SCIENCE OF REVIEWS

2011-07-29T07:54:00.001+07:00

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Pain in the genitourinary tract

2009-04-24T01:31:00.000+07:00

It is usually associated with distention of hollow viscus or the capsule of an organ. Pain may be local or referred.
A. Renal
Pain of Renal origin is usually located in the ipsilateral costovertebral angel. It may radiate to the umbilicus and may be referred to the ipsilateral testicle in men or the labium in women. In infection, the pain is typically constant. Nausea and vomiting may result from reflex stimulation of the celiac ganglion.
B. Ureteral
It is usually acute and a result of obstruction. Distention may cause a constant dull ache, while the spasms result in colic. Upper: result in pain referred to the scrotum or to the labium. Mid: pain in the lower quadrant (may be confused with apendicitis). Lower: associated with symptoms of vesical irritability.
C. vesical
Urinary retention results in severe suprapubic discomfort. Cystitis pain is usually referred to the distal urethra and is associated with micturition.
D. Prostatic
pain is located in perineum. Pain radiates to the lumbosacral spine, inguinal canal, or lower extremities. Inflammatory result in irritative voiding complaints.
E. Penile
Pain in the flaccid penis is secondary to inflammatory caused by STD. Pain in the erect penis may be due to peyronie's disease(fibrous plaque of the tunica albuginea) or to priapism(prolonged painful erection).
F. Testicular
Acute pain within the scrotum with radiation to the ipsilateral groin. Varicocele or hydrocele results in heaviness without radiation.

Hematologic evaluation

2009-04-21T06:12:00.001+07:00

Several Hematologic disorders may have an impact on the outcomes of surgery. Two of the more common clinical situations faced by the medical consultant are the patient with preexisting anemia and the assessment of bleeding risk. Most data suggest that morbidity and mortality increase as the preoperative hemoglobin level decreases. Hemoglobin levels below 7 or 8 g/dl appear to be associated with significantly more preoperative complications than higher levels. When the directed bleeding history is unreliable or incomplete or when abnormal bleeding is suggested, a formal evluation of hemostasis should be done prior to surgery and should include measurement of prothrombine time, the activated partial thromboplastin time, the platelet count, and the bleeding time.

Heart disease

2009-04-18T19:52:00.002+07:00

Cardiac disease may be exacerbated by many of the physiologic changes accompanying surgery,including fluctuations in heart rate, blood pressure, blood volume, oxygenation, pH, and coagulability. Increased circulating cathecolamines or sympathetic nervous system activity may precipitate arrhytmias as well as increase heart rate and blood pressure. Anesthesia and medications such as vagolytics and muscle relaxants have direct effects on myocardial contractility, automaticity, and conduction. The greatest risk occurs in the 72 hours following operation, when fluid volume shifts, fluctuations in heart rate and blood pressure, and medication changes are greatest and the ability to control them is compromised.
Cardiac conditions masquerading as surgical illnesses
1. Myocardial infarction or angina
2. Right heart failure
3. Ascites or pericardial disease
4. Dysphagia due to left atrial enlargement or disease of the aorta.
5. Back and abdominal pain due to aortic dissection.
The ECG should reveal evolving or recent infarction, and the physical examination and chest x-ray should demonstrated heart failure or sign of pericardial disease. Echocardiography will confirm valvular disease and pericardial disease and may reveal a source of emboli.
Goldman index:
- s2 gallop 11
- MI in previous 6 months 10
- more than five VPCs/min. 7
- nonsinus rhythm 7
- age >70 years 5
- emergency operation 4
- intrathoracic, intraperitoneal, aortic surgery 3
- significant aortic stenosis 3
- poor general medical condition 3

Mortality rate: score is 0-5, 1%. 6-12, 7%. 13-25, 13%. >26, 78%.

inguinal hernia

2009-04-18T07:43:00.000+07:00

Types of operations for inguinal hernia
-the goal of all hernia repairs is to eliminate the peritoneal sac (in the case of indirect hernia) and to close the fascial defect in the inguinal floor.
A. Simple high ligation of the sac through an inguinal incision is the key to the repair of indirect hernias in infans and children.
B. Macy repair is combined with a tightening of internal ring.
C. Open Mesh hernia repair
D. Laparoskopik technique, less pain and more rapid return to work, but expensive.
E. Bassini repair, the tradisional autologous tissue repairs. This is conjoined tendon is approximated to pouparts ligament and the spermatic cord remains in its normal anatomic position under the external oblique aponeurosis.
F. Halsted repair, external oblique beneath the cord but otherwise resembles the bassini repair.
G. Lotheissen-mcvay repair, bringing the conjoined tendon farther posteriorly and inferiorly to coopers ligament. Its effective for femoral hernia but always requires a relaxing incision to relieve tension
H. Shouldice repair, more extensive dissection required. The transversalis fascia is first divided and then imbricated to pouparts ligament. Finally, the conjoined tendon and internal oblique muscle are also approximated in layers to the inguinal ligament.

NON SURGICAL MANAGEMENT
Truss, should be fitted to provide adequate external compression over the defect in the abdominal wall. It should be taken off at night and put on in the morning before the patient arises. Its may cause fibrosis of anatomic structure so that subsequent repair may be more difficult.

Prognosis
- recurrence may be triggered by chronic cough, prostatism, constipation, poor tissue quality,infection and poor operative technique.

Amputation

2009-04-18T07:37:00.002+07:00

Amputation have four aims
1. The removal of all diseased tissue
2. The relief of pain
3. Primary healing of the amputation wound is desirable
4. Construction of a stump that will permit the most useful function with or without prosthetic fitting is most consequential in functional patients.

Level of amputation
is determined by assesing the healing of the limb in association with the functional potential of the patient. Technical decissions regarding amputation level are based on adequacy of blood flow, extent of tissue necrosis, and location of tumor. Circulatory status may be ditermined by measurement of the peripheral pulses and the capilary refill time and by noting the presence of rubor, the conditon of the skin, and the presence of ischemic atrophy. Patient with ambulatory potential should be preserved in order to maintain nearly normal walking with the least of expenditure of energy. Transtibial prosthesis 10-40%, transfemoral 50-70%, crutches 60%.
A. Clinical examination:
palpable pulses: femoral pulse for above-knee, popliteal pulse for below-knee.
B. Measurement of blood pressure
doppler ultrasound and pneumatic cuff is a useful for determining the level of amputation.
C. Oxygen tension measurement
transcutaneus measurement use a modified clark-type oxygen electrode. If PaO2 above 40mgHg indicates that good healing, but intermediate values do not correlate closely with healing.

Diabetes Mellitus

2009-04-16T22:30:00.001+07:00

management of the diabetic patient before, during, and after surgery is an important responsibility of the surgeon. hyperglycemia should be avoided during surgery. the greater danger is from severe unrecognized hypoglycemia.
-preoperative
physical trauma combined with physiologic stress may cause epinephrine and cortisol level to rise, in each case resulting in increased blood glucose levels. hypocalemia may prevent B cell from secreting adequate amounts of insulin and may thereby raise blood glucose levels in patients with type 2 diabetes. an ecg to rule out myocardial infarction, a chest x ray to identify hidden pneumonia or pulmonary edema, urinalysis can rule out urinary tract infection and proteinuria, serum creatinine levels are used to asses renal function. the serum glucose concentration should ideally be between 100 and 200mg/dL, but operation can be safely performed in patients whose serum glucose is as high as 350-400mg/dL preoperatively.
a. type 2 Diabetes mellitus
if the serum glucose level is below 250mg/dL on the morning of surgery, sulfonylureas should be withheld. long acting sulfonylureas should be discontinued on the day before surgery and 5% glucose solution should be administered iv at a rate of about 100mL/h. this means that over a 10-hour period, only 50g of glucose would be given.
if the fasting glucose level is above 250-300mg/dL or if the patient is taking small doses of insulin but does not actually require insulin to prevent ketoacidosis, an alternative approach is to add 5 units of insulin directly to each liter 0f 5% glucose solution being given at 100mL/h. if the operation is lengthy, blood glucose levels should be measured every 3-4 h during surgery to ensure adequate glucose control. the goal is to maintain glucose levels between 100 and 200mg/dL, but there is little immediate metabolic harm in allowing levels to go as high as 250mg/dL.
b. type 1 Diabetes mellitus
patients require insulin during surgery. the following methode: 1. subcutaneous administration of long -acting insulin. 2. constant infusion of a mixture of glucose and insulin. 3. separate infusion of glucose and insulin. blood glucose levels should be monitored at least every 2 hours during the procedure to avoid hypoglycemia below 60mg/dL and hyperglycemia above 250mg/dL.

- postoperative
an infusion of 1.5 units or less of insulin per hour, when given with 5% glucose, rarely results in hypoglycemia. blood glucose levels should be measured every 2-4 hours and the patient monitored for signs and symptoms of hypoglycemia ( anxiety, tremulousness, profuse sweating without fever ). a marked increase in glucose and insulin requirements postoperatively suggest the presence of occult infection.

drug reactions

2009-04-10T05:01:00.000+07:00

Prompt recognition of these reactions, drug withdrawl, and appropriate therapeutic interventions can minimize toxicity. Sulfonamide antibiotics, allupurinol, amine antiepileptic drugs (phenytoin and carbamazepine), lamotrigine, and the oxicam are associated with the highest risk of these reactions.
Pathogenesis of drug reactions
Cutaneus responses to drugs can arise as a result of immunologic or nonimmunologic mechanisms.
Immunologic :
Drug frequently elicit an immune response , but small number of individuals experience clinical hypersensitivity reactions . IgE dependent drug reactions are usually manifest in the skin and gastrointestinal, respiratory and cardiovascular systems. Primary symptoms and signs include pruritus, urticaria, nausea, vomiting, cramps, bronchospasm and laryngeal edema and occasion anaphylatic shock with hypotension and death.
Immune complex dependent reactions is characterized by fever, arthritis, arthritis, neuritis, edema, and an urticaria, popular, or purpuric rash. In classic serum sickness , symptoms develop 6 days or more after exposure to a drug, the latent period representing the time needed to synthesize antibody. The antibodies responsible are largely of the igG or igM class.
Cytotoxicity and delayed hypersensitivity may be important in the etiology of morbilliform exanthema, hypersensitivity syndrome , SJS , or TEN, but this is not proven.
Nonimmunologic drug reactions :
The mechanisms may be due to activation of effect pathways, overdosage , cumulative toxicity , side effects, ecologic disturbance , interactions between drugs, metabolic alterations , exaggeration of preexisting dermatologic conditions , or inherited protein or enzyme deficiencies.

allergic rhinoconjunctivitis

2009-04-10T04:57:00.000+07:00

after exposure to allergen:
-sneezing
-itching of nose and eyes
-clear rhinorrhea or nasal congestion
It is the most common allergic disease and significantly affects quality of live as well as school performance and attendance. It frequently coexist with asthma. Prevalence is at 15% in the postadolescent years.
The pathologic changes in allergic rhinoconjunctivitis are chiefly hyperemia, edema, and increased serous and mucoid secretions caused by mediator release, all of which lead to variable degrees of nasal obstruction, pruritus, and rhinorrhea.
Laboratory:
Eosinophilia often can be demonstrated on smears of nasal secretions or blood.
Skin testing to identify allergen-specific IgE is the most sensitive and specific test for inhalant allergies, alternatively, radioallergosorbent assay test (RAST), immuno CAP, or other in vitro tests can be done for suspected allergens.
Treatment
* identification and avoidance of causative allergens cannot be overstated.
* antihistamines-to control itching, sneezing, and rhinorrhea. Sedating antihistamines: diphenhydramine, chlorpheniramine, hydroxyzine, clemastine.
* decongestan-phenilephrine and oxymetazoline should not be used for more than 4 days. Pseudoephedrine and phenylpropanolamine are often combined with antihistamines or expectorants.
* corticosteroids- mometasone nasal spray has been approved for use in children.
* other pharmacologic agents- montelukast is approved for perennial allergic rhinitis in children 6 months and older. Intranasal ipratropium can be used as adjunctive therapy for rhinorrhea.
* surgical therapy- turbinectomy and functional sinus surgery

pruritus

2009-04-10T04:56:00.000+07:00

Typical features
-pruritus
-facial and extensor involvement in infants and young children
- flexural lichenification in older children and adolescents
- chronic or relapsing dermatitis
-personal or family history of Atopic disease
Clinical :
Erythematous papules associated with excoriations, vesiculation, and serous exudate, thickened skin with accentuated markings /lichenification and fibrotic papules. It may be secondarily infected with candida.
Treatment:
-avoidance of irritants such as detergents, chemicals, and abrasive materials as well as extremes of temperature and humidity is important in managing this disease.
-avoidance of food allergens: eggs, milk, peanuts, soy, wheat, and fish, etc.
- patients with Atopic dermatitis have evaporative losses due to a defective skin barrier. Appliying a wet facecloth or towel to the involved area for 15-20 minutes
-an effective emollient combined with hydration therapy will help skin healing and can reduce the need for topical corticosteroids. Petroleum jelly / vaseline is effective. Moisturizers often need to be applied several times daily .
-corticosteroids can decrease s aureus colonization. discontinued when inflammation resolves.
-calcineurin inhibitors: its immunomodulatory agents that inhibit the transcription of proinflammatory cytokines as well as other allergic mediators and target key cells in allergic inflammation.
-anti-infective therapy : mupirocin, cephalosporin.
-antipruritic agents: antihistamines, anxiolytics.

urticaria and angioedema

2009-04-10T04:54:00.000+07:00

Urticaria: Erythematous, blanchable, circumscribed, pruritic, edematous papules ranging from 1-2mm to several centimeters in diameter and involving the superficial dermis. Individual lesions can coalesce.
Angioedema : edema extending into the deep dermis or subcutaneous tissues.
Both resolve without sequelae-urticaria usually within hours , angioedema within 72 hours.
Mast cell degranulation, dilated venules, and dermal edema are present in most forms of urticaria or angioedema.
Physical stimuli including pressure, cold, heat, water, or vibrations.
Clinical:
The immediate form is known as familial cold urticaria, in which Erythematous macules appear rather than wheals, along with fever, arthralgias, and leukocytosis.
The delayed form consists of Erythematous, deep swellings that develop 9-18 hours after local cold challenge without immediate lesions.
Solar urticaria , which occurs within minutes after exposure to light of appropriate wavelength , pruritus is followed by morbilliform Erythema and urticaria.
Laboratory:
Specific tests for physical urticarias such as an ice cube test or a pressure test.
Treatment:
- Avoidance of the triggering agents.
- epinephrine, especially when laryngeal edema complicates an attack.
- H1 antihistamines, cyproheptadine-cold urticaria. Diphenhydramine - dermographism. hydroxyzine- cholinergi urticaria.
- corticosteroids - usually not indicated in the treatment of acute or chronic urticaria.
- tricyclic antidepressant doxepin blocks both H1 and H2 histamine receptors.

Food allergy

2009-04-10T04:52:00.000+07:00

* temporal relation between ingestion of a suspected food and onset of allergic symptoms.
* positive prick skin test or in vitro test to a suspected food allergen confirmed by a double-blind, placebo-controlled food challenge.
the highest prevalence of food allergy is found in children with moderate to severe Atopic dermatitis. Children with asthma have been found to have food-induced wheezing in some studies.
Clinical:
-most reactions to foods occur minutes to 2 hours after ingestion.
- hives, flushing, facial angioedema , and mouth or throat itching are common.
- anaphylatoid reactions can occurs after ingestion of foods such as certain fish containing high amounts of histamine.
Treatment:
- eliminating and avoiding foods

endothelium injury

2009-04-10T04:49:00.000+07:00

*neutrophil-endothelium interaction
The Accumulation and infiltration of inflammatory leukocytes, specifically neutrophils, at sites of injury contribute to the cytotoxity of vital tissues and result in organ dysfunction.
*nitric oxide
NO is derived from endothelial surfaces in response to acetylcholine stimulation, hypoxia,endotoxin,cellular injury, or mechanical shear stress from circulating blood. NO also can reduce microthrombosis by reducing platelet adhesion and aggregation.
*prostacyclin
It is an arachidonate product.
*endothelins
*platelet-activating factor
*atrial natriuretic peptides

Pain

2009-04-02T22:43:00.001+07:00

Pain resulting from injury to the nervous system (neuropathic) may not indicate tissue damage and thus may not be a useful sensory phenomenon: rather it may constitute a pathologic process itself.
Malignant pain :
The goal is to reduce suffering during a terminal illness. opioids can be used in high doses unless excessive adverse effects occur. Tricyclic antidepressants, anticonvulsants, and nsaid may provide additional relief. Other drug: bupivacaine and clonidine may relieve pain related to nerve invasion. When medical management fails, the surgical treatment is indicated such as 1. Epidural administered morphine, 2. Ablation to interrupt pain transmission.
Cancer pain that is unilateral and focal may be treated with cordotomy, creating a lesion in the spinothalamic tract designed to interrupt pain transmission. Percutaneous cordotomy using a radiofrequency needle is done at the C1-2 level. This is less traumatic for the patient and may produce analgesia in both the arm and the leg. Other, Ablative are used rarely. These include midline myelotomies, rhizotomies, and neurectomies.

Renal stone

2009-04-02T06:34:00.001+07:00

- flank pain, hematuria, pyelonephritis, previous stone passage.
- costovertebral tenderness
- red cells in urine
- stone visualized on urography, ultrasonography, or spiral CT scan.

If the stone acutely obstructs the ureteropelvic junction or a calix, moderate to severe Renal pain will be noted, often accompanied by nausea, vomiting, and ileus. Hematuria is common. Staghorn calculi which may form a cast of all calices and the pelvis. Symptoms of infection , if present, will be exacerbated.
Laboratory:
Leukocytosis is to be expected. Urinalysis may reveal red and white blood cells and bacteria. A pH of 7,6 or higher implies the presence of urea-splitting organisms. A pH below 5,5 is compatible with the formation of uric acid or cystine stones. If the pH is fixed between 6 and 7, Renal tubular acidosis should be considered as a cause of nephrocalcinosis. A 24 hours urine collection for calcium may reveal hypercalciuria, which occurs with hyperparathyroidism and idiopathic hypercalciuria.
Imaging:
90% of calculi are radiopaque: calcium, cystine.
Nonopaque stone will be seen as radiolucent defect in the opaque contrast media.
Stone analysis:
Stone chemical composition should be analyzed.
Treatment:
- a high fluid intake 3-4L/d
specific:
* calcium stone formers, stop vitamin D suplements.
* oral orthophosphates are effective in decreasing urine calcium and increasing inhibitor activity
* thiazide diuretics, decreasing the calcium/oxalate content in urine by 50%.
* antibiotics
* percutaneous nephrostomy and percutaneous nephrolithotomy
* pulverization by means of ultrasonic, electrohydraulic, or laser probes passed through the nephrostomy tract may also be useful.
* residual infection stones may be dissolved by percutaneous irrigation with hemiacidrin
* extracorporeal shock wave lithotripsy/ eswl
* open surgical removal of stones

Benign prostatic hyperplasia

2009-03-31T21:14:00.001+07:00

*prostatism: nocturia, hesitancy, slow stream, terminal dribbling, frequency
*residual urine
*acute urinary retention
*uremia in advanced cases
BPH is probably related to hormonal factors. Hyperplasia of the prostate causes increased outflow resistance. A higher intravesical pressure is required to accomplish voiding, causing hypertrophy of the vesical and trigonal muscles.
Stagnation of urine can lead to infection.
The size of the prostate rectally is not of primary diagnostic importance. The american urological association (AUA) developed a seven-items that can assist the patient and physician in evaluating the patients lower urinary tract symptoms (LUTS).
Laboratory:
Urinalysis reveal evidence of infection.
Residual urine is commonly increased >50cc.
Time urinary flow rate will be decreased <10-15 cc/s.
Serum prostate-specific antigen may be slightly elevated <4 ng/mL if it is over >10 ng/mL , cancer should be suspected.
Imaging:
The enlarged gland may cause an identation in the inferior surface of the bladder, which may result in a " J hook" deformity of the distal ureter. Pelvic ultrasound can obviate bladder catheterization and can also accurately predict the amount of residual urine.
Cystoscopic:
It will reveal secondary vesical changes (trabeculation) and enlargement of the periurethral prostatic glands. It may identify other conditions: bladder stones and tumors.
Treatment:
Conservative: alfa adrenergic blocking agents to relax the prostatic capsule and internal sphincter . 5alfa reductase inhibitors or antiandrogens to decrease the volume of the prostate. Catheterization is mandatory for acute urinary retention. Catheter should be left indwelling for 3 days while detrusor tone returns.
Surgical: indications are impairment of or threat to renal function and bothersome symptoms. Prostatectomy: transurethral resection/incision of the prostate(<50g), retropubic, suprapubic, and perineal.
- transurethral vaporization
- transurethral microwave chemotherapy
-transurethral needle/ultrasound ablation
-laser Prostatectomy

Obstruction of the large intestine

2009-03-30T10:15:00.002+07:00

-constipation-obstipation
-abdominal distention and sometimes tenderness
-abdominal pain
-nausea and vomiting
-characteristic x-ray finding
The wall of the right colon is thinner than that of the left colon and its luminal caliber is larger, so the cecum is at greatest risk of perforation in these circumstances. If the cecum acutely reaches a diameter of 10-12 cm, the risk of perforation is great.
deep, visceral, cramping pain from obstruction of the colon is usually referred to the hypogastrium. Borborygmus may be loud and coincident with cramps.
Feculent vomiting is a late manifestation.
Abdominal distention and tympany, and peristaltic waves may be seen if the abdominal wall is thin. High-pitched, metallic tinkles associated with rushes and gurgles may be heard on auscultation. Localized tenderness or a tender , palpable mass may indicate a strangulated closed loop. Fresh blood may be found in the rectum in Intussusception and in carcinoma of the rectum or colon. Colonoscopy may be diagnostic and perhaps therapeutic in some patients with strictures or Neoplasms.
Imaging
The distended colon frequently creates a picture frame. Water-soluble contrast medium should be used if strangulation or perforation is suspected.
Treatment
The primary goals of treatment are resection of all necrotic bowel and decompression of the obstructed segment to prevent prevent perforation .

Obstruction of the small intestines

2009-03-29T21:17:00.002+07:00

Complete proximal obstruction
-vomiting
-abdominal discomfort
-abnormal oral contrast x-rays or CT scan
Complete mid or distal obstruction
-colicky abdominal pain
-vomiting
-abdominal distention
-constipation-obstipation
-peristaltic rushes
-dilated small bowel on x-ray
-transition point on CT scan

Mechanical obstruction may be complete or partial. Simple obstruction occludes the lumen only. Strangulation obstruction impairs the blood also and leads to necrosis of the intestinal wall. Paralytic ileus / adynamic ileus, a disorder in which there is neurogenic failure of peristalsis to propel intestinal contents but no mechanical obstruction.
Etiology
1. Adhesions- from abdominal operations or inflammation, congenital bands
2. Neoplasms-particularly near the ileocecal valve
3. Hernia
4. Intussusception- invagination of one loop of intestine into another is rarely encountered in adults and is usually caused by a polyp or other intraluminal lesion .
5. Volvulus- results from rotation of bowel loops about a fixed point.
6. Foreign bodies
7. Gallstone ileus
8. Inflammatory bowel disease
9. Stricture
10. Cystic fibrosis
11. Hematoma

Swallowed air is the major source of gaseous distention because nitrogen is not well absorbed by mucosa. Bacterial fermentation produces gas too. Fluid fills the lumen proximal to the obstruction, because the bidirectional flux of salt and water is disrupted and net secretion is enhanced.
A. Simple obstruction
- presenting as profuse vomiting that seldom becomes feculent even in prolonged obstruction.
-upper abdominal pain/cramping periumbilical recurs every few minutes.
-vital sign may be normal
-dehydration
-abdominal distention is minimal to absent in proximal obstruction .
-peristalsis may be visible beneath the abdominal wall in thin patients .
-peristaltic rushes ,gurgles, and high-pitched tinkles are audible in coordination with attacks of cramping pain in distal obstruction.
-rectal examination is usually normal.
Laboratory:
-early stages may be normal
-there are hemoconcentration, leukocytosis, serum amylase, electrolyte abnormalities.
Imaging:
-supine and upright plain abdominal : a ladder like pattern, air-fluid levels. It May be minimal or absent in early obstruction .
-opaque Gallstones and air in the biliary tree should be looked for.
B. Strangulation obstruction
-shock that appears early in the course of obstruction suggests a strangulated closed loop.
-high fever may develop
-cramping abdominal pain become a severe countinuous ache.
-vomitus may contain gross or occult blood
Laboratory :
-Marked leukocytosis
-lactic acidosis does not resolve with volume resuscitation.
Imaging:
-intraperitoneal fluid
-loss of mucosal pattern.
Treatment :
1. Nasogastric suction/tube- to relieve vomiting, avoid aspiration, reduce abdominal distention.
2. Fluid and electrolyte resuscitation
-should begin with isotonic saline solution.
-not undergo operation until hypokalemia has been treated.
3. Antibiotics should be given
4. Required plasma or blood
5. Operation
-the patient has been rehydrated and vital organs are functioning satisfactorily.

Preoperative procedures associated with anesthesia

2009-03-28T10:15:00.001+07:00

perioperative complications and deaths are frequently caused by a combination of factors, including concurrent disease, complexity of the operation, and adverse effects of anesthesia.
Patients were evaluated the night before surgery. Higher-risk patients should be evaluated in a preoperative evaluation clinic one or more days preoperatively.
*physical status classification
1. Patien has no organic, physiologic, biochemical or psychiatric disturbance
2. Patien has mild to moderate systemic disturbance (eg. Essential hypertension, diabetes mellitus)
3. Patien has severe systemic disturbance
(eg. Heartdisease)
4. Patient has severe systemic disturbance that is life-threatening with or without surgery (eg. Congestive heart failure, persistent angina pectoris)
5. Patien is moribund and has little chance for survival, but surgery is to be performed as a last resort (eg. Uncontrolled hemorhage as from a ruptured abdominal aneurysm.
History and physical examination
The history shuld include a review of the patients previous experience with anesthesia, and data should be elicited regarding any allergic reactions, delayed aweking, prolonged paralysis from neuromuscular blocking drugs, and jaundice. The presence and severity of any concurrent disease(eg. Hepatitis), coagulopathies, diabetes mellitus or cardiorespiratory dysfunction should be note. Social history : drug, alcohol, and tobacco use and famili history.
The physical examination should focus on the cardiovascular system, lungs, and upper airway. If abnormalities are found, additional test (ecg, pulmonary function tests, etc) may be indicated.
Laboratory test
Eg, Elective surgery should not be performed if the hemoglobin concentration is less than 10 g/dl. More important is the need to determine why the patient is anemic.
Informed consent
Key components of an informed consent include decision-making capacity, patient voluntariness, disclosure, preferences of the reasonable person, legal issues in disclosure, recommendations, the patients understanding, clinical decisions, and autonomous authorization. The patient should be allowed to ask questions.

Postoperative pain

2009-03-25T22:20:00.001+07:00

The factors responsible for these differences includes duration of surgery, degree of operative trauma, type of incision, and magnitude of intraoperative retraction. Feelings such as helplessness, fear, and uncertainty contribute to anxiety and may heighten the patients perception of pain. The physiology of postoperative pain involves transmission of pain impulses via splanchnic (not vagal) afferent fibers to the central nervous system, where they initiate spinal, brain stem, and cortical reflexes. Spinal responses to skeletal muscle spasm, vasospasm, and gastrointestinal ileus. Brain stem responses to pain include alterations in ventilation, blood pressure, and endocrine function. Cortical responses include voluntary movements and psychologic changes, such as fear and apprehension. These emotional responses facilitate nociceptive spinal transmission, lower threshold for pain perception, and perpetuate the pain experience.
A. Physician-patient communication
Close attention, frequent reassurance, discussions with the patient every day.
B. Parental opioids
Side effects of Morphine include respiratory depression(rare because pain is powerful respiratory stimulant), nausea and vomitting, and clouded sensorium.
Meperidine is an opioid about one-eighth the potency of morphine. Hydromorphone in a dose of 1-2mg im every 2-3hours. Methadone in average dose 10mg im or orally every 4-6mg hours.
C. Nonopioid parental analgesic
Ketorolac(NSAID) 30mg has analgesic efficacy roughly equivalent to that of morphine 10mg. Complications (Nsaid) of ketorolac have not yet been reported with short-therm perioperative.
D. Oral analgesic
For more severe pain, oxycodon is an opioid with slightly less potency than morphine. Hydrocodone is a synthetic opioid with properties similar to those of codein.
E. Continous epidural analgesia
Epidural opioids produce intense, prolonged segmental analgesia with relatively less respiratory depression or sympathetic, motor, or other sensory disturbance. Epidural morphine is usually administered as a continuous infusion at a rate of 0,2-0,8 mg/h with or without the addition of 0,25% bupivacaine. Bladder catheterization is almost always required.

Chest x-ray suggestive of an aortic tear

2009-03-24T01:48:00.001+07:00

1. Widened mediastinum
2. Abnormal aortic contour
3. Tracheal shift
4. Nasogastric tube shift
5. Left apical cap
6. Left or right paraspinal stripe thickening
7. Depression of the left main bronchus
8. Obliteration of the aorticopulmonary window
9. Left pulmonary hilar hematoma

Antibiotic prophylaxis of surgical site infections

2009-03-22T19:18:00.002+07:00

the use of prophylactic antibiotics has been demonstrated to reduce the incidence of postoperative wound infections significantly. A single dose of an apropriate intravenous antibiotics or combination of antibiotics is as effective as multiple-dose regimens that extend into the postoperative period. The dose should be repeated every 3-4 hours to ensure maintenance of a therapeutic serum level. A first generation cephalosporin is as effective as later generation agents. All prophylactic antibiotics should be given intravenously at induction of anesthesia or roughly 30-60 minutes prior to the skin incision.
*Cefazolin 1-2g iv : head and neck, neurologic, thoracic, non cardiac vascular, orthopedic, cesarean, hysterectomy, gastroduodenal, billiary, urologic,breast and hernia
*Cefotetan/cefoxitin 1-2g: appendectomy, colorectal

Clinical spectrum of infection and sirs

2009-03-21T09:04:00.002+07:00

¥ infection= identifiable source of microbial insult.
¥ Sirs= two or more of following criteria T: >38'c or <36'c, Hr: >90 beats/min, Rr: >20 breaths/min, ^L: >12000/ml or <4000/ml or >10%band forms.
¥ sepsis= identifiable source of infection+sirs.
¥ severe sepsis= sepsis+organ dysfunction.
¥ septic shock= sepsis+cardiovascular collapse.

Hirschprung's disease

2009-03-18T23:23:00.003+07:00

dr. OS " congenital megacolon is caused by malformation in the pelvic parasympathetic system which results in the absence of ganglion cells in auerbachs plexus of a segment of distal colon. Not only is there an absence of ganglion cells, but the nerve fibers are large and excessive in number, indicating that the anomaly may be more extensive than the absence of ganglion cells".
Patient with hirschsprungs disease have an increased frequency of mutation in several genes, including GDNF, its receptor Ret, or its coreceptor Gfra-1. Initial investigations indicate that GDNF promotes the survival, proliferation, and migration of mixed population of neural crest cells in culture.
Clinical presentation: abdominal distention, failure to pass meconium (48 hours), and bilious emesis. Abnormal peristalsis, a functional distal intestinal obstruction. Complication is enterocolitis ( fever, failure to thrive, and lethargy, dehidrated.
The definitive diagnosis is made by rectal biopsy. Samples of mucosa and submucosa are obtained at 1cm, 2cm,3cm from dentate line.
Treatment: rehydration, antibiotics, nasogastric decompression, rectal irrigations. If HD doesnt respond to nonoperative management, a decompressive stoma is required. It is important to ensure that this stoma is placed in ganglion-containing bowel, which must be confirmed by frozen section at the time of stoma creation. HD requires surgery in all cases. This included a colostomy in the newborn period, followed by a definitive pull-through operation after the child weighed over 10kg.

Meckel's diverticulum

2009-03-18T22:30:00.004+07:00

A meckels diverticulum is remnant of a portion of the embryonic omphalomesenteric (vitelline) duct. It is located on the antimesenteric border of the ileum, usually within 60 cm of the ileocecal valve. Perforation of meckel's diverticulum may occur if the outpouching becomes impacted with food, leading to distension and necrosis. Diagnosis may be made by technetium pertechnetate scans when the patient with bleeding. Treatment is surgical. If the base is narrow and there is no mass present in the lumen of the diverticulum, a wedge resection of the diverticulum with transverse closure of the ileum can be performed. When a mass of ectopic tissue is palpable, if the base is wide, or when there is inflammation, it is preferable to perform a resection of the involved bowel and end-to-end ileoileostomy.

Specific musculoskeletal tumors

2009-03-18T07:01:00.002+07:00

bone forming tumors
*osteoma
This small, sessile benign body tumor occurs most often in the skull and neither causes symptoms nor requires treatmen. It consists of an abnormal excrescence of surface bone. Similar lesions occur posttraumatically on the femur in the area of the adductor magnus insersion (rider's bone), or in relation to the medial collateral ligament of the knee(pellegrini-stieda lesion).
*osteoid osteoma
Patients prevent with local pain, which can be quite severse and is often relieved by aspirin. Radiographically, a small (less than 1 cm) lucent lesion (nidus) is seen, typically surrounded by marked reactive sclerosis. Sometimes areas of radiodensity are seen within the lucent lesion, corresponding histologically to disorganized woven bone formation.

Colon normal physiology

2009-03-16T23:40:00.002+07:00

*fluid and electrolyte exchanges
- water, sodium, potassium, chloride, bicarbonate, and amonia.
Colon is a major site for waters absorption (1000-2000 mL/d) and electrolyte exchanges. Sodium is absorbed via Na-K ATPase. Water is absorbed passively along an osmotic gradient. Potassium is secreted into the colonic lumen and absorbed by passive diffusion. Chloride is absorbed via a chloride-bicarbonate exchange.
*short-chain fatty acids
Acetate, butyrate and propionate are produced by bacterial fermentation of dietary carbohidrates. Its important source of energi for the colonic mucosa
*colonic microflora and intestinal gas
Approximately 30% of fecal dry weight is composed of bacteria. endogenous microflora are crucial for the breakdown of carbohidrates and proteins in the colon and participate in the metabolism of bilirubin, bile acids, estrogen, and cholesterol also production of vit K.
*motility
The large intestine doesnt demonstrate cyclic motor activity. Colon displays intermitten contraction. Cholinergic activation increases colonic motility.
*defecation
Is a complex, coordinated mechanism involving colonic mass movement, increased intra-abdominal and rectal pressure, and relaxation of the pelvic floor.

Emergency care (burn)

2009-03-16T18:02:00.003+07:00

1. Care at the scene
-airway
initial attention must be directed to the airway. Any patient should be placed on 100% oxygen via a nonrebreather mask if there is any suspicion of smoke inhalation. If the patient is unconscious or respiratory distress, ET should be performed
-other injuries and transport
The patient is assessed for other injuries and then transported. Patients should be kept flat and warm and be given nothing by mouth.
- cold application
After several minutes have elapsed, further cooling does not alter the pathologic process. Iced water should never be used, even on the smallest of burns. If ice or cold water is used on larger burns, systemic hypothermia often follows, and the associated cutaneous vasoconstriction can extend the thermal damage.
2. Emergency room care
protocol ABC must be strictly followed.
-emergency assesment of inhalation injury
Careful inspection of the mouth and pharynx should be done early. Hoarsness and expiratory wheezes are signs of potentially serious airway edema or inhalation injury. Copious mucus production and carbonaceous sputum are positif signs.
A decreased p:f ratio, the ratio PaO2 to FIO2 is the earliest indicator of smoke inhalation. Ratio 400-500 is normal, ratio less than 300, impending pulmonary problem. Ratio 250 is a indication ET.
- fluid resuscitation
- tetanus prophylaxis
- gastric decompression
- pain control
- psychosocial care
2. Care of the burn wound
- escharotomy

The physiologic response to burn injury

2009-03-16T13:20:00.003+07:00

Sirs with infection is a major factor determining morbidity and mortality in thermally injured patients. Pathologic alterations of the metabolic, cardiovasculer, gastrointestinal, and coagulation systems occur, with resulting hypermetabolisme, increased cellular, endothelial and epithelial permeability, classic hemodynamic alterations, and often extensive microthrombosis.
A. Burn shock
It is not easily or fully repaired by fluid resuscitation. Tissue trauma and hypovolemic shock result in the formation and release of local and sistemic mediators, which produce an increase in vascular permeability and microvascular hydrostatic pressure.
-histamine, it predominantly disrupt venular endothelial tight junctions, permitting egress of fluid and proteins. Its involved only in the very early increase in microvascular permeability.
-seretonin, released immediately postburn via platelet aggregation, and acts directly to increase pulmonary vascular resistance, and indirectly to amplify the vasoconstrictive effects of norepinephrine, histamine, angiotensine II and select eicosanoids at the microvascular level
-eicosonoids, these subtances do not directly alter vascular permeability but increased levels of the vasodilator prostaglandins, such as PGE2, and prostacyclin /PGI2 result in arterial dilatation in burn tissue that increases blood flow and hydrostatic pressure in the injured microcirculation and accentuates edema formation.
-kinins, specifically the bradikinins, increase vascular permeability, primarily in the venule.
-as hematologically measured, it resembles disseminated intravascular coagulation and may correlate with organ failure and outcome.
B. Metabolic response to burn injury
*hypermetabolism
Resting energy expenditure/REE after burn injury can be as much as 100% above predictions based on standard calculations for size, age, sex, and weight. On average, the RRE is approximately 1,3 times the predicted BMR obtained using the harris-benedict equation.
Glucose is elevated in almost all critically-ill patient, including those with burn injuries.
Plasma insulin levels typically are elevated in burn patients. Which can be defined as hepatic insulin resistance
Lipolysis occured. The majority of released fatty acids are not oxidized, but rather re-esterified into triglycerides, resulting in fat accumulation in the liver.
Proteolisis is increased. Protein intake greater 1g/kg per day or 2g/kg per day with normal renal function.
*Neuroendocrine response
-catecholamine are massively elevated following burn injury, and appear to be the major endocrine mediators of the hypermetabolic response in thermally injured patient.
-growth hormone levels are attenuated following thermal injury.
-thyroid hormone serum concentrations are altered in patient with large burns. Total T3 and T4 are reduced and reverse T3 concentration are elevated.
C. Immunologic response to burn injury
The immune status of the burn patient has a profound impact on outcome in terms of survival and major morbidity.

Postoperative Care

2009-03-13T06:52:00.002+07:00

the recovery from major surgery can be divided into three phases
1. An immediate or postanesthetic phases
2. An intermediate phase, encompassing the hospitalization period
3. A convalescent phase

An immediate post operative period
A. Monitoring
1. Vital signs
2. Central venous pressure
3. Fluid balance
4. Other types of monitoring
B. Respiratory care
C. Mobilization and position in bed
D. Diet
E. Administration of fluid and electrolytes
F. Drainage tubes
G. Medications
H. Laboratory examinations and imaging

The intermediate postoperative period
A. Care of wound
B. Management of drains
C. Pulmonary care
D. Fluid and electrolyte management
E. Gastrointestinal tract care
F. Pain