rapid transfusion device for selected cases should also be considered. Because unexplained changes in pulmonary mechanics or hypotension during a nephrectomy procedure may reflect diaphragmatic injury and pneumothorax, such changes should be discussed with the surgeon to facilitate prompt intervention. This may require direct repair of a rent in the diaphragm as well as needle decompression of a pneumothorax and chest tube insertion. Particularly in the setting of limited renal reserve, in addition to consideration of transfusion triggers and strict avoidance of unjustifiable blood product administration, a note of caution is warranted regarding the potential for resuscitation “overshoot” in response to acute hemorrhage. Strict attention to appropriate monitors during fluid resuscitation and appropriate use of arterial blood gas assessment, assisted by good communication with the surgeon, will help avoid the risk of pulmonary edema from fluid overload. Postoperative Considerations Up to 20% of patients undergoing nephrectomy develop postoperative complications, and operative mortality rates following radical nephrectomy are as high as 2%. Added to standard concerns, such as hemorrhage and unrecognized visceral injury, are atelectasis, ileus, superficial and deep wound infections, temporary or permanent renal failure, and incisional hernia. The most common radical nephrectomy complications are adjacent organ (4% bowel, spleen, liver, diaphragm, or pancreas) and vascular injury (2%). Overall complication rates are similar whether an open or laparoscopic 3551 approach is used. Analgesia can be achieved with epidural or spinal analgesia strategies, systemic opioids, and nonopioid adjuncts. Recent findings of improved recovery using epidural analgesia for major abdominal surgeries149 have not been assessed specifically for nephrectomy surgery. Specific Procedures Simple and Donor Nephrectomies Simple nephrectomy is sufficient intervention for irreversible nonmalignant disease such as untreatable infection, unsalvageable kidney trauma, or a nonfunctioning kidney due to calculi or hypertensive disease. In up to 86% of patients with hypertension that is presumed to be renovascular in origin with noncorrectable unilateral renal artery disease, hypertension control improves after simple nephrectomy. During donor procedures, several steps are added to simple nephrectomy, including administration of drugs intravenously just prior to explant to achieve low-level anticoagulation (e. Just over one-third of renal transplants in the United States are from living donors, and, compared to cadavers, living kidney donation is associated with improved short- and long-term outcomes (i. Radical Nephrectomy Renal cell carcinoma is the main indication for radical nephrectomy and accounts for 90% to 95% of kidney neoplasms and 3% of all malignancies in adults. With the exception of hereditary syndromes with high tumor rates (see earlier), a positive family history incurs a two- to threefold increased risk of 3552 kidney cancer, but such cases constitute only 2% of radical nephrectomies. Hematuria, a palpable mass, and flank pain compose the classic triad at presentation, but renal tumors are more often (approximately 72%) diagnosed incidentally during workup for other nonurologic problems. Occasionally, tumors are discovered owing to signs or symptoms of vena caval involvement such as dilated abdominal veins, (left) varicocele, lower extremity edema, or pulmonary embolism. Symptomatic tumors usually reflect more advanced disease and are more often associated with metastasis and a poor prognosis. Transitional cell cancers of the upper urothelial tract (ureters, renal pelvis) are also treated by radical nephrectomy with resection of the associated ureter, including a cuff of bladder tissue. Up to one-third of kidney cancer patients have metastases at diagnosis, but many are still candidates for surgery.
Rebreathing can occur if the valves stick in the open position discount atorlip-10 10 mg amex cholesterol hair treatment, and total occlusion of the circuit can occur if they are stuck shut generic 10mg atorlip-10 with mastercard cholesterol levels and stress. If the expiratory valve is stuck in the closed position buy generic atorlip-10 10mg line cholesterol risk ratio calculator canada, breath-stacking and barotrauma or volutrauma can result. Obstructed filters located in the expiratory limb of the circle breathing system have caused increased airway pressures, hemodynamic collapse, and bilateral tension pneumothorax. Causes of circle system obstruction and failure include manufacturing defects, debris, patient secretions, and particulate obstruction from other odd sources such as albuterol nebulization. In one report, cracks in the flow transducer tubing used by this system produced a leak in the circle system that was difficult to detect. Some of these2 undesirable interactions were quite dramatic, such as sevoflurane interacting with desiccated Baralyme, resulting in fires within the breathing system and severe patient injury. Other reactions between agents such as desflurane or sevoflurane and desiccated strong base absorbents can produce more insidious patient morbidity and potentially even death from the release of byproducts such as carbon monoxide or compound A. The canisters can be filled either with loose bulk absorbent or with absorbent supplied by the factory in prefilled plastic disposable cartridges called prepacks. Free granules from bulk absorbent can create a clinically significant leak if they lodge between the clear plastic canister and the O-ring gasket of the absorber, or between other joints in the circuit. By weight, the approximate composition of “high moisture” soda lime is 80% calcium hydroxide, 15% water, 4% sodium hydroxide, and 1% potassium hydroxide (an activator). This addition produces a harder and more stable pellet and thereby reduces dust formation. The efficiency of the soda lime absorption varies inversely with the hardness; therefore, little silicate is used in contemporary soda lime. It consists primarily of calcium2 hydroxide and calcium chloride and contains two setting agents: calcium sulfate and polyvinylpyrrolidone. The absence of these chemicals eliminates the undesirable production of carbon monoxide, the potentially nephrotoxic substance known as compound A, and may reduce or eliminate the possibility of a fire in the breathing circuit. The current size particles represent a compromise between resistance to gas flow and absorptive efficiency. The smaller the granule size, the greater the surface area that is available for absorption. The granular size of soda lime used in clinical practice is between 4 and 8 mesh, a size at which absorptive surface area and resistance to flow are optimized. Mesh size refers to the number of openings per linear inch in a sieve through which the granular particles can pass. Calcium hydroxide accepts the carbonate to form calcium carbonate and sodium (or potassium) hydroxide. The absorptive capacity of calcium hydroxide2 lime is significantly less and has been reported at 10. However, as previously mentioned, absorptive capacity is the product of both available chemical reactivity and physical (granule) availability. As the absorbent granules stack up in the absorber canisters, small passageways inevitably form. Because of this phenomenon, functional absorptive capacity of either soda lime or calcium hydroxide lime may be substantially decreased. This compound is a substituted 1698 triphenylmethane dye with a critical pH of 10. When the absorbent is fresh, the pH exceeds the critical2 pH of the indicator dye, and it exists in its colorless form. This change in color indicates that the absorptive capacity of the material has been consumed. Unfortunately, in some circumstances ethyl violet may not always be a reliable indicator of the functional status of absorbent. For example, prolonged exposure of ethyl violet to fluorescent lights can produce photodeactivation of this dye. Increased spontaneous respiratory rate (requires that no neuromuscular blocking drug be used) 2. Initial increase in blood pressure and heart rate, followed later by a decrease in both 3. Soda lime and Amsorb generally fit this description, but inhaled anesthetics do interact with all absorbents to some extent. During sevoflurane anesthesia, factors apparently leading to an increase in the concentration of compound A include (1) low flow or closed circuit anesthetic techniques; (2) the use of 1699 Baralyme (now no longer available); (3) higher concentrations of sevoflurane in the anesthetic circuit; (4) higher absorbent temperatures; and (5) fresh absorbent. Under certain conditions, this process can produce very high carboxyhemoglobin concentrations, reaching 35% or more. Absence of the reservoir bag facilitates retrograde flow through the circle system (Fig. Several factors appear to increase the production of carbon monoxide and result in increased carboxyhemoglobin levels. Change absorbents regularly (on Monday mornings, since the absorbent may have become desiccated over the weekend) 3. Specifically, this can occur as the result of interactions between the strong-base absorbents (particularly with the now obsolete Baralyme) and the inhaled anesthetic, sevoflurane. When desiccated strong- base absorbents are exposed to sevoflurane, absorber temperatures of several hundred degrees may result from their interaction. The build-up of very high temperatures, the formation of combustible degradation by-products (formaldehyde, methanol, and formic acid), plus the oxygen- or nitrous oxide- enriched environment provide all the substrates necessary for a fire to occur. The indicator2 color change from off-white to violet is permanent and profound, indicating both exhaustion and/or desiccation and eliminating the possibility for unintentional use of expended absorbent. It is supplied on a polymer matrix base and rolled up as a fixed spiral in a cylinder. An advantage is that the2 exhausted absorbent can be recycled by the manufacturer. Table 25-7 Absorbent Comparisons138a Anesthesia Ventilators The ventilator on the modern anesthesia workstation serves as a mechanized substitute for the manual squeezing of the reservoir bag of the circle system, the Bain circuit, or another breathing system. As recently as the late 1980s, anesthesia ventilators were mere adjuncts to the anesthesia machine. Today, in newer anesthesia workstations, they have attained a prominent central role. Classification 1702 Ventilators can be classified according to their power source, drive mechanism, cycling mechanism, and bellows type. Older pneumatic ventilators required only a pneumatic power source to function properly. Drive Mechanism and Circuit Designation Double-circuit ventilators (in which one circuit contains patient gas and the other circuit contains drive gas) are used most commonly in modern anesthesia workstations. In a double-circuit ventilator, a driving force— pressurized gas—compresses a component analogous to the reservoir bag known as the ventilator bellows. Some newer pneumatic anesthesia workstations have the ability for the user to select whether compressed air or oxygen is used as the driving gas. These “piston”-type ventilators use a computer-controlled stepper motor instead of compressed drive gas to actuate gas movement in the 1703 breathing system.
However order atorlip-10 10mg otc cholesterol ratio of 2.9, the actual ﬁgures are expected to be higher than these estimates because (1) the infection can be asymptomatic purchase 10mg atorlip-10 fast delivery cholesterol test canada, particular in men; (2) trichomoniasis is not a reportable disease in United Sates and other countries; and (3) the sensitivities of different diagnostic tests varied between different labora- tories generic atorlip-10 10 mg visa foods to bring cholesterol down, which often have little quality control on these methods. Although direct microscopy examination of vaginal secretion and urine samples remains the most common diagnostic test for this infection, detection of T. The sensitivities of both direct microscopy examination and culture are low, only 40–70% . However, the draw- backs of this assay are the instability of the probe, and the necessity to handle and dispose of radioactive materials. In one primer pair, a 102 bp genomic fragment was ampliﬁed and termed as A6p sequence, which appears highly selective for a broad range of T. Historically, the preferred method for diagnosis of herpes infection was viral isolation in tissue culture followed by type-speciﬁc immunoﬂuorescence detection. The advan- tages of this fully automated assay are that it greatly reduces the turnaround time by reading up to 98 results in 2. By comparing these ﬁngerprints to a database of reference spectra by the use of various algorithms, bacteria can be rapidly identiﬁed . The acquisition time for this technique is only about 10 min for identiﬁcation of Haemophilus spp. Another similar study was also demonstrated 29 Molecular Diagnostics of Sexually Transmitted Diseases 549 in which signiﬁcant interspecies differences between N. Cluster analysis successfully separated mass spectra collected from three groups that corresponded to N. This approach, requiring only one bacterial colony for testing and using a fast and easy measuring protocol, provides a powerful tool for the rapid identiﬁcation of pathogenic Neisseria and can be adopted for other sexually transmitted pathogens . From an epidemiological perspective, accurate delineation of sexual networks and disease transmission patterns within populations can be constructed and understood by molecular typing methods. Automation and miniaturization will be the main future directions in the devel- opment of molecular diagnostics, as many of the available molecular tests are still labor-intensive. For most automated systems, the biggest challenge will remain at the initial sample preparation and processing procedures, even though a few recent developments of molecular detection workstations may be able to provide solutions for this longstanding issue. Highly automated extraction and detection systems are in the development pipeline that will allow small laboratories to perform high- throughput molecular detection. Schmid G (2004) Economic and programmatic aspects of congenital syphilis prevention. Dinc B, Bozdayi G, Biri A et al (2010) Molecular detection of cytomegalovirus, herpes sim- plex virus 2, human papillomavirus 16–18 in Turkish pregnants. Watson M, Lambden P, Clarke I (1991) Genetic diversity and identiﬁcation of human infec- tion by ampliﬁcation of the chlamydial 60-kilodalton cysteine-rich outer membrane protein gene. Soderblom T, Blaxhult A, Fredlund H, Herrmann B (2006) Impact of a genetic variant of Chlamydia trachomatis on national detection rates in Sweden. Catsburg A, van Dommelen L, Smelov V et al (2007) TaqMan assay for Swedish Chlamydia trachomatis variant. Klint M, Hadad R, Christerson L et al (2011) Prevalence trends in Sweden for the new variant of Chlamydia trachomatis. Alexander S, Coelho da Silva F, Manuel R, Varma R, Ison C (2011) Evaluation of strategies for con ﬁ rming Neisseria gonorrhoeae nucleic acid ampliﬁcation tests. Pope V, Fox K, Liu H et al (2005) Molecular subtyping of Treponema pallidum from North and South Carolina. J Clin Microbiol 34(1):49–54 29 Molecular Diagnostics of Sexually Transmitted Diseases 553 57. Dangor Y, Ballard R, da L Exposto F, Fehler G, Miller S, Koornhof H (1990) Accuracy of clinical diagnosis of genital ulcer disease. Chapel T, Brown W, Jeffres C, Stewart J (1977) How reliable is the morphological diagnosis of penile ulcerations? Dylewski J, Hsanze H, Maitha G, Ronald A (1986) Laboratory diagnostics of chancroid: sensitivity of culture medium. Chui L, Albritton W, Paster B, Maclean I, Marusyk R (1993) Development of the polymerase chain reaction for diagnosis of chancroid. Maeda S, Deguchi T, Ishiko H et al (2004) Detection of Mycoplasma genitalium, Mycoplasma hominis , Ureaplasma parvum (biovar 1) and Ureaplasma urealyticum (biovar 2) in patients with non-gonococcal urethritis using polymerase chain reaction-microtiter plate hybridiza- tion. Simms I, Eastick K, Mallinson H et al (2003) Associations between Mycoplasma genitalium , Chlamydia trachomatis and pelvic inﬂammatory disease. Blanchard A, Hamrick W, Duffy L, Baldus K, Cassell G (1993) Use of the polymerase chain reaction for detection of Mycoplasma fermentans and Mycoplasma genitalium in the urogeni- tal tract and amniotic ﬂuid. Bebear C, de Barbeyrac B, Bebear C, Renaudin H, Allery A (1997) New developments in diagnostic and treatment of mycoplasma infections in humans. Mirnejad R, Amirmozafari N, Kazemi B (2011) Simultaneous and rapid differential diagno- sis of Mycoplasma genitalium and Ureaplasma urealyticum based on a polymerase chain reaction-restriction fragment length polymorphism. J Clin Microbiol 42(2):683–692 29 Molecular Diagnostics of Sexually Transmitted Diseases 555 97. Samra Z, Rosenberg S, Madar-Shapiro L (2011) Direct simultaneous detection of 6 sexually transmitted pathogens from clinical specimens by multiplex polymerase chain reaction and auto-capillary electrophoresis. Riley D, Roberts M, Takayama T, Krieger J (1992) Development of a polymerase chain reaction-based diagnosis of Trichomonas vaginalis. Bizzini A, Greub G (2010) Matrix-assisted laser desorption ionization time-of-ﬂight mass spectrometry, a revolution in clinical microbial identiﬁcation. There are approximately nine million new tuberculosis cases and two million deaths reported each year [1, 2]. Its generation time is 15–20 h, so visible growth takes 3–6 weeks on solid media. Kilic (*) Department of Microbiology , Gulhane Military Medical Academy , Ankara 06018 , Turkey e-mail: abkilic@gata. The cell wall confers shape, size, and protection against osmotic pressure, and it probably protects the plasma membrane from deleterious molecules in the cellular environment. The cell wall compo- nents of mycobacteria determine their most prominent feature: staining of the cell wall by carbol fuchsin is resistance to decolorization by acid alcohol (i. Despite the use of decolorizing agents containing ethyl alcohol-hydrochloric acid, carbol fuchsin cannot be readily removed from the cell wall. In the cell wall, the mycolic acids are largely bound to peptidoglycan by phosphodiester bridges and to arabinogalactan by esteriﬁed glycolipid linkages. The agglutination serotype of strain and colony morphology is related to the mycosides [6, 9 ]. Another important cell component of mycobacteria is cord factor (trehalose 6,6¢ -dimycolate) that is thought to correlate with virulence. Cord factor may cause chronic granulomas and inhibits migration of leukocytes [7 ]. Newly acquired tuberculosis infections occur at a frequency of every second in the world. South-East Asia is the second 30 Diagnosis of Mycobacterium tuberculosis 559 most affected region in the world with 3.
For donors who provide both lungs and the heart to a single recipient discount atorlip-10 10mg with amex lipoprotein cholesterol definition, a combined cardiopulmonary surgical extraction is performed cheap atorlip-10 10 mg line cholesterol check. Surgical techniques have been developed to allow three recipients from one thoracic donor: two single- lung transplants and a heart transplant buy 10 mg atorlip-10 otc cholesterol your body makes. The heart is removed first, leaving a18 small cuff of left atrium attached to the lungs. The harvesting team will ask for systemic heparinization just prior to exsanguination and excision. Marginal donors are typically used for patients who do not meet the standard recipient criteria, with advanced age a common reason for alternative listing. Death is defined by cessation of circulation (arterial monitoring showing pulse pressure is zero, or Doppler monitoring showing no flow) and respiration after withdrawal of futile treatment measures. Timing of withdrawal of support is to maximize the function of organs from these donors. Informed consent is required for organ donation and for any preorgan recovery procedures, such as drug administration or vascular cannulation. A plan for the donor’s care should be in place if the patient does not die within the anticipated time frame, and ideally care should be transferred back to the team that knows the patient and family. Predicting death within an hour of withdrawal of support is not an exact science, so evaluation tools to help predict which patients will die within this time frame are useful (Table 52-3). For death to be declared, 3657 circulation and respiration must be absent for a minimum of 2 minutes before the start of organ recovery. The major goal of surgical management during procurement is to limit warm ischemia time (with rapid cooling techniques and minimal in situ dissection). Living donors must be healthy and without significant cardiopulmonary, neurologic, or psychiatric disease; diabetes; obesity; or hypertension. The vast majority of living kidney grafts are retrieved laparoscopically with only a small number of these robotically assisted. A28 recent national study suggests that robotically assisted surgeries are still associated with increased complications over hand-assisted laparoscopic kidney retrieval. Fluid loading overnight before surgery (versus fluid administration starting with surgery) is associated with better creatinine clearance acutely during the procedure, and some suggest a colloid bolus30 just before pneumoperitoneum. Nitrous oxide is32 contraindicated for laparoscopic donor nephrectomy because distended bowel can get in the way of the surgeons. For patient comfort, central venous lines33 (if used) are generally placed after induction of anesthesia. For open nephrectomy, the patient is positioned in the lateral decubitus position with the bed flexed to expose and arch the flank. Donors are generally managed with general anesthesia, but epidural and combined epidural–spinal techniques (supplemented with intravenous propofol) as34 well as general–epidural combined techniques are used. Postoperative pain following donor nephrectomy can be severe, and patient-controlled analgesia is often used. The pain can still be severe enough to limit respiratory effort and mobilization of the patient, however. Furthermore, a survey of 123 donors showed that one-third of them had chronic pain after the open procedure, suggesting postoperative pain management is often not optimal. Fortunately, perioperative mortality is rare but cannot be denied as a possible outcome during preoperative patient discussions. Although left lateral segmentectomy is a big operation, it is generally well tolerated (Fig. Nonetheless, living left lobe donors must be healthy and without a history of or risk for thromboembolic disease. By comparison, donor right hepatectomy needed for adult-to-adult liver transplantation is a major procedure (Fig. The residual liver volume of the donor must be greater than 35% of original volume to prevent “small for size” syndrome in the donor. Because risk for this syndrome is increased in older donors or in patients with cholestatic or hepatocellular disease, including steatosis, adult-38 to-adult living donors should have no liver disease. Serious complication rates are high for right liver donors (up to a third of donors depending on the center), including air embolism, atelectasis, pneumonia, respiratory depression, and biliary tract damage. Most centers do not43 perform living adult-to-adult liver transplants in very ill recipients. Large liver resections may require virtually complete hepatic venous exclusion (cross-clamping of the hepatic pedicle usually without cava clamping). Without the collaterals developed by patients with chronic liver disease, normal donors may experience significant hypotension when the hepatic pedicle is cross clamped. Blood pressure is maintained largely through reflex increases in endogenous vasopressin and norepinephrine levels. If vasopressors are needed, vasopressin and norepinephrine are reasonable choices to enhance normal endogenous reflexes. Isovolemic hemodilution has been reported to reduce allogeneic red cell requirements in major hepatic resections. At experienced centers, blood45 loss is usually less than 1 L, and transfusion requirements are usually not high. Blood salvage is useful, and some centers offer autologous donation programs for donors. A wide variety of general anesthetics are used for liver donors, and epidural analgesia is useful for pain management,46 though patient-controlled analgesia is preferred in some centers because of the potential for perioperative coagulopathy. Abdominal wall catheters placed by the surgeons may be useful for postoperative pain management. Hypophosphatemia (with excessive loss of phosphate in the urine) is common after hepatectomy and should be treated with sodium phosphate49 infusions to maintain phosphate levels of 3. Some living liver donors can experience chronic low platelet counts after hepatectomy. Considerable variability in intestinal absorption, genetic and induced differences in metabolism of these drugs, changing dosage requirements with aging, and idiosyncratic complications all mandate individualization of immunosuppressive regimens. Immunosuppressed patients who are undertreated risk rejection; overimmunosuppression can be toxic, especially to the kidneys. All immunosuppression regimens carry major risks, such as infection, malignancy, and progressive vascular disease. Immunosuppression regimens differ considerably from center to center, and anesthesiologists must communicate with the transplant team to obtain the schedule and dose of immunosuppressive agents for each patient, especially because immunosuppression drug options have expanded. It is51 particularly important to review drug regimens with transplant coordinators when posttransplant patients are scheduled for surgery because the transplant team needs information about peak and trough drug levels that may not be accessible on the hospital record. These include hypertension (often requiring therapy), hyperlipidemia, ischemic vascular disease (including in heart recipients), diabetes, and nephrotoxicity. Cyclosporine causes acute nephropathy, which is usually reversible with drug cessation.