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Characterization of hyperkalemic periodic paralysis: a survey of genetically diagnosed individuals cheap hydrochlorothiazide 12.5 mg on line hypertension quality measures. Muscle channelopathies: recent advances in genetics generic 25mg hydrochlorothiazide with mastercard prehypertension weight loss, pathophysiology cheap hydrochlorothiazide 12.5 mg overnight delivery blood pressure essential oils, and therapy best hydrochlorothiazide 12.5 mg hypertension guidelines 2013. Pathophysiologic and anesthetic considerations for patients with myotonia congenita or periodic paralyses. Feasibility of full and rapid neuromuscular blockade recovery with sugammadex in myasthenia patients undergoing surgery—a series of 117 cases. A standardized protocol for the perioperative management of myasthenia gravis patients: experience with 110 patients. Lambert-Eaton myasthenic syndrome: from clinical characteristics to therapeutic strategies. Autoimmune inflammatory neuropathies: updates in pathogenesis, diagnosis, and treatment. Cardiac arrest after succinylcholine in a pregnant patient recovered from Guillain-Barre syndrome. Hypo and hypersensitivity to vecuronium in a patient with Guillain-Barre syndrome. Multiple sclerosis: current and emerging disease- 1611 modifying therapies and treatment strategies. Increased risk of dementia in people with previous exposure to general anesthesia. Anaesthesia for deep brain stimulation and in patients with implanted neurostimulator devices. Malignant hyperthermia deaths related to inadequate temperature monitoring, 2007–2012: a report from the North American malignant hyperthermia registry of the malignant hyperthermia association of the United States. Comparison of the therapeutic effectiveness of a dantrolene sodium solution and a novel nanocrystalline suspension of dantrolene sodium in malignant hyperthermia normal and susceptible pigs. Activated charcoal effectively removes inhaled anesthetics from modern anesthesia machines. Severe neurologic manifestations in acute intermittent porphyria developed after spine surgery under general anesthesia. Cardiac arrhythmias following anesthesia induction in infantile-onset Pompe disease: A case series. Regional anesthetic techniques are an alternative to general anesthesia for infants with Pompe’s disease. Noncardiogenic pulmonary edema and rhabdomyolysis after protamine administration in a patient with unrecognized McArdle’s disease. McArdle’s disease (glycogen storage disease type V) and anesthesia-a case report and review of the literature. Hepatic glycogen synthase deficiency: an infrequently recognized cause of ketotic hypoglycemia. A retrospective audit of anesthetic techniques and complications in children with mucopolysaccharidoses. Perioperative complications in patients diagnosed with mucopolysaccharidosis and the impact of enzyme replacement followed by hematopoietic stem cell transplantation at early age. Perioperative course and intraoperative temperatures in patients with osteogenesis imperfecta. Laparoscopic splenectomy in patients with hereditary spherocytosis: Report on 12 consecutive cases. Pediatric pulmonary hypertension: Guidelines from the American Heart Association and American Thoracic Society. Fetal hemoglobin reactivation and cell engineering in the treatment of sickle cell anemia. Spinal versus general anesthesia for cesarean section in patients with sickle cell anemia. Sudden death from cord compression associated with atlantoaxial instability in rheumatoid arthritis: A case report. Treating skin and lung fibrosis in systemic sclerosis: A future filled with promise? The role of regional and neuroaxial anesthesia in patients with systemic sclerosis. Ventricular dysfunction and aortic root dilation in patients with recessive dystrophic epidermolysis bullosa. Cardiac surgery in a patients with pemphigus vulgaris: anesthetic and surgical considerations. To test for leaks, the circle system is pressurized to 30-cm water pressure, and the circle system airway pressure gauge is observed (static test). To check for appropriate flow to rule out obstructions and faulty valves, the ventilator and a test lung (breathing bag) are used (dynamic test). In addition, the manual/bag circuit must be actuated by compressing the reservoir bag, in order to rule out obstructions to flow in the manual/bag mode. Delivery of a hypoxic mixture may still result from (1) the wrong supply gas, either in the cylinder or in the main pipeline; (2) a defective or broken safety device; (3) leaks downstream from the safety devices; (4) inert gas administration (e. The backup oxygen cylinder must be turned on (since the tank valve should always be turned off when not in use), and the wall/pipeline supply sources must be disconnected. Carbon monoxide may be produced when volatile anesthetics are utilized, particularly with desiccated absorbents. These, in combination with the oxygen- or nitrous oxide–enriched environment of the circle system, have produced very high temperatures and fires within the breathing system. This is because a breathing system disconnection would be obvious since the ascending bellows would not refill/rise during exhalation. Contemporary machines with descending bellows, however, have been carefully redesigned to address the initial limitations. The newer workstations have fresh-gas decouplers or peak-inspiratory pressure limiters that were designed to prevent these complications. However, if the reservoir bag has a large leak or is absent altogether, patient awareness under anesthesia and delivery of a lower-than-expected oxygen concentration could occur due to entrainment of room air. The anesthesia machine is, conceptually, a pump for delivering medical gases and inhalation agents to the patient’s lungs. The function of the anesthesia machine is to (1) receive gases from the central supply and cylinders, (2) meter them and add anesthetic vapors, and finally, (3) deliver them to the patient breathing circuit. The machine has evolved over the past 160 years1 from a rather simple ether inhaler to a complex device of valves, pistons, vaporizers, monitors, and electronic circuitry. The “pump” in the modern anesthesia machine is either a mechanical ventilator or the lungs of the spontaneously breathing patient, or perhaps, a combination of the two. The anesthesia pump has a supply system: medical gases from either a pipeline supply or a gas cylinder, alongside vaporizers delivering potent inhaled anesthetic agents that are mixed with the medical gases. The anesthesia pump also has an exhaust system, the waste gas scavenging system, which removes excess gases from the patient’s breathing circuit.
Such a weapon should be relatively easy to produce purchase hydrochlorothiazide 25mg with amex blood pressure chart elderly, inexpensive generic hydrochlorothiazide 12.5 mg fast delivery prehypertension home remedies, highly infectious hydrochlorothiazide 12.5mg free shipping pulse pressure 73, and contagious buy hydrochlorothiazide 25 mg amex arrhythmia questions, resulting in widespread morbidity and mortality. To be effective, there should be little or no natural immunity, which is currently the case with diseases such as smallpox for which we no 4246 longer routinely vaccinate individuals, except in the military and in high-risk public health areas. Category A includes weapons that are highly contagious, that are associated with a high mortality rate, and that have all the characteristics of a relatively ideal weapon of mass destruction. Table 59-4 Biologic Agents Used for Warfare Smallpox The last case of naturally occurring smallpox in the world was reported in 1977 in Somalia. In 1978, two laboratory workers were infected with the28 disease in the United Kingdom. Terrorists might consider using smallpox as a weapon because an increasing number of people no longer carry immunity. Routine vaccination for smallpox is no longer performed, except in the military and for some public health-care workers considered at high risk of contracting the disease (individuals whom the government would rely on to staff vaccination stations if there were a breakout). Forty to eighty percent of patients exposed to the smallpox virus28 will become infected with the disease. Smallpox is highly infective, requiring only 10 to 100 organisms to infect an individual. The mortality rate is approximately 30% in unvaccinated patients and as high as 50% if smallpox occurs in communities that have no native immunity against smallpox. The protective effect of the smallpox vaccine decreases with time, but even at 20 4247 years, the vaccine would provide some protection. When an unvaccinated person is initially infected, she or he develops a prodrome of malaise, headache, and backache, with the onset of fever to as high as 40˚C. This progression is in contradistinction to chickenpox, in which the rash develops at the same time as the fever. Unlike chickenpox, smallpox has a predilection for the distal extremities and face, though no part of the body is spared. Also, all lesions in a patient with smallpox are at the same stage, whereas with chickenpox, lesions are at multiple different stages: papules, vesicles, pustules, and scabs. Most cases of smallpox are transmitted through aerosolized droplets that are inhaled, but clothes and blankets that have come in contact with pustules, until the scab falls off, are infectious; the organism can be transmitted in these linens. It is transmitted human to human, and if used as a bioterrorism agent, would likely be dispersed by aerosols in the environment with the hope that multiple humans would be infected and would transmit the virus to other humans. With the collapse of the Soviet Union, there was a concern that some stores of smallpox made it into rogue countries that may have developed their own biologic weapons. Though only 1% of patients who survive smallpox become blind, it accounted for one-third of all cases of blindness in Europe. Such patients are readily identified because of the presence of smallpox lesions on the face. Patients were quarantined and all their contacts were vaccinated, because there was a 3- to 7-day window with the naturally occurring virus before the patient developed symptoms and signs of smallpox. The vaccine is made from a live vaccinia virus developed in calf lymph, but is not an attenuated smallpox virus itself. There are stockpiles of vaccines placed strategically throughout the United States just for such an event. A bifurcated needle is dipped into the reconstituted vaccine and then 10 to 15 points of entry are made into the dermis of the upper deltoid. Because of the side effects of smallpox vaccinations, people with immunologic disorders, eczema (active or with a history of severe eczema), and pregnant or nursing women should not receive the vaccine. Many obstacles have been overcome to develop second- and third- generation smallpox vaccines. Before 2001, the vaccine that was used, Dryvax (similar to what Jenner used in the 18th century), contained live attenuated virus and was the reason that immunocompromised individuals developed adverse events when vaccinated. Anthrax Bacillus anthracis (anthrax) was probably used as a biologic weapon in the Middle Ages, when troops laying siege to a town would catapult infected animal carcasses over the ramparts into the inhabited areas. For reasons discussed later, this method was not a particularly effective method of infecting the native population. During the twentieth century, several countries, including the United States, Great Britain, Russia, and Iraq, studied ways to “weaponize” anthrax. Inhalation anthrax, which was relatively uncommon32 in the past, has an 80% fatality rate. One of the letters that was mailed in the anthrax attacks of 2001 contained 2 g of weapons-grade anthrax. In a terrorist attack, for maximum effect, anthrax could be aerosolized and sprayed from airplanes or delivered through a dispersion device mounted on top of a missile. The attacks on North America in 2001 and the accidental release of spores at a biologic facility in the city of Sverdlovsk in the former Soviet Union in 1979 are illustrative of the potential of anthrax as a weapon. In the United States, 5 of 11 cases resulted in death (45% mortality rate); in the former Soviet Union, 66 of 77 died (86% mortality rate). Fortunately, they used a nonpathogenic strain of anthrax and so there were no casualties. As demonstrated in 200132 in the United States, terrorists are sophisticated enough that they might be successful in obtaining and releasing weapons-grade anthrax. Such attacks, even if detected early, would create mass hysteria and greatly affect the34 entire country and world. The disease is all but gone from North America, but is still prevalent in many developing countries, and herbivores, especially cattle, usually die within 24 to 48 hours of contracting the disease. The carcass has such a large number of organisms, that humans, who are relatively resistant to infection, can be exposed and contract the disease. From a public health perspective, inhalation anthrax is most concerning, as it usually affects 2,000 to 20,000 people worldwide per annum. People can be exposed through contact with animals in an agricultural or industrial setting (i. It manifests as an influenza-like disease with fever, myalgias, malaise, and a nonproductive cough with or without chest pain. The most notable finding on physical examination and laboratory testing is a widened mediastinum. Usually when a patient develops profound dyspnea, death ensues within 1 to 2 days. In the past, penicillin G was the treatment of choice, but since weaponized anthrax has been engineered to be resistant to penicillin G, ciprofloxacin or doxycycline is more commonly used. A more recent study concluded that this drug regimen is the best strategy for managing a small-scale attack, as 4250 occurred in 2001. The first documented use of plague as a biologic weapon was in40 1346 when the Tartars in their siege of the fortress at Kaffa catapulted infected corpses into the city. The plague was used by Unit 731 to infect27 large areas of China, and as many as 200,000 Chinese may have died. Surprisingly, the organism is only viable for approximately 60 minutes after being distributed; if dispersed by an airplane, its viability would limit its infectivity for only 10 km from the dispersion site. Rodents and fleas are its natural hosts, and they re-infect each other by fleas biting infected rodents.
When all the implants have been seated buy 25 mg hydrochlorothiazide visa heart attack 5 days collections, the degree of angulation and the tilt (just anterior to the foramina angulated purchase hydrochlorothiazide 25mg on line blood pressure 60100, multiunit abutments are placed on the implants (Figure and loop of the nerve) purchase 25 mg hydrochlorothiazide with visa arrhythmia associates. The surgeon must be sure the distal portion of the osteotomy is These abutment angulations are chosen to ensure that the pros- relieved adequately to accommodate the angled abutments hydrochlorothiazide 25 mg low cost blood pressure numbers what do they mean. After closure the The mucoperiosteal fap should be carefully closed to assure that soft tissue must be in a position that allows the impression the tissue is well adapted to the copings and abutments. It may copings to be engaged by the impression material or scanning be necessary to tack the fap down with transosseous sutures, if device or camera. B, A bone reduction guide is used to assure that adequate alveoloplasty has been achieved before implants are placed. C, Vertical dimension of occlusion is used as a reference point for ade- quate alveolar bone reduction. D, All on 4 surgical guide is used to assist the surgeon in establishing the desired posterior angulation of the implant and the buccal-lingual inclination. Note that the screw access is adjusted to allow paralleling of the posterior abutments with the straight anterior abutments. Since the introduction of the frst barrier membranes 8 studies have examined the healing mechanisms and pattern in the early 1980s, research in the feld of guided bone of alveolar ridge resorption after a tooth is extracted. Barrier membranes play a key role in successful dogs and determined that there were seven distinct phases. Teir biocompatibility, ability to main- Clafn,2 the frst to report on dogs and humans, noted tain space, occlusivity, and manageability dictate bone regen- that healing was slower in humans than in dogs. Resorbable barriers can be phologic changes taking place after tooth extraction on made of natural or synthetic materials, such as collagen, poly- duplicate study casts; they concluded that the buccal plate glycolide, and polylactic acid. During the 1990s, guided bone regeneration 4 frmed in a histologic study by Araujo and Lindhe. Te term was proven to be a successful and viable technique for ridge 5 10-12 socket preservation, attributed to Cohen, involves the place- augmentation. Autogenous bone, allografts, xenografts, allo- number of materials have been studied for this purpose, and plasts, and growth factors have been used alone or in combi- they have shown comparable results. To date, the data are insufcient to prove the socket means to maintain the socket intact, as a cavity. An ideal graft Te term socket augmentation best describes the goal of the material should remain in place to provide a scafold for bone procedure, which is to fll a cavity by generating new bone. If the defect Indications for the Use of the Procedure is horizontal, it may lead to thread exposure, dehiscence, or fenestration. Ideally, the residual ridge width should be no Changes in alveolar ridge dimensions occur in well-defned less than 6 mm for a 4-mm diameter implant. If not corrected, these alterations can lead to unfa- is vertical, it may lead to placement of shorter implants than vorable functional and esthetic results. Te healing mechanisms after injury (in this for stability of the blood clot and provides a scafolding for case, ridge augmentation procedures) are very similar from new bone formation. Te diference is in the individual’s ability socket occurs even if the site is grafted, because the bundle to heal. Age, certain systemic diseases, medications, social bone present in the crest and inner portion of the socket is habits, and oral hygiene habits play key roles in the indi- 4 resorbed and replaced by woven bone. Clinicians should consider these factors before recommending treatment for their patients. Guided Bone Regeneration for Vertical and Socket augmentation does not prevent remodeling after Horizontal Defects tooth extraction, but it may minimize it. An adequate zone of keratinized mucosa and association with dental implant procedures, can be used to tension-free closure of the fap margins minimize or prevent augment defcient alveolar ridges, to cover implant fenestra- wound dehiscence. In some instances, it in residual osseous defects and postextraction sites, and to may be necessary to improve the quality and quantity of soft treat peri-implant disease. If needed, an elevator can After administration of a local anesthetic, the tooth should be be used to further luxate the tooth. For maxillary anterior periotome can be used to carefully luxate the tooth (Figure 20-1, teeth, apical pressure and careful rotation allow for successful A). The periotome should be used only in the interproximal spaces, extraction, maintaining an intact buccal plate. A gentle but frm rocking move- been removed, the socket should be cleared of any remaining ment in the buccal-lingual direction should be applied to widen granulation tissue with an excavator and thorough irrigation. Care must be taken not to crush the material because The selection of the graft material is at the surgeon’s discretion. A fgure-eight 4-0 chromic gut suture is placed to secure A resorbable cellulose or collagen plug can be used as a dressing the graft and dressing (Figure 20-1, B). Similarly, blood supply plays Before surgery, careful consideration should be given to the a key role in wound healing and should be taken into consider- fap design. For that purpose, a trapezoid-shaped fap with a wide base eration in ridge augmentation procedures is primary closure. Next, elevation of the fap begins with a Woodson is carried out in a sulcular fashion, extending to at least one elevator at the crest and mesial and distal line angles, followed adjacent tooth on either side of the defect or to the distal end in by release of the periosteum with a periosteal elevator. Vertical releasing incisions are made at should be taken not to damage adjacent vessels or nerves or the mesial-buccal and distal-buccal line angles or at the distal the fap itself. Next, a #701 fssure bur can be used to create vascular Providing vascular channels from the recipient bed is the key to channels. The distribution of these channels should provide the ensuring an adequate fow of nutrients to the graft. Again, care should be taken scraping instrument can be used to decorticate the recipient bed not to damage adjacent teeth, vessels, or nerves or the fap itself and collect autogenous shavings that can be mixed with the graft (Figure 20-2, B). The graft material should be mildly con- The graft should be delivered in small quantities to allow for densed; however, as mentioned, care must be taken to avoid appropriate placement and to prevent extrusion of any graft par- crushing the particles because this may alter their properties ticles into the fap. The membrane should be trimmed so that it adapts to pins used depends on the size and design of the membrane. Larger the recipient bed, and the surgeon must make sure the edges do membranes may require three to fve pins, whereas two or three not come in contact with the vertical releasing incisions. Vertical releasing incisions can be closed with single wound dehiscence and infection. For this purpose, periosteal interrupted or continuous locking 5-0 chromic sutures. Small- releasing incisions can be made, taking into account adjacent caliber sutures in the unattached mucosa can help with postopera- vessels or nerves. A B C D Figure 20-2 A, Midcrestal and papilla-sparing incisions with ver- tical releases extending to the vestibule. D, Two resorbable membranes have been secured with fxation pins to contain the graft material. E, Closure is obtained with 4-0 Vicryl sutures in a horizontal mattress E fashion and 4-0 and 5-0 interrupted chromic sutures. Te same principles described in steps 1, 2, and 3 can be applied for this modifcation. For vertical regeneration, a tenting efect is required to provide space for new bone formation; this prevents the membrane from collapsing due to the pressure exerted by the soft tissue. Tis can be achieved either by the implant itself (providing supracrestal placement for a tenting efect) or by tenting screws (Figure 20-3).
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Urine electrolyte analysis is not discriminative hydrochlorothiazide 25 mg discount prehypertension bp range, as urine sodium is high in both disorders buy 25 mg hydrochlorothiazide visa hypertension with ckd, particularly in association with intravenous saline administration generic hydrochlorothiazide 12.5 mg fast delivery arteria spinalis anterior. Nearly 90% of strokes can be54 attributed to an ischemic mechanism such as atherosclerosis buy hydrochlorothiazide 12.5 mg free shipping hypertension of the eye, thrombosis, cardio-embolism, or hypotension. Unusual causes of stroke such as carotid artery dissection, hypercoagulation syndromes, or infective endocarditis should be considered in younger patients without apparent risk factors. Transient ischemic attacks may precede stroke and should be considered as a warning sign. The prognosis after stroke varies depending on the size and location of the lesion. In patients with acute ischemic stroke, the duration of coma appears to be the most important predictor of outcome and successful therapy. Rapid clot lysis and restoration of circulation via systemic thrombolysis limits the extent of brain injury and improves outcome after thrombotic stroke. In general, heparin is only recommended for early secondary prophylaxis in patients with suspected cardiac embolism. Aspirin 325 mg has been shown to reduce the risk of early recurrent ischemic stroke. It is recommended within 24 to 48 hours of stroke onset in most patients, but it does increase the risk of hemorrhagic stroke. The frequency of deep venous thrombosis in acute stroke is reduced by anticoagulants (e. The majority of patients with acute ischemic stroke present with severe arterial hypertension. However, severe hypertension (blood pressure >220/120 mmHg) should be controlled because of increased risk of hemorrhagic transformation; a lower threshold is indicated after alteplase administration (blood pressure >185/110). Steroids are of no value in the treatment of ischemic stroke, and although some have advocated therapeutic hypothermia, there is insufficient evidence to recommend this approach in stroke outside of research settings. Hyperglycemia is also associated with poor outcome in ischemic stroke, and it is recommended to monitor and maintain blood glucose within the range of 140 to 180 mg/dL. Randomized trials demonstrate that hemicraniectomy improves survival in this setting. Case series suggest that suboccipital craniectomy can be life-saving in this situation, and that patients can recover with acceptable functional outcomes. Of patients who survive their initial cardiac arrest, in- hospital mortality ranges from approximately 50% to 90%, and a high percentage of survivors suffer brain injury with significant long-term disability. The pathophysiology of anoxic brain injury is multifactorial, and includes excitatory neurotransmitter release, accumulation of intracellular calcium, and oxygen free radical generation. Unfortunately, pharmacologic therapies aimed at several of these pathways, including barbiturates, benzodiazepines, corticosteroids, calcium channel antagonists, and free radical scavengers have failed to improve the outcome of anoxic brain injury. Based largely on two small, single-center randomized trials published in 2002 that showed outcome benefits, mild therapeutic hypothermia (target temperature 33°C) has been widely applied to unconscious patients who survive initial resuscitation from cardiac arrest due to ventricular fibrillation or tachycardia. However, a much larger, multicenter randomized trial60 published in 2013 found no benefit to targeting a temperature of 33°C compared to 36°C. Based on this study, therapeutic hypothermia can no61 longer be recommended as routine therapy after cardiac arrest. Strict fever control with a target temperature of 36°C appears to result in similar outcomes. Cardiovascular and Hemodynamic Aspects of Critical Care Types of Shock One of the most common and urgent requirements for critical care is the presence of shock. Shock is a state characterized by tissue oxygen delivery that is inadequate to meet demand. Often this is associated with circulatory instability and severe systemic hypotension. Shock states are commonly classified according to the primary cause of circulatory failure. Obstructive shock, as the name suggests, is characterized by an obstruction to forward flow such as may happen with a tension pneumothorax, pericardial tamponade, or pulmonary embolism. Shock of all kinds is highly morbid and despite extensive research and aggressive management, the mortality from shock remains staggeringly high. Approximately 35% to 40% of patients die within 28 days of the onset of septic shock, and the mortality rate is 70% to 80% for patients with cardiogenic shock. The mortality from hypovolemic shock is highly variable and depends upon the etiology and the rapidity of recognition and treatment. Mortality from septic shock may be improving, as evidenced by the fact that control-group mortality in sepsis trials has decreased from 46% to approximately 20% between 2001 and 2014,62 63–65 although this may reflect broader screening and inclusion of less sick patients than in past trials. Cardiogenic and septic shock are discussed in more detail in the following section, whereas the causes and treatment of hypovolemic and obstructive shock are discussed in Chapters 39 and 53. The pathophysiologic characteristics include a reduction in contractility, usually accompanied by dilatation of cardiac cavities and venous congestion. Determining the etiology of cardiogenic shock is of utmost importance because the treatment varies considerably based on the underlying mechanism. Consequently, therapy should minimize myocardial oxygen demand and raise oxygen delivery to the ischemic area. This goal is complicated by the fact that many resuscitative approaches to correct hypotension increase myocardial oxygen consumption (e. Synthetic B-type natriuretic peptide (nesiritide) and dopamine agonists such as fenoldopam have similar effects, but have shown inconsistent benefit in large randomized trials and are not recommended for routine management. Septic Shock Septic shock is a form of distributive shock associated with infection and the activation of the systemic inflammatory response. Other noninfectious causes of distributive shock include acute spinal cord injury, pancreatitis, burns, fulminant hepatic failure, multiple traumatic injuries, toxic shock syndrome, anaphylatic and anaphylactoid reactions, and drug or 4102 toxin reactions, including insect bites, transfusion reactions, and heavy metal poisoning. Septic shock is the most common shock syndrome, accounting for roughly two-thirds of shock patients in broad critical care populations. The initiating event in septic shock appears to be the interaction between organism-specific ligands on pathogens and ligand-specific receptors (e. The resulting release of immune mediators sets in motion a complex series of events that results in altered gene expression, T-cell differentiation, complement activation, elaboration of pro-coagulant processes, and the production and release of other immunomodulatory cytokines. A global decrease in cardiac contractility, combined with relative hypovolemia, may reduce oxygen delivery to tissues. Thus, a metabolic acidosis may be present despite normal levels of oxygen transport. A decrease in cellular77 oxygen extraction capacity may result from factors other than hypoperfusion, such as direct cellular damage by toxins and/or mediators or maldistribution of blood flow. The impact of impaired perfusion on organ function depends on individual susceptibility to hypoxia.
