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The following should be regarded as rough guidelines: Your colleagues should be experts in their field They will generally be younger than you purchase dutasteride toronto hair loss cure india, because older colleagues usually don’t have the time Your co-authors should enjoy writing and be good at it dutasteride 0.5mg line hair loss regrowth shampoo. Emphasise the fact that it is an Flying Publisher project and that you could publish the individual chapters on the internet within a few weeks generic 0.5mg dutasteride mastercard hair loss from stress. Discuss the following items: Subject and title of their contribution Length Fee Deadline Word processing software (mostly Word) The most important message to put across to your authors during this discussion is: “You will be No. The authors need to know that they are not working on just any old project, but on an adventure with exciting and successful years ahead. Set a time limit within which you expect a final decision about the candidate’s participation in the project. Those who cannot perform this task themselves should delegate the job to a professional reader. Calculate printing costs and think about whether foundations or sponsors might be interested in taking on part of the edition. Author Books which are not freely available on the internet are like cars without wheels. Doctor As you can see, publishers who take their task seriously and want to be more than just a figurehead have plenty to do. By collaborating on a textbook project you will learn things from which you will benefit for the rest of your lives. If a printing machine is set up and the first 1000 copies have been printed, it costs €3. In fact – as we will see later on – a publisher can only pay his authors an appropriate fee of 25 Euro per page, for example, if he sells more than 1000 copies. Getting the train on the track Book format – Against the light – References – Journalistic handbooks – Styles – Key combinations – Letters to the authors – Kick-off – List of contributors – Bank details The editorial team is complete – lectorship, secretariat, mentor, proofreaders – and the authors of your choice have agreed. The authors need four more things before kick-off: A document into which they can insert their text, A set of instructions for the compilation of the references, Assistance with writing (style and technique), and The starting signal together with the deadline. Document for the texts The authors must not be allowed to write at random, but must write their texts into a template supplied by you. Before you send the template to your authors, you must define the book format, because the maximum width of tables and diagrams depends on this format. Over a glass of red wine in your library, you should decide how high and how wide your book needs to be. In the menu “Apply to” (bottom right in the dialogue window) select “Whole document”. Put the printouts on top of the book that felt so good in your hand and hold it up against the light. Before you send your authors the template for the text, you must prepare two more things. Firstly, instructions for the compilation of the references and secondly, instructions on how to write well. The New England Journal of Medicine, for example, uses the format surname, initial of first name, et al. There are more details in these three lines than most authors can cope with without help: There is no full stop after the initials of first names; several initials are written together. If there are more than 6 authors, the first 3 are named, then comes a comma, followed by “et al” and finished with a full stop. Only the end digits of the last page number, which are necessary for clear identification. Thus, 2423-2429 becomes 2423-9, 134-141 becomes 134-41, 1891-1901 becomes 1891-901. You will save both yourself and your authors a lot of work in the proofreading phase. Assistance with writing Doctors are grateful for assistance with writing, despite A levels, a medical degree and post-doctoral lecture qualification. Style Some suggestions, very general and valid for every subject: The important things come first, the unimportant ones later. Procedure: first, collect material, then sort the facts, and finally structure them. Technique The number of text elements which you require for your textbook is limited. The most important rule is: you must never – and this applies to your authors as well – change typeface or type size via the pop-down menus shown in Fig. Among other things, a style contains information about type size, typeface, and also line spacing between your text and the previous and subsequent text section. If you want to change the style of a paragraph, you just have to position the cursor somewhere in the paragraph. If you want to allocate a style to several paragraphs, you must mark the paragraphs first. The advantage of styles: later, you can alter your entire text in a matter of minutes, simply by changing type size and spacing for the individual styles. The central control station for styles is located under Format -> Style & formatting. Getting the train on the track Working with Word Every doctor who writes thinks he knows his word-processing software. The cursor goes to the beginning or the end of the current screen page respectively. In order to help your authors save time, we have put together a few tips and tricks in the appendix for working effectively with Word. Deadline, Kick-off You have now assembled all the elements for the kick-off of your project. As we already mentioned in the last chapter: good deadlines are clear deadlines of 6 weeks to 4 months. As an exception, 6 months is acceptable, while longer time limits than this can only rarely be justified. Arrange different deadlines with your authors, so that not all chapters arrive at the editorial office at the same time. This will save you unnecessary email correspondence towards the end of the project. Ask your authors to confirm receipt of the letter, and keep an account of this confirmation. Author Anyone who is afraid or knows from experience that he cannot meet a deadline should not become involved in book projects. It is a lesson for life, from which you will profit far above and beyond the book project. If publication on the internet is planned, you can then insist that your text appears on the net within a very short time. There are other things to be done on top of this: Financing Opening and closing credits: Imprint, Foreword, Contents, Index Cover design and text for the back cover Founding a publishing house Setting up a website Negotiations with sponsors Checking the deadline Accepting texts, passing them on to the readers, sending them from there together with questions and comments back to the authors, receiving corrections, sending the text to be proofread.
There are several small facial muscles buy dutasteride 0.5mg without a prescription cure hair loss with gotu kola, one of which is the corrugator supercilii dutasteride 0.5 mg generic hair loss 20 year old female, which is the prime mover of the eyebrows cost of dutasteride hair loss cure dec 2013. These muscles are located inside the eye socket and cannot be seen on any part of the visible eyeball (Figure 11. If you have ever been to a doctor who held up a finger and asked you to follow it up, down, and to both sides, he or she is checking to make sure your eye muscles are acting in a coordinated pattern. Muscles of the Eyes Target Prime Movement Target motion Origin Insertion mover direction Superior Common Moves eyes up and toward (elevates); Superior tendinous ring Superior surface of nose; rotates eyes from 1 Eyeballs medial rectus (ring attaches to eyeball o’clock to 3 o’clock (adducts) optic foramen) Inferior Common Moves eyes down and (depresses); Inferior tendinous ring Inferior surface of toward nose; rotates eyes Eyeballs medial rectus (ring attaches to eyeball from 6 o’clock to 3 o’clock (adducts) optic foramen) Common Moves eyes away from Lateral Lateral tendinous ring Lateral surface of Eyeballs nose (abducts) rectus (ring attaches to eyeball optic foramen) Common Medial Medial tendinous ring Medial surface of Moves eyes toward nose Eyeballs (adducts) rectus (ring attaches to eyeball optic foramen) Surface of eyeball Moves eyes up and away Superior Inferior Floor of orbit between inferior from nose; rotates eyeball Eyeballs (elevates); oblique (maxilla) rectus and lateral from 12 o’clock to 9 o’clock lateral (abducts) rectus Moves eyes down and Suface of eyeball Superior away from nose; rotates Superior between superior Eyeballs (elevates); Sphenoid bone eyeball from 6 o’clock to 9 oblique rectus and lateral lateral (abducts) o’clock rectus Table 11. Muscles involved in chewing must be able to exert enough pressure to bite through and then chew food before it is swallowed (Figure 11. The masseter muscle is the main muscle used for chewing because it elevates the mandible (lower jaw) to close the mouth, and it is assisted by the temporalis muscle, which retracts the mandible. Muscles of the Lower Jaw Target motion Prime Movement Target Origin Insertion direction mover Maxilla arch; zygomatic Closes mouth; aids chewing Mandible Superior (elevates) Masseter Mandible arch (for masseter) Table 11. Muscles That Move the Tongue Although the tongue is obviously important for tasting food, it is also necessary for mastication, deglutition (swallowing), and speech (Figure 11. Extrinsic tongue muscles insert into the tongue from outside origins, and the intrinsic tongue muscles insert into the tongue from origins within it. The extrinsic muscles move the whole tongue in different directions, whereas the intrinsic muscles allow the tongue to change its shape (such as, curling the tongue in a loop or flattening it). The extrinsic muscles all include the word root glossus (glossus = “tongue”), and the muscle names are derived from where the muscle originates. The genioglossus (genio = “chin”) originates on the mandible and allows the tongue to move downward and forward. The palatoglossus originates on the soft palate to elevate the back of the tongue, and the hyoglossus originates on the hyoid bone to move the tongue downward and flatten it. The normal homeostatic controls of the body are put “on hold” so that the patient can be prepped for surgery. Control of respiration must be switched from the patient’s homeostatic control to the control of the anesthesiologist. Among the muscles affected during general anesthesia are those that are necessary for breathing and moving the tongue. Under anesthesia, the tongue can relax and partially or fully block the airway, and the muscles of respiration may not move the diaphragm or chest wall. To avoid possible complications, the safest procedure to use on a patient is called endotracheal intubation. Placing a tube into the trachea allows the doctors to maintain a patient’s (open) airway to the lungs and seal the airway off from the oropharynx. Post-surgery, the anesthesiologist gradually changes the mixture of the gases that keep the patient unconscious, and when the muscles of respiration begin to function, the tube is removed. It still takes about 30 minutes for a patient to wake up, and for breathing muscles to regain control of respiration. Muscles of the Anterior Neck The muscles of the anterior neck assist in deglutition (swallowing) and speech by controlling the positions of the larynx (voice box), and the hyoid bone, a horseshoe-shaped bone that functions as a solid foundation on which the tongue can move. The muscles of the neck are categorized according to their position relative to the hyoid bone (Figure 11. The suprahyoid muscles raise the hyoid bone, the floor of the mouth, and the larynx during deglutition. These include the digastric muscle, which has anterior and posterior bellies that work to elevate the hyoid bone and larynx when one swallows; it also depresses the mandible. The stylohyoid muscle moves the hyoid bone posteriorly, elevating the larynx, and the mylohyoid muscle lifts it and helps press the tongue to the top of the mouth. The strap-like infrahyoid muscles generally depress the hyoid bone and control the position of the larynx. The omohyoid muscle, which has superior and inferior bellies, depresses the hyoid bone in conjunction with the sternohyoid and thyrohyoid muscles. The thyrohyoid muscle also elevates the larynx’s thyroid cartilage, whereas the sternothyroid depresses it to create different tones of voice. Muscles That Move the Head The head, attached to the top of the vertebral column, is balanced, moved, and rotated by the neck muscles (Table 11. This muscle divides the neck into anterior and posterior triangles when viewed from the side (Figure 11. Muscles That Move the Head Target motion Movement Target Prime mover Origin Insertion direction Temporal Rotates and Individually: rotates bone tilts head to the Skull; head to opposite side; Sternocleidomastoid Sternum; clavicle (mastoid side; tilts head vertebrae bilaterally: flexion process); forward occipital bone Individually: laterally Transverse and Rotates and Skull; flexes and rotates articular processes Occipital tilts head Semispinalis capitis vertebrae head to same side; of cervical and bone backward bilaterally: extension thoracic vertebra Temporal Rotates and Individually: laterally Spinous processes bone tilts head to the Skull; flexes and rotates Splenius capitis of cervical and (mastoid side; tilts head vertebrae head to same side; thoracic vertebra process); backward bilaterally: extension occipital bone Table 11. The back muscles stabilize and move the vertebral column, and are grouped according to the lengths and direction of the fascicles. From the sides and the back of the neck, the splenius capitis inserts onto the head region, and the splenius cervicis extends onto the cervical region. The erector spinae group forms the majority of the muscle mass of the back and it is the primary extensor of the vertebral column. It controls flexion, lateral flexion, and rotation of the vertebral column, and maintains the lumbar curve. The erector spinae comprises the iliocostalis (laterally placed) group, the longissimus (intermediately placed) group, and the spinalis (medially placed) group. The iliocostalis group includes the iliocostalis cervicis, associated with the cervical region; the iliocostalis thoracis, associated with the thoracic region; and the iliocostalis lumborum, associated with the lumbar region. The three muscles of the longissimus group are the longissimus capitis, associated with the head region; the longissimus cervicis, associated with the cervical region; and the longissimus thoracis, associated with the thoracic region. The third group, the spinalis group, comprises the spinalis capitis (head region), the spinalis cervicis (cervical region), and the spinalis thoracis (thoracic region). The transversospinales muscles run from the transverse processes to the spinous processes of the vertebrae. Similar to the erector spinae muscles, the semispinalis muscles in this group are named for the areas of the body with which they are associated. The semispinalis muscles include the semispinalis capitis, the semispinalis cervicis, and the semispinalis 464 Chapter 11 | The Muscular System thoracis. Important in the stabilization of the vertebral column is the segmental muscle group, which includes the interspinales and intertransversarii muscles. The scalene muscles include the anterior scalene muscle (anterior to the middle scalene), the middle scalene muscle (the longest, intermediate between the anterior and posterior scalenes), and the posterior scalene muscle (the smallest, posterior to the middle scalene). The muscles of the vertebral column, thorax, and abdominal wall extend, flex, and stabilize different parts of the body’s trunk. The brain sends out electrical impulses to these various muscle groups to control posture by alternate contraction and relaxation. Muscles of the Abdomen There are four pairs of abdominal muscles that cover the anterior and lateral abdominal region and meet at the anterior midline. These muscles of the anterolateral abdominal wall can be divided into four groups: the external obliques, the internal obliques, the transversus abdominis, and the rectus abdominis (Figure 11. On the flanks of the body, medial to the rectus abdominis, the abdominal wall is composed of three layers. The external oblique muscles form the superficial layer, while the internal oblique muscles form the middle layer, and the transverses abdominus forms the deepest layer.
Through the process of saccharolytic fermentation order dutasteride 0.5 mg fast delivery hair loss in men vs women, bacteria break down some of the remaining carbohydrates buy dutasteride 0.5mg low price hair loss cure date. This results in the discharge of hydrogen order cheap dutasteride on line hair loss on lower leg, carbon dioxide, and methane gases that create flatus (gas) in the colon; flatulence is excessive flatus. More is produced when you eat foods such as beans, which are rich in otherwise indigestible sugars and complex carbohydrates like soluble dietary fiber. Absorption, Feces Formation, and Defecation The small intestine absorbs about 90 percent of the water you ingest (either as liquid or within solid food). The large intestine absorbs most of the remaining water, a process that converts the liquid chyme residue into semisolid feces (“stool”). Of every 500 mL (17 ounces) of food residue that enters the cecum each day, about 150 mL (5 ounces) become feces. You help this process by a voluntary procedure called Valsalva’s maneuver, in which you increase intra-abdominal pressure by contracting your diaphragm and abdominal wall muscles, and closing your glottis. The process of defecation begins when mass movements force feces from the colon into the rectum, stretching the rectal wall and provoking the defecation reflex, which eliminates feces from the rectum. It contracts the sigmoid colon and rectum, relaxes the internal anal sphincter, and initially contracts the external anal sphincter. The presence of feces in the anal canal sends a signal to the brain, which gives you the choice of voluntarily opening the external anal sphincter (defecating) or keeping it temporarily closed. If you decide to delay defecation, it takes a few seconds for the reflex contractions to stop and the rectal walls to relax. If defecation is delayed for an extended time, additional water is absorbed, making the feces firmer and potentially leading to constipation. On the other hand, if the waste matter moves too quickly through the intestines, not enough water is absorbed, and diarrhea can result. The number of bowel movements varies greatly between individuals, ranging from two or three per day to three or four per week. Of the three major food classes (carbohydrates, fats, and proteins), which is digested in the mouth, the stomach, and the small intestine? The pancreas produces pancreatic juice, which contains digestive enzymes and bicarbonate ions, and delivers it to the duodenum. In addition to being an accessory digestive organ, it plays a number of roles in metabolism and regulation. The liver lies inferior to the diaphragm in the right upper quadrant of the abdominal cavity and receives protection from the surrounding ribs. In the right lobe, some anatomists also identify an inferior quadrate lobe and a posterior caudate lobe, which are defined by internal features. The liver is connected to the abdominal wall and diaphragm by five peritoneal folds referred to as ligaments. These are the falciform ligament, the coronary ligament, two lateral ligaments, and the ligamentum teres hepatis. The falciform ligament and ligamentum teres hepatis are actually remnants of the umbilical vein, and separate the right and left lobes anteriorly. The porta hepatis (“gate to the liver”) is where the hepatic artery and hepatic portal vein enter the liver. These two vessels, along with the common hepatic duct, run behind the lateral border of the lesser omentum on the way to their destinations. The hepatic portal vein delivers partially deoxygenated blood containing nutrients absorbed from the small intestine and actually supplies more oxygen to the liver than do the much smaller hepatic arteries. After processing the bloodborne nutrients and toxins, the liver releases nutrients needed by other cells back into the blood, which drains into the central vein and then through the hepatic vein to the inferior vena cava. This largely explains why the liver is the most common site for the metastasis of cancers that originate in the alimentary canal. Plates of hepatocytes called hepatic laminae radiate outward from the portal vein in each hepatic lobule. Between adjacent hepatocytes, grooves in the cell membranes provide room for each bile canaliculus (plural = canaliculi). The bile ducts unite to form the larger right and left hepatic ducts, which themselves merge and exit the liver as the common hepatic duct. This duct then joins with the cystic duct from the gallbladder, forming the common bile duct through which bile flows into the small intestine. A hepatic sinusoid is an open, porous blood space formed by fenestrated capillaries from nutrient-rich hepatic portal veins and oxygen-rich hepatic arteries. Hepatocytes are tightly packed around the fenestrated endothelium of these spaces, giving them easy access to the blood. From their central position, hepatocytes process the nutrients, toxins, and waste materials carried by the blood. Other materials including proteins, lipids, and carbohydrates are processed and secreted into the sinusoids or just stored in the cells until called upon. The hepatic sinusoids also contain star-shaped reticuloendothelial cells (Kupffer cells), phagocytes that remove dead red and white blood cells, bacteria, and other foreign material that enter the sinusoids. The portal triad is a distinctive arrangement around the perimeter of hepatic lobules, consisting of three basic structures: a bile duct, a hepatic artery branch, and a hepatic portal vein branch. Thus, before they can be digested in the watery environment of the small intestine, large lipid globules must be broken down into smaller lipid globules, a process called emulsification. Bile is a mixture secreted by the liver to accomplish the emulsification of lipids in the small intestine. The components most critical to emulsification are bile salts and phospholipids, which have a nonpolar (hydrophobic) region as well as a polar (hydrophilic) region. The hydrophobic region interacts with the large lipid molecules, whereas the hydrophilic region interacts with the watery chyme in the intestine. This results in the large lipid globules being pulled apart into many tiny lipid fragments of about 1 µm in diameter. Bile salts act as emulsifying agents, so they are also important for the absorption of digested lipids. While most constituents of bile are eliminated in feces, bile salts are reclaimed by the enterohepatic circulation. Once bile salts reach the ileum, they are absorbed and returned to the liver in the hepatic portal blood. Bilirubin, the main bile pigment, is a waste product produced when the spleen removes old or damaged red blood cells from the circulation. These breakdown products, including proteins, iron, and toxic bilirubin, are transported to the liver via the splenic vein of the hepatic portal system. Bilirubin is eventually transformed by intestinal bacteria into stercobilin, a brown pigment that gives your stool its characteristic color! In some disease states, bile does not enter the intestine, resulting in white (‘acholic’) stool with a high fat content, since virtually no fats are broken down or absorbed. Hepatocytes work non-stop, but bile production increases when fatty chyme enters the duodenum and stimulates the secretion of the gut hormone secretin.
A history of systemic steroid use may require the deliv- ery of a peri-operative course of steroids in order to avoid the consequences of adrenal suppression which may present as an Addisonian crisis cheap dutasteride master card hair loss under arms. Adrenal suppres- sion occurs when a patient receives longterm exoge- nous steroids in daily dose equal to or greater than 10 mg order generic dutasteride on-line hair loss cure youtube. Once adrenal suppression has occurred proven 0.5 mg dutasteride hair loss juice fast, the adre- nal gland takes approximately 3 months to recover function (after steroid discontinuation). Therefore, ster- oid supplementation is required for patients who are currently on exogenous steroids or have discontinued a longterm course in the past three months. The amount and duration of supplemental steroid coverage re- quired depends on the invasiveness of the surgery. For minor surgery, a single dose of hydrocortisone (25 mg) sufﬁces, while for major surgery, the patient requires 100 mg of hydrocortisone daily for 2-3 days. The Anesthetic Machine liver gases to the patient in precise, known con- The anesthetic machine also allows the delivery 2. The evolved substantially over the years, the essential volatile anesthetic gases, such as sevoﬂurane and features have remained remarkably constant. The concentra- tion of the volatile gas in the ﬁnal mixture is de- Gases (oxygen, air and nitrous oxide) come from termined by a dial on or near the vaporizer. For pipelines entering the operating room through safety reasons, only one volatile agent can be de- the wall (Figure 9). Although The ventilator allows positive pressure ventila- 100% oxygen can be delivered to the patient, usu- tion of the anesthetized patient. The ventilator ally a mixture of oxygen (with air or nitrous ox- can be set to deliver a speciﬁc tidal volume (in ide) is selected. The relative concentrations of the which case pressure varies according to lung gases to be delivered are controlled by ﬂowme- compliance) or to achieve a certain peak inspira- tory pressure (in which case volume varies ac- 34 cording to lung compliance). The ventilator moves the Figure 9 Pathway of gas ﬂow in anesthetic machine gas mixture through the common gas outlet and into the anesthetic circuit, the tubing that connects to the pa- tient’s airway. There are several other types of circuits which are useful in speciﬁc clinical situations or are of historical interest. The origin and pathways of gas ﬂow that applies to most anesthetic machines is de- The shaded shapes represent (from left to right): volatile anesthetic va- picted in schematic form in Figure 9. Image by Wikimedia user TwoOneTwo, available under the Creative Commons It is imperative that all anesthesia equipment undergo Attribution-Share Alike 3. It is the responsibility of the anesthesiologist to ensure that the equipment is in functioning condition prior to the administration of every anesthetic. The practice of • pulse oximeter anesthesia involves the use of some key monitors that are not commonly seen in other health care settings. Ex- • apparatus to measure blood pressure amples include the pulse oximeter, the capnograph and • electrocardiography the peripheral nerve stimulator. The Canadian Anesthe- sia Society guidelines for intra-operative monitoring • capnograph when an endotracheal tube or are listed in Table 8. There are methods of invasively monitoring the cardiovascu- lar, renal and central nervous systems in the peri- Monitors which must be exclusively available: operative period. The pharmacology of each of the important drugs used in the delivery of anesthesia can be found in the “Drug Finder” (Chapter 6). However, often it is used in • regional combination with sedation in which case monitor- ing is required. While local anesthesia is inade- • general quate for more invasive procedures such as those The ﬁndings on pre-operative assessment, the na- involving the body cavities, local inﬁltration is ture of the surgery and the patient’s preference often used as an adjunct in post-operative pain all factor into the choice of anesthetic technique. Care must be taken to avoid intra- Contrary to popular belief, studies have failed to vascular injection and to avoid exceeding the identify one technique as superior (lower morbid- toxic dose of the local anesthetic in use. Regardless of the technique em- ployed, the anesthesiologist must ensure patient comfort, maintenance of physiologic homeostasis and provision of adequate operating conditions. Sedation involves the delivery of agents (usually intra- venous) for the purpose of achieving a calm, relaxed pa- Many different agents have been used for sedation. The tient, able to protect his own airway and support his term “neurolept anesthesia” refers to the (now histori- own ventilation. The range of physiologic effects of se- cal) use of high doses of droperidol (a butyrophenone, dation is varied and is dependent on the depth of seda- in the same class as haloperidol) in combination with tion provided: minimal, moderate or deep. Cur- under minimal sedation will be fully responsive to ver- rently, agents are chosen with speciﬁc effects in mind. The short-acting appear calm and relaxed and would have normal car- benzodiazepine, midazolam, is a popular choice be- diorespiratory function. Propo- receiving deep sedation would be rousable only to re- fol, an anesthetic induction agent, can be infused in peated or painful stimuli. In some instances, the patient sub-anesthetic doses to produce a calm, euphoric pa- may require assistance in maintaining a patent airway. Often it is used in combination with local or regional anesthesia to provide a more palatable experience for the patient. Care must be taken to reduce the dose administered to the frail, elderly or debilitated patient, in whom depressant ef- fects may be exaggerated. While regional techniques are perceived to be “safer” than general anesthesia, they do carry risks of their own. The central neuraxial blocks have many potential complications, both early and late, which will be discussed in the next section. There are some patients in whom a regional technique offers at least short term beneﬁts over general anesthe- sia. For example, in those undergoing total hip arthro- plasty, the use of spinal or epidural anesthesia is associ- ated with less intra-operative blood loss, less post- operative hypoxemia and a lower risk of post-operative deep venous thrombosis formation. While it seems in- tuitive that physiologic homeostasis is more readily achieved when regional anesthesia is employed, the an- esthesiologist must always remain vigilant: numerous 42 General Anesthesia General anesthesia is a pharmacologically-induced, re- versible state of unconsciousness. General anesthesia may be used alone or in combination with local anesthe- sia or a regional technique. An example of such a “com- bined technique” would be the use of epidural and gen- eral anesthesia in a patient undergoing an abdominal aortic aneurysm repair. Such a technique allows the con- tinued use of the epidural for post-operative pain man- agement and may confer a lower morbidity and mortal- ity in high risk patients. Brachial Plexus Block monitor and manage the patient’s physiologic status but he or she must ensure that the patient remains calm and cooperative. The anesthesiolo- gist must be alert to the development of complica- tions and must also be prepared to convert to a general anesthetic at any point in the procedure. Understanding the anatomy of the region (Figure 10, Figure 11) is crucial to understanding the blocks. In epidural anesthesia, a tiny plastic catheter is placed into the epidural space, which is the anatomic space lo- cated just superﬁcial to the dura. Epidural catheters placed for surgical anesthesia or an- algesia are most commonly used at the thoracic or lum- bar regions depending on the site of the surgery. From the epidural space, it is slowly absorbed into the subarach- noid space where it blocks the nerves of the spinal cord From “Introduction to Regional Anaesthesia” by D. The volume of anesthetic delivered Figure 12 Insertion of Tuohy needle into epidural and the site of the catheter determine the level or space “height” of the block.