Pituitary gland disorders and anesthetic management

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Describes the anaesthetic management of pituitary surgeries

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Pituitary gland disorders and anesthetic management

  1. 1. PITUITARY GLAND DISORDERS AND ANESTHETIC MANAGEMENTPRESENTER : DR UNNIKRISHNAN P. COORDINATOR : DR MAYA MODERATORS: DR JAYAKUMAR DR RAVI
  2. 2. .
  3. 3. WE HAVE TO• optimize the patient undergoing the surgery
  4. 4. WE HAVE TO• take care of the patient perioperatively
  5. 5. ANATOMY
  6. 6. .
  7. 7. .SOMATOTROPES 50% GHMAMMOTROPES 25% PROLACTINCORTICOTROPES 15% ACTHTHYROTROPES 10% TSHGONADOTROPES 10% LH & FSHNULL CELLS INERT
  8. 8. ANATOMY
  9. 9. ANATOMY
  10. 10. CONTROL OF PITUITARY FUNCTION
  11. 11. ↑ACTHCORTICOTROPIN RELEASINGHORMONE .THYROTROPIN RELEASING HORMONE ↑TSH & PROLACTINGROWTH HORMONE RELEASING ↑GHHORMONEGROWTH HORMONE INHIBITING ↓GH &TSHHORMONE[SOMATOSTATIN]GONADOTROPIN RELEASING ↑LH & FSHHORMONEPROLACTING INHIBITING HORMONE ↓PROLACTIN
  12. 12. DISORDERS OF PITUITARY FUNCTION
  13. 13. HYPOPITUITARISMAETIOLOGYDEVELOPMENTAL: KALLMANN SYNDROMETRAUMATIC: SURGERY RADIATION HEAD INJURYNEOPLASM : PITUITARY ADENOMA CRANIOPHARYNGIOMARATHKE’S CYST METASTASISINFILTRATORY / INFLAMMATORY : SARCOIDOSISVASCULAR : PITUITARY APOPLEXY SHEEHANS SYNDROMEINFECTION
  14. 14. CLINICAL FEATURES
  15. 15. CLINICAL FEATURES
  16. 16. LAB DIAGNOSIS• PRINCIPLE:• DEMONSTRATE LOW LEVELS OF TROPIC HORMONES IN THE SETTING OF LOW TARGET HORMONE LEVELS..
  17. 17. LAB DIAGNOSISHORMONE TESTSGROWTH HORMONE INSULIN TOLERANCE TEST, GHRH TEST, L-DOPA TESTPROLACTIN TRH TESTACTH INSULIN TOLERANCE TEST METYRAPONE TEST , ACTH STIMULATION TESTLH/FSH GnRH TESTCOMBINED ANTERIORPITUITARY TEST
  18. 18. TREATMENTDEFICIENCY REPLACEMENT HYDROCORTISONE 10-20 MG AM 5- 10 MG PMTSH L-THYROXINE 0.075-0.15 MG DAILYFSH / LH males TESTOSTERONE ENANTHATE 200MG IM EVERY 2 WEEKS females CONJUGATED OESTROGEN 0.65- 1.25MG QD X 25 DAYSGH SOMATOTROPIN 0.1-1.25 MG SC QDVASOPRESSIN INTRANASAL VASOPRESSIN 5-20µG BD
  19. 19. CURRE <10 MG ASSUME ADDITIONAL STEROID COVER NOTNTLY QD NORMAL HPA REQUIREDTAKIN [PREDNIS AXISGSTERO STEROID REPLACEMENT OLONE]ID >10MG QD MINOR 25MG HYDROCORT. AT INDUCTION SURGERY MODERATE USUAL PREOP.DOSE + 25MG SURGERY HYDROCORT. AT INDUCTION + 100MG/ DAY FOR 24 HRS MAJOR USUAL PREOPERATIVE STEROID + SURGERY 25 MG HYDROCORTISONE AT INDUCTION +100MG/DAY X 48-72 H HIGH GIVE SAME DOSESTOPPE < 3 MS TREAT AS IF OND STEROIDS >3 MS NO PERIOP. STEROID
  20. 20. STEROIDSUPPLIMENTATION[Miller/7/e] SURGERY HYDROCORTISONE MAJOR 200 MG/DAY PER 70 KG MINOR 100 MG/DAY PER 70 KG DECREASE THE DOSE BY 25%/DAY UNTIL ORAL FEEDS START, THEN USUAL MAINTENANCE DOSE
  21. 21. PITUITARY TUMOURS
  22. 22. TYPES• ADENOMAS ARE THE COMMONEST CAUSE OF ABNORMAL ENDOCRINE PITUITARY FUNCTION• 10-15% OF ALL INTRACRANIAL TUMORS• MOST ARE BENIGN; 50% PROLACTINOMAs CELL TYPE HORMONE SYNDROME LACTOTROPE PROLACTIN HYPOGONADISM GALACTORRHOEA GONADOTROPE FSH / LH HYPOGONADISM SOMATOTROPE GH ACROMEGALY GIGANTISM CORTICOTROPE ACTH CUSHINGS DISEASE
  23. 23. EFFECTSIMPACTED STRUCTURE CLINICAL IMPACTPITUITARY HORMONAL IMBALANCEOPTIC CHIASMA VISUAL FIELD ABNORMALITIES OPTIC /OCULOMOTORHYPOTHALAMUS TEMPERATURE DYSREGULATION APPETITE/THIRST DISORDERS OBESITY DIABETES INSIPIDUSCAVERNOUS SINUS OPHTHALMOPLEGIAFRONTAL LOBE PERSONALITY DISORDERBRAIN HEADACHE HYDROCEPHALUS EPILEPSY
  24. 24. EVALUATION ANDDIAGNOSIS IN GENERALBASAL PROLACTIN LEVELS, TFTHIGH QUALITY MRIOPHTHALMIC EVALUATION NECESSARYTREATMENT : DEPENDS ON TUMORSURGERY /RADIATION/MEDICAL
  25. 25. Craniopharyngiomas• are benign, suprasellar cystic masses that present with headaches, visual field deficits, and variable degrees of hypopituitarism. They are derived from Rathkes pouch and arise near the pituitary stalk
  26. 26. RATHKE’S CYSTS• Developmental failure of Rathkes pouch obliteration may lead to Rathkes cysts• compressive symptoms, diabetes insipidus, and hyperprolactinemia due to stalk compression
  27. 27. ACTH SECRETING TUMORSCLINICAL CONDITION RESULTINGFROM INCREASED ACTH SECRETIONBY PITUITARY ADENOMA-”CUSHINGSDISEASE”MOST ARE MICROADENOMASMORE IN WOMENEARLY DIAGNOSIS
  28. 28. ACTH SECRETING TUMORSMOONS FACE BUFFALO OBESITYPROXIMAL MYOPATHY OSTEOPOROSISVERTEBRAL COLLAPSESTRIAE HIRSUITISM ACNEDIABETESHYPERTENSION LVHHYPERNATREMIA HYPOKALEMIA ALKALOSISOSASGERDRENAL STONE MENTAL DISTURBANCE
  29. 29. ACTH SECRETING TUMORSDIFFERENCE FROM ECTOPIC ACTHPRODUCING TUMORS: SLOW ONSET,HYPOKALEMIA LESS INTENSE,HIGHDOSE STEROID CAN SUPPRESSCORTISOL SECRETION UNLIKE AS INECTOPIC PRODUCTION OF CORTISOL
  30. 30. ACTH SECRETING TUMORSDIAGNOSISURINARY FREE CORTISOLHIGH DOSE DEXAMETHASONESUPPRESSION TEST [2MG Q6H X 48h]CRH TEST EXAGGERATED RESPONSEACTH  UNDETECTABLE ADRENAL TUMOR 10-100 ng/L PITUITARY DEPENDENT >200 ng/L ECTOPIC ACTH SECRETION
  31. 31. ACTH SECRETING TUMORSTREATMENTSURGERY-CURATIVE IN <80%PRETREATMENT WITHMETYRAPONE/BETACONAZOLEREVERSES EFFECTS OF EXCESSCORTISOL AND DECREASEPERIOPERATIVE MORBIDITY
  32. 32. ACTH SECRETING TUMORSPERIOPERATIVE CONCERNSBLEED EASILYTENDS TO HAVE HIGH CVPPROPER Rx OF HTN AND DMENSURE NORMAL INTRAVASCULARVOLUME & ELECTROLYTESOSTEOPENIAHIGH CHANCE OFFRACTURES CAREFUL POSITIONINGIMMUNOSUPPRESSION / INFECTION
  33. 33. PROLACTINOMAS>50% OF FUNCTIONING TUMOURSMAJORITY ARE MICROADENOMAMORE IN WOMEN [90%]2º AMENORRHOEA, INFERTILITY,GALACTORRHOEAMACROADENOMA MORE IN MENPRESSURE EFFECTS MAIN SYMPTOMPROLACTIN >400 mU/ L
  34. 34. PROLACTINOMAS:RxM E D I C A LFIRST LINE;CURATIVE IN UPTO 95%CABERGOLINE [LONG ACTING]BROMOCRIPTINE [SHORT ACTING]S U R G I C A LONLY IF DOPAMINE RESISTANCE/SIDE EFFECTSINVASIVE ADENOMA, COMPROMISING VISION
  35. 35. ACROMEGALY
  36. 36. GH GH GH everywhere…GH hyper secretion from a pituitarymacroadenomaIf occurs before epiphyseal fusionGigantismAfter epiphyseal fusionAcromegaly
  37. 37. Clinical FeaturesFACE INCREASE IN SIZE OF SKULL AND SUPRAORBITAL RIDGES ENLARGED MANDIBLE *large blade* INCREASE IN SPACING BETWEEN TEETH MALOCCLUSSIONHANDS&FEET SPADE SHAPED CARPAL TUNNEL SYNDROME INCREASED HAND AND FOOT SIZE *SpO2 probe*MOUTH&TONGUE MACROGLOSSIA ,THICKENED PERI EPIGLOTTIC FOLDS AND LARYNGEAL SOFT TISSUES SMALL LARYNGEAL APERTURE *difficult laryngoscopy* OBSTRUCTIVE SLEEP APNOEASOFT TISSUE THICK SKIN DOUGH LIKE FEEL TO PALMSKELETAL VERTEBRAL ENLARGEMENT KYPHOSIS OSTEOPOROSISCVS HYPERTENSION CARDIOMEGALY LV DYSFUNCTIONENDOCRINE IMPAIRED GLUCOSE TOLERANCE, DIABETESOTHERS ARTHROPATHY, PROXIMAL MYOPATHY THYROID ENLARGEMENT *tracheal compression* RLN PALSY
  38. 38. DIAGNOSIS24 H GROWTH HORMONE LEVELSELEVATED S.IGF LEVELSORAL GLUCOSE TOLERANCE TEST FAILURE OF GROWTH HORMONE SUPPRESSION TO TO <1µG/L WITHIN 1-2 HRS OF AN ORAL GLUCOSE LOAD 75G
  39. 39. TREATMENTSURGICAL RESECTION [cure rate upto 70%]Soft tissue swelling improvesGH level returns to normalIGF-1 levels normalisedComplication : hypopituitarism ,recurrence
  40. 40. TREATMENTMEDICALDopamine agonists: Bromocriptine, CabergolineSomatostatin Analogues: Octreotide ,Lanreotide preoperative shrinkageGH receptor antagonist : Pegvisomant
  41. 41. PRE ANESTHETIC CHECK-UPDETAILED & CAREFUL AIRWAY ASSESSMENTINDIRECT LARYNGOSCOPYOSAS : SNORING , DAYTIME SLEEPINESSCENTRAL RESPIRATORY DEPRESSIONPERIOPERATIVE AIRWAY COMPROMISE : RISK OFDEATH IS 3 FOLD HIGHHYPERTENSION : ARRHYTHMIAS,CCF CHECKANTIHYPERTENSIVESLV DYSFUNCTIONDIABETES MELLITUS [IN 50%]VISUAL FUNCTIONRAISED ICPHORMONAL FUNCTION: CHECK RECENT REPORTS /OPTIMIZE
  42. 42. SURGERYAPPROACHES TRANS SPHENOIDAL TRANS ETHMOIDAL TRANS CRANIAL
  43. 43. WHY TRANSSPHENOIDAL APPROACH RAPID ACCESS LESS TRAUMA, LESS BLEEDING LESS COMPLICATIONS
  44. 44. OTHER APPROACHESTRANS FRONTAL : IF SUPRASELLAREXTENSION / POSTOP SEIZURESPTERIONAL CRANIOTOMYTRANSCRANIAL : IF SMALLSPHENOID;S/E HIGH CHANCE OFHYPOPITUITARISM
  45. 45. REMEMBER TO GIVE..HYDROCORTISONE 100 MG•.PROPHYLACTIC ANTIBIOTICS•.
  46. 46. ACCESSING THE AIRWAY… BAG & MASK VENTILATION: MAY NEED OROPHARYNGEAL AIRWAY 4 GRADES OF AIRWAY INVOLVEMENT GRADE 3 & 4 : TRACHEOSTOMY FIBREOPTIC LARYNGOSCOPYGRADE 1 NO SIGNIFICANT INVOLVEMENTGRADE 2 NASAL & PHARYNGEAL MUCOSA HYPERTROPHYGRADE 3 GLOTTIC STENOSIS / VOCAL CORD PARESISGRADE 4 2&3 i.e. GLOTTIC & SOFT TISSUE INVOLVEMENT
  47. 47. SO BE READY WITH……• LARGER FACE MASKS• LONG BLADED LARYNGOSCOPS• ILMA• FIBREOPTIC LARYNGOSCOPE IF AVAILABLE• TRACHEOSTOMY SET• N.B.NASAL INTUBATION HAZARDOUS IF PREVIOUS TRANSSPHENOIDAL SURGERY HAS BEEN DONE
  48. 48. POST INTUBATIONPOSITION TUBE TO ALLOW ACCESS TO THE INCISION SITE PACK THE MOUTH AND POSTERIOR PHARYNX ↓LARYNGOSPASM ↓PONV LUMBAR DRAIN IF SUPRASELLAR EXTENSION SUPRASELLAR PART PROLAPSES10 ML ALIQUOTES OF .9% SALINE INTO FIELD
  49. 49. TRANSSPHENOIDAL ROUTEENT SURGEON WILL ASSIST NEUROSURGEONXYLOMETAZOLINE SAFER FOR PREPARATION OF NASAL MUCOSASUPINEMODERATE DEGREE HEAD UP / CAUTION:IF >15ºHEAD SLIGHTLY TURNED {CAUTION : NECK VEINS ? OBSTRUCTION}SURGEON BEHIND THE HEAD OR TO THE RIGHT OR LEFTETT & BAINS CIRCUIT AWAY FROM FIELDC-ARM : WEAR LED APRON
  50. 50. .• .
  51. 51. .
  52. 52. INTRAOPERATIVE PERIOD
  53. 53. EFFECT OF AGENTS ON SECRETION OF HORMONES NOT A BIG CONCERN .↑ ICP : ? TIVA BETTER ? AVOID NITROUS OXIDESHORT ACTING AGENTS HASTEN RECOVERY AT END { PROPOFOL,SEVOFLURANE ETC}VENTILATE TO NORMOCAPNOEAPERIODS OF INTENSE STIMULATION : SHORT ACTING OPIOIDPATIENT SHOULD NOT WAKE UP WITH PAIN ? IV MORPHINE 20’ BEFORE ENDB/L MAXILLARY NERVE BLOCK PREVENT HYPERTENSIVE RESPONSE DURINGGAEXAGGERATED RESPONSE TO EPINEPHRINE [ WITHOUT HALOTHANE]TEMPERATURE DYSREGULATIONHYPOGLYCEMIAABNORMAL ENDOCRINE FUNCTIONCHANCE OF CAROTID ARTERY INJURY
  54. 54. .
  55. 55. .
  56. 56. MONITORS
  57. 57. COMPLICATIONSTRANS TRANS CRANIALSPHENOIDALINJURY TO FRONTAL LOBE ISCHEMICCAROTID DAMAGEINJURY TO INJURY TO OPTIC CHIASMAPONS POST OP SEIZURES [SUBFRONTAL] ANOSMIA
  58. 58. EXTUBATIONRAPID & SMOOTH EMERGENCE NEEDEDFOR NEUROLOGICAL ASSESSMENTSUCTION UNDER DIRECT VISIONREMOVE THROAT PACK ; BUT DON’TDISLODGE NASAL PACKS & STENTSRETURN OF RESPIRATION,LARYNGEALREFLEXESOBEYING TO VERBAL COMMANDSEXTUBATION
  59. 59. Postoperative concerns….AIRWAYBLOOD IN ORO AND NASOPHARYNXNASAL PACKSPREDISPOSITION TO AIRWAYOBSTRUCTIONNASAL CPAP CANT BE APPLIEDNARCOTICS WITH CAUTION
  60. 60. Post operative concerns…ANALGESIAPAIN : TRANSSPHENOIDAL-MODERATETRANSCRANIAL-MORE INTENSENASAL PACK-DISTRESSINGCODEINEMORPHINE i.m.MORPHINE PCA
  61. 61. Post operative concerns..ENDOCRINE MANAGEMENTHYDROCORTISONE 50-50,25-25,20-10[6pm]Prolactinoma :few days / Cushings :few monthsENDOCRINOLOGY REVIEW
  62. 62. POSTOPERATIVE COMPLICATIONSDIABETES INSIPIDUSSUSPECT IF URINE O/P >2mL/Kg/h &S.Na >143 mmol/LPOLYURIA,THIRSTSEND PLASMA OSMOLARITY[>295mosm/Kg] AND URINEOSMOLARITY [<300 mosm/Kg]
  63. 63. POSTOPERATIVE COMPLICATIONS:D.I.IF AWAKE AND NORMAL THIRST: FLUIDSCOMA/THIRST MECHANISMABOLISHED/VERY HIGH URINE VOLUMEDESMOPRESSIN ACETATE [DDAVP]PROBLEM:HYPONATREMIAUSUALLY RESOLVES IN FEW DAYS
  64. 64. POSTOPERATIVE COMPLICATIONSHYPONATREMIACAUSES : DDAVP Rx, SIADHMONITOR S.ELECTROLYTESFLUID RESTRICTIONUSUALLY RESOLVE WITHIN 10 DAYSNATRIURESIS+DIURESIS  CEREBRALSALT WASTING SYNDROMEDD: SIADH
  65. 65. POSTOPERATIVE COMPLICATIONSSIADH: WATER RETENTION Rx :WATER RESTRICTIONCSW  Rx : HYPERTONIC SALINE
  66. 66. POSTERIOR PITUITARY
  67. 67. DIABETES INSIPIDUSEXCRETION OF ABNORMALLY LARGEAMOUNTS OF DILUTE URINE24H URINE VOLUME >50ML/KG ANDOSMOLARITY <300MOSM/LURINARY FREQUENCY,NOCTURIA,DAY TIME FATIGUE, POLYDIPSIA
  68. 68. COMPLETE D. INSIPIDUSNEOPLASM CA BRONCHUS-SMALL CELL CA,CA PANCREAS,CA PROSTATECNS DISORDERS MENINGITIS,HEAD INJURY,CVA,HYDROCEPHALUS,GBSPULMONARY TB , PNEUMONIADRUGS CHLORPROPAMIDE ANTIDEPRESSANTS HALOPERIDOL CARBAMAZEPINE CHEMOTHERAPY THIAZIDES MORPHINE NSAIDSPOST-OP PAIN NAUSEA
  69. 69. CAUSESCRANIAL / NEUROGENICIDIOPATHICTRAUMA / POST SURGICALTUMOURVASCULAR [SHEEHAN’S SYNDROME,AORTO-CORONARY BYPASS]GRANULOMAINFECTIONSFAMILIALNEPHROGENICGENETICMETABOLIC : HYPOKALEMIA , HYPERCALCEMIADRUG : LITHIUM , DEMECLOCYCLINPOISONING :HEAVY METALPOST OBSTRUCTIVE : PROSTRATE , URETERALVASCULAR : SICKLE CELL DISEASE
  70. 70. INVESTIGATIONS• WATER DEPRIVATION TEST WATER PITUITARY EXOGENOUS DEPRIVATION VASOPRESSIN VASOPRESSIN D.I.INCREASE NORMAL NO IN URINE EFFECT OSMOLARITY
  71. 71. TREATMENT PITRESSIN • 5u / mL im TANNATE • Q48H SYNTHETIC • 50 u / mL in isotonic saline LYSINEVASOPRESSIN • DRODID nasal spray • 1-2µg bd iv or s/cDESMOPRESSIN • 10-20 µg bd/tid nasal spray • 100-400 µg bd / tid orally
  72. 72. DESMOPRESSIN1-Deamino 8-D Arginine VasoPressin [DDAVP]ONSET 15 MIN AFTER INJ, 60 MIN AFTER ORALACTS SELECTIVELY AT V2 RECEPTORS TO INCREASE URINE CONCENTRATIONOTHERS:THIAZIDES/CHLORPROPAMIDE CARBAMAZEPINE CLOFIBRATE
  73. 73. PERIOPERATIVE MANAGEMENTPOST HYPOPHYSECTOMY• RECOVER IN FEW DAYS TO 6 MONTHSPOST HEAD TRAUMA /POSTSURGERY• RECOVER AFTER A SHORTER PERIOD
  74. 74. COMPLETE D. INSIPIDUSJUST BEFORE SURGERYUSUAL DOSEINTRA NASALLY OR aq.VASOPRESSIN100 mU IV BOLUS F/B CONSTANTINFUSION OF 100-200 mU/HRISOTONIC IVFsP.OSMOLARITY HOURLYIF >290 mOsm/L  HYPOTONIC IVFsINCREASE VASOPRESSIN INFUSION >200mU/ HR
  75. 75. PARTIAL D. INSIPIDUSPOST OPERATIVELY, INTRANASALVASOPRESSIN / PITRESSIN TANNATE5-10 U /DAY IM
  76. 76. CONCERNS: VASOPRESSINOXYTOCIC PROPERTIES [CAUTIONPREGNANCY]CORONARY VASOCONSTRICTOR[CAUTION CAD]STICK TO CORRECT DOSE
  77. 77. SIADHWATER OVERLOAD, LOW SERUMOSMOLARITY,HYPONATREMIA…STILL.. PERSISTENT ADH SECRETION MORE WATER RETENTION
  78. 78. CLINICAL FEATURES WEIGHT GAIN LETHARGY CONFUSION ABNORMAL REFLEXES CONVULSION COMA….FEATURES OF HYPONATREMIA AND BRAIN EDEMA
  79. 79. DIAGNOSISPatient with hyponatremia excrete urine which is hypertonic relative to plasma….
  80. 80. DIAGNOSISURINE Na >20 mEq/lLOW BUN , S.CREATININE, S.URIC ACID , S.ALBUMINS.Na <130 mEq /LPLASMA OSMOLALITY <270 mOsm /LHYPERTONIC URINE RELATIVE TO PLASMAUNABLE TO EXCRETE URINE EVEN AFTER WATERLOADINGADH ASSAY IN BLOODN.B. : PATIENTS SUSPECTED FOR SIADH SHOULDBE SCREENED FOR ADRENAL INSUFFICIENCY &HYPOTHYROIDISM
  81. 81. TREATMENTMILD-MODERATE SYMPTOMSRESTRICT FLUIDS 500-1000 ML/ DAYSEVERE5% SALINE IV 200-300ML OVER SEVERALHRS FOLLOWED BY FLUID RESTRICTIONRx UNDERLYING PROBLEM
  82. 82. TREATMENTDRUGSPHENYTOIN ,NALOXONE ,BUTORPHANOLEFFECT ON RELEASE -CLINICALLYINEFFECTIVELITHIUM BLOCK EFFECT OF ADH ONRENAL TUBULES ,TOXICITY > BENEFITSDEMETHYL CHLORTETRACYCLINE 900-1200 mg/day interfere with ability of renaltubules to concentrate urine
  83. 83. PERIOPERATIVE MANAGEMENTCONCERNSANEMIAMALNUTRITIONFLUID &ELECTROLYTE IMBALANCELOW URINE OUTPUTDELAYED AWAKENINGMENTAL CONFUSION
  84. 84. .
  85. 85. ALSO NOTE…..USUALLY ONLY FLUID RESTRICTION IS NEEDED ; RARELY, HYPERTONIC SALINEAGE OF PATIENT AND TYPE OF ANESTHETIC AGENT HAVE NO BEARING WITH INCIDENCE OF SIADH
  86. 86. REFERENCES ANESTHESIA AND UNCOMMON DISEASES, FLEISHER,5/e PITUITARY DISEASE AND ANESTHESIA,M.SMITH & N.P HIRSH,BJA, 85 (1) 2000 STOELTING’S ANESTHESIA & COEXISTING DISEASE, 5/e HARRISONS PRINCIPLES OF INTERNAL MEDICINE,17/e LEE MCGREGOR’S SYNOPSIS OF SURGICAL ANATOMY,12/e REVIEW OF MEDICAL PHYSIOLOGY,WILLIAM F GANONG,22/e
  87. 87. .READING UNCOMMON THINGSWHICH WE HAVENT FACED YETMAY WASTE TIME….FACING UNCOMMON THINGSWHICH WE HAVENT READ YETMAY WASTE LIVES….

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