- Cleft lip and cleft palate are congenital deformities caused by failure of facial structures to fuse properly during development in utero.
- The document discusses the epidemiology, classifications, embryology, etiology, pathophysiology, associated conditions, timing of surgery, anesthetic concerns, and postoperative care for patients undergoing cleft lip and cleft palate repair surgery.
- Key anesthetic considerations include the patient's young age, potential for a difficult airway, risk of multiple surgeries, shared airway with the surgeon, and potential for associated congenital anomalies.
A basic overview on the management of intra-operative bronchospasm: the risk factors, triggers, diagnosis, prevention and management. Includes a case scenario – discussion.
ASA Guidelines for Management of the Difficult AirwaySun Yai-Cheng
Practice Guidelines for Management of the Difficult Airway
An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway
Anesthesiology 2013; 118(2):251-270
A basic overview on the management of intra-operative bronchospasm: the risk factors, triggers, diagnosis, prevention and management. Includes a case scenario – discussion.
ASA Guidelines for Management of the Difficult AirwaySun Yai-Cheng
Practice Guidelines for Management of the Difficult Airway
An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway
Anesthesiology 2013; 118(2):251-270
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
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
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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
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the 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 lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
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. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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.
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
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
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
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
2. INTRODUCTION
• Definition : Unilateral or bilateral fissure in the upper lip and/or soft palate
(may extend into hard palate) due to failure of fusion of maxillary and
medial & lateral nasal processes
• MC type of craniofacial deformities worldwide
3. EPIDEMIOLOGY
• Incidence : 1 in 1000 live births forCleft lip (CL)
1 in 2500 LBs forCleft palate (CP)
• Isolated CL – 25%
• Isolated CP – 25%
• Combined CL+CP (CLP) – 50%
• CL & CLP is more common in males, while CP is more common in females
4. CLASSIFICATIONS
I. Veau’s classification
A) Cleft lip
Class I : U/L notching of vermillion border, not extending into the lip
Class II : cleft extending into the lip, but not including the floor of the nose
Class III: cleft extending into the floor of the nose
Class IV: any b/l cleft of the lip, whether incomplete or complete
5. B) Cleft palate
Class I : soft palate
Class II : soft/hard palate, extending no further than incisive foramen
Class III: complete unilateral cleft, extending from uvula to incisive foramen,
then deviating to one side
Class IV: two clefts extending forward from the incisive foramen into the
alveolus
6. II. Kernahan and Stark’s classification
1. Clefts of structures anterior to the incisive foramen
2. Clefts of structures posterior to the incisive foramen
3. Clefts affecting structures anterior and posterior to the incisive foramen
III. Nagpur classification
Group I – cleft lip only
Group Ia – cleft lip + cleft alveolus
Group II – cleft palate only
Group III – cleft lip + cleft alveolus + cleft palate
7. IV. LAHSHAL classification
LAHSHAL is a paraphrase of the anatomic areas affected by cleft
• L – lip
• A – alveolus
• H – hard palate
• S – soft palate
• H – hard palate
• A – alveolus
• L – lip
8. TYPES OF CLEFTS
A) CL
• U/L or B/L
• Complete (lip, nasal floor, alveolus) or
Incomplete (lip only)
B) CP
• U/L or B/L
• Primary/Prepalatal (anterior palate, alveolus, lip, nostril floor, alae nasi) or
Secondary/Postpalatal (posterior to incisive foramen)
• Complete or Incomplete
9. EMBRYOLOGY
• Development of facial structures starts @ end of 4th week
• 5 facial prominences around stomatodeum
Unpaired frontonasal process
Paired maxillary prominences
Paired mandibular prominences
• Frontonasal process gives rise to medial & lateral nasal processes
10. • In following 2-4 weeks:
- 2 Medial nasal processes fuse in midline – upper lip
- Mandibular processes fuse in midline – lower lip
- Frontonasal process – bridge of the nose
- Medial nasal process – tip of nose and philtrum of upper lip
- Lateral nasal process – ala of the nose
- Maxillary and medial nasal process fuse – primary palate
- 2 outgrowths from maxillary prominences c/as palatine shelves fuse –
secondary palate
11. ETIOLOGY
• Exact etiology unknown
• Multifactorial origin with genetic and environmental influences
• Familial: affected parents have a 3-5% chance of an affected child, and with
one affected child, sibling risk is 20-40%
• Monozygotic twins show the same defect in 40-50% of cases, but only 5% in
dizygotic twins.
• Some cases may result from mechanical obstruction by tongue position,
structural hypoplasia
12. • Environmental factors:
- Maternal smoking or tobacco exposure
-Viral infections (Rubella)
- Poor nutrition
• Teratogenic drugs - Steroids, Mercaptopurine, Mtx,Valium, Dilantin,
Anticonvulsants (phenytoin, BZD), Salicylates
• The risk increases with rising maternal and paternal age
• Folic acid 400 mcg/day has a role in preventing CLP
13. PATHOPHYSIOLOGICAL FEATURES
• Difficulty in
- Feeding since birth
- Suckling
- Swallowing
- Phonation
• Abnormal dentition
• Inadequate weight gain,
nutritional deficiencies, anemia
• Chronic URTI
• Regurgitation of fluid & food
predispose to LRTI and ear
infections
14. ASSOCIATED CONDITIONS
• 70% - isolated cleft defect, 30% - syndrome
• >200 syndromes/sequences associated
• Additional abnormalities are most likely a/w isolated CP and least likely with
isolated CL
• Craniofacial abnormalities are most common, f/b CNS abnormalities e.g.
mental retardation and seizures, congenital cardiac disease, renal and
abdominal defects
15.
16. WHENTO UNDERGO SURGERY
• CL – ASAP (usually 3 months)
• Soft palate – 12-15 months
• Hard palate – 4-5 yrs
• No active infection
• No decompensated heart disease
• Rule of 10 : Hb >10
TLC <10000
>10 lbs for CL, >10 kgs forCP
• NOTE : Lip is repaired first as it decreases the width of palate defect
17. • CLP patients are likely to require further surgery either for plastic
improvements or for associated abnormalities. Around 20% will require
pharyngoplasty for velopharyngeal dysfunction at around 4-6 years
• Primary palatoplasty disrupts normal palate growth and despite orthodontic
treatment, some will require significant maxillofacial surgery in their teens
to correct midface hypoplasia and maxillary retrusion
18. ANESTHETIC CONCERNS
1. Young age
2. Difficult airway
3. Repeated surgeries
4. Shared airway
5. Associated congenital anomalies
19. PREOPERATIVE ASSESSMENT
• HISTORY:
General - Birth history, developmental milestones, vaccination status
Symptomatic - Recurrent infections, associated congenital heart defects,
breathing/feeding difficulties
• EXAMINATION:
General, identify associated congenital defects
Airway evaluation, location & size of defect
• INVESTIGATIONS:
CBC, Urine (R/M), CXR, X-ray mandible, Echo, As per associated anomalies
22. INDUCTION
• ASA monitors
• Propofol + Fentanyl + MR
• Anticipated difficult airway – Sevoflurane + N2O
• In patients with hypoplastic mandibles or wide cleft palate , tongue can prolapse
into nasopharynx leading to airway obstruction during the induction of anaesthesia
• During laryngoscopy, place lubricated dental roll/gauze in the cleft to prevent
trauma to underlying tissue
• RAE (South pole) tube, Oxford tube, Armored tube
• Coventional laryngoscopy fails –Video LS, FOI, Lightwand
• Throat pack
• Check ET tube position after positioning, following insertion & opening of mouth
gag
23. MAINTENANCE
• Iso/Sevo + N2O + Fenta +Vec/Atra
• Fluid – RL, Holliday-Segar formula
• Normothermia, normocapnia, homeostasis
• Surgeons use Adrenaline – ensure dose/concentration (1 ml/kg of 1:200000)
• Remove throat pack at the end & examine oral cavity for edema or bleeding
• At the end of the surgery, the pharynx and the oral cavity s/b gently
suctioned, if possible under vision using the laryngoscope
• Do not exert pressure on the suture line
• Avoid insertion of OPA/NPA
24. EXTUBATION
• AWAKE
• Postpone if any evidence of swelling of tongue/uvula
• Nurse in lateral or prone position
• Head should be kept in dependent position, turned to the side and extended
• In this position, the blood or mucus will be drained out without any risk of
aspiration
25. POSTOPERATIVE PERIOD
COMPLICATIONS
i. Airway obstruction – 6% overall, 25% if any congenital anomaly +nt
ii. Bleeding
iii. Hypothermia
iv. Tongue edema
v. Flap edema
vi. Subglottic edema
vii.Mucosal swelling of hypopharynx
26. Causes ofTongue Edema:
Venous stasis
Hematoma formation
Ischemia
Necrosis
To reduce the incidence of tongue swelling during surgery , the gag s/b
released every 60-90 min to allow for tongue perfusion .
27. POST-OP ANALGESIA
A) SYSTEMIC:
• Paracetamol – 15 mg/kg PO as a premedication
30 mg/kg PR post induction
• Opioids - Morphine (0.1 mg/kg - 0.2mg/kg iv), Meperidine, Fentanyl
• Diclofenac suppository 1 mg/kg, 12 hourly
• NSAIDS – Ketorolac, Ibuprofen (avoided for 12 h post-operatively)
B) LOCAL infiltration
29. IN PROGRESS
• The timing and the type of surgery have been hugely debated over the
recent years
• The advantages of fetal wound healing are being explored with
experimental evidence, suggesting in-utero surgery for cleft lip and palate
repair provides superior wound healing without scarring