Preterm infants have significant physiological immaturity that impacts anesthesia considerations. Their respiratory, cardiovascular, renal and neurological systems are underdeveloped. Anesthesia can more easily cause apnea, hypothermia, hypoglycemia and other complications in preterm infants. Careful attention must be paid to temperature control, fluid management, glucose levels and minimizing respiratory depressant effects. Regional anesthesia techniques are preferable when possible to reduce medication doses.
Hypothyroidism and hyperthyroidism have significant clinical effects. Both should be optimized. Anesthesia providers should be able to diagnose and manage.
A short presentation including a fictitious case study on prematurity. Focusing on the causes of prematurity, acute complications, chronic complications and bronchopulmonary dysplasia.
Hypothyroidism and hyperthyroidism have significant clinical effects. Both should be optimized. Anesthesia providers should be able to diagnose and manage.
A short presentation including a fictitious case study on prematurity. Focusing on the causes of prematurity, acute complications, chronic complications and bronchopulmonary dysplasia.
A miscarriage is the loss of pregnancy from natural causes before the 20th week of pregnancy. Most miscarriages occur very early in the pregnancy, often before a woman even knows she is pregnant. There are many different causes for a miscarriage. In most cases, there is nothing you can do to prevent a miscarriage.
Nutritional Management of Premature InfantsMCH-org-ua
International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)
Neonatal necrotizing enterocolitis
NEC is the most common life-threatening emergency of the gastrointestinal tract in the newborn period. The disease is characterized by various degrees of mucosal or transmural necrosis of the intestine. The cause of NEC remains unclear but is most likely multifactorial. The incidence of NEC is 1-5% of infants in neonatal intensive care units (NICUs). Both incidence and case fatality rates increase with decreasing birthweight and gestational age. Because very small, ill preterm infants are particularly susceptible to NEC, a rising incidence may reflect improved survival of this high-risk group of patients.
Clinical Manifestations
Infants with NEC have a variety of signs and symptoms and may have an insidious or sudden catastrophic onset (Table 96-1). The onset of NEC is usually in the 2nd or 3rd week of life but can be as late as 3 mo in VLBW infants. Age of onset is inversely related to gestational age. The 1st signs of impending disease may be nonspecific, including lethargy and temperature instability, or related to gastrointestinal pathology, such as abdominal distention and gastric retention. Obvious bloody stools are seen in 25% of patients. Because of nonspecific signs, sepsis may be suspected before NEC. The spectrum of illness is broad, ranging from mild disease with only guaiac-positive stools to severe illness with bowel perforation, peritonitis, systemic inflammatory response syndrome, shock, and death. Progression may be rapid, but it is unusual for the disease to progress from mild to severe after 72 hr.
Diagnosis
A very high index of suspicion in treating preterm at-risk infants is crucial. Plain abdominal radiographs are essential to make a diagnosis of NEC. The finding of pneumatosis intestinalis (air in the bowel wall) confirms the clinical suspicion of NEC and is diagnostic; 50-75% of patients have pneumatosis when treatment is started (Fig. 96-4). Portal venous gas is a sign of severe disease, and pneumoperitoneum indicates a perforation (Figs. 96-4 and 96-5). Hepatic ultrasonography may detect portal venous gas despite normal abdominal roentgenograms .
Complications of pregnancy are health problems that occur during pregnancy. They can involve the mother's health, the baby's health, or both. Here are some complications which a woman may face during pregnancy.
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.
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.
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
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
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
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
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
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.
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.
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.
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
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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.
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
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2. Premature babies - born before 37 weeks
Gestational Age determines the extent of
physiological immaturity.
3. Respiratory system
• ALVEOLI develop 17-28 WKS
• Pulmonary capillaries 28-36 wks
• Before 32-34 wks surfactant deficeint
more prone to RDS
• mechanical ventilation
• more than 28 days of oxygen supplementation BPD
4. CONTROL OF RESPIRATION /APNOEA
• Chemoreceptor blunted response
• Normal biphasic response to hypoxaemia
replaced by apnoea.
• incidence higher in preterm.
• Apnoea pause more than 20 sec alone
or less than 20 sec + bradycardia
5. • Preterm - 10% type 1 fibre diaphragm and intercostal muscles
(25% term)
apnoea at time of physiological stress.
• After operation, apnoeas are frequent in the first 12 h
and can continue until 48–72 h.
6. Anatomical differences
Large occiput
Large sized tongue
Larynx : more cephalic, funnel shape
Epiglottis : short, stubby, omega shaped,
angled over laryngeal inlet
Vocal cords angled
Cricoid cartilage : Narrowest portion
8. Tube that easily passes the vocal cords
may be tight in the subglottic region
Uncuffed tubes preferred
Cuffed tubes : leak maintained around cuff
(with or without inflation) to prevent trauma
resulting in subglottic oedema and
subsequent post-extubation stridor.
9. • Airway
Highly compliant
• Chest wall
Lungs : non compliant
Alveoli thick walled at birth
Dead space ventilation similar to adults
Oxygen consumption 2-3 times higher
Work of breathing 3 times that in adults ----
increased by cold stress / airway obstruction
Hypoxic and hypercapnic drives not well developed
Depress respiration in these patients
10. Weaker intercostal muscles,diaphragm
Horizontal , pliable ribs
Protruberant abdomen
Diaphragmatic and intercostal muscles
Low type 1 muscle fibres – ability to perform repeated
exercise
• Early fatigue
• Desaturation
11. Anaesthetic considerations
Limited respiratory reserve
Horizontal ribs prevent ‘bucket handle’ action
seen in adult breathing : limit increase in VT
Ventilation primarily diaphragmatic
Bulky abdominal organs , stomach filled
with gases from poor bag mask ventilation –
impinge on contents of the chest , splint diaphragm
reducing adequate ventilation
12. Chest wall more compliant : low FRC
FRC decreases with apnoea , anaesthesia causing lung
collapse
Closing volume larger than FRC until 6-8 years
Causes an increased tendency for airway closure at end
expiration.
Thus, neonates generally need IPPV
during anaesthesia and would benefit from a
higher respiratory rate and the use of PEEP.
13. CPAP during spontaneous ventilation improves
oxygenation and decreases work of breathing
Apnoea common post op in premature infants
14. Cardiovascular system
Stroke volume - fixed by noncompliant and immature LV
CO sensitive to HR changes
Activation of parasympathetic nervous system,
anesthetic overdose, or hypoxia -- trigger bradycardia --
profound reductions in CO
15. Sympathetic nervous system
Baroreceptor reflexes
Blunted response to exogenous catecholamines
Immature heart -- more sensitive to depression by volatile
anesthetics and opioid-induced bradycardia
Not fully mature
17. Anaesthetic Implications
Bradycardia associated with hypoxia : treat with oxygen
and ventilation initially
Patent ductus contracts in 1st few days of life
fibrose within 2-4 weeks
Closure of foramen ovale is pressure dependent
closes in the first day of life
18. Neonatal pulmonary vasculature reacts to rise in Pa02 and
pH and fall in PaCO2 at birth
Alterations in pressure and with response to hypoxia and
acidosis : reversion to transitional circulation may occur in
the first few weeks after birth.
19. A term baby has 18–20 g /dl of haemoglobin (Hb);
in prematurity, this can be 13–15 g/ dl,
70–80% of which is HbF.
•Fetal Hb has a reduced ability to release oxygen;
•Compensation the relatively high blood volume,
Hb concentration, and cardiac output .
Haematology
20. •This compensation is much less in the preterm baby.
A target haematocrit of 40–45% facilitates oxygen delivery; this
may necessitate earlier perioperative blood transfusion
EARLY BLOOD TRANSFUSION
TARGET HAEMOCRIT 40-45%
21. Metabolism and temperature
regulation
Vulnerable to hypothermia
Large body surface area to weight ratio
thin skin (non keratinized)
decrease brown fat (nonshivering thermogenesis)
PREVENT HYPOTHERMIA
22. Low body temperature
Respiratory depression
Acidosis
Decreased cardiac output
Increased duration of action of drugs
Decrease in platelet function
Increase in the risk of infection
23. Anaesthetic considerations
Heat lost during anaesthesia mostly via radiation
Also by conduction, convection and evaporation
Optimal ambient temperature to prevent heat loss
34ºC for premature infant
32ºC for neonates
28ºC in adolescents and adults.
24. Peri-operative heat loss is vital
Placing baby on warming mattress and warming the surgical
unit (80° F or warmer) : conduction
Keeping infant in incubator and covered with blankets :
convection. Cover head too.
Evaporation : humidification of inspired gases,
use of plastic wrap to decrease water loss through skin,
warming of skin disinfectant solutions.
25. Hot air blankets : most
effective means of
warming children
Anesthetics alter many
thermoregulatory
mechanisms, particularly
nonshivering
thermogenesis in neonates.
AVOID OVERHEATING!
26. Kidneys
Renal function diminished due to
-Small perfusion pressures
-Immature glomerular Fxn
-Immature tubular function
Nearly complete maturation -- ≈ 20 weeks after birth
Complete maturation -- 2 years of age
Free water and solute clearance impaired in PRETERM
More prone to dehydration
T1/2 of medications -prolonged (antibiotics)
27. • Preterm infants impaired ability to concentrate urine, so
cannot tolerate under and over hydration.
• They are unable to retain sodium
prone to hyponatraemia.
• Water loss is common in preterm infants
due to the large body surface area and thin skin,
particularly in the first few days of life.
prone to hyponatraemia.
28. Liver
Functional maturity of the liver- incomplete
Metabolic enzyme developed but not inducible.
With growth of infant ability to metabolize medications ↑
(1) Hepatic blood flow ↑, more drug delivered
(2) Enzyme systems develop , induced
Cytochrome P450 system ≈ 50% adult values at birth.
29. CYP3A : present at adult values at birth
Other cytochromes absent or reduced
Phase II reactions : involve conjugation to facilitate renal
excretion
Often impaired in neonates(preterm)
Jaundice (decreased bilirubin breakdown)
long drug t1/2
the half-life of morphine and benzodiazepines is several days
30. Preterm infant’s liver - minimal glycogen stores
Unable to manage large protein loads
Thus increased tendency :
hypoglycemia
acidemia
failure to gain weight when diet contains too much
protein
31. GIT
Birth -- gastric pH is alkalotic
Day 2 -- pH in normal physiologic range
Coordination of swallowing with respiration
under developed in preterm
High incidence of gastroesophageal reflux
32. Glucose metabolism
Hypoglycaemia : common in preterm
less glycogen store
underdeveloped glucogenic pathway.
May lead to neurological damage
Glucose levels : monitored regularly
.
Infusion of 10% glucose may be used.
33. Neonates - appreciate pain
(increased HR , BP , neuro-endocrine response)
Narcotics depress the ventilation response to a rise in PaC02.
BBB poorly formed : barbiturates, opioids, antibiotics and
bilirubin cross --- prolonged duration of action
Central nervous system
34. • Intraventricular haemorrhage
occurs in 25% of very low birth weight infants
within the first 72 hours of life.
Intraventricular haemorrhage complicated by ventricular
dilation, progress to hydrocephalus.
35. • Recently anaesthetic agents effect on the developing
brain leading to later memory and learning impairment.
• SO, only essential surgery should be
performed in early life.
Ketamine should probably be avoided in premature babies
37. Retinopathy of prematurity
More common in preterm infants
• cause vasoconstriction of retinal vessels
high concentrations of supplemental oxygen,
• lead to retinal detachment, fibrosis
blindness in children,
• prevented avoiding exposure to high concentration of 02.
38. Total body water -- preterm infants > term infant
Water soluble drug - large Vd - requires large loading dose
(antibiotics, succinylcholine)
Fat , muscle content ↑ with age
Drug redistributing into fat have long clinical effect
Drug redistributing into muscle
39. Inhaled anaesthetics
Small safety margin between anaesthetic overdose
and inadequate depth of anaesthesia
Anaesthetic requirement preterm < term neonates
.
Infants : higher MAC than older children or adults
Uptake more rapid : increased RR , CI
41. Thiopental : larger dose in children
- Shorter elimination t1/2
- Greater plasma clearance
Neonate ( 3-4mg/kg)
- Less protein binding
-Longer t1/2
-Impaired clearance
42. Opioids
More potent in preterm
Easier entry across BBB
Decreased metabolic capability
Increased sensitivity of respiratory centers
43.
44. PRE-OP ASSESSMENT
Detailed history from both the parents .
Points to be asked-
• Gestational age at birth and the current gestational age
• Weight
• Periods and duration of mechanical ventilation,
oxygen therapy.
• Apnoeas – frequency, duration, possible triggers
• Co-morbidities, particularly cardiac
45. Preoperative fasting
Greater risk for aspiration –
Low gastric pH
High residual volumes
Type Fasting time (hrs)
Clear liquids 2
Breast milk 4
Infant formula 6
Solid (fatty or fried) foods 8
46. • ADVANTAGES OF THESE LIBERAL GUIDELINES-
- Prevent dehydration and hypoglycemia
- Reduce the risk of aspiration
.
Cont….
48. A crossmatch should be taken where blood loss
is anticipated to be greater than 10% of blood volume.
All premature babies should have an echocardiogram
performed before surgery
49. -
Premedication is not required
However, atropine should be considered to pre-empt
transient bradycardia
50. INTRA-OPERATIVE MANAGEMENT
• The PRETERM may already be intubated and
ventilated prior to arrival in the operating theatre.
• A range of uncuffed tubes should be available.
• If the infant has undergone prolonged ventilation,
there is a possibility of subglottic stenosis.
51. • An orogastric tube is useful after intubation
to decompress the stomach and to minimise
splinting of the diaphragm and facilitate ventilation.
• AVOID excessive oxygen concentrations predispose to
retinopathy of prematurity.
• A balanced anaesthetic technique should be used
Cont….
52. • For pain, Paracetamol is commonly used.
• NSAIDs for analgesia are C/I due to renal
immaturity.
• NSAIDs may cause premature closure of a PDA.
Cont….
53. • Where opiates are necessary, short acting such as fentanyl.
• The use of local anaesthetic techniques is encouraged
local infiltration by the surgeon or
caudal, epidural or spinal.
54. Theatre/equipment
• Should have all the necessary equipment and staff for this.
• Ideally 2 oxygen saturation probes
• one on the right hand and
• one on the lower limb
to compare pre ductal and post ductal levels.
• ECG via neonatal electrodes, non-invasive blood pressure,
capnography and temperature monitoring are mandatory.
55. • The theatre pre-warmed to achieve a temperature 25°C.
Active warming by such as overhead heaters should be used
as well as a paediatric heat moisture exchange.
• All fluid and blood products warmed prior
• irrigation fluid is warmed prior to use.
• prevent unnecessary exposure.
• Surgical drapes lightweight, preferably plastic allow the
baby to be clearly seen.
Cont….
56. • Blood glucose closely monitored.
• a widely accepted cut off is a blood sugar of <2.6mmol/L.
• Glucose can be given as a bolus of 1-2ml/kg of 10% glucose.
• Regular blood sugars should be checked in order to confirm
nomal glucose level
Cont….
57. Extubation
Plan for awake intubation
Return of gag reflex
Responsive and purposeful
Regular respiration
58. FLUID MANAGEMENT
• Ideally, fluid
acid–base, electrolyte corrected before reaching ot
Hb deficits should be
• The estimated maintenance fluid requirement of a preterm
infant is 100 ml /kg/24 h21.
• During surgery, the maintenance fluid should be isotonic (e.g.
Hartmann’s solution, 0.9% sodium chloride).9
59. • Preterm infants often receive a glucose-containing solution
to maintain normoglycaemia continue during surgery.
• Estimation of blood loss can be difficult
• replacement can be guided by
capillary Hb and haematocrit
perceived ongoing and anticipated losses, and
cardiorespiratory status.
• The extremely premature and those with cyanotic heart disease
need a haematocrit of 35–40% to maintain oxygenation.
60. • As a transfusion guideline, the volume of packed cells
required(ml)=desired increment in Hb (g dl21)*weight (kg)*3
• Platelets and fresh frozen plasma is given as
10–20 ml /kg21, and cryoprecipitate as 5–10 ml /kg21.
61. • Third-space losses 1–2 ml/ kg/hfor superficial surgery,
4–7 ml /kg/ hfor thoracotomy, and
5–10 ml/ kg /hfor abdominal surgery.9
62. • Hypotension, diminished heart sounds, tachycardia,
increased core-peripheral temperature gradient, and
delayed capillary refill suggest fluid depletion.
• Urine output is a good indicator of fluid
status and perfusion; an output of 0.5–2 ml/kg /h is the
norm.
• However, monitoring such small volumes is difficult.
63. • If an arterial line is in situ, the position of
the dicrotic notch and the area under
the arterial waveform can give valuable
information to guide fluids.
• Care must be taken during drug injections
not to introduce air bubbles into the circulation
Which may traverse right-to-left shunts.
As little as 0.2–0.4 ml kg can BE DANGEROUS
65. POST-OPERATIVE CARE
A decision whether to extubate or not????
consider the preoperative state of the baby
type of surgery performed.
If plans extubate, fully awake and
managing adequate tidal volumes without support.
66. period. apnoea-major concern
Premature babies under 60 weeks gestational age
need high dependency unit for at least 12 hours
and for a further 12 hours following any apnoeic
Cont….
67. Continuous apnoea alarm monitoring must be available
IV caffeine at 10mg/kg
CPAP may well be useful at this stage