This topic is so important in airway management that #NoDesat has become a trending meme on Twitter. You can be an average intubator, but a master oxygenator and you and your patient will likely be fine. On the other hand, if you’re a great intubator but poor at oxygenation you will face tough times when encountering an unexpected difficulty during intubation.
Anesthetic consideration in smokers,alcoholics and addictsAftab Hussain
Anaesthetic consideration in smokers alcoholic and drug addicts. As an anaesthesiologist we must be aware with the problems associated with their management and interaction with anaesthetics.
Preoperative sedation and premedication in pediatrics Nida fatima
Sedation and premedication
Why? --Aims of premedication!
When?
How?
Drugs for premedication!
Routes for administration!
Side effects & complications!
Parental Anxiety
SEPARATION ANXIETY
Kids not small adults
Sedative -omitted for neonates and sick infants.
child's age, body weight, drug history, allergic status and medical or surgical conditions
Avoid needles!!
Oral premedication ≠ risk of aspiration pneumonia
Allay Anxiety & fear.
Reduce saliva and airway secretions.
Enhance the hypnotic effects of general anaesthesia.
Reduce postoperative nausea & vomiting.
Thoracic Epidural Analgesia is the Gold Standard for Major Abdominal SurgeryEdward R. Mariano, MD
At Anesthesiology 2019, the annual meeting of the American Society of Anesthesiologists (#ANES19), I debated Dr. Jeff Gadsden from Duke on the topic of whether or not thoracic epidural analgesia is the gold standard for major abdominal surgery. Dr. Vijay Gottumukkala organized and moderated the debate and assigned sides: pro (me) and con (Jeff).
This topic is so important in airway management that #NoDesat has become a trending meme on Twitter. You can be an average intubator, but a master oxygenator and you and your patient will likely be fine. On the other hand, if you’re a great intubator but poor at oxygenation you will face tough times when encountering an unexpected difficulty during intubation.
Anesthetic consideration in smokers,alcoholics and addictsAftab Hussain
Anaesthetic consideration in smokers alcoholic and drug addicts. As an anaesthesiologist we must be aware with the problems associated with their management and interaction with anaesthetics.
Preoperative sedation and premedication in pediatrics Nida fatima
Sedation and premedication
Why? --Aims of premedication!
When?
How?
Drugs for premedication!
Routes for administration!
Side effects & complications!
Parental Anxiety
SEPARATION ANXIETY
Kids not small adults
Sedative -omitted for neonates and sick infants.
child's age, body weight, drug history, allergic status and medical or surgical conditions
Avoid needles!!
Oral premedication ≠ risk of aspiration pneumonia
Allay Anxiety & fear.
Reduce saliva and airway secretions.
Enhance the hypnotic effects of general anaesthesia.
Reduce postoperative nausea & vomiting.
Thoracic Epidural Analgesia is the Gold Standard for Major Abdominal SurgeryEdward R. Mariano, MD
At Anesthesiology 2019, the annual meeting of the American Society of Anesthesiologists (#ANES19), I debated Dr. Jeff Gadsden from Duke on the topic of whether or not thoracic epidural analgesia is the gold standard for major abdominal surgery. Dr. Vijay Gottumukkala organized and moderated the debate and assigned sides: pro (me) and con (Jeff).
Anaesthesia challenges in neonatal emergencies-1.pptxsouravdash24
Neonatal emergencies present unique challenges in anesthesia, requiring specialized knowledge and skills to ensure safe and effective care for these vulnerable patients. This presentation delves into the intricacies of providing anesthesia to neonates in emergency situations, discussing physiological differences, equipment considerations, medication dosages, and monitoring techniques tailored to this population. Explore essential strategies and best practices for managing airway, ventilation, and hemodynamic stability in neonatal emergencies, aiming to optimize outcomes and mitigate risks. Whether you're a seasoned anesthesiologist or a healthcare professional seeking insight into neonatal anesthesia, this presentation offers valuable insights into navigating the complexities of neonatal emergencies with confidence and expertise.
complete information about the fluid resuscitation in burn patients, types of care given to the patient in the hospital after burning accidents, fluid replacement therapy, medical management, nursing management.
Establishing and maintaining normal extracellular volume (ECV) is required to achieve normotension. The achievement of an optimal fluid status, as expressed by "dry weight" (DW), should allow for controlling blood pressure (BP) in the large majority of HD patients
Dystocia is best treated by Caesarean section (CS) in the West African Dwarf (WAD) doe. However, this otherwise simple procedure is often associated with high mortalities of does and/or kids because certain simple and inexpensive measures are not taken in the handling of affected does during the period-operative period. This clinical discuss looks at these measures and how they may be effected in a routine farm/clinic practice.
Journal club covid vaccine neurological complications ZIKRULLAH MALLICK
the risks of adverse neurological events following SARS-CoV-2 infection are much greater than those associated with vaccinations, highlighting the benefits of ongoing vaccination programs.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
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
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
2. Anaesthesia in emergency laparotomy situations is
provided by experienced and competent
anaesthetists.
They are rarely involved in preoperative
management and frequently only meet the critically
ill patient in theatre.
Preoperative management is usually prescribed by
a surgeon or general physician.
2
3. Patient presenting for emergency laparotomy can be of
any age, neonates to elderly.
Patients usually present late, after they have taken
some form of local treatment, which chiefly includes
herbal medicines mixed with lots of heavy metals and
steroids.
Co-morbid conditions should also be taken in account
like – Diabetes mellitus,hypertension,thyroid
conditions,CAD.
In spite of the correct surgical diagnosis, the critical
condition of these patients is frequently not recognised.
3
4. Common causes of sick laparotomies –
Perforation peritonitis
AIO
SAIO
Blunt trauma abdomen
Penetrating abdominal injuries like stab wound and
gun shot injuries.
4
5. Problems in sick laparotomies :
Sepsis
Profound dehydration,
Hypovolaemia & pre renal ARF
Respiratory compromise
Electrolyte imbalances and
Acidosis which are often overlooked and not
corrected.
5
6. Common problems in an emergency laparotomy
Cardiovascular Hypovolaemia, Dehydration,Sepsis and septic shock
Respiratory Hypoxia, Tachypnoea, Atelectasis
Blood Anaemia, If septic - potential coagulopathy
Renal Oliguria or anuria due to acute renal failure
CNS Decreased level of consciousness, confusion
Anxiety, Pain, Possibility of intoxication
Gastro-intestinal Full stomach, Abdominal distension
Bowel perforation or obstruction
Metabolic Pyrexia, Hypothermia, Acidosis, Electrolyte disturbance,
Hypoglycaemia 6
7. As a result perioperative mortality in this group of
patients is very high. These patients sometimes
require more then 10 litres of intravenous fluids in
first 24 hours (excluding intra-operative fluids) and
medical and nursing staff may lack the confidence
to infuse such volumes.
7
8. However treating this group of patients with
aggressive resuscitation reduces the mortality
significantly.
So it is very important to encourage the
perioperative team (anaesthetists and non-
anaesthetists) to provide effective pre-operative
preparation of critically ill patients.
8
10. Patient presentation
Patients presenting with abdominal emergencies for
laparotomies often come to hospitals very late.
They have often been sick for some days with a
perforated or obstructed bowel.
It is extremely important to establish the duration of
their disease, as this can give some idea of the
degree of dehydration and electrolyte imbalance.
10
11. DEHYDRATION
Reasons for dehydration include:
no oral intake especially in children
vomiting/ diarrhoea
fever
high environmental temperature
third space loss (fluid in the body which is not
available to the circulation for example oedema,
ascites or other collections).
11
12. 12
When taking the history enquire specifically about the
oral intake,vomiting/diarrhoea,fever and also the colour
and amount of urine over the last day as profound
dehydration and hypovolaemia will result in oliguria or
even anuria.
13. Physical examination
The ABCD framework should be used for both
examination and initial management.
Airway can be a problem so should be checked in
every patient.
Rapid Airway Assessment
LEMON law
1,2,3 rule
Breathing - an increased respiratory rate (RR) is an
early warning sign caused by acidosis or hypoxia and is
often ignored.
Tachypnoea can also be caused by pain, anxiety or
pyrexia.
Check the oxygen saturation and record respiratory rate
regularly.
13
14. Circulation - the cardiovascular system is usually
significantly compromised due to hypovolaemia.
Assess:
heart rate (HR)
blood pressure (BP)
pulse - is it weak or well filled?
capillary refill time; make sure it is done properly -
press for 5s (count to 5) then release the pressure
and count refill time.
This sign is very accurate in children and young
adults, less reliable in very anaemic or old patients. 14
15. core - peripheral temperature gradient –
check the difference between the temperature of
the trunk, which is usually hot (pyrexia) and the
extremities which are cold (vasoconstriction).
This is a very good indicator of the intravascular
volume; especially useful to observe the trend - the
difference should reduce during resuscitation.
15
16. degree of dehydration –
severe thirst, decreased skin turgor, dry tongue,
sunken eyes, sunken fontanelle in a newborn.
However, decreased skin turgor or sunken eyes
may be masked by oedema resulting from
hypoalbuminaemia.
16
17. Disability - assess the mental status; adult patients
can be apathetic occasionally agitated; children can
fluctuate between being apathetic and agitated.
Document all of your findings on an appropriate
chart.
17
18. ACIDOSIS
Increasing risk of death with metabolic acidosis as
demonstrated by arterial pH, lactate, and base
deficit clearance.
The deleterious effects of acidosis -
CVS - decreased cardiac contractility and cardiac
output,vasodilation and hypotension,bradycardia,
and increased susceptibility to ventricular
dysrhythmias.
Decreased hepatic and renal blood flow.
Acidosis directly reduces the activity of the extrinsic
and intrinsic coagulation pathways. 18
19. These adverse effects are generally not seen until
pH decreases below 7.2.
Pre op ABG is important to evaluate the PaO2 &
pH.
Therapy for metabolic acidosis remains directed
toward correcting the underlying hypoperfusion.
Resuscitation endpoints include normalization of
arterial pH, base deficit, and lactate.
19
20. Bicarbonate administration should be deferred until
the pH persists below 7.15, despite optimal fluid
loading and inotropic support.
20
21. WHAT ARE THE ELECTROLYTE
ABNORMALITIES
21
hypovolemia vomiting Fluid
sequestration
Decreased
absorption
Hyponatremia
Hypokalemia
Hypochloremia
Hypomagnesemia
22. 22
In all cases of dehydration due to bowel obstruction there
is a total body deficit of Na+ and water and therefore
whatever the Na+ concentration (i.e. whether the patient
is hyponatremic or hypernatremic) replacement needs to
be with a fluid with a high Na+ content (0.9% saline or
ringer lactate).
Correct fluid deficit according to U.O., CVP,Vitals etc to
achieve normovolemia.
23. 23
K+ should be added to the fluid if necessary
(usually 20-40mmol/l provided the patient is not
anuric or hyperkalaemic).
The aim should be to correct the dehydration over
24 hours, giving half the calculated amount in the
first 8 hours and the second half over the following
16 hours.
If the patient is very hypernatremic (Na+ >
155mmol/ l) rehydration should be done slowly
because of the risk of cerebral oedema.
24. RESPIRATORY COMPROMISE
24
Increased
abdominal pressure
Splinting due to
pain
Increased abdominal
distension
1. Increased work of
breathing
2. Decreased FRC
3. Decreased TV
4. Basal atelectasis.
5. Decreased PaO2
6. Increased PaCO2
*Decreased oxygen reserve, so desaturates rapidly, preoxygenate
(denitrogenate) adequately.
25. FULL STOMACH
Accumulation of fluid and air.
Increased intra-gastric pressure
Persistent vomiting
Loss of bowel motility.
Increased risk of aspiration
This increases both volume & acidity of aspirate.
Give H2 blockers, antiemetics, nasogastric
suctioning and RSI.
25
26. Pre Op Investigations
Hemogram
Renal function test,blood sugar
ECG
Chest X ray
ABG
HIV,Hbs
26
27. PREMEDICATION
Avoid premedications like opioids & BZD with resp.
depressant activity.
For analgesia – tramadol,NSAIDS
Avoid using anticholinergics in pts with tachycardia
or hyperthermia.
Antacids can stimulate vomiting.
Avoid prokinetics.
H2 blockers with antiemetics are preferred.
27
28. NASOGASTRIC DECOMPRESSION
Nasogastric suctioning preoperatively
What to do with the tube
28
Decreases respiratory
compromise,
Decreases aspiration
risk
Leave the tube
Allows gastric
decompression
&
Removal may induce
vomiting
Remove the tube
Doesn’t ensure empty
stomach
&
Keeps LES patent
Difficulty in mask
ventilation & intubation.
OR ??
29. Management
The main purpose of the preoperative treatment
is to optimise the patient’s condition and maximise
their chance of survival.
Early effective resuscitation improves oxygen
delivery to the tissues and reduces mortality in this
group of patients.
29
30. Preoperative resuscitation obviously takes time but
long delays before surgery should be avoided as
early surgical management improves the outcome
in septic patients.
The preoperative plan should be discussed
between the surgical and anaesthetic teams to
achieve the right balance between providing
adequate resuscitation and the risk of delaying
surgery.
Most patients will benefit from 2-4hours
preoperative resuscitation.
The best area to carry out resuscitation is ICU/HDU
if available. 30
31. Make a management plan following the ABC
framework.
Airway and Breathing
Provide oxygen with the face mask at 2-4 l/min
Circulation
insert iv cannula, preferably 16G or 2x 18G
take a sample for Hb, electrolytes and consider
crossmatching (see below).
Infuse first litre of normal saline or ringer lactate
rapidly over 15 min. During the following hour give
2000mls,watching clinical signs. 31
32. Insert Foley catheter; measure and record the initial
amount and colour (concentration) of urine in the
bag and discard it.
Crossmatching is essential as the patient may be
severely anaemic, and the “normal” Hb level is due
to haemoconcentration caused by severe
dehydration & hypovolemia.
32
33. Further treatment
request urgent surgical opinion.
if abdominal X-ray requested by surgeon, and
patient is very sick make sure that he/she is
transported to X- ray department on a stretcher or
wheel-chair and iv fluids are continued. If possible
accompany the patient.
antibiotics prescribed should be administered iv as
soon as possible
insert NG tube
check temperature 33
34. Further management
Assess the patient after each 1 - 2 l of fluids. Whenever
possible warm the fluids even if patient is pyrexial. Use
either crystalloids and colloids, but avoid glucose 5 or
10%.
Ringer lactate seems slightly better then normal saline
as it results in less hyperchloraemic acidosis.
The correct volume of fluid is more important then the
type.
When the initial resuscitation is completed, potassium
containing fluids (20mmol KCl /litre) may be used
providing there is an adequate urine output.
34
35. Assessment of progress of resuscitation involves
assessment of:
HR
BP
capillary refill time
RR
Improving peripheral temperature
filling of neck veins
urine output
CVP monitoring
35
36. What about inotropes?
Noradrenaline & dopamine are frequently used in to
treat sick patients with abdominal emergencies.
36
37. Patients who do not respond to fluid resuscitation
and require an inotrope infusion have a very high
mortality and are often in an irreversible clinical
situation.
Inotropes can also divert attention from providing
adequate fluid resuscitation by increasing the blood
pressure without adequate volume expansion.
In cases of septic shock, adrenaline or
noradrenaline can be used provided adequate fluid
administration has been achieved.
37
38. Electrolyte imbalance
K+ levels are important as cardiac arrhythmias
may result from hypo or hyperkalaemia. Sick
patients are normally depleted due to K+ loss from
diarrhoea and third space losses.
However, anuric patients are at risk of
hyperkalaemia.
After initial resuscitation, when the patient is
passing good volumes of urine, it is justified to add
20 -40mmol of KCl to each litre of IV fluids.
38
39. Anaesthesia
The correct timing of anaesthesia and surgery
depends on the underlying problem.
Resuscitation should be as complete as possible,
but delay dramatically increases the risk to the
patient in cases of peritonitis or bleeding.
39
40. Ideally following resuscitation and before
anaesthesia, the patient will be stable with
a pulse less than 100/min,
a blood pressure greater than 90 systolic,
established urine output and
good capillary return.
40
41. Patients require general anaesthesia with intubation
and ventilation. Diligent preparation is extremely
important.
On top of the usual routine preparation and
equipment check there is enough oxygen for a long
case, adequate amounts of IV fluids (warmed) and
high volume suction.
Empty the urine bag and suction NG tube.
41
42. Very sick patients are frequently hypotensive
immediately after induction.
Make sure there is a large bore IV line through
which you can infuse fluids fast.
42
43. Prepare “emergency” drugs:
Vasopressor, ready and diluted in the syringe
Atropine
In case of high risk patients, also prepare diluted
adrenaline.
43
44. Induction
Preoxygenation is followed by rapid sequence
induction with cricoid pressure.
Thiopentone or ketamine can be used. In
hypotensive patients, ketamine is a better choice.
This should be followed by suxamethonium.
The cricoid pressure is absolutely mandatory as
regurgitation is almost guaranteed.
44
45. Maintenance
If hypotension follows induction of anaesthesia, it
should be treated with rapid infusion of fluids and
ephedrine or adrenaline boluses.
If hypotension does not respond to vasopressor,
adrenaline is indicated.
It has been suggested that keeping inspired oxygen
level around 80% intra-operatively and for 2 hours
after surgery might reduce the incident of wound
infection and post operative nausea and vomiting
(PONV).
45
46. During anaesthesia make sure that the patient
receives an adequate amount of fluids and use
ephedrine or adrenaline as your second line of
treatment.
In septic patients who are unresponsive to
inotropes, hydrocortisone 2-3mg/kg should be
considered.
46
47. Normothermia during and after surgery improves
recovery, decreases oxygen consumption (increased by
shivering), reduces wound infection and decreases
blood loss.
Intravenous fluids should be warmed, as patients always
cool down during surgery, especially in air-conditioned
operating theatres.
This can be achieved by putting the fluids into a simple
water bath. Using hot-water bottles (wrapped in cotton
sheets) and applying them to armpit and groins can also
help to warm up patients.
Appropriate antibiotics should be administered pre- or
intra-operatively 47
48. Post-operative period
Patients are best managed in a recovery area, and
then in an Intensive Care Unit (ICU) or High
Dependency Unit (HDU) if possible.
Supplementary oxygen (3-4 litres/minute) should
be continued for the first 24 hours if available.
48
49. Careful monitoring of basic physiological
parameters (RR, HR, BP, oxygen saturation, urine
output, temperature) is essential over next 24
hours.
Signs such as tachypnoea, tachycardia,
hypotension, hypoxia, oliguria, changed mental
state or hypothermia should trigger immediate
review by the medical staff.
49
50. Adequate pain control should be established. This
is usually achieved by intravenous opioid in
recovery followed by intramuscular injections when
required.
Paracetamol suppositories can be a valuable
addition.
NSAID suppositories should be used only in
patients with good renal function.
50
51. Intravenous fluid requirements will remain high in
the immediate post-operative period.
Patients will continue to have third space loss and
residual fluid deficit from the preoperative period.
Therefore fluid requirements will be above the
maintenance amount of 3 litres per day.
Often 4 - 6 litres are required in the first 24 hours
and should be given as normal saline.
51
52. Although the calculated fluid balance will be
positive, increased insensible losses (fever, tropical
environment), fluid loss from drains and continuing
third space losses due to the underlying pathology
result in continued fluid deficit in the circulation.
Adding 20mmol of potassium to each 1000ml bag
of fluid is recommended, providing the urine output
is adequate.
The daily requirement of potassium is 70 -
100mmol.
52