This document discusses anesthesia considerations for scoliosis surgery. It begins by defining scoliosis and describing factors like the Cobb angle that determine surgical indications. It then covers preoperative evaluation and preparation, including tests to assess pulmonary and cardiac function. Intraoperatively, anesthesia aims to control blood loss and preserve spinal cord function using techniques like prone positioning, evoked potential monitoring, hypotensive anesthesia and steroid administration if needed. Postoperative care focuses on pulmonary toilet, fluid management to prevent hyponatremia, and pain control during recovery. New minimally invasive surgical techniques may further reduce complications and blood loss.
VASCULITIS INTRODUCTION.
TYPES OF VASCULITIS
DIAGNOSING CRIERIA
TREATMENT AND GUIDELINES
DRUGS USED IN BURGER'S DISEASE
A CASE ON VASCULITIS
APPROACH OF TREATMENT
PATIENT COUNSELLING FOR THE PARTICULAR PATIENT
This presentation is about pulmonary manifestations of systemic vasculitis,in it m discussing about WEGNER,S GRANULOMATOSIS, churg-strauss syndrome and MPA
VASCULITIS INTRODUCTION.
TYPES OF VASCULITIS
DIAGNOSING CRIERIA
TREATMENT AND GUIDELINES
DRUGS USED IN BURGER'S DISEASE
A CASE ON VASCULITIS
APPROACH OF TREATMENT
PATIENT COUNSELLING FOR THE PARTICULAR PATIENT
This presentation is about pulmonary manifestations of systemic vasculitis,in it m discussing about WEGNER,S GRANULOMATOSIS, churg-strauss syndrome and MPA
Vasculitis syndrome an approach -and-basic principles of treatmentSachin Verma
Vasculitides are a hetrogenous group of conditions characterized by inflammation and necrosis of blood vessels.
A broad group of syndromes may result from this process,since any type,size, and location of vessel may be involved.
Rheumatoid arthritis is the most common systemic inflammatory disease characterized by symmetrical joint involvement.
Extraarticular involvement, including rheumatoid nodules, vasculitis, eye inflammation, neurologic dysfunction, cardiopulmonary disease, lymphadenopathy, and splenomegaly, can be manifestations of the disease.
Churg-Strauss syndrome is a disorder marked by blood vessel inflammation. This condition is also known as eosinophilic granulomatosis with polyangiitis (EGPA).
Vasculitis syndrome an approach -and-basic principles of treatmentSachin Verma
Vasculitides are a hetrogenous group of conditions characterized by inflammation and necrosis of blood vessels.
A broad group of syndromes may result from this process,since any type,size, and location of vessel may be involved.
Rheumatoid arthritis is the most common systemic inflammatory disease characterized by symmetrical joint involvement.
Extraarticular involvement, including rheumatoid nodules, vasculitis, eye inflammation, neurologic dysfunction, cardiopulmonary disease, lymphadenopathy, and splenomegaly, can be manifestations of the disease.
Churg-Strauss syndrome is a disorder marked by blood vessel inflammation. This condition is also known as eosinophilic granulomatosis with polyangiitis (EGPA).
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
Welcome to Secret Tantric, London’s finest VIP Massage agency. Since we first opened our doors, we have provided the ultimate erotic massage experience to innumerable clients, each one searching for the very best sensual massage in London. We come by this reputation honestly with a dynamic team of the city’s most beautiful masseuses.
We understand the unique challenges pickleball players face and are committed to helping you stay healthy and active. In this presentation, we’ll explore the three most common pickleball injuries and provide strategies for prevention and treatment.
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
6. Clinical significance of
Cobb’s Angle
• Angle < 10 normal curvature
• Angle > 25 raised pulmonary artery
pressure
• Angle > 40 surgery is indicated
• Angle > 65 restrictive lung disease
• Angle > 100 severe pulmonary dysfunction.
• However, patients with neuromuscular type
may have a much more profound decrease
in pulmonary function for any given curve
severity
7. Causes of Scoliosis
• Congenital
• Idiopathic: 70% of cases
• Mostly in females . On the rt. Side.
• Neuromuscular: cerebral palsy,dysautonomia,
poliomylities and dystrophic myopathy ,myotonia.
• Traumatic: fracture, radiation, burn, surgery
• Syndroms: neurofibromatosis, Marfan S
Ehler Danlos.
10. Spinal Fusion
• The goal of scoliosis surgery is to
achieve spinal fusion from one
vertebra above the curve to one
below. Instrumentation is inserted
to keep spine in best possible
position.
Harrington rod, sublaminar wiring
12. Preoperative preparation
• Clear chest infection .
• Wake up test.
• Posibility of post operative mechanical ventilation
Premedication
Heavy sedation should be avoided in severe
scoliosis.
13. Anesthetic Problems associated
with Scoliosis Surgery
• Problems related to the patient:
1) Respiratory , cardiovascular
neuromuscular abnormalities or
syndromes.
14. Problems related to the surgery
1. Prone position
2. Blood loss and third space loss
3. Lengthy operation
4. Preservation and monitoring of
spinal cord function.
5. Heat loss.
15. Monitoring
• Routine monitors: oximeter, ECG,
capnography, and core body tempe
• Arterial catheter to monitor beat to beat
changes.
• CVP
• Urinary catheter
• Blood loss and replacement are monitored.
• Patient’s position
16. Induction of anesthesia
• Two large intravenous lines
• IV agent other than ketamine is used.
• A loading dose of fentanyl : 1-3µg/kg then
continuous infusion : 5 µg/kg/hr.
• Suxamethonium. is avoided in paralyzed
patients or neuromuscular aetiology.
• Intermediate non depolarizing ms. relaxent
like cis-atracurium or Vecuronium is used
for intubation and maintenance of
relaxation.
17. Positioning of patient
Prone position :
• CVS
• Respiration
• Head and neck.
• Nerves
• Air way : armoured tube
• Soft tissues
Use Relton-Hall operation frame
Reassessment of patient position is
advisable at regular intervals.
18.
19. Maintenance of anaesthesia
• Aim: smooth and continuous anaethesia.
• Avoid bolus dosing of i.v drugs and /or
change in conc. of inhalational agents.
• Nitrous oxide in oxygen + narcotics + inter
mediate ms. relaxant + inhalational agent
<1MAC
• IPPV.
• Fluid therapy (warmed).
21. Measures taken to reduce blood loss and
need for homologous blood transfusion
1. Proper anesthetic management
2. Infiltration with epinephrine 1/200,000 not
exceeding the upper limit
3. Isovolaemic haemodilution.
4. Use hypotesive anesthesia.
5. Use predonated autologous blood .
6. Cell salvage .
22. Hypotensive anesthesia
• Only used in appropriate patients.
• Blood pressure is lowered to a mean value of 50-60
mmHg BUT high risk patients : 65 mmHg.
Patients who are considered at high risk are:
1. Those with rigid deformity (angle > 120).
2. Those with associated kyphosis.
3. Those with neurofibromatosis.
4. Those with congenital scoliosis.
5. Those with pre-existing neurological defecit.
• Potent inhalation agents : Has the disadvantage of
interference with SEP .
Delay in performing the wake-up test.
23. Warning signs during hypotensive
technique
• Note that , the additive effect
of hypotension and surgical
pressure on spinal cord may
result in spinal cord dysfunction.
• Warning signs:
1) Excessive dry field.
2) Dark venous blood.
3) Deterioration of SEPs.
• Should Cardiac arrest occurred
in prone position it would be fatal.
24. Preoperative autologous blood
donation
• Indications:
1. Bl. Loss > 1000 ml.
2. Hb.>11 gm (Hct = 33%).
• In patients weighing > 50 kg → 450 ml each visit.
• In patients < 50 kg use this formula:
Vol. of donated bl. = donor wt. (kg)
450ml 50 kg
25. Acute isovolaemic haemodilution
• Indications:
1. Bl. Loss >1000ml.
2. Base line Hct > 36%.
1-2 units of blood are removed from the patient immediately
before or after induction of anaesthesia,then this vol is
replaced by colloids or crystalloidsto keep the pt
normovolemic but with Hct25%
Typically the target Hb is 25 -27% . ( why 25-27%?)
It allows for substantial haemodilution.
It allows some margin for safety when blood loss beings to occur during
surgery.
Note that:
Blood is retransfused in REVERSE ORDER.
Tachycardia is a WARNING SIGN ,it means hypovolaemia and need for
retransfusion.
26. Intra-operative cell salvage
• Indications:
• Blood loss >1000 ml.
• Blood loss confined to discrete area.
• Characterestics of salvaged blood:
• = Packed RBCs in saline (Hct is 55%).
• No platelets.
• No clotting factors .
• No WBCs.
• Contraindications:
• ??? Oncologic surgery.
• ??? Enteric contamination (abdominal trauma).
• Topical haemostatic agent (gelfoam).
• Amniotic fluid.
27. Monitoring of the spinal cord
• Wake up test .
• Neurophysiological tests(evoked potential):
SSEP and MEP
28. Wake-up test
• TWO ASSISTANTS SHOULD BE PRESENT.
• N20-02+ narcotics+ relaxant +
inhalation
• Hazards of wake up test:
Tracheal extubation.
Air embolism .
Dislodgement of spinal
instrumentation.
Rod fracture
29. 2)Somatosensory Evoked
Potentials
• SEPs monitors spinal cord sensory pathway.
Can be applied continually and in mentally
retarded patient.
• SITES OF STIMULATION
• Median nerve at the wrist.
• Common peroneal nerve at the knee
• Posterior Tibial at the ankle
Injury or ischemia of spinal cord will change
SSEPs .
The change is in the form of increased latency
and decrease of amplitude.
30. Motor evoked potential
• MEP is basically an electomyographic potential
recorded over muscles in the hand or foot in
response to depolarization of the motor cortex
using transcranial magnetic or electrical stimulus.
• These modalities are profoundly affected by
aneasthetic agents, the former will be
unrecordable and the later recordable only during
intravenous aneasthesia .
MEP cannot be recorded in the presence of
complete neuromuscular blockade.
31. Spinal Cord Protection
• 1) Immediate administration of a
cource of corticosteroids is useful.
Methylprednisolone:
a bolus of 30 mg/kg followed by
infusion of 5 mg/kg for 24 hours.
• 2) Reestablish normotension, normooxia
and normocarbia.
• 3) Instruct surgeon to decrease traction
on spinal cord.
32. Extubation of the patient
(A) Extubation may be performed immediately at the
end of the surgery provided that :
Preoperative V.C was accepted.
Procedure was relatively uneventful.
(B) Extubation in the ICU
Indications for postoperative mechanical ventilation:
• (I) The decision may be taken preoperatively if:
• VC was < 30% of predicted value.
• Severe gas exchange abnormality (↑PaCO2).
• Duchenne muscular destrophy.
• Severe cerebral palsy.
• Patient with congenital heart.
• Patient with neurofibromatosis
34. Post operative care
• Pulmonary care.
• Fluid management.
• Pain control.
• Laboratory studies.
35. Postoperative pulmonary care
• Deep breathing and cough.
• Antibiotics .
• Bronchodilators.
• Theophylline.
• Postoperative pain relieve.
36. Fluid management
• SIADH is common.
• Blood:
hyponatremia and hypo-osmolality,
• Urine:
concentrated
decreased urine output and increased
urine osmolality.
Administration of large amount of fluids in an attempt to
increase urine out put will be :
Unsuccessful
Will worsen the hyponatremia.
So administer balanced salt solution aiming at keeping
urine output at the rate of 0.5 ml/Kg/hr.(Furosemide
may be added. Hypertonic saline for severe cases.
Specific treatment is demeclocycline.
37. New Surgical technique:
have used a thoracoscopic technique
through an anterior approach for spinal
fusion and placement of fixation devices.
Blood loss could be reduced to 400
cc and no surgery related
complications were found.