This document discusses abomasal displacements and volvulus in cattle. It begins with the normal anatomy of the abomasum and surrounding structures. It then discusses left displacement of the abomasum (LDA), including risk factors, clinical signs, diagnosis, treatment options such as medical techniques and surgical procedures like right paralumbar fossa omentopexy. Right displacement of the abomasum (RDA) and abomasal volvulus (AV) are also covered, explaining their clinical signs, diagnosis, and surgical treatment approaches. The document provides detailed descriptions of surgical techniques like proximal and distal paravertebral nerve blocks, omentopexy procedures, and abomasopexy. It concludes with advantages
In these slides we will go through the surgical anatomy of the gut,pathophysiology of intestinal obstruction, clinical presentation and management. Also we will discuss specific types of intestinal obstruction.
ANESTHETIC MANAGEMENT OF TRACHEOESOPHAGEAL FISTULA by Dr.Sravani VishnubhatlaDrSravaniVishnubhatl
Learning Objectives:
Review the clinical presentation of a patient with tracheoesophageal fistula (TEF)
Understand the prevalence of TEF, types, and associated syndrome
Discuss the diagnosis of TEF
Describe the medical and surgical management of TEF
Understand the anesthetic-related implications and develop an anesthetic plan
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
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ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
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- Prix Galien International Awards Ceremony
2. Greater Omentum
Consists of 2 leaves
Superficial leaf (1)
Left longitudinal groove of rumen
Greater curvature of abomasum and
duodenum (2)
Deep leaf (3)
Right longitudinal groove of rumen
Decending duodenum
Both leaves form sling for intestine
1
3
2
2
2
3. Lessor Omentum (1)
Connects peritoneum between
Liver (2)
Lesser curvature of abomasum (3)
Cranial duodenum (4)
Covers right side of omasum
Key to other structures
Mesoduodenum (5)
Greater omentum (6)
2
3
4
1
5
6
7. Incidence of Abomasal Displacement
10% RDA
90% LDA
91% occur within first 6 weeks of calving
Most likely to occur
Adult diary cattle in early postpartum period
Prevalence in well managed herd varies
0.2 – 2.5%
8. Predisposing Factors
Abomasal atony
High grain/low roughage diets
[VFA] Gas accumulation Distention
Roughage (large particles)
Stimulates rumination via touch receptors
Increases salivary buffer action
Hypocalcemia
Milk fever
smooth muscle tone and motility
4.8 x risk of developing LDA than normocalcemic
9. Predisposing Factors
Abomasal atony
Metritis, retained placenta, severe mastitis
Endotoxins and endogenous pyrogens (IL-1) depress motility
Result in hypocalcemia
Electrolyte disturbances
Lack of exercise/confinement
High producing diary cows
Large abdominal cavities more room for displacement
Genetic selection
11. LDA Clinical Signs
Percussion left paralumber fossa
Above/below line from point of
elbow to tuber coxae
Ping over gas filled portion of
abomasum
13. LDA Diagnosis
Clinical signs
Percussion
Liptak test
Centesis area below gas ping in “abomasum”
Fluid pH < 4.5 Abomasum
Burnt almond odor of gas Abomasum
14. Normal Transit
Simple LDA cases
normal serum electrolyte
levels
Normal acid/base balance
Anion Gap
H2CO3
-
Cl-
K+
Na+
15. Normal Transit
Not a complete obstruction
Chloride secreted in abomasum
Absorbed in small intestine
+ Mild hypochloremia
+ Mild metabolic alkalosis
19. LDA Treatment
Medical techniques
Cast in right lateral recumbency
Roll into dorsal recumbency/shake legs
Roll over to left lateralrecumbency Stand
Surgical techniques
Right paralumbar fossa omentopexy
Left paralumbar fossa abomasopexy
Right paramedian abomasopexy
Percutaneous abomasopexy
21. RDA Clinical Signs and DDx
Clinical signs similar to LDA
Differential diagnosis
Cecal dilitation or volvulus
Gas in spiral colon
Small intestinal obstruction or volvulus
Torsion about root of mesentery
Pneumorectum
Pneumoperitoneum
Physometra
Abomasal volvulus
22. RDA Diagnosis
Clinical signs
Precussion
Ping under last 5 ribs in dorsal abdomen
Rectal palpation
23. Slow Transit
Potential for sequestration of HCl in
abomasum
Hyochloremia (loss of anions)
Obstruction
Reabsorption of Cl-
by small intestine
26. RDA Treatment
Medical techniques
Rolling contraindicated
Progression to Abomasal volvulus
Surgical techniques
Difficult to distinguish RDA vs. AV
Right paralumbar fossa omentopexy or
abomasopexy
Right paramedian abomasopexy
27. AV Clinical Signs
Colic
Tachycardia (> 100 bpm)
Dehydration
Bilateral abdominal distention
Feces abscent or watery but scant
AV Compete obstruction of flow of ingestia through duodenum
28. AV Differential Diagnosis
Cecal dilitation or volvulus
Gas in spiral colon
Small intestinal obstruction or volvulus
Torsion about root of mesentery
Right abomasal displacement
29. AV Diagnosis
Clinical signs
Precussion
Ping
Extends from 8th
rib to middle of right paralumbar fossa
Ventral border is horizontal
Fluid in abomasum
Ballottement
Rectal palpation
30. AV Clinical Pathology
Similar to RDA but more severe
Hypochloremia
Hypohalemia
Metabolic alkalosis Metabolic acidosis
More chronic cases
Dehydration
Poor peripheral perfusion
Shock
31. AV – Right Flank
Typical orientation
Counterclockwise viewed from right flank
35. RDA Treatment
Surgical techniques
Right paralumbar fossa omentopexy
Best choice
Integrity of abomasum often compromised
Abomasopexy procedures do not work well
Progniosis
Depends on degree of damage to abomasal mucosa
Vagal indigestion syndrome common
36. Proximal Paravertebral Nerve Block
T13, L1, and L2
Sensory and motor to
Skin
Fascia
Muscle
Peritoneum
37. Proximal Paravertebral Nerve Block
Nerve most localized
Intervertebral foramen
Walk needle of caudle edge of transverse process
Single site rather than dorsal and ventral branches individually
Transverse process slopes forward
Technique
Injection site 3 – 4 cm from midline
Local bled of 2% lidocaine hydrochloride
Use 1 in 16-ga needle as trocar for 10 cm 20-ga needle
38. Proximal Paravertebral Nerve Block
Technique
Once transverse process encountered
Needle walked off caudle border and advanced 0.75 cm
10 ml 2% lidocaine hydrochloride
Temporary lateral deviation of spine
Lumbar muscle paralysis
39. Distal Paravertebral Nerve Block
Branches of T13, L1, and L2 blocked at ends of
transverse processes of L1, L2, and L4 (not L3)
Technique
25 ml 2% lidocaine hydrochloride per site
18-ga needle inserted under each transverse process
10 ml 2% lidocaine hydrochloride
40. Distal Paravertebral Nerve Block
Technique
Withdrawn short distance and redirected craniad and
caudad
2% lidocaine hydrochloride
Infiltration of ventral branches
41. Distal Paravertebral Nerve Block
Technique
Needle redirected dorsal and caudal to transverse
process
2% lidocaine hydrochloride
Infiltration of dorsolateral branches
No deviation of spine
No lumbar muscle paralysis
42. Inverted L Nerve Block
Vertical line passes caudal to last rib
Horizontal line passes ventral to transverse
processes
100 ml 2% lidocaine hydrochloride
43. Right Paralumbar Fossa Omentopexy
Vertical incision in middle of paralumbar fossa
3 – 5 cm ventral to transverse processes
20 – 25 cm long
Skin
SQ
47. LDA Manipulation
Abomasum returned to normal position
Follow peritoneal surfaces ventrally
Hand between rumen and body wall
Elevate caudal ventral blind sac of rumen
48. LDA Manipulation
Abomasum returned to normal position
Follow peritoneal surfaces ventrally
Hand between rumen and body wall
Elevate caudal ventral blind sac of rumen
49. Right Paralumbar Fossa Omentopexy
Gently pull omentum out through incision
Retract dorsad and caudad until pylorus is visualized
Omentum on both sides of pylorus
Palpable firmness of torus pyloricus muscle
Omentopexy
Close to pyloroduodenal
junction
3 – 4 cm caudal
Appendage “sows ear”
6 – 8 cm vertical section of
greater omentum
Distribute pexy of wide area
50. Right Paralumbar Fossa Omentopexy
#2 or #3 chromic gut
Incorporate omentum in peritoneum and
transversus abdominal muscle closure
51. Right Paralumbar Fossa Omentopexy
External/internal abdominal oblique muscles
closure
Single layer, simple continuous pattern, #2 - #3 chromic
gut
Skin closure
Ford interlocking pattern, #3 polymerized caprolactam
(Vetafil)
53. AV Manipulation
Typical orientation
Counterclockwise
Viewed from right flank
Viewed from rear
54. Advantages and Disadvantages:
Right Paralumbar Fossa Omentopexy
Prognosis
LDA 86% - 90%
Complications
Redisplacement 3.6% - 4.2%
Incisional infection
Peritonitis
Advantages
Animal in standing position
Surgeon can perform procedure alone
Allows abdomial exploration
Used to correct LDA, RDA, and AV
Disadvantages
More skill
Proper position of abomasum
Proper area for fixation
Abomasum position less anatomically correct than abomasopexy
Not good if suspect adhesions beteen abomasum and left body wall
56. Left Paralumbar Fossa Abomasopexy
Well distented abomasum
Along greater curvature
2 – 3 cm from attachment of greater
omentum
Ford interlocking pattern 5 – 7 cm
Bites through submucosa
#2 - #3 monofilament, non-absorbable
2 m long
2 long tags with straight needles
Decompress abomasum
57. Left Paralumbar Fossa Abomasopexy
Anchor suture tags
Cranial site 10 cm caudal/right of xiphoid
process
Pass cranial suture through ventral
abdomin
Assistant applies pressure of site with
hemostats
Assistant pulls needle
through skin
Repeat with caudal suture
58. Left Paralumbar Fossa Abomasopexy
Reduction of abomasum
Each suture is placed through a sponge before
being tied
59. Advantages and Disadvantages:
Left Paralumbar Fossa Abomasopexy
Prognosis
83.5% - 94%
Complications
Entrapment of small intestine between abomasum and body wall
Abomasal fistula formation if
Suture penetrates abomasal mucosa
Suture not removed in 2 – 3 weeks
Advantages
Animal in standing position
Best choice for cows in advanced pregnancy (> 7 months)
Best choice for rumenotomy with concurrent TRP
Disadvantages
Only for LDA not for RDA or AV
Requires assistant to guide needle placement
60. Percutaneous Abomasopexy
Toggle
5 cm long plastic rod
30 cm long nylon suture
Trocar with stylet
Used to place toggle in the abomasum
62. Percutaneous Abomasopexy
Trocar with stylet inserted into abomasum
Stylet removed
Abomasal odor confirmed
First toggle passed through cannula to abomasum
63. Percutaneous Abomasopexy
Trocar with stylet inserted into abomasum
Stylet removed
Abomasal odor confirmed
Second toggle passed through cannula to
abomasum
65. Advantages and Disadvantages:
Percutaneous Abomasopexy
Prognosis
80% - 88%
Complications
Pexy viscera or omentum
Abomasal rupture at suture site
Peritonitis
Abomasal obstruction
Advantages
Quick, inexpensive, easy to perform
May be good choice for cows that are poor surgical candidates
Disadvantages
Requires dorsal recumbency
Only for LDA not for RDA or AV
Requires assistants
Abomasum must be distended with gas
66. Laparascopic Assisted Abomasopexy
Minimally invasive technique for surgical correction of LDA
Developed to reduce incidence of complications
Traditional laparotomy
Percutaneous toggle placement
67. Laparascopic Assisted Abomasopexy
Advantages
Reduced surgical time and cost
Reduced healing time
Can immediately go back into production
Reduced milk discarding
Antibiotics not required
Allows abdominal exploratory
Any degree of gas distention
Even minimally dilated
69. Laparascopic Assisted Abomasopexy
Single toggle
Toggle bar
Stainless steel with central recess
Epoxy filling recess securing suture to toggle
Suture
Twin 80cm strands
Marker 4.5 cm from toggle bar
Marker
70. Two-Step Technique: Step 1 - Standing
Left paralumbar fossa and last 3 ribs
aseptically preped
2 local blebs (5 ml) 2% lidocaine
2 stab incisions (1 cm)
Laparascope portal (I)
10 cm caudal to last rib
10 cm ventral to transverse process
Instrument portal (II)
11th
intercostal space
20 cm ventral to spinous process
II
I
71. Two-Step Technique: Step 1 - Standing
Pneumoperitoneum
Left paralumbar fossa
Position I
Veress needle with silicon tubing
Insufflation pump
72. Two-Step Technique: Step 1 - Standing
Trocar-cannula assembly inserted in left paralumbar fossa (I) through stab
incision
Laparascope inserted into cannula
Abdominal exploratory
74. Two-Step Technique: Step 1 - Standing
Trocar-cannula assembly inserted in 11th
ICS (II) through stab incision
Instrument portal
75. Two-Step Technique: Step 1 - Standing
Toggle trocar passed through instrument portal
and inserted into abomasum
Toggle bar passed through trocar into abomasal
lumen
77. Two-Step Technique: Step 2 – Dorsal Recumbency
Right parameadian area aseptically preped
2 local blebs (5 ml) 2% lidocaine
2 stab incisions (1 cm)
Laparascope portal (III)
5 cm lateral from midline
20 cm distal to xyphoid
Instrument portal (IV)
5 cm lateral from midline
10 cm distal to xyphoid
78. Two-Step Technique: Step 2 – Dorsal Recumbency
Laparascope and grasping forceps inserted
through portals
79. Two-Step Technique: Step 2 – Dorsal Recumbency
Abomasum and suture material identified
Suture retrieved using grasping forceps
80. Two-Step Technique: Step 2 – Dorsal Recumbency
Excess suture withdrawn through instrument portal up to preset marker on
suture
Abomasum in proper anatomical position
Remove laparasope and cannulas
Skin incisions closed
Single interrupted suture
81. Two-Step Technique: Step 2 – Dorsal Recumbency
Suture ends each passed through separate 14
ga needles inserted through gauze stent
Needles removed
Suture tied over gauze stent
Leave 3 cm of play in suture
Suture removed after 3 – 4 weeks
82. One-Step Technique - Dorsal Recumbency
Animal is sedated and placed in dorsal
recumbency
Area aseptically prepared from
Xyphoid process to 10 cm caudal to umbilicus
Width of 20 cm each side of ventral midline
83. One-Step Technique - Dorsal Recumbency
3 local blebs (5 ml) 2% lidocaine
3 stab incisions (1 cm)
Portal site I (laparoscope)
2 cm left of umbilicus
Portal site II (grasping forceps)
3 cm caudal and 7 cm right of xyphoid process
Portal site III (needle holder)
5 cm right and 3 cm cranial to umbilicus
84. One-Step Technique - Dorsal Recumbency
Fixation site IV
10 cm long line block using 2% lidocaine
3 - 5 cm right of linea alba
Centered between umbilicus and xyphoid process
Four 1-cm long skin incisions
Perpendicular to ventral midline
Spaced 2.5 cm apart
86. One-Step Technique - Dorsal Recumbency
Grasping forceps used to locate abomasum
Grasp abomasum in middle of greater
curvature
2 – 3 cm from greater omentum attachment
Fixation site
87. One-Step Technique - Dorsal Recumbency
2 PDS suture with curved needle (1/2, 40mm)
is used
Needle straightened to facilitate manipulation of needle
Needle introduced into abdomen through one
of cutaneous incisions
Needle grasped intra-abdominally using needle
holder
88. One-Step Technique - Dorsal Recumbency
Needle and suture passed through serous and
muscular layers of abomasum
Stitch measuring 2 cm
Running perpendicular to greater curvature
Site inspected for gas or fluid leakage
89. One-Step Technique - Dorsal Recumbency
18 G needle inserted through abdominal wall
Used as guide to exteriorize needle and suture
Suture pulled out of abdominal cavity
90. One-Step Technique - Dorsal Recumbency
3 other sutures are placed in similar fashion
Correct positioning of abomasum verified by
pulling gently on sutures to approximate
abomasum to body wall
93. One-Step Technique - Dorsal Recumbency
Follows two-step technique
Except once toggle bar inserted into abomasum,
suture ends not passed into abdominal cavity
Specially designed instrument is used to drive
toggle suture from left flank to ventral
abdomen
Suture is tied as in two-step technique
94. Right Paramedian Abomasopexy
Incision
15 – 20 cm long, parallel and 3 – 4 cm right of midline
Extending caudal from a point 4 – 8 cm caudal to xiphoid
Six distinct layers
Skin
SQ fascia
Deep pectoral muscle in cranial 1/3
External rectus sheath
Rectus abdominus muscle
Internal rectus sheath
Peritoneum
95. Right Paramedian Abomasopexy
Exploratory
Decompress abomasum and exteriorize
Identify pylorus
Omentum on both sides of pylorus
Palpable firmness of torus pyloricus muscle
Identify greater omentum
Greater curvature (arrow)
Sweeps to left side of rumen
Covering ventral surface of rumen
96. Right Paramedian Abomasopexy
Abomasopexy
3 horizontal mattress sutures
Lateral aspect of greater curvature of abomasum free of omentum
Seromuscular layer
Peritoneum and internal rectus sheath
#2 chromic gut
Simple continuous pattern
Peritoneum and internal rectus sheath
At least 6 bites incorporating abomasum
Seromuscular layer
97. Right Paramedian Abomasopexy
Closure
External rectus sheath
Horizontal mattress pattern
#3 chromic gut
Skin
Ford interlocking pattern
#3 polymerized caprolactam (Vetafil)
98. Advantages and Disadvantages:
Right Paramedian Abomasopexy
Prognosis
83.5% - 95%
Complications
Incisional hemorrhage, dehiscence, herniation or fistulation
Advantages
Strong adhesions develop between abomasum and body wall
Abomasum returns near normal position during placing in dorsal recumbency
Correct LDA, RDA or AV
Disadvantages
Dorsal recumbency
Bloat, regurgitation, aspiration
Requires assistants