Transurethral resection of the prostate (TURP) is a common surgery performed to relieve urinary symptoms caused by an enlarged prostate. Regional anesthesia such as spinal anesthesia is generally preferred over general anesthesia for TURP. Key complications during the procedure include hypotension from sympathetic blockade, hemorrhage, perforation of the bladder or prostate capsule, hypothermia from cold irrigation fluids, and potential for developing TURP syndrome from fluid absorption. Careful patient assessment, fluid management, and monitoring are important to help prevent complications during this common urological procedure.
Dr Ho Siew Hong shared his experience on how to perform the ideal puncture for PCNL in a lecture to Asian urologists during the Advanced Urology Course 2008 in Singapore
TURP step by step operative urology series
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Dr Ho Siew Hong shared his experience on how to perform the ideal puncture for PCNL in a lecture to Asian urologists during the Advanced Urology Course 2008 in Singapore
TURP step by step operative urology series
for more resources:
www.uronotes2012.blogspot.com
enter your mail & press follow us by mail to receive our daily feeds
Use focusing Shock Waves to breakdown
a stone into small pieces.
Shock waves are acoustic pulses.
Pass through better in water and solid but
not in air.
Introduce in 1980 by Dornier which is a supersonic aircraft company
HoLEP: the gold standard for the surgical management of BPH in the 21st CenturyDr. Manjul Maurya
HoLEP is at least as effective as other surgical therapies, including TURP, OP and other laser modalities, with fewer complications, shorter hospital stays, and decreased catheter time. These benefits make HoLEP the procedure of choice for men seeking surgical relief for BPH related LUTS and the gold standard for the 21st Century.
Retrograde Intrarenal Ureteroscopic Surgery (RIRS)Urovideo.org
Gerhard J. Fuchs, M.D., Dr. med., F.A.C.S.
Professor of Urology, UCLA School of Medicine
Vice Chair, Cedars Sinai Department of Surgery
Medallion Chair in Minimally Invasive Urology
Cedars-Sinai Medical Center
Los Angeles, USA
The surgical treatment of an injury or defect within the urethra's walls is known as urethroplasty. The three most frequent factors leading to urethral damage that needs to be repaired are trauma, iatrogenic injury, and infections. The gold standard treatment for urethral strictures is urethroplasty, which has a lower recurrence rate than dilatations and urethrotomies. Although recurrence rates are higher for this challenging treatment group, it is likely the only effective treatment option for chronic and severe strictures.
Urethroplasty is not regarded as a small procedure, taking three to eight hours on average in the operating room. Between 20% and 30% of urethroplasty patients may benefit from the ease of going under the knife for a shorter period of time and going home the same day. On average, hospital stays last two to three days. Seven to ten days may be needed for hospitalization for more complicated surgeries.
Fewer than ten percent of patients experience significant complications after urethroplasty, while complications, particularly recurrences, are more frequent in long and complex strictures.
Use focusing Shock Waves to breakdown
a stone into small pieces.
Shock waves are acoustic pulses.
Pass through better in water and solid but
not in air.
Introduce in 1980 by Dornier which is a supersonic aircraft company
HoLEP: the gold standard for the surgical management of BPH in the 21st CenturyDr. Manjul Maurya
HoLEP is at least as effective as other surgical therapies, including TURP, OP and other laser modalities, with fewer complications, shorter hospital stays, and decreased catheter time. These benefits make HoLEP the procedure of choice for men seeking surgical relief for BPH related LUTS and the gold standard for the 21st Century.
Retrograde Intrarenal Ureteroscopic Surgery (RIRS)Urovideo.org
Gerhard J. Fuchs, M.D., Dr. med., F.A.C.S.
Professor of Urology, UCLA School of Medicine
Vice Chair, Cedars Sinai Department of Surgery
Medallion Chair in Minimally Invasive Urology
Cedars-Sinai Medical Center
Los Angeles, USA
The surgical treatment of an injury or defect within the urethra's walls is known as urethroplasty. The three most frequent factors leading to urethral damage that needs to be repaired are trauma, iatrogenic injury, and infections. The gold standard treatment for urethral strictures is urethroplasty, which has a lower recurrence rate than dilatations and urethrotomies. Although recurrence rates are higher for this challenging treatment group, it is likely the only effective treatment option for chronic and severe strictures.
Urethroplasty is not regarded as a small procedure, taking three to eight hours on average in the operating room. Between 20% and 30% of urethroplasty patients may benefit from the ease of going under the knife for a shorter period of time and going home the same day. On average, hospital stays last two to three days. Seven to ten days may be needed for hospitalization for more complicated surgeries.
Fewer than ten percent of patients experience significant complications after urethroplasty, while complications, particularly recurrences, are more frequent in long and complex strictures.
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...The Lifesciences Magazine
Deep Leg Vein Thrombosis occurs when a blood clot forms in one or more of the deep veins in the legs. These clots can impede blood flow, leading to severe complications.
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.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
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
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
The Importance of Community Nursing Care.pdfAD Healthcare
NDIS and Community 24/7 Nursing Care is a specific type of support that may be provided under the NDIS for individuals with complex medical needs who require ongoing nursing care in a community setting, such as their home or a supported accommodation facility.
2. INTRODUCTION
Benign prostate hyperplasia is responsible for majority of urinary
symptoms in men over 50 yrs of age
TURP is a type of prostate surgery done to relieve moderate to severe
urinary symptoms caused by an enlarged prostate(BPH(
-TURP uses cystoscopy and a resectoscope to remove tissue protruding
into the prostatic urethra.
-So this procedure is most commonly performed on elderly patients- a
population with high incidence of cardiac, respiratory and renal disease.
-Safe anaesthesia depends on detection and optimisation of co-existing
diseases, and weighing the relative risks and benefits of regional and
general anaesthesia for each patient.
3. ANATOMY OF PROSTATE GLAND
Pyramidal shaped organ
Lies below urinary bladder & located
infront of the rectum, posterior to
the pubic symphysis & superior to
the perineal membrane
Normal weight- 20 g
Encircles urethera as it emerges from
base of bladder.
It Is enclosed within a capsule
composed of collagen, elasten &
large no. of smooth muscles
Microscopic anatomy
-1.Transitional
-2.Central
-3.periphery zone
4. Transional zone:
-This is the area surrounding the prostatic urethra.
It is were the BPH occurs.
Central zone:
It is the area surrounding the ejaculatory duct
Peripheral zone:
This zone covers the posterior & lateral zone aspects of the prostate. It is the
most common area affected by chronic prostatitis & adenocarcinoma.
5. The Prostate Gland is rich in blood supply, mainly from inferior vesical
artery
The prostatic venous plexus drains into internal iliac vein & communicates
with the vertebral plexus, thereby allowing neoplastic spread to
vertebrae
The prostatic vessels & the autonomic innervations run between the
layers of the lateral prostatic fascia & the prostate.
-Arteries and veins penetrate the capsule and branch inside the gland.
-The venous sinuses adjacent to the capsule are particularly large.
Nerve Supply
-Prostatic plexus-Sympathetic- T12-L2(contraction of smooth muscles of
capsule & stroma(
-Parasympathetic- S2-S4(prostatic secretion(
-Pain fibres from Prostate, Prostatic Urethra and Bladder mucosa- S2-S4
-Bladder distension pain – T12-L2
6. SURGICAL PROCEDURE
-TURP - performed by inserting a
Resectoscope through urethra.
-Prostatic tissue is resected into pieces
with an electrically powered cutting-
coagulating metal loop.
-Pieces washed out by irrigating solution.
-Prostatic capsule preserved- If violated,
large amounts of irrigating fluid is
absorbed into circulation, periprostatic
and retroperitoneal spaces.
7. -Surgery normally takes 30-60 mins-
depending on size of gland and
experience of surgeon.
-Position- Lithotomy position
-At the end of surgery- a 3-lumen
catheter placed to allow continuous
irrigation using normal saline for
upto 24 hours after surgery
8. IRRIGATION FLUIDS
-Properties of ideal Irrigation Solution-
1.Transparent- allows visualization
2.Isotonic
3.Electrically non conductive- allows diathermy to work.
4.Non-hemolytic
5.Non metabolised
6.Non-toxic
7.Inexpensive
8.Easy to sterilize
11. COMPLICATIONS OF
IRRIGATION FLUIDS
-Glycine-
-Normal plasma glycine levels are 13 to 17 mg/L
-Transient blindness is attributed to glycine toxicity.
-Glycine is a major inhibitory-transmitter acting in the spinal cord and brain-
stem.
-Glycine also has been implicated in the myocardial depression and
hemodynamic changes associated with TURP syndrome.
-Ammonia Toxicity-
-Absorption of glycine can result in CNS toxicity because
of oxidative bio-transformation of glycine to ammonia.
12. -Mannitol-
-Rapidly expands blood volume and causes pulmonary edema in cardiac
patients.
-Glucose-
-Causes severe hyperglycemia in diabetic patients
Distilled Water is electrically inert and inexpensive and has excellent optical
properties.
-Extremely Hypotonic.
-When absorbed into the circulation in large amounts,
plain water causes Hemolysis, Shock, and Renal failure.
-Thus Isotonic fluids are preferred- ) these solutions are kept slightly
hypotonic to preserve transparency(
14. PREOPERATIVE ASSESSMENT
History and Examination:
-Cardiovascular- Major risk factors for IHD )HTN, DM,
Smoking,Hypercholesterolemia and family history( – can lead to
silent perioperative MI.
-Heart failure- fluid overload increases risk
-Respiratory- Inability to lie flat due to dyspnoea will make awake
spinal anaesthesia poorly tolerated.
-CNS- Confused patients may not lie still during spinal anaesthesia.
-Musculoskeletal- Degenerative changes in vertebral column
makes SAB technically difficult. Arthritic joints may get damaged in
lithotomy position.
Endocrine- rule out h/o DM
-Drug history- Beta blockers, ACE inhibitors, Alpha blockers,
Warfarin
15. INVESTIGATIONS
Routine tests required are-
-Complete blood count
-Creatinine and electrolytes )to detect renal impairment due
to obstructive uropathy(
-Urine analysis to screen UTI ) increased risk of
postoperative septicaemia if left untreated(
-ECG for symptomatic patients and routinely for above
60years.
-Blood grouping
16. Special tests for particular circumstances-
--Clotting studies )PT-INR if on Warfarin(
--ABG and PFT )if severe respiratory disease suspected(
--Chest radiogram )suspicion of metastasis(
17. CHOICE OF ANAESTHESIA TECHNIQUE
ADVANTAGES DISADVANTAGES
REGIONAL
ANAESTHESIA
1.Useful in patients with
significant respiratory disease
1.Does not prevent penile erection
which can interfere with surgery
2.For good post-op analgesia
3.Allows to monitor level of
consciousness and detect early
signs of TURP syndrome
4.Earlier recognition of bladder
perforation or capsular tear
5.Possible reduced blood loss
GENERAL
ANAESTHESIA
1.Useful in patients who are
unable to lie supine for a long
time.
1.Position reduces FRC
2.Penile erection can be
prevented by deepening of
anesthesia
2.Increased risk of aspiration
3.Allows better control of CO2-
reduced bleeding
3.Post op analgesia needed
18. TECHNIQUE
-SUB-ARACHANOID BLOCK
-Check for any contraindications of SAB
-A fluid preload of 500-1000 ml of warmed NS/RL.
-Preloading assists -compensation of spinal induced vasodilatation and
hypotension
-provides a small sodium load to counter hyponatremia
often occuring with TURP
-A confirmed block till atleast T10, should be done.
-Intraoperative sedation with IV Midazolam can be considered for anxious or
confused patients )Early manifestations of TURP syndrome should be kept
in mind(
-Thermometer, Warming blankets and Fluid warmer should be kept available
for detection and prevention of hypothermia due to cold irrigation solutions.
19. Subarachanoid anesthesia is generally preferred over
continuous Epidural anesthesia for the following
reasons:
1- It is technically easier to perform in the elderly
2- Duration of surgery is not generally very long.
3- Incomplete block of sacral nerve roots that occasionally
occurs with the epidural technique is avoided with
subarachnoid anesthesia.
20. GENERAL ANAESTHESIA
--Either a spontaneously breathing technique with face
mask or Laryngeal mask is used or relaxant technique is
appropriate.
--Elderly patients are susceptible to hypotensive effects of
induction and maintainance agents.
--These patients have a reduced requirement for Volatile
anesthetic agents as well.
--NDMR’s should be used with consideration of possible
renal impairment.
22. 1-Hypotension
-hypotension following sympathetic blockade of SAB.
-uncommon with blocks extending to T10, but high blocks causes resistant
hypotension and bradycardia.
2-Haemorrhage
-Depends on resection time (2-5ml/min) and size of gland (20-50ml/g)
-Bleeding requiring transfusion occurs in about 2.5% of procedures.
-Serial hematocrit levels are the most sensitive indicators of the need for
transfusion.
-Severe blood loss are the result of clotting abnormalities caused by the
release of Urokinase from the prostate
-Anti-fibrinolytics such as IV Aminocaproic acid (4-5g in first hour, then
1g/hour) IV Tranexamic acid can be used to minimize active blood loss.
23. 3-Bladder Perforation
-Complicates about 1% of cases.
-Most perforations are Extra-peritoneal- result in supra-pubic, inguinal or
peri-umbilical pain in the awake patient. The surgeon may notice reduced
return of irrigation fluid from the bladder.
-Intraperitoneal perforation- less common, but more serious. In these cases
the abdominal pain is generalized, and the patient may complain of
shoulder-tip pain. (referred from the diaphragm)
-Pallor, sweating, nausea and vomiting, and associated hypotension
depending on the size of the perforation.
-Perforation may present as sudden, unexpected hypotension under general
anesthesia.
-Management consists of immediate laprotomy and correction of the defect.
24. 4-Hypothermia
-Use of room-temperature IV fluids and large volumes of irrigation
fluids leave elderly patients hypothermic.
-All irrigation fluid should be warmed to body temperature prior to use.
-Post-operative shivering can cause massively increased myocardial
oxygen requirements.
5-Bacteraemia and sepsis
Septic shock following TURP is rare.
-Antimicrobial prophylaxis - single dose of Gentamicin 3 - 4mg/kg on
induction.
25. 6-Complications due to Positioning
-Lithotomy position- causes nerve compression (especially common
peroneal nerve from pressure effects exerted by the stirrups)
-Dislocation of hip prostheses.
-Compartment syndrome in lower legs
-Respiratory compromise in patients with pre-existing lung disease
(reduction of functional residual capacity)
7-Erection
-Occurs as a result of surgical stimulation due to light planes of
anaesthesia
-Makes cystoscopy technically difficult.
-The erection usually subsides with deepening of anaesthesia.
26. TURP SYNDROME
-TURP syndrome is a term applied to a constellation of symptoms and
signs caused primarily by excessive absorption of irrigating fluid.
-Occurs in up to 8% of cases in mild form, but is severe in 1-2% of
cases.
-Resection of prostatic tissue opens an extensive network of venous
sinuses, which allows the irrigation fluid to be absorbed into the
systemic circulation.
27. Simple principles govern the amount of absorption:
1-Duration of the procedure-
10 to 30 mL of fluid is absorbed per minute of resection time, with as
much as 6 to 8 L absorbed in some procedures lasting up to 2
hours.
2-Height of the irrigation fluid bag above the patient (increased height
implies increased hydrostatic pressure driving the fluid
intravenously)
3-Vascularity of the diseased prostate
4-Capsular or bladder perforation allowing large volumes of irrigation
fluid into peritoneal cavity from where it is absorbed
28. -Factors which increase the risk of TURP syndrome
1-Pre-existing hyponatraemia or pulmonary oedema
2-Prostate size larger than 60-100g
3-Reduced venous pressure
4-Procedures longer than 1 hour
5-Hydrostatic pressure > 60cm H2O (height of bag above patient(
6-Inexperienced or slow surgeon
29. Classical triad of features of TURP syndrome:-
1-Hypertension
2-Bradycardia
3-Altered mental status
30. -Investigations required for diagnosis-
1-Serum Sodium- levels below 120mEq/l - symptomatic.
2-ECG – QRS widening, ST segment elevation, T wave inversion
( below sodium levels of 115 mEq/l(
3-Hyperammonemia ( by-product of glycine metabolism(
31. Management of TURP syndrome
1-Initial management follows the airway, breathing and circulation
(ABC( guidelines. Awake patients need to be sedated and
ventilated.
2-Anesthetised patients with mask airways may need intubation and
positive pressure ventilation.
3-Surgeon should be informed and surgery terminated
32. 4-Initial management of fluid overload and hyponatraemia involves
stopping IV fluids.
5-Inj frusemide 40mg IV to promote diuresis.
6-Patients should be closely monitored on an intensive care unit.
7-Hypertonic saline solutions ( 3% or 5%( should be used to increase
the serum sodium level by about 1 mmol/l/hour (not exceding an
increase of 20mmol/l in the first 48 hours of therapy(
8-Sodium levels should be checked every few hours. Therapy with
hypertonic saline should be stopped when symptoms cease or the
sodium level reaches 124-132mmol/l.
(Rapid correction has been implicated as a cause of central pontine
myelinolysis, which causes irreversible brain damage(
33. 9-Convulsions should be acutely treated with a benzodiazepine (e.g.
diazepam 5-10mg( or small doses of thiopentone (25 - 100mg(.
In the presence of intractable seizures, the sodium level may be
corrected more rapidly at a rate of up to 8-10mmol/l/hour for the first
4 hours of therapy
34. 1-Bladder spasm
2-Blood loss – Usually about 500 ml (2.4-4.6 ml/ min of resection(
3-Clot retention – resulting in bladder distension causing vagal
stimulation and pain(
4-Deep vein thrombosis
5-MI
6-TURP syndrome
POSTOPERATIVE
COMPLICATIONS
35. SUMMARY
-TURP is a procedure carried out on a predominantly elderly population with a
higher incidence of coexisting disease.
-A thorough pre-operative assessment is important in detecting at-risk
patients, and helping to choose the anaesthetic technique.
-SAB is widely considered the most suitable technique, although GA has a
similar morbidity and mortality profile.
-Subarachnoid block to T10 provides excellent anaesthesia without notable
hypotension
-TURP syndrome is a rare but potentially fatal complication . Early recognition
and prompt treatment are essential.
-Blood loss is difficult to quantify and may be significant. Close attention to the
patient’s clinical state and communication with the surgeon are vital.