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Inability to Cannulate the Left Superior Vena Cava If a left superior vena cava is present buy divalproex 500 mg fast delivery symptoms 4 days before period, this approach should not be used effective 500 mg divalproex medications prednisone. Preoperative transthoracic echocardiography or an intraoperative transesophageal echocardiogram can usually make this diagnosis 250mg divalproex free shipping medicine 20. One advantage of the lower ministernotomy incision is that it can be easily extended to a full sternotomy divalproex 250 mg with amex keratin treatment, if necessary. Lower Ministernotomy Closure the upper and lower portions of the right side of the sternum are reapproximated with one stainless steel wire placed vertically. Malalignment of Right Side of the Sternum Failure to approximate the upper and lower portions of the divided right hemisternum will result in a bony deformity at the level of the third interspace. Care must be taken to push the upper and lower portions into the same plane before tightening the vertical wire. Distortion of the Superior Aspect of the Incision Tight closure of the muscle layers superiorly will create a dimpling effect. Technique A 6- to 8-cm midline skin incision is made starting approximately 2 to 3 cm below the suprasternal notch. Short flaps of subcutaneous tissue are developed both superiorly and inferiorly to expose the sternum. With a pneumatic or a small oscillating saw, the sternum is divided from the suprasternal notch down to the third or fourth interspace. Injury to Internal Thoracic Artery the retractor blades should be opened carefully to prevent damage to the internal thoracic vessels. Injury to Costal Cartilages the bone cutter should divide the sternal half into the intercostal space and not into the costal cartilages. Skin Injury the upper and lower ends of the skin incision must be protected from saw and traction injuries. The cannula is introduced into the right atrium through a purse-string suture below the right atrial appendage. Minimizing Air in Left Ventricle the usual deairing techniques may not be feasible through this incision (see Chapter 4). At the completion of the procedure, a soft drain is placed in the mediastinum and brought out below the xiphoid process. The upper and lower portions of the right, left, or both sides of the sternum are reapproximated with a wire placed vertically. Submammary Right Thoracotomy This incision is cosmetically very appealing for young girls and women requiring atrial septal defect closure. It may be used for mitral valve surgeries, although access to the ascending aorta for cross-clamping may be difficult. Technique the skin incision is made in the submammary fold of the right breast in an adult or the anticipated future breast fold in a preadolescent girl. This is carried down to the chest wall, and the pectoralis major and pectoralis minor insertions onto the ribs are dissected free up to the fourth interspace. The intercostal muscle is divided just on the upper edge of the 5th rib, and the pleural space is entered. Two single-blade retractors are placed: one between the ribs and the other at a right angle to the first retractor to spread the subcutaneous tissue and muscle. After opening the pericardium, traction sutures can be placed to allow for exposure of the inferior vena cava, superior vena cava, and proximal ascending aorta. A tie around the tip of the right atrial appendage retracted inferiorly aids in cannulation of the superior vena cava and ascending aorta. Inability to Cannulate the Left Superior Vena Cava A left superior vena cava is not accessible from this approach. Difficult Ascending Aortic Cannulation the ascending aorta in older children and adults may be difficult to cannulate through this incision. The use of an arterial cannula with a tapered introducer may allow for safe and controlled aortic cannulation when aortic exposure is suboptimal. Closure of Submammary Right Thoracotomy After placing a chest tube through a small stab wound just lateral to the skin incision. Correct Chest Tube Placement the chest tube should be inserted through an incision just lateral to the skin opening. Placement of the chest tube lower than the submammary line creates an unnecessary scar that is not hidden by the usual two-piece bathing suit or tube top. Intercostal nerve blocks with a long-acting local anesthetic in several interspaces can be administered before chest closure from within the pleural space. The thymic vessels are all electrocoagulated to prevent the formation of a hematoma or troublesome oozing during the operation. The pleura is peeled away from the inferior pericardium with a dry sponge, thereby preventing inadvertent entry into the pleural cavities. The electrocautery blade can be used to incise the pericardium and at the same time coagulate the edges. The pericardium can then be opened in the usual inverted T fashion and suspended from skin edges or the retractor. The blades of the retractor should be placed as low as possible, and the sternum should be opened only to the extent that is essential for adequate exposure. Many surgeons prefer sternal retractors with three to four blades, which can swivel horizontally and thereby lessen the stress on the sternal edges. Dissection Around the Aorta the posterior aspect of the aorta is not always free, and therefore the cross-clamp may not include the entire wall of the aorta. In primary cardiac surgeries, the area between the pulmonary artery and aorta is dissected in a limited manner to allow a large curved or right-angled clamp to be passed behind the aorta. Incorporation of adequate adventitial tissue in closure of the aortotomy or various cannulation sites, including the superior vena cava and pulmonary artery, is a safe and effective technique. The adventitial component is a natural tissue that acts like a reinforcing pledget, adding strength to the closure. Injury to the Aorta During dissection and passing of the clamp behind the aorta, care must be taken to avoid injury to the posterior wall. If such a complication occurs, it is best to control the bleeding digitally or by packing the area while preparations are made to initiate cardiopulmonary bypass. With the patient on bypass and the aorta cross-clamped, the aorta is opened and the posterior wall is repaired under direct vision. Injury to the Right Pulmonary Artery On rare occasions when the right pulmonary artery takes a more caudal course, it may be injured during dissection around the aorta. If such a problem arises, it is best to control the bleeding by packing the area and to correct the lesion when the heart is decompressed on full cardiopulmonary bypass. The right pulmonary artery can also be injured during dissection of the superior vena cava, especially when passing a tape around this vessel. Dissection Around the Cavae Dissection required to pass umbilical tapes around the venae cavae in preparation for total cardiopulmonary bypass may be tedious and occasionally may result in injury to the great veins.

There are no randomized controlled trials and recommendations rely on case reports and retrospective data discount divalproex 500mg amex symptoms thyroid cancer. If steroids are used order divalproex 500 mg fast delivery treatment plan for anxiety, the initial dose of prednisone is 1 mg/kg/d for 1 to 2 weeks followed by a slow taper over 1 to 3 months cheap 500mg divalproex amex treatment research institute, depending on the response divalproex 500mg lowest price treatment 001. A renal biopsy may be helpful not only to aid in diagnosis but also as a means of predicting response to therapy. The majority of these diseases require immunosuppressive therapy with steroids (high- dose intravenous corticosteroids consisting of 250 to 1,000 mg of methylprednisolone per day for 3 days or oral prednisone)in combination with a steroid sparing agent (cyclophosphamide, mycophenolate, or rituximab), and occasionally plasmapheresis. For example, the pauci- immune nephridities include Granulomatosis with polyangiitis and Microscopic polyangiitis both of which are initially treated with pulse steroids combined with either cyclophosphamide or rituximab [86]. Immune complex glomerulonephritides include a host of different diseases which require a variety of different approaches. Some of these diseases do not require renal-specific therapies, such as for postinfectious glomerulonephritis or glomerulonephritis associated with bacterial endocarditis. In the former case, spontaneous remission usually occurs; in the latter, antibiotic treatment of the underlying condition may result in clearing of the immune complex–induced renal lesion. Dopamine at low doses dilates the interlobular arteries, afferent and efferent arterioles resulting in increased renal blood flow. However, a recent, large randomized trial in cardiac surgery patients showed no renal protective effect [16]. Coexisting fever or any other evidence of urinary infection proximal to the obstruction requires a rapid decompression procedure to avoid bacteremic shock. If this is not possible, as is occasionally the case in patients with prostatic enlargement or urethral stricture, urethral dilation or percutaneous cystostomy should be performed. Because of the defects in distal nephron function associated with high- grade obstruction, patients may develop hyperkalemia, hyperchloremic metabolic acidosis, and hypernatremia. Water and bicarbonate replacement are often required and can be administered as a solution of 5% glucose and water to which sodium bicarbonate has been added. Hyperkalemia may respond to the institution of a diuresis that accompanies the relief of the obstruction and as well as correction of the acidosis. As such, this postobstructive diuresis is considered appropriate to the pre-existing volume expansion. In some patients with correction of bilateral obstruction, a large diuresis and natriuresis may ensue, which result in hypovolemia and, sometimes, frank shock. The mechanism for this inappropriate diuresis is poorly understood but may involve release of a natriuretic substance. These patients require fluid replacement, usually with hypotonic saline, to repair the deficit and match urinary losses. A useful technique is to measure the urinary sodium and potassium concentrations periodically to determine the composition of the replacement fluid. However, care must be taken to avoid excessive fluid replacement as this will simply prolong the diuresis. When possible, aminoglycoside antibiotics or other nephrotoxic drugs should be replaced with nonnephrotoxic agents. If this is not feasible, the risk should be minimized by taking prophylactic measures (see previous discussion). In addition, the dosage of drugs dependent on renal metabolism and excretion should be adjusted appropriately. If the dose or dosing interval is unchanged, reduced renal function leads to accumulation of the drug in body fluids and eventual drug toxicity. Phenytoin, independent of its excretion, may reach toxic concentrations because a larger proportion of the administered drug is displaced from albumin-binding sites in uremia. Drug doses need to be altered in most instances to account for residual renal function and the effect of dialysis on drug removal. It is important to remember that as the patient recovers renal function, upward adjustment of the dosage of renally excreted drugs is necessary. The degree of catabolism reflects the level of the patient’s metabolic stress and is, in turn, a function of the severity of the underlying illness. Protein and caloric requirements are much higher for patients with catastrophic illness and multiple organ system failure than for those with mild or moderate illness. Although caloric replacement needs to be adequate to reduce tissue catabolism, prevent ketosis, and meet the patient’s basal nutritional needs, the clinician must avoid providing excessive substrate for generation of metabolic waste products. This is particularly challenging for patients who are not yet being dialyzed; once patients are on dialysis, they are allowed more liberal fluid intake and can receive a greater intake of carbohydrates, protein, and fat, limited only by the rate of dialytic fluid and solute removal. As discussed in Chapters 212 and 214, the need for nutritional support is becoming an indication for renal replacement therapy [91]. Hyperkalemia Hyperkalemia is the most immediately life-threatening electrolyte imbalance encountered in patients with renal disease (see Chapter 199). Urine flow rate is an important determinant of tubular potassium secretion; therefore, oliguric patients are more prone to potassium imbalance than are nonoliguric patients. Metabolic Acidosis the kidneys’ ability to excrete metabolically produced acids may be reduced, particularly in parenchymal and obstructive disease. Indeed, pure tubular acid excretion abnormalities may exist independently of azotemia (renal tubular acidosis). Metabolic acidosis that results from failure of the tubules to excrete hydrogen ions or conserve bicarbonate normally produces a hyperchloremic or low anion gap acidosis (see Chapter 198). Bicarbonate supplementation in the setting of metabolic acidosis remains controversial as there are no studies demonstrating a beneficial effect of this approach. In addition, bicarbonate supplementation may cause volume overload and hypernatremia and may exacerbate hypocalcemia by lowering the ionized calcium level. Abnormal Salt and Water Metabolism Although most fluids administered to patients are hypotonic, plasma osmolality normally remains within tightly fixed limits. The process by which plasma tonicity is preserved depends on the suppression of vasopressin release and the movement of free water in the ascending limb of the loop of Henle. This situation, referred to as nephrogenic diabetes insipidus, is most common in tubulointerstitial disease and in partial obstruction of the urinary tract. High serum phosphorus levels lead to formation of insoluble calcium phosphate salts, which may precipitate in soft tissue. If the product of the serum calcium and phosphorus concentrations exceeds 70, precipitation in soft tissues becomes more likely. Although there is no published data correlating the treatment of hyperphosphatemia with improved outcomes, phosphate binders are typically initiated when phosphate levels rise to more than 6. The main phosphate binders available include calcium salts (calcium acetate and calcium carbonate), sevelamer, and lanthanum hydroxide. Although potent, aluminum- based binders are generally avoided because of concerns with aluminum toxicity. The exact identities of the so-called uremic toxins are not known, although many possibilities have been suggested. One cannot deduce on the basis of urea nitrogen and creatinine levels exactly when a patient will become uremic.

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Antivenom Administration If possible generic 500 mg divalproex visa medications safe for dogs, informed consent should be obtained before antivenom administration generic divalproex 500 mg treatment plant. Epinephrine and endotracheal intubation equipment should be immediately available at the bedside during initial antivenom administration purchase 250 mg divalproex mastercard symptoms 89 nissan pickup pcv valve bad, and a physician should be available to manage any acute adverse drug effects that may develop discount 250 mg divalproex otc medicine used during the civil war. This antiserum contains pooled, purified Fab immunoglobulin fragments from sheep immunized with one of four different pit viper venoms. Although there are no defined end points in terms of time or dosage for when to withhold antivenom, antivenom is beneficial for treating only findings directly related to continued presence of unbound, circulating venom (e. The efficacy of antivenom in preventing local wound necrosis is limited, because it cannot reverse local cellular damage once it has been initiated by rapidly acting venom enzymes and nonenzymatic polypeptides [13]. As children generally receive similar quantities of venom in a bite as adults do, pediatric dosing is the same as for adults. The starting dose is four to six vials for patients with signs or symptoms of systemic toxicity or evidence of progressive local venom effects. In victims with hypotension or severe bleeding, the starting dose should be increased to 8 to 12 vials [14]. Each vial should be reconstituted with 18 to 25 mL of warm sterile water or saline and the vials gently agitated (vigorous shaking of the vials may cause development of foam, resulting in less delivered protective antibody fragments). The total dose to be administered is diluted in 250 mL of normal saline and infused over 1 hour (starting slowly at the onset of infusion and gradually increasing the rate). During the first hour after the dose is completed, the patient is monitored for further progression of local effects and systemic symptoms, and laboratory studies are rechecked. Coagulation studies may not normalize after the initial dose, because time is required for repletion of coagulation factors after venom neutralization, but there should be evidence of improvement [15,16]. Further doses may be needed at the physician’s discretion depending on the patient’s clinical picture. Adverse effects of antivenoms, as heterologous serum products, are divided into three major groups: acute allergic and nonallergic anaphylaxis, and delayed serum sickness. Acute reactions most commonly manifest with urticaria, although bronchospasm, hypotension, and angioedema can also occur [17]. Serum sickness is characterized by pruritus, fever, arthralgias, lymphadenopathy, and malaise, which can occur 1 to 2 weeks after antivenom therapy [18]. The incidence of acute reactions to CroFab is approximately 8%, and serum sickness occurs in approximately 13% of patients [19]. Management of acute reactions centers on rapid diagnosis, temporarily halting the infusion and treating with epinephrine, antihistamines, and steroids (see Chapter 69). Generally, once the reaction is controlled, the antivenom infusion can be restarted, possibly in a more dilute state and at a slower rate. Serum sickness is relatively benign and easily treated with steroids, antihistamines, and nonsteroidal anti-inflammatory drugs until symptoms resolve. Most cases do well with oral prednisone (1 to 2 mg/kg/d) until symptoms resolve, followed by a taper over another week. If organ perfusion fails to respond promptly with crystalloid infusion (1 to 2 L in an adult and 20 to 40 mL per kg in a child), administration of albumin may be considered [1,7]. Although pit viper envenomation can result in significant coagulopathies, the incidence of clinically significant bleeding in the United States is low [20]. Management of coagulopathy in patients with evidence of major bleeding may require administration of packed red blood cells, platelets, fresh-frozen plasma, and/or cryoprecipitate [1,21]. It is important to begin antivenom therapy before the infusion of such products to avoid augmenting the consumptive coagulopathy. If renal failure occurs, dialysis may be required, although it does not remove circulating venom components [1,3]. Although steroids are useful in the management of adverse reactions to antivenom (see previous discussion), there is no role for them in the primary management of snake envenomation. Wound Care and Surgery Wound care begins with cleaning the bite site with a suitable germicidal solution and covering it with a dry, sterile dressing. As soon as antivenom, if indicated, has been started, the extremity should be elevated in a well-padded splint in a position of function with cotton between the digits [1]. Antibiotics are unnecessary unless field management involved incisions into the bite site [23] or the wound appears clinically infected. If ruptured, they should be unroofed after any attendant coagulopathy has been reversed, and managed with wet to dry dressings [3]. Physical therapy is an important part of the care plan for returning the extremity to its pre-envenomation functional capacity. The speed with which snake venom is absorbed makes routine excision of the bite site fruitless, and routine exploration of the site does little to mitigate systemic effects of venom, may worsen the overall outcome by adding surgical trauma, and can prolong hospitalization [1]. The incidence of compartment syndrome after snake envenomation appears low despite the frequently impressive local findings of bitten extremities [25]. Myonecrosis that occurs is usually caused by direct venom effects and rarely vascular compromise from elevated intracompartmental pressures [25]. In combined series of nearly 2,000 victims of pit viper envenomation, only four patients required fasciotomy; each of these patients received inappropriate ice treatment or inadequate antivenom therapy [25]. If there is concern about an impending compartment syndrome, intracompartmental pressures should be checked using any standard technique. If pressures exceed 30 to 40 mm Hg and remain elevated for more than 1 hour despite treatment with antivenom, limb elevation, and possibly mannitol infusion (1 to 2 g per kg in a normotensive patient), fasciotomy may be required [26]. While some evidence suggests that fasciotomy may actually worsen local myonecrosis [27], unabated elevation of intracompartmental pressures can have disastrous effects, such as debilitating neuropathy [28], and fasciotomy may still be required. Disposition and Outcome Patients with apparent dry bites can be discharged from the emergency department if they remain asymptomatic with normal laboratory values (repeated prior to discharge) and vital signs after 8 hours of observation [29]. The envenomated patient can be discharged from the hospital when all venom effects have begun to resolve and when antivenom therapy is complete, which is usually within 48 hours after admission. At the time of discharge, every patient should have appropriate follow-up arranged for continued wound care and physical therapy, and should be warned about the symptoms of serum sickness. Venom-induced coagulopathy and thrombocytopenia may recur anytime up to 14 days after the last dose of antivenom [30], and fatal intracranial bleeding and other cases of major delayed bleeding have been reported [31,32]. If on follow-up there is evidence of clinically significant bleeding, if the laboratory coagulopathy 3 is worsening or severe (i. The major reasons for poor outcomes in pit viper envenomation are delay in presentation, inadequate fluid resuscitation, inappropriate use of vasopressors, and delay in administration or inadequate dosing of antivenom [35]. The incidence of upper-extremity functional disability after pit viper envenomation is at least 32% [36], and may be higher when careful, objective functional measurements are obtained [37]. Coral Snake Envenomation There are fewer than 100 coral snake bites reported in the United States each year [38]. Owing to their much less effective venom-delivery mechanism (small fangs fixed in an upright position on the anterior maxillae), only approximately 40% of coral snake bites result in envenomation [1,40], although it has been estimated that one large coral snake is capable of delivering enough venom to kill four to five humans [41].

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The inferior vena caval cannula can be too far down obstructing the hepatic vein drainage safe divalproex 250mg medicine klimt, which can lead to postoperative liver dysfunction generic divalproex 500 mg free shipping medications ordered po are. The superior vena caval cannula can be too high buy divalproex 250 mg cheap medicine 4 you pharma pvt ltd, interfering with innominate and azygos vein drainage divalproex 250mg sale medicine 018. As mentioned previously, inadequate head and neck venous return can result in cerebral edema and postoperative neurologic complications. In cases of bicaval cannulation, cardiopulmonary bypass is usually begun with only superior vena caval return, and its adequacy is ascertained by noting the volume of venous return and the central venous pressure. If the central venous pressure remains high, the superior vena caval cannula is moved around until a near-zero central venous pressure is achieved. Retrograde Aortic Dissection Retrograde aortic dissection is indeed a catastrophic complication that may follow femoral or external iliac cannulation. A diseased artery, faulty cannulation technique, and trauma produced by a high-velocity perfusion jet are major factors that may cause a tear of the intima with medial separation. It is therefore essential to introduce an adequately sized, beveled, smooth cannula into a relatively normal vessel in an atraumatic manner. The arterial return into the false lumen is responsible for excessive pressure in the arterial line while the actual perfusion of the patient is inadequate. The femoral artery or the external iliac artery on the opposite side should then be cannulated if not involved; otherwise, the ascending aorta, the subclavian or axillary artery must be cannulated. Traumatic Disruption and Dissection of the Ascending Aorta Intraoperative traumatic dissection or disruption of the ascending aorta is a rare but dramatic complication of open-heart surgery. The areas of aortic cannulation, the proximal anastomosis of an aortocoronary saphenous vein graft, and an aortotomy done for exposure of the aortic valve are the usual sites prone to such a complication. Although faulty techniques always predispose a surgical procedure to complications, poor tissue quality and the presence of infection are the most common key precipitating factors in the development of aortic injury. The only preventive measure is awareness of the possibility of such complications and meticulous surgical technique in handling the tissues. There continues to be many modifications of the chemical composition of the cardioplegic solution, the optimal temperature (cold or warm), and the route of infusion (antegrade or retrograde). As the concepts of myocardial preservation and surgical approaches have evolved, improved cannulas and cardioplegia delivery systems have been introduced. Although any large-bore needle or cannula is satisfactory, those with a trocar introducer and a side arm for direct intraaortic pressure monitoring are most useful. Insufficient Infusion Pressure Distortion of, or insufficient pressure in, the aortic root may prevent adequate coaptation of the aortic valve leaflets, as will aortic valve insufficiency. The cardioplegic solution passes through the open valve and overdistends the left ventricle, which can cause direct myocardial injury. Digital pressure on the right ventricular outflow tract at the level of the aortic annulus may produce coaptation of the leaflets and prevent regurgitation of the cardioplegic solution. Excessive Infusion Pressure Excessive infusion pressure can traumatize the coronary arteries, resulting in ischemic myocardial injury. Accurate monitoring of the infusion pressure in the aortic root can be satisfactorily accomplished from the side arm of specially designed cannulas. A bubble trap is now incorporated into cardioplegia administration systems to minimize this possibility. Impurities in the Cardioplegic Solution Impurities and particulate matter may be present in the cardioplegic solution and can occlude terminal coronary arteries, causing myocardial injury. Warm Cardioplegic Solution Between infusions, the cardioplegic solution remaining in the tubing warms up. The warm solution should be flushed out through either the free arm of the Y connecting tube or into the vent before infusion into the coronary system. Maintaining Uniform Cooling Uniform cooling of the myocardium by infusion of cold cardioplegic solution is an integral part of myocardial protection. At some institutions, temperature probes in various parts of the septum and ventricular wall are used to monitor myocardial temperature during the course of the surgery. We typically utilize moderate systemic hypothermia, insulating pads, and topical cooling on the right ventricular surface in order to ensure uniform cooling. Inadequate Protection of the Right Ventricle Despite all precautions to keep the heart cool, the anterior surface of the heart tends to rewarm because of the ambient air temperature and the heat radiated from the operating room lights. A gauze pad soaked with cold saline and ice placed over the heart provides additional protection for the right ventricle. Topical Hypothermia Placement of an insulating pad, a commercially available cooling “jacket,” or a cold lap pad behind the heart can minimize rewarming of the heart by the warmer blood in the descending aorta during the cardioplegic arrest. This technique is equally useful in patients who have more than mild insufficiency of the aortic valve. Cannula Damage to Coronary Ostium Excessive pressure from the cannula against the coronary ostium can cause an intimal tear or late ostial stenosis. Size of the Cannula the cannula must be the correct size, and only a snug fit is necessary to prevent leakage. A cannula head that is too large or excessive pressure on the coronary ostium may not only interfere with satisfactory perfusion of the coronary system but can also traumatize the coronary ostium. Short Left Main Coronary Artery the cannula can also interfere with satisfactory infusion of cardioplegic solution if the left main coronary artery is short. A branching artery may have its origin very near the ostium of the left main artery and therefore be obstructed by the head of the cannula itself. A flexible, hand-held, soft-tipped cannula with a collar around the tip can provide satisfactory infusion of cardioplegic solution directly into the coronary arteries. The collar presses against the aortic wall and the coronary ostium to prevent spillage of cardioplegic solution into the aorta. The technique provides retrograde perfusion of segments of myocardium that may not be equally perfused by the antegrade route in patients with severe coronary artery disease. To ensure optimal myocardial protection, an integrated method of antegrade and retrograde cardioplegia delivery is used in most centers. Almost all retrograde cannulas are dual lumen to allow infusion of cardioplegic solution and monitoring of pressure in the coronary sinus. A balloon, manually inflatable or self-inflating, surrounds the distal body of the cannula, approximately 1 cm from the tip, proximal to the flow holes. Technique Through a stab incision in the center of a 4-0 Prolene purse-string suture in the mid-atrium, a special retroplegia cannula is introduced and directed into the coronary sinus. When difficulty is experienced in placing the retrograde cannula, it is often possible to elevate the decompressed P. Intraoperative transesophageal echocardiography can often be helpful in directing the cannula along the course of the coronary sinus and verifying the correct position of the cannula. Perforation of the Coronary Sinus the stylet and cannula must be guided into the coronary sinus very gently and not be advanced if any resistance is encountered.

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