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%.
Saturday, April 18, 2009
inguinal hernia
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.
-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
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.
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.
Subscribe to:
Posts (Atom)
