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There is range but they are not particularly host-specific and some evidence that the incidence of blood parasites generally cause only mild or inapparent clinical in birds has decreased in some areas as a result of symptoms order 50 mg fildena visa erectile dysfunction doctor nyc. Diagnosis is based on identification of decreased numbers of invertebrate vectors generic 50 mg fildena free shipping erectile dysfunction causes std. For most species of Haemoproteus the intermediate Passerine families reported to be most commonly hosts are hippoboscid flies purchase fildena 100mg on line diabetic erectile dysfunction pump, biting midges (Culicoides infected with hematozoa in one European study in- spp purchase fildena 25 mg overnight delivery xylitol erectile dysfunction. The most commonly encountered parasites been reported are numerous and include mynahs, included Haemoproteus sp. Other blood parasites that are occasionally seen in Schizonts have a predilection for development in passerines include the small tick-borne erythrocytic skeletal and cardiac muscle, lung and spleen. Sporogony occurs in the inver- be associated with intramuscular megaloschizonts tebrate host, schizogony occurs in erythrocytes and (eg, commonly seen in free-ranging infected Pied pigment is formed from the host cell hemoglobin. These birds Each of the avian plasmodia has a limited host range show multiple, yellow streaks in pectoral and other but they do not appear to be particularly host-spe- muscles, and most are presented thin, weak and unable to fly. Orange juice may be Piroplasmosis is an important tick-borne infection added to the drinking water to make the drug more that has been identified in many species of birds in palatable. These parasites may infect either erythrocytes anemia, fever, lethargy and occasionally jaundice. Parasitized cells are so distorted by Some passerine species in which piroplasmosis has the organism that it may be difficult to determine been identified include crows, rooks, larks, sparrows their origin. Megaloschizonts can be found in brain, liver, lung, kidney, intestinal tissue and lymphoid tissue. Filarial Worms Microfilaria and adult filiarial nematodes (Ser- Most leucocytozoon infections are subclinical, al- ratospiculum amaculata and Diplotriaena sp. These birds hemorrhaged from protozoal finches, honeyeaters, thrushes, grackles, sparrows cysts within hepatic and renal tissue. Most infections have not been associated that the leucocytozoon may have been transmitted with any disease and the parasites have been found from free-flying black flies infected by feeding on incidentally in blood smears (microfilaria) or at ne- local leucocytozoon-infected crows. Splendidofilaria passerina may be which had been trapped in South America, may have pathogenic in sparrows. Treatment is not generally been particularly susceptible because of lack of pre- 38,43,57 warranted but levamisole may be useful. Genera affecting pas- finches, swallows, tits, warblers, thrushes, starlings, serines include Polymorphous, Plagiorhynchus, blackbirds, canaries and lyrebirds. Trypanosoma The Superb Lyrebird, the largest passerine species, Trypanosomes are found worldwide but their inci- is a ground-dwelling inhabitant of rain forests in dence is low and they may only be found during southeastern Australia. Vectors are site Plagiorhynchus menurae has been identified in thought to include hippoboscid flies (Ornithomyia lyrebirds showing weakness, emaciation and respira- avicularia), red mites (Dermanyssus gallinae), tory distress. Invertebrates are postulated to the parasites may be transmitted by contamination be the intermediate hosts. These cysts are interme- diate stages of the acanthocephalan Oncicola poma- Trypanosomes have been identified in over 14 pas- tostomi, the adult stages of which are found in the serine families, including Fringillid finches and ca- intestines of dingos and feral cats. These cysts have been Because tapeworms require arthropods as interme- reported to cause death in wood thrushes by ob- diate hosts, they are predominately a problem in structing the cloaca. They are normally Schistosomes are trematodes that live in blood ves- not seen in canaries or exclusively seed-eating birds sels. Gigantobilharzia huronensis is a blood fluke (such as Gouldian Finches), except in situations that has been reported in North American gold- where parent birds feed insects to their offspring or finches and cardinals. Ema- sites have been found worldwide in passerine species ciation, diarrhea, general debilitation and death may such as sparrows, corvids, starlings and thornbills. Dragon- hexacanth larvae may be noted on gross or micro- flies and snails are intermediate hosts. Praziquantel scopic examination of droppings, but these are may be useful in treating trematodes. Certain finch species, eg, parrot finches and Diamond Firetails, are particu- Nematodes larly prone to developing intestinal obstructions Ascaridia: Two main types of roundworms affect from heavy Choanotaenia sp. Both types of roundworms may be Tapeworms can be avoided by limiting access to in- associated with weight loss, diarrhea, general debil- termediate hosts and by using insect-proof screen- ity and sometimes neurologic symptoms. However, some birds may not accept thrush, thrush, blackbirds, Australian magpies, cur- these alternative foods and may die or be left suscep- rawongs and corvids. Fenbendazole, piperazine Effective anthelmintics for passerines include praz- and levamisole are useful in treating ascarid infections. Susceptibility does not depend on dietary preferences, and the parasite has Trematodes been found to cause disease in a variety of seed-eaters These parasites have complicated life cycles that (such as canaries), insectivorous and omnivorous spe- typically involve snails as initial intermediate hosts cies (such as weavers, whydahs, jays and mynahs) and other invertebrates as secondary intermediate and honeyeaters. It is unlikely that appropriate conditions for completion of the life cycle will be found, except Birds with low numbers of capillaria may be subclini- possibly in planted aviaries. Higher parasite loads may lead to weight loss, diarrhea, general ill health and death. These worms Trematodes are seen occasionally in wild-caught pas- may localize to a variety of sites along the gastroin- serines. Mechanical re- may be found by directly swabbing lesions or by fecal moval of worms and treatment with low doses of flotation. Aviary hygiene and removal of earthworms Arthropod Parasites are important control measures. Levamisole, fenben- Respiratory Mites: Respiratory acariasis (“air sac dazole and oxfendazole may be effective in some mite infection”) caused by Sternostoma tracheacolum cases. Occasionally, tricular and proventricular worm parasite does not the mites may be visualized by wetting the feathers affect psittacine birds. The parasite lives under the of the bird’s neck with alcohol and transilluminating koilin lining of the ventriculus, and characteristic the trachea with a bright source of light. Attempts present, they may be visible as tiny, dark, moving, to identify intermediate hosts in this species have pinhead-sized spots. Failure to see the mites does not been unsuccessful, but other species of Acuaria are rule out their occurrence because the mites may be believed to be transmitted by arthropod vectors. Other species of Ster- (which has been described in the House Sparrow, nostoma mites have been recorded in passerines in- starling, catbird and gallinaceous birds) and Spirop- cluding S. Cytodites nudus is another mite that has been asso- The parasite is found behind the nictitating mem- ciated with respiratory disease in free-ranging pas- brane or in the conjunctival sac or the nasolacrimal serines. Worms and may be found in the abdominal cavity as well as should be mechanically removed and any inflamma- the respiratory system. Respiratory Nematodes: Syngamus trachea (gape- Treatment is as described for other air sac mites. Corvids, starlings and black- External Parasites birds are particularly susceptible. Levamisole, ivermectin and Skin and Feather Mites fenbendazole are effective in treating this parasite, Scaly Mites: Knemidokoptes pilae (and several other but caution should be exercised when treating birds less common species) tend to cause hyperkeratotic with heavy infections. Scaly mite lesions start as pyhynchus are genera that have been reported on crusts on the plantar surface of the foot and gradually Passeriformes. Flexion of the joints of the digits causes ated with extensive dermatitis as well as cysts and the thickening keratin to split and gradually enlarge, skin tumors on hawfinches and a Lanceolate War- making it difficult for the bird to perch. Hanging a dichlorvos pest strip near birds af- lesions in passerines are sometimes referred to as fected with quill mites has eliminated the parasite in “tassel foot” because of this characteristic appearance some cases.

A small molecule C5a receptor antagonist pro- tects kidneys from ischemia/reperfusion injury in rats discount fildena 50 mg online erectile dysfunction doctors san francisco. Interleukin-18 binding protein transgenic mice are protected against ischemic kidney injury generic 100 mg fildena free shipping erectile dysfunction my age is 24. Guanosine supplementation reduces apoptosis and protects renal function in the setting of ischemic injury 100 mg fildena otc erectile dysfunction treatment aids. Single injection of naked plasmid encoding hepatocyte growth factor prevents cell death and ameliorates acute renal failure in mice purchase fildena 50mg fast delivery erectile dysfunction clinics. Tight junction proteins and oxidative stress in heavy metals induced nephrotoxicity. Prevalence and risk factors for aminoglycoside nephrotoxicity in intensive care units. Cocaine-induced acute interstitial nephritis: a case report and review of the literature. Acidity of fuids including that of plasma is determined by their hydrogen concentration or [H ], often con-+ fusingly expressed as its negative logarithm or pH. Acid–base analysis often yields important diagnostic information, and its physiol- ogy represents the crossroads between electrolyte balance and the respiratory system. The last century gave rise to three commonly used approaches to acid–base prob- lems in clinical medicine. In 1908, Henderson described his equation for carbonic acid equilibrium, which was rewritten in logarithmic form by Hasselbalch in 1917. Recently, the Stewart approach has become increasingly popular, especially in the setting of critical care medicine. This chapter will discuss all of these approaches and use their context to consider renal acid–base handling. Na , K and Cl are the most important+ + − examples, but others include Mg , Ca , sulfate and lactate. Carbonate ion formation equilibrium: ë û ë û ë û ë 3 û 5 Acid–Base 59 dissociated. Balanced salt solutions contain variable amounts of negative ions that are metab- olized, such as lactate or acetate. Singling out− 3 2 this equation is attractive as it facilitates dividing acid–base abnormalities in respi- ratory and non-respiratory or metabolic disorders. Respiratory− 2 3 compensation, either spontaneously or by altering the settings of mechanical venti- lation may occur within minutes. Metabolic compensation is slower and may take hours to days, and is mainly regulated by the kidney. To determine whether the compensation is suffcient and to identify mixed acid–base disorders, rules of thumb have been proposed (Table 5. Values above 11 m Eq/L for the adjusted anion gap suggest a metabolic acidosis due to nonvolatile acids (Table 5. A normal adjusted anion gap metabolic acidosis is sometimes confusingly referred to as hyperchloremic metabolic acidosis. The urine anion gap is the same as the urine strong ion difference and can be used to further differentiate between causes of metabolic acidosis. If the measured response is different, a mixed acid base disturbance may be present. As acid–base disturbances infuences every aspect of physiology including the cardiovascular, respiratory and immune systems, it is reasonable to start symp- tomatic treatment in the critically ill with severe deviations of pH from normal. When using a buffer, it should be remembered that administering sodium bicarbonate may transiently decrease intracellular pH, if ventilator settings are not changed simultaneously. In addition, there is no trial that has shown a beneft in terms of mortality when using sodium bicarbonate to attenuate acidosis. In critical care medicine, their role is often compensatory, by regulating plasma electrolyte concentrations. However, the kidneys may also cause acid–base disturbances, for example in acute kidney injury or various types of renal tubular acidosis. When discussing renal acid–base handling, it is important to point out that differ- ent explanations for observed cellular mechanisms exist depending on which approach to acid–base medicine is adhered to. Interestingly, most of the physiological concepts dealing with renal transporters have been developed before the Stewart approach became popular. In the proximal2 convoluted tubule hydrogen ions are excreted into the tubular lumen through a Na -+ H exchanger. These2 3 2 2 5 Acid–Base 65 diffuse through the aquaporin channels into the cytosol. There, again mediated by carbonic anhydrase, the reaction is reversed and hydrogen and bicarbonate ions are formed again. Chloride reabsorption has three main routes: (1) passive+ − 3 due to the electrochemical concentration gradient, (2) active by chloride channels and (3) coupled through various chloride-anion exchangers. Depending on the acid– base status, the different components are either up regulated or down regulated. In alkalosis, chloride excretion is less due to down regulation of pendrin and band 3 protein. As a reaction type B-cells will change and become type-A cells in order to try to increase the hydrogen secretion. Since distal bicarbonate reabsorption is still possible, plasma bicarbonate is normally slightly decreased and blood pH low normal. In the absence of ammonium, less hydrogen can be buffered and thus less hydrogen can be excreted, causing an acidosis. Causes of aldosterone defciency include Addison’s disease, congenital adrenal hyperplasia and drugs inhibiting aldosterone synthesis. Causes of aldosterone resistance include congenital causes, such as pseu- dohypoaldosteronism type 1 and 2 and acquired causes, such as interstitial nephrop- athies and drugs. These start to develop when the glomerular fltration rate is less than 20–25 % of normal. Conclusion Stewart’s strong ion approach, Siggaard-Andersen’s standard base excess approach and the Henderson-Hasselbalch based bicarbonate centered approach are popular frameworks for understanding acid–base disorders in the critically ill. Basic concepts, views of renal acid–base handling and clinical application of these methods were discussed in this chapter. Provided that hypoalbuminemia is corrected for in the latter two, all methods are mathematically compatible and may perform equally well in clinical practice, especially in uncomplicated acid– base disorders. However, if acid–base disorders become increasingly complex, which is the case in many critically ill patients, Stewart’s approach may be superior. Although 5 Acid–Base 67 considered diffcult, this method disentangles and quantifes the various factors responsible for complex mixed acid–base disorders, thus arguably providing the best overview.

This decreased capability corre- lates significantly with the increased severity of the disease as assessed through the Webster rating scale purchase 25mg fildena with amex erectile dysfunction protocol ebook. In fact discount 50 mg fildena with amex impotence lab tests, patients with demen- tia of the Alzheimer type discount 150 mg fildena free shipping impotence risk factors, though having abnormalities in the basal gan- glia cheap fildena 50 mg fast delivery erectile dysfunction doctor milwaukee, have no difficulty in changing postural set in response to altered sup- port conditions (63). Spasticity Hemiparetic patients often stand asymmetrically and with broader stance than normals; further, sway during quiet stance is larger than in normal subjects (72). Further, the normal sequence of activation first in the distal and then in the proximal muscles in response to a postural per- turbation is lost. In fact, in hemiparetic patients the proximal and distal muscles of the affected limb are coactivated, whilst on the so-called healthy side the timing of muscle activation is normal (75). Peripheral neuropathy Eliminating vision does not necessarily increase postural sway in qui- et stance, nor does it result in longer latencies to postural perturbations suggesting that vision is not as critical as somatosensory information for postural control (82-84). Nevertheless, vision can be an important substi- tute for loss of somatosensory or vestibular function (83, 85). Sway dur- ing stance on a firm surface is larger than normal in subjects with so- matosensory loss due to diabetic peripheral neuropathy (86-92). Diabetic patients with loss of somatosensory information due to pe- ripheral neuropathy have significantly delayed latencies of postural re- sponses to surface displacements (92, 93). As a matter of fact, patients with peripheral neuropathy have an approximately 23 times higher risk of falling than do healthy control subjects (94, 95). This finding has implications for understanding how patients with peripheral neuropathy may benefit from a cane for postural stability in stance (96). Patients with other types of sensory loss, as tabes dorsalis (97) or Friedreich’s ataxia (98,99), show increased power spectrum of body sway during quiet stance with a peak around 1 Hz. Conversely, diabetic patients may develop sensorimotor dis- tal symmetric polyneuropathy involving both large and small afferent fi- bres (102). This suggests that the signal coming from the length-sensitive spindle secondaries is better suited than that from the spindle primaries in detecting the slow changes in length of the leg muscles due to the displacements of the body centre of mass during quiet stance. Vestibular deficit Patients with acute unilateral lesion exhibit body oscillations mainly di- rected toward the affected labyrinth (103, 104). Quiet stance is usually not impaired in patients with compensated vestibular disorders (105). An adap- tive increase in somatosensory loop gain occurs in patients with chronic loss of vestibular system (106, 107). The cause of this instability may be twofold; the more basic being the impairment of vestibulo-spinal re- flexes (104, 114). Chronic bilateral vestibular deficit does not affect postural reflexes not even with eyes closed (82, 83, 93, 104, 115). This phenomenon sug- gests that integrity of labyrinthine reflexes is not a necessary condition for the occurrence of postural reflexes. Differential diagnosis of vestibular and proprioceptive deficits has been attempted using dynamic posturography (117). Measuring trunk sway in the form of roll angle and pitch angular velocity during simple clinical tests of equilibrium could distinguish patients with a well defined balance deficit from healthy con- trols (118). Non-linear analysis of orthostatic posture in patients with ver- tigo or balance disorders has been used to assess differences connected with different vestibular disorders (119). When patients with unilateral vestibular deficit stand balancing on a platform continuously moving in an anterior-posterior direction the dis- placement of head and hip is significantly larger than that of normal sub- jects (120), under both visual conditions. In spite of this, the cou- pling between head and platform movements is nearly normal under all conditions. Afferent input from neck muscle vibration is integrated with con- current vestibular input in determining the postural response. Neck vi- bration in normal subjects is combined with vestibular input to signal that no head movement has occurred, so it is assumed that the lower body has tilted forwards which provokes a compensatory sway (121). Conversely, in the total absence of vestibular function, the neck signal may represent a real head movement, so the preferential response is a head tilt to restore upright posture. Bilateral vibration of dorsal neck muscles has been reported to increase sway in patients with central vestibular lesions whereas patients with unilateral peripheral lesions are unaffected by vibration (122). Cerebellar disease Lesions in different regions of the cerebellum produce very different effects on postural control. Lesions of the lateral hemisphere can produce profound disorders of timing for arm and hand coordination without significant effects on posture or gait (99). The most profound deficits in dynamic postur- al control occur with damage to the anterior lobe of the cerebellum, which receives somatosensory inputs from throughout the body and pro- jects to the spinal cord via the red nucleus and reticular formation. Pa- tients with anterior lobe atrophy of the cerebellum show frequencies of 2- 4 Hz in the power spectrum of body sway during quiet stance (124). Babinski (126) first stated that posturo-kinetic coordination was lost in patients with cerebellar disease. Preparation and execution of move- ments are delayed and more variable in cerebellar patients (66). Therefore, it seems that cerebellum regulates the time course and modulates the amplitude of motor patterns. Diener et al (127) found abnormal timing of postural responses in patients with cerebellar deficits while performing rapid arm elevation while standing upright. The score corresponds to the number of sec- onds subjects maintain the test position. Timing starts when subjects as- sume the proper position and indicate to be ready. Timing stops if subjects move either foot from the proper position, open the eyes in the eyes- closed trial, or reach the 60-s time limit (132-134). Maximum score, when performance lasts less than 60 s, is the longest period recorded in three (132) or five repetitions (135) of the trial. Franchignoni et al (136) in a sample of subjects aged 55-71 years found that in half of subjects performance duration is below 35 s. Timing starts when the subject raises one foot off the ground and stops when a change of posture occurs (i. In order to reduce the ceiling effect, Briggs (132) suggests to use a 45-s time limit. No significant difference has been found be- tween right and left or dominant and nondominant limbs while perform- ing the one-legged stance test (135, 132). No significant difference was found in mean balance time between subjects who had fallen versus those who had not fallen, nor between shoes-on and shoes-off test performance (132). The one-legged stance test balance time decreases significantly as age increases (135). Construct validity has been shown by the significant correlation with Tinetti mobility scale. Feet are parallel, freely spaced apart (with an intermalleolar distance of 20 cm) and placed on a non-slip mat, behind a starting line that is not allowed to be stepped over.

Emergency and supportive care should be insti- when food is warmed in a microwave oven and not tuted discount fildena 25mg without prescription impotence blood pressure medication. Immedi- from the mouth through the crop into the distal ate treatment consists of removing the hot food and esophagus or into the proventriculus will aid in iden- replacing it with cool water 150 mg fildena fast delivery erectile dysfunction causes cancer. Small frequent feedings should be used to In some cases buy cheap fildena 150mg impotence workup, the crop may develop a defect while minimize the stretching force placed on the crop discount fildena 100mg impotence grounds for divorce in tn. The affected skin present in the acute phase when it is difficult to should be opened, the subcutaneous tissues debrided, determine the extent of the injury, or in the chronic the crop and esophagus closed and the skin defect stage when a well developed fistula is present. The wound should be evaluated periodically and debrided of any food ma- Chronic crop fistulae are generally easier to deal terial or necrotic tissue accumulates. Because a cutaneous tissues are healthy, the skin defect may be fistula has developed, the serosa of the ingluvies and closed or it may be left to heal by second intention. These must be separated using scissors to circumferentially Cases of acute crop burn are significantly more chal- excise the edge of the fistula. Severe cases of section, the tissue plane between the ingluvies and crop burn may be fatal as a result of metabolic the skin is identified and separated. The skin is changes, sepsis and absorption of toxins from ne- normally adherent to the crop, being attached by two crotic tissues. Initial treatment should be supportive layers of striated muscle that form a sling-like sup- and should include shock therapy, broad spectrum port for the diverticulum of the crop. In tissues are separated, closure is as described for cases of severe burns with significant edema, fascio- ingluviotomy. In less severe cases, clinical signs may preserved and allowed to granulate over a stent. If simply be consistent with a “sick bird:” lethargy, enough viable tissue remains, it may be sutured anorexia and fluffed appearance. This can be accom- patient must be fed frequently small volumes of soft plished using a needle catheter intestinal feeding or liquid diets until the capacity of the ingluvies tube11 or by tube-feeding directly into the proven- 1 increases. It is important to instruct the owner on placed to provide postoperative local drainage and proper methods for tube-feeding, and it must be may also be used for wound irrigation. If the defect is so large that wound delineation between healthy and devitalized tissues contraction cannot occur, a dermoplasty may be per- becomes apparent,1 and it may take as long as 7 to 14 formed once there is a healthy bed of granulation days. A rotating skin flap will generally provide what tissue should be removed and what is viable tissue to cover the defect. Ingluviotomy Eventually, the devitalized tissue will separate from viable tissue and the edges of the crop and skin will Neonates are susceptible to ingestion of foreign ob- heal together, forming a fistula (see Color 30). Feeding tubes, small toys andunhulled Any tissue that is obviously necrotic should be de- seed may also be ingested. Small objects may be retrieved from the crop using a The definitive correction should be postponed until flexible endoscope and a biopsy instrument. Many approximately five days after the injury when the foreign bodies including feeding tubes can be pal- demarcation between healthy and devitalized tissue is apparent. It is important to evaluate the Intubate the patient and pack the esophagus with moistened entire crop, because devitalized mucosa may occur gauze to prevent flush solution from entering the pharyngeal area. The aboral extent of the Remove any necrotic tissue and thoroughly clean the under- crop at the thoracic inlet is a location where devital- lying bed of granulation tissue with a dilute chlorhexidine ized areas are often missed. Once the tissue defect is thoroughly cleaned, debride the At surgery, all necrotic tissue must be removed and edges of the fistula to remove granulation tissue and com- the tubular structure of the esophagus and ingluvies pletely separate the crop from overlying skin. In some cases this may be very chal- Separate the skin and crop further by careful blunt dissection with strabismus scissors. The crop is initially closed If possible, the length of the crop should be main- with an inverting suture pattern making certain that the tained even if only a thin strip of esophageal tissue incision line extends past the defect on both ends. Esophageal strictures are more likely to can be closed in a simple interrupted pattern. The surgical closure of a burn should be delayed as long as possible to allow the body to differentiate between healthy and devitalized tissue. Instilling a Indications for ingluviotomy include foreign body re- dilute water-soluble lubricant into the crop may help moval,1,29 placement of a feeding tube and gaining prevent iatrogenic injury to the crop and esophageal endoscopic access to the proventriculus and ventricu- wall. This is not as easy as it sounds, and care moist cotton to prevent fluids from refluxing into the must be taken to prevent iatrogenic injury to the oral cavity. Specific bleeding can be controlled with radiosurgery, but the incision in the crop should not be made using this unit. This area of the crop is less subject to stress as gical forceps will result in unnecessary tissue the crop fills and is out of the path of a feeding tube. The Because of the ability of the ingluvies to stretch, the incision is closed using an inverting technique with incision should be made only about half the size an absorbable material swaged on an atraumatic necessary to accomplish the procedure; however, needle. Two-layer inverting patterns are frequently having adequate exposure is more important than recommended;4 however, one layer of simple continu- having a small incision, and retrieval of large foreign ous appositional sutures over-sewn with an inverting bodies through small ingluviotomy incisions should pattern is effective and is less compromising on the not be attempted. The crop incision should be made with saline or air to check for leakage prior to skin closure. Radiosurgery should be Foreign bodies can be removed manually or impacted used to seal only specific vessels. Once the skin is incised, the left leg may be further retracted cau- Surgical approaches to the abdomen involve invasion dally and somewhat dorsally to expose the abdomi- of the air sac, allowing anesthetic gas to escape nal wall. This effect can be mini- artery and vein should be identified passing over the mized by packing the borders of the incision with lumbar fossa toward the pubis. The incision is extended caudally air sac, pass through the lung and out the trachea. For any celiotomy, the pa- tient should be positioned with the cranial part of the The intercostal vessels coursing along the cranial body elevated 30 to 40° to prevent irrigation fluids border of the last two or three ribs should be ligated from flowing craniad and entering the lungs follow- or coagulated. Similarly, patients with sealed by inserting the indifferent electrode inside ascites should have the fluid removed from the the thoracic wall, lightly opposing the electrodes, coelomic cavity prior to opening the air sacs. Mois- withdrawing the electrodes until the cranial aspect of tened cotton may be placed in the caudal pharynx to the rib is encountered, then activating the electrodes. The celiotomy approaches used identify the vessel visually and apply a hemostatic for access to the avian abdomen include left lateral, clip. Skin incisions can be made will need to be transected at their dorsal and ventral in varying arrangements and combinations depend- extents and removed to achieve adequate visualiza- ing on the surgical procedure and the degree of ab- tion of the viscera. In small birds, excision of the ribs dominal exposure that is required (Figure 41. This Left Lateral Celiotomy method is preferred, because closure of the incision is A left lateral celiotomy provides the best exposure of easier. Once the incision is made through the muscu- the proventriculus, the ventriculus, the female repro- lature, the shiny surface of the caudal thoracic or the ductive tract and the left kidney (Figure 41. In some patients, the With the patient in right lateral recumbency, the lung extends caudally as far as the seventh rib. If extend from the cranial extent of the pubis to just the abdominal air sac is entered instead of the caudal dorsal to the uncinate process of the fifth or sixth rib. Medially, the proventriculus can be seen the groove of the groin web caudally to the region of suspended by the air sacs and suspensory ligaments.