1) The document discusses anaesthetic management for laparoscopic cholecystectomy in patients with coronary artery disease (CAD), outlining how to provide safe anaesthesia for non-cardiac surgery in these high-risk patients.
2) Patients with CAD have increased perioperative cardiac risk due to exaggerated hemodynamic responses to stimuli. Careful preoperative risk stratification is important to identify risk factors and determine if preoperative intervention is needed.
3) Intraoperatively, the goals are to maintain a normal heart rate and blood pressure, adequate oxygen delivery, and minimize hemodynamic stress responses through careful use of anesthetic agents and techniques. Close monitoring is important to detect and treat any cardiac complications promptly.
Erector spinae plane block is a relatively novel approach to pain management for a variety of surgical procedures. ESP block is a challenging anesthesia and analgesia technique that needs more research.
Erector spinae plane block is a relatively novel approach to pain management for a variety of surgical procedures. ESP block is a challenging anesthesia and analgesia technique that needs more research.
During atrial fibrillation, the heart's upper chambers — called the atria — beat chaotically and irregularly. They beat out of sync with the lower heart chambers, called the ventricles. For many people, AFib may have no symptoms. But AFib may cause a fast, pounding heartbeat, shortness of breath or light-headedness.
Title: Sense of Smell
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 primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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
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
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
anesthesia in patient a patient with IHD posted for lap cholecystectomy. presentation.pptx
1. Anaesthetic management
for lap cholecystectomy
in patient with CAD
Dr. Daisy Karan
Professor, Dept of Anaesthesioly & Critical Care,
IMS & SUM Hospital
2. AIM OF THE DISCUSSION
How to provide” safe anaesthesia” for” non cardiac surgery” in
patient suspected or diagnosed of having ‘CORONARY ARTERY
DISEASE’ .
CAD is a spectrum of closely related manifestations all resulting
from imbalance between demand and supply of oxygen to heart
ANGINA AMI HEART FAILURE
SCD
ISCHEMIC
CARDIOMYOPATHY
3. WHAT’S THE DIFFERENCE FROM NORMAL
PATIENTS ?
Increased perioperative cardiac morbidity and mortality
Exaggerated hypotension (induction )
Exaggerated hypertension (laryngoscopy,intubation,abdominal
distension,pain )
4.
5. PREOP GOALS- IDENTIFY SIGNS OF IHD
Risk factors
Male gender/ post menopausal
women
Increasing age
Hypercholesterolemia
Systemic hypertension
Cigarette smoking
Diabetes mellitus
Obesity
Sedentary lifestyle
Family history (premature
development of ischemic heart
disease)
History & symptoms
Dyspnoea-NYHA classification for
exercise tolerance
Angina-(stable or unstable) Canadian
classification for angina
H/O previous MI
H/O PCI ( timing and type)
Metabolic Equivalents (MET SCORE)
Specific Diagnostic tests(ECG with
pathological Q waves)
Risk of peri-operative re-infarction
is related to the time elapsed
Incidence of re-infarction
30-80% - < 3 months
15% - 3-6 months
5% - > 6 months
6.
7.
8. WHY TO DO RISK STRATIFICATION ?
Helps to determine whether pre-op intervention is required before
undergoing surgery.
Identifies peri-op risk factors like associated disease (thyroid
disease,diabetes)
Helps the health providers to calculate the benefit –to-risk ratio for a
procedure better.
Tries to modify risk factors by pharmacologic interventions.
Helps to decide when to take up the patient for surgery.
Risk is related to both surgery and patient specific characteristics
10. HOW URGENT IS SURGERY?
EMERGENCY SURGERY (required WITHIN 6 HRS)
URGENT SURGERY ( necessary WITHIN 6-24 HRS)
TIME SENSITIVE SURGERY (WITHIN 1-6 WEEKS) (ONCOSURGERY )
ELECTIVE SURGERY (can delay upto 1 year )
12. Risk of major cardiac events (MACE)
0=0.4% , 1=0.6%, 2=6.6% , >3= 11%
13.
14. Case scenario
A 55 YR OLD MALE with history IHD with drug eluting stent in situ POSTED FOR
ELECTIVE LAPARASCOPIC CHOLECYSTECTOMY.
H/O HTN ,BP-142/89mm Hg
No H/O Chest pain or breathlessness on daily work.
DES 1year back with no new symptoms.
Medications-DAPT, atenolol,ACEI
ECG- Anterolateral ischemia.
15. PREOP EVALUATION
HISTORY TAKING
CVS EXAMINATION
FUNCTIONAL STATUS- GOOD
RISK STRATIFICATION
FURTHER TESTING × as RCRI Score is =1
& Intermediate surgery
PROCEED FOR SURGERY
16. PREOP MEDICATION MANAGEMENT
Beta blockers
CCB,Diuretics
Statins
Antihypertensives (ACEI)-
Antiarrhythmics
Nitrates
Antiplatelets –Aspirin and Clopidogrel
Should continue the therapy and may
recommend initiation in untreated patients
Already taking should continue taking including
morning of surgery to minimize tachycardia and
ischemia.
However not initiated prophylactically
May be continued in periop period
Should continue
Typically continued particularly with prior heart failure
Only held back in pts with hemodynamic instability or
extensive surgery with anticipated third space loss.
19. PREOP INVESTIGATIONS
Routine Investigations
Hematocrit
Blood glucose
Lipid profile
Renal function tests
X-ray chest
Special Investigations
ECG(12 –LEAD)
EXERCISE ECG
(TMT)/DOBUTAMINE STRESS
TEST
ECHO
SCREENING BIOMARKERS
BNP (>92 ng/ml), or NT-pro-
BNP (300ng/l)
TROPONIN
If RCRI>2
20. Conclusion:
Preoperative NT-proBNP is strongly associated with vascular death and MINS within 30
days after noncardiac surgery and improves cardiac risk prediction in addition to the
RCRI.
22. IN IHD patients there is higher elevation in RAP and
PCWP and higher fall in CO
HIGH LEVELS OF ADRENALINE AND CATECHOLANINES
Tachycardia
Coronary vasoconstriction
increased tendency of thrombosis in coronary vessels CO2
Contractility
Arrhythmia
23. What can be done…..?
MINIMISE
HEMODYNAMIC
EFFECT
GRADUAL
INSUFFLATION
↑ CIRCULATING
VOLUME BEFORE
PNEUMO.
Pre-load
augmentation
Stockings to ↓
pooling
Minimise duration
of fasting
LIMIT IAP <15 mm Hg
AVOID SNS STIMULATION
α blockers
βblockers
Vasodilators
Dexmed
25. INTRAOP GOALS
Low to normal HR
Normal BP
Maintain CPP=ABP-LVEDP
Avoid hypothermia
Maintain myocardial contractility
Adequate arterial oxygen content
27. INTRAOP DRUG CHOICE
PREMEDICATION-
To allay anxiety, fear use benzodiazepenes (MIDAZOLAM).
Effective control of catecholamine surge with intravenous opiods (FENTANYL)
Opiods may be selected as the primary anesthetics in pts. with compromised LV
function.
INDUCTION-
ETOMIDATE: causes minimal hemodynamic changes
PROPOFOL :decrease myocardial contractility with significant decrease in BP and HR.
THIOPENTONE: decrease myocardial contractility with significant INCREASE IN HR
28. INTRAOP DRUG CHOICE
INTUBATION- (Blunting the hemodynamic response is crucial)
VECURONIUM most cardio stable
MAINTENANCE-
AHA guidelines suggest volatile anesthetics for maintenance of anesthesia in pts.
who are hemodynamically stable with no evidence of CHF.
Avoid halothane
ISOFLURANE is safer
N2o use is questionable as it increases PVR, predisposes to diastolic
dysfunction and subsequent myocardial ischemia.
29. MANAGING PERIOP MI
RISKS REMAIN TILL 72 HRS
DIAGNOSIS: ECG
Any ST upsloping >1mm
ST downsloping of >2mm
ST elevation
T wave inversion
TREATMENT:
Stop surgery & desufflate abdomen
100 % oxygen
inj. Morphine/opiods
sublingual nitrate/ β blockers
Aspirin/statin
inj heparin if plausible to stop stent
thrombosis
31. CONCERN DURING EMERGENCE AND
EXTUBATION
EXTUBATION
OPIODS/LIGNOCAINE/
ESMOLOL/VASODILAT
ORS
SUPPLEMENT
OXYGEN
POST OP PAIN
MULTIMODAL
TECHNIQUES
STOP
SHIVERING
AND PONV
ISCHEMIA
MONITORING
12 Lead ECG
MONITOR
URINE OUTPUT
32. TAKE HOME MESSAGE
Urgent surgery
Low risk surgery
High risk surgery with MET>4
RCRI≤ 1
Elevated risk
RCRI≥ 2
MET< 4 or unknown
NO FURTHER
TESTING
STRESS TESTING
BIOMARKERS
CT Angio
Optimise oxygen supply /demand
imbalance
