By S. Roy. Cabarrus College of Health Sciences. 2018.
Masks deliver either a ﬁxed If higher inspired oxygen concentrations are concentration or have interchangeable Venturis to needed in a spontaneously breathing patient trusted dapoxetine 30 mg, a vary the oxygen concentration (Fig dapoxetine 30mg lowest price. A one-way valve diverts the oxygen ﬂow into patient that may cause crusting or thickening the reservoir during expiration. An inspired oxygen con- Hypotension centration of 100% can only be achieved by using either an anaesthetic system with a close-ﬁtting This can be due to a variety of factors, alone or facemask or a self-inﬂating bag with reservoir and in combination, that reduce the cardiac output, non-rebreathing valve and an oxygen ﬂow of the systemic vascular resistance or both (see also 12–15L/min. This is the commonest cause of hypotension after • Consider cross-matching blood if not already anaesthesia and surgery. Fluid loss may also occur as a result of tissue • Get surgical assistance if internal haemorrhage damage leading to oedema, or from evaporation suspected. Initially, systolic blood pressure Reduced myocardial contractility may be reduced minimally but the diastolic eleva- ted as a result of compensatory vasoconstriction The commonest cause is ischaemic heart disease, (narrow pulse pressure). The always be interpreted in conjunction with the diagnosis should be considered on ﬁnding: other assessments. Management The commonest cause of oliguria is hypovolaemia; anuria is usually due to a blocked catheter. If the diagnosis is unclear, a ﬂuid challenge (maxi- A tachycardia may not be seen in the patient taking mum 5mL/kg) can be given and the response ob- beta blockers and up to 15% of the blood volume served; an improvement in the circulatory status may be lost without detectable signs in a ﬁt, young suggests hypovolaemia. An arterial blood sample should be about the diagnosis, ﬂuids can be restricted ini- analysed; a metabolic acidosis is usually found tially and a diuretic (e. As the • inotropes, antiarrhythmics, bronchodilators; legs are taken down from the lithotomy position, • antidepressants in overdose. The patient may be pyrexial and if the cardiac output Coronary artery ﬂow is dependent on diastolic pressure is measured, it is usually elevated. Hypotension and tachycardia are therefore constriction ensues along with a fall in cardiac particularly dangerous. The diagnosis should be suspected in any patient who has had surgery associated with a sep- tic focus, for example free infection in the peri- Management toneal cavity or where there is infection in the Correction of the underlying problem will result in genitourinary tract. Spe- hours after the patient has left the recovery area, ciﬁc intervention is required if there is a signiﬁcant often during the night following daytime surgery. If there is is corrected by the administration of ﬂuids associated pyrexia, it may be an early indication of (crystalloid, colloid), the use of vasopressors (e. The combination of hypo- sists, then providing there is no contraindication a volaemia and vasodilatation will cause profound small dose of a beta blocker may be given intra- hypotension. Rarely, the quire early diagnosis, invasive monitoring and cir- development of an unexplained tachycardia after culatory support in a critical care area. Antibiotic anaesthesia may be the ﬁrst sign of malignant therapy should be guided by a microbiologist. Has an effect at the 78 Postanaesthesia care Chapter 3 chemoreceptor trigger zone and increases gastric sue trauma), most patients start drinking within motility. Severe to 1400, who is still unable to take ﬂuids by mouth side-effects, particularly dry mouth and blurred at 1800 will require: vision. This is The patient should be reviewed at 0800 with complemented by clinical evaluation of the pa- regard to further management. This is usually seen as thirst, a • any continued bleeding; dry mouth, cool peripheries with empty superﬁcial • rewarming of cold peripheries causing veins, hypotension, tachycardia and a decrease vasodilatation. An The patient who has undergone major surgery will additional 1L of Hartmann’s solution per 24h may require close monitoring to ensure that sufﬁcient need to be added to the above regimen to account volumes of the correct ﬂuid are administered. A for such losses and adjusted according to the pa- standard postoperative regimen for the ﬁrst 24h tient’s response. These losses may continue for up postoperatively might therefore consist of: to 48h after surgery and sufﬁcient extra volumes of • 1. The of the day as described above to ensure that the effect of this is to increase water absorption by the volumes and type of ﬂuid prescribed are adequate kidneys and reduce urine output. In addition: This results in sodium retention and increased uri- • The ﬂuid balance of the previous 24h must be nary excretion of potassium. Modern surgical treatment re- into the tissues, which have the same effect as any stores function more rapidly, a process facilitated other form of ﬂuid loss and are often referred to as by the elimination of postoperative pain. Such volumes are difﬁcult to example is the internal ﬁxation of fractures, fol- 80 Postanaesthesia care Chapter 3 lowed by potent analgesia allowing early mobiliza- what to expect postoperatively, what types of anal- tion. Ineffective treatment of postoperative pain gesia are available and also by allowing patients to not only delays this process, but also has other im- explore their concerns. Their nervous systems can be consid- pneumonia; ered to be sensitized to pain and will react more • muscle wasting, skin breakdown and cardio- strongly to noxious stimuli. Bad previous pain ex- vascular deconditioning; periences in hospital or anticipation of severe pain • thromboembolic disease—deep venous for another reason suggest that extra effort will be thrombosis and pulmonary embolus; required to control the pain. Prescribing should take these factors into • Economic costs: account rather than using them as an excuse for in- • prolonged hospital stay, increased medical adequate analgesia. There is no difference between complications; the pains suffered by the different sexes having the • increased time away from normal same operation. Pain following surgery on the • pain due to ischaemia from tissue swelling, body wall or periphery of limbs is less severe and haematoma formation restricting the circulation for a shorter duration. Regular measurement of pain means that it is more difﬁcult to ignore and the efﬁcacy of interventions Factors affecting the experience of pain can be assessed. There are a variety of methods of Pain and the patient’s response to it are very assessing pain; Table 3. The numeric score is to facilitate experiences and expectations rather than com- recording and allows trends to be identiﬁed.
Pathogenesis - The infection purchase 30mg dapoxetine amex, once established in the kidney generic dapoxetine 90mg amex, tuberculous granuloma is formed. Differential diagnoses of opacity in X-ray film are: - calcified mesenteric lymph node - Gall stones or concretion in appendix - Phlebolith or any calcified lesion Treatment: Most small ureteric stones and non-obstructive kidney stones can be managed conservatively by treating the pain and any underlying infection with analgesics and antibiotics and then expecting the stone to be washed out by the urine and following the patient taking a follow up x-ray. Big stones, obstructing the urine outflow, and failure of expectant treatment are the indication for the following. Benign tumors of the kidney vary greatly, and have little significance most of the time. Renal injuries Renal injuries are relatively uncommon injuries partly due to the inaccessible location of the kidneys in the retroperitoneum. Injuries to ureters are extremely rare in traumas; however ureteric injuries are fairly common in endoscopic ureteric procedures. Renal injuries can be divided as mild, moderate severe or first, second and third degree renal injuries respectively. First degree renal injury is an injury limited to the kidney parenchyma resulting in only subcapsular hematoma, hematuria may not be there. Second-degree renal injury is said to happen when the injury involved the pelvicalyceal system but not the renal major vessels, hematuria is evident Third degree renal injury is characterized by renal artery or renal vein involvement Clinical features Hematuria: - the most important symptom in renal injuries, extent and duration of hematuria determines the severity Pain in the flank area and hypochondrium Fullness, tenderness and bruises in the flanks may be detected Hypotension and shock in third degree injuries are seen Treatment Conservative: - first degree and some second degree renal injuries replacement of fluid and blood transfusion if needed catheterization and follow up Surgery: - severe forms of renal injury 229 Urinary Bladder Bladder Injuries The bladder is one of the visceral organs that are commonly involved in either blunt or penetrating injuries. Bladder rupture can be either intra peritoneal where urine peritonitis occurs and needs laparotomy and closure , While extra peritoneal rupture can be managed conservatively by passing an indwelling catheter. Bladder outlet obstruction This is the commonest presentation of all urologic problems and quite diverse disorders produce bladder outlet obstruction. If the cause is urethral stricture, suprapubic cystostomy is done to relieve the acute retention. Bladder Stones Stones are also formed in the bladder, and if stone is formed without any predisposing factor it is called primary vesical calculus. Whereas, a stone formed in the presence of distal obstruction or foreign body acting as a nidus, is called secondary vesical calculus. Clinical Feature - Males are more effected than females - Pain characteristically occurs at the end of micturition - The pain is referred at the end of the penis or labia majora - In young boys, screaming and pulling of the penis with hand at the end of micturition - Interruption of urinary stream and changing of body position to resume micturition. Diagnosis Radio opaque stone or filling defect in X-ray film 230 Treatment Cystolithotomy (Open surgical removal) Bladder Cancer Bladder tumor is common in people exposed to chemical carcinogens. Occupational exposure to chemicals such as dye factory workers and cigarette smoking are considered to be strongly associated with bladder cancer. More than 80% of bladder cancer is transitional cell origin and only 25% of the tumors are muscle invasive. Muscle invasive transitional cell Carcinoma is solid tumor, large based and possesses potential of distant metastasis to the lungs, bones and liver. Possible treatment is radical surgery, removing the bladder and lymph nodes around it, then urinary diversion. Benign prostatic Hyperplasia starts in the periurethral zone and as it increases in size it compresses the outer peripheral zone. The gland is acted upon by testosterone, male hormone, incriminated to cause the enlargement. Clinical Feature - acute urinary obstruction - Symptoms of prostatism (frequency , dysuria, urgency, dribbling, hesitancy) - Chronic retention, overflow incontinence, and renal insufficiency. Prostatic carcinoma Prostatic cancer is most common malignant tumor in men over the age of 65 years. Clinical Feature Advanced disease gives rise to symptoms including - Bladder out let obstruction - Pelvic pain and hematuria - Bone pain , renal failure Diagnosis and assessment - Rectal examination – stony hard gland with obliteration of the median sulcus. Bilateral orchidectomy The urethra and penis The urethra Congenital abnormalities Meatal stenosis This is a condition which usually follows fibrosis after circumcision and if left untreated leads to chronic retention then chronic renal failure Clinical Feature Spraying and dribbling in lesser degree of stenosis Urinary retention Treatment Meatotomy/meatoplasty (Plastic reconstruction of the meatus) Congenital valves of the posterior urethra This is a condition with presence of symmetrical of valves. It can cause obstruction to the urethra of boys and is not visualized on urethroscope. Hypospadias This is the most common congenital malformation where meatus open onto the under side of the penis, perineum or prepuce. Treatment Surgical repair Urethral Injuries There are two types • Rupture of the membranous urethra 233 • Rupture of the bulbar urethra: blow to the perineum is the mechanism of injury Clinical Features - Retention of urine - Perineal hematoma - Bleeding from the external meatus Treatment - No attempts to catheterize should be made before urethroscopy or urethrography - Suprapubic catheter insertion then surgery (urethroplasty) after 3 months. Rupture of the membranous urethra: most commonly due to pelvic fracture or can also be due to penetrating injuries. Treatment: is circumcision Paraphymosis: Is a condition in which tight foreskin is retracted and causes constriction to the penis. The Testis and Scrotum The Testis Incomplete Descent This is a condition in which the testis is arrested in some part of its path to the scrotum. Clinical Features - Right side in 50% of the cases - Left 30%, - bilateral in 20% The position of the undescended testis is intra abdominal or inguinal canal or in the superficial inguinal pouch. Hazards The risks of incomplete descent of the testes include - Sterility in bilateral cases - Pain due to trauma - Associated inguinal hernia - Torsion - Epididymo-orchitis - Atrophy - Increased liability to malignant diseases Treatment: Orchidopexy Testicular Torsion Torsion of the spermatic cord may cause ischemia and necrosis of the testis 235 Predisposing conditions - Inversion of the testis (rotated testes, upside down, or transverse lie) - High investment of the tunica vaginalis (clapper-bell deformity) - Separation of epididymis from the body of testis Clinical Features Most common between 10-25 years of age. Vomiting is also common Treatment emergency exploration is mandatory orchidectomy if necrotic testis is found, orchidopexy if viable orchiopexy is advised on the unaffected side Hydrocele Hydrocele is an abnormal collection of serous fluid in the tunica. Types include:- Primary Secondary Etiology: - excessive production and defective absorption Treatment: - Hydrocelectomy Malignant tumors of the Testis 1-2% of all malignant tumors are Testicular Carcinoma. Classification Tumors are classified based on Histologic predominant cells - Seminoma (40%) - Teratoma (32%) - Combined seminoma and teratoma (14%) - Lymphoma (7%) - Other (7%) Seminoma - Occurs in age range between 35-45 years - Extremely rare in children before puberty - Tumor compresses the neighboring structure as it grows - In rapidly growing tumors there may be areas of necrosis - Spread is via the lymphatics, blood born is rare. Clinical features: - Testicular tumors may be asymptomatic for several months except lump in the testis - Sensation of heaviness - Pain in one - third of the cases - On examination, the testis is enlarged, smooth, firm, and heavy. Outline the important steps of investigating a patient with right flank mass and hematuria. Discuss the management of a 13 year-old patient with intermittent urinary retention and initial hematuria. Outline common causes of acute urinary retention and indicate the recommended treatment.
Pharmacokinetics Following oral administration discount 30mg dapoxetine overnight delivery, oseltamivir is readily absorbed from the gastrointes- tinal tract 30 mg dapoxetine fast delivery. After conversion to the active metabolite oseltamivir carboxylate in the liver, it distributes throughout the body, including the upper and lower respiratory tract (Doucette 2001). The active metabolite is detectable in plasma within 30 minutes and reaches maximum concentrations after 3 to 4 hours. Once peak plasma concentrations have been attained, the concentration of the active metabolite declines with an apparent half-life of 6 to 10 hours (He 1999). In patients with renal impairment, metabolite clearance decreases linearly with creatinine clearance, and averages 23 h after oral administration in individuals with a creatinine clear- ance < 30 ml/min (Doucette 2001). A dosage reduction to 75 mg once daily is rec- ommended for patients with a creatinine clearance < 30 ml/min (1. The drug and the active metabolite are excreted by glomerular filtration and active tubular secretion without further metabolism (Hill 2001). Neither compound interacts with cytochrome P450 mixed-function oxidases or glucuronosyltransferases (He 1999). Thus, the potential is low for drug-drug in- teractions, which appear to be limited to those arising from competitive inhibition of excretion by the renal tubular epithelial cell anionic transporter. Probenecid blocks the renal secretion of oseltamivir, more than doubling systemic exposure oseltamivir carboxylate (Hill 2002). This competition is unlikely to be clinically 196 Drug Profiles relevant, but there has been speculation about using probenecid to “stretch” osel- tamivir stocks in situations of pandemic shortage (Butler 2005). The metabolism of oseltamivir is not compromised in hepatically impaired patients and no dose adjustment is required (Snell 2005). In elderly individuals, exposure to the active metabolite at steady state is approxi- mately 25 % higher compared with young individuals; however, no dosage adjust- ment is necessary (He 1999). Young children 1 to 12 years of age clear the active metabolite oseltamivir car- boxylate at a faster rate than older children and adults, resulting in lower exposure. Increasing the dose to 2 mg/kg twice daily resulted in drug exposures comparable to the standard 1 mg/kg twice daily dose used in adults (Oo 2001). Toxicity The most frequent side effects are nausea and vomiting which are generally of a mild to moderate degree and usually occur within the first 2 days of treatment. In many cases, it is not possible to reliably estimate their frequency or establish a cause relationship to oseltamivir exposure:! Aggravation of diabetes Oseltamivir use does not appear to be associated with an increased risk of skin re- actions (Nordstrom 2004); however, anecdotal reports describe isolated skin reac- tions, i. The use of oseltamivir in infants younger than 1 year is not recommended as studies on juvenile rats revealed potential toxicity of oseltamivir for this age group. Moreo- ver, high drug levels were found in the brains of 7-day-old rats which were exposed to a single dose of 1,000 mg/kg oseltamivir phosphate (about 250 times the recom- mended dose in children). Further studies showed the levels of oseltamivir phos- phate in the brain to be approximately 1,500 times those seen in adult animals. How- ever, given the uncertainty in predicting the exposure in infants with immature blood-brain barriers, it is recommended that oseltamivir not be administered to children younger than 1 year, the age at which the human blood-brain barrier is generally recognised to be fully developed (Dear Doctor-Letter, http://InfluenzaReport. Oseltamivir 197 Oseltamivir is a pregnancy category C drug, as there are insufficient human data upon which to base a risk evaluation of oseltamivir to the pregnant woman or de- veloping foetus. In lactating rats, oseltamivir is excreted in the milk, but oseltamivir has not been studied in nursing mothers and it is not known, if oseltamivir is excreted in human milk. After reports of psychological disorders in patients treated with oseltamivir, Japa- nese authorities have amended the patient information to list psychiatric effects, such as delusions, in the list of side effects. Efficacy Treatment Oseltamivir, 75 mg bid for 5 days, administered to otherwise healthy adults with naturally acquired febrile influenza when started within 36 hours of the onset of symptoms, reduced the duration of the disease by up to 1. Earlier initiation of therapy was associated with a faster resolution: initiation of therapy within the first 12 h after fever onset reduced the total median illness duration 3 days more than intervention at 48 h. In addition, the earlier administration of oseltamivir reduced the duration of fever, severity of symptoms and the times to return to baseline activity (Aoki 2003). A meta-analysis of 10 placebo-controlled, double-blind trials suggests that oseltamivir treatment of influenza illness reduces lower respira- tory tract complications, use of antibacterials, and hospitalisation in both healthy and “at-risk” adults (Kaiser 2003). The efficacy and safety of oseltamivir in patients with chronic respiratory diseases (chronic bronchitis, obstructive emphysema, bronchial asthma or bronchiectasis) or chronic cardiac disease has not been well defined. In one small randomised trial oseltamivir significantly reduced the incidence of complications (11 % vs. Oseltamivir treatment may be less effective for influenza B than for influenza A (for efficacy against H5N1 strains, see below). A cost-utility decision model, including epidemiological data and data from clinical trials of antiviral drugs, concluded that for unvaccinated or high-risk vaccinated patients, empirical oseltamivir treatment seems to be cost-effective during the influ- enza season, while for other patients, treatment initiation should await the results of rapid diagnostic testing (Rothberg 2003). Prophylaxis When used in experimentally infected individuals, prophylactic use of oseltamivir resulted in a reduced number of infections (8/21 in the placebo group and 8/12 in the oseltamivir group) and infection-related respiratory illness (4/12 vs. These findings were confirmed by a clinical trial in 1,559 healthy, non-immunised adults aged 18 to 65 years, who received either 198 Drug Profiles oral oseltamivir (75 mg or 150 mg daily) or placebo for six weeks during a peak period of local influenza activity (Hayden 1999b). A meta-analysis of seven prevention trials showed that pro- phylaxis with oseltamivir reduced the risk of developing influenza by 70-90 % (Cooper 2003). A cost-effectiveness analysis based on a decision analytic model from a govern- ment-payer perspective calculated that the use of oseltamivir post-exposure pro- phylaxis is more cost-effective than amantadine prophylaxis or no prophylaxis (Risebrough 2005). Another recent meta-analysis, however, found a relatively low efficacy of oseltamivir (Jefferson 2006), leading the authors to conclude that osel- tamivir should not be used in seasonal influenza control and should only be used in a serious epidemic and pandemic alongside other public health measures. Selected Patient Populations A double-blind, placebo-controlled study investigated the efficacy of once-daily oral oseltamivir for 6 weeks as a prophylaxis against laboratory-confirmed clinical influenza in 548 frail older people (mean age 81 years, > 80 % vaccinated) living in homes for seniors (Peters 2001). Compared with placebo, oseltamivir resulted in a 92 % reduction in the incidence of laboratory-confirmed clinical influenza (1/276 = 0.
Therefore generic dapoxetine 30 mg visa, to decrease airborne infections dapoxetine 60mg discount, keep the number of personnel reduced to a minimum. If there is no system to provide this, windows should be open to allow ingress of fresh outside air and escape of anesthetic gases. At regular intervals, conduct a more thorough cleaning by mopping the floor and washing the walls with detergents. Instruments All instruments and garments to be used in surgical procedures must be sterile and this is attained by sterilization. Sterilization: - is a process by which inanimate objects are made free of all microorganisms. It uses steam at a pressure of 750 0 mmHg above atmospheric pressure and temperature of 120 C for 15-30 minutes. Appropriate indicators must be used each time to show that the sterilization is accomplished. Noxythiolin:- Releases formaldehyde in contact with tissues, broad spectrum, expensive, weak and slowly bactericidal Alcohol plus chlorhexidne Alcohol plus povidon iodine useful mixtures Chlorhexidine plus cetrimide 40 Review Questions 1. Using your knowledge of the properties of the different antiseptics which one would you choose for your heath center? What is the most important measure you would take for a patient who comes to the emergency room with a contaminated wound? Types of Suture Materials Suture materials can generally be classified as absorbable and non absorbable. Catgut (natural or biologic type) Vicryl (Synthetic) Non absorbable: This is a type of suture material that remains unabsorbed by the tissue. Figure 2: Continuous Sutures Useful Tips: • Place a single suture and ligate but only cut the short end of the suture. Figure 3: Mattress Sutures Fig 3 a: Horizontal Fig 3 b: Vertical Mattress sutures may be either vertical or horizontal. Small bites of the subcuticular tissues on alternate sides of the wound are taken and then pulled carefully together. Introduction Successful wound management with rapid and complete healing and minimal complication depends on understanding the basic principles of assessment, bacteriology and application of the general principles of wound care. The primary goal of wound management is to aid the natural body process to produce optimal functional and cosmetic result. This requires an understanding of the basic principles of wound care and the process of healing. Failure to do this may result in delay of healing and unwanted secondary complications which may be distressing to the physician, patient and family and may lead to greater economic loss. It is caused by a transfer of any form of energy into the body which can be either to an externally visible structure like the skin or deeper structures like muscles, tendons or internal organs. There are integrated sequences of events leading to cellular proliferation and remodeling. It is characterized by vaso-constriction, clot formation and release of platelets and other substances necessary for healing and help as a bridge between the two edges. It is characterized by classical inflammatory response, vasodilatation and pouring out of fluids, migration of inflammatory cells and leukocytes and rapid epithelial growth. It is characterized by fibroblast, epithelial and endothelial proliferation, Collagen synthesis, and ground substance and blood vessel production. Equilibrium between protein synthesis and degradation occurs during this phase with cross linking of collagen bundles leading to slow and continuous increase in tissue strength of the wound to return to normal. Clinical types of healing Traditionally, wound healing can be classified into three clinical types: Healing by first, second and third intention. Healing by first intention: This is a type of healing of clean wound closed primarily to approximate the ends. Healing by Second intention: This occurs in wide, contaminated wounds, which are not primarily closed. Healing takes place by granulation tissue formation, tissue contraction and epithelialization. Healing by third intention: This occurs in wounds which are left open initially for various reasons and closed later (delayed primary closure) 48 Factors affecting healing Healing of a wound can be affected by various conditions. In the history, one has to answer the following principal questions: • How the wound was caused and what caused it? General inspection and specific tests have to be done to assess the following conditions: • Extent of skin loss • Degree of circulation • Damage to nerves, tendons, bone and other structures (deep under) the skin • The degree of contamination • Presence of foreign body and tissue necrosis 49 Classification of wounds Once wound is carefully assessed, it is necessary to classify into a specific type in order to plan a proper management scheme. Closed wounds: These are wound types, which have an intact epithelial surface, and skin cover not completely breeched. Example: Contusion, Bruise, Hematoma Open wounds: These are wounds caused by injury which leads to a complete breakt of the epithelial protective surface. Example: Abrasion, Laceration, Puncture, Missile injuries, Bites… The following method is the traditional surgical wound classification scheme that was introduced in 1964. This method classifies wounds according to the likelihood or rate of wound infection. Clean: Non-traumatic, non-infected wound, no break in sterility technique, the respiratory, gastrointestinal or genitourinary tracts not entered. Clean-contaminated: Minor break in technique, oropharynx entered, gastrointestinal or respiratory tracts entered without significant spillage, genitourinary or biliary tracts entered in absence of infected urine or bile. If other serious conditions exist, which endanger the patient’s life, the wound should be covered with sterile gauze and priorities attended to. However, the goal in all cases is to establish a good environment to assist wound healing and prevent infection. Proper wound care includes the following measures: • Adequate hemostasis locally to stop bleeding.
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