1. Common procedures for treating nephrolithiasis include cystoscopic procedures like ureteroscopy with stone extraction and lithotripsy, as well as extracorporeal shock wave lithotripsy (ESWL) and percutaneous or laparoscopic nephrolithotomy.
2. ESWL uses focused acoustic shockwaves to fragment stones within the kidney without invasive surgery. It is commonly used for stones 4-20mm in size.
3. Radical prostatectomy and cystectomy are major surgeries for urological cancers that require extensive dissection and carry risks of significant blood loss. Robotic assistance and laparoscopic approaches are now commonly used.
This document discusses extracorporeal shock wave lithotripsy (ESWL), a treatment for kidney and ureteral stones. It describes how ESWL works to fragment stones using shock waves, and compares older lithotripters that used water baths to newer generations that do not. It outlines factors affecting successful ESWL treatment and discusses preparations, potential effects of shock waves, and anesthetic considerations and choices for pain management during the procedure.
This document discusses urolithiasis and treatments for kidney stones such as extracorporeal shockwave lithotripsy (ESWL). It provides details on the history and technique of ESWL, noting that it was first used successfully in 1980. It also discusses anesthetic considerations for ESWL and other stone removal procedures like percutaneous nephrolithotomy.
TURP is a common procedure to relieve BPH symptoms by resecting prostate tissue. Key considerations for anesthesia include assessing cardiac, respiratory and renal function due to the elderly patient population. Regional anesthesia is preferred to allow early detection of complications like TURP syndrome. Potential intraoperative complications are hypotension, hemorrhage, bladder/capsule perforation, hypothermia, and infection. Careful fluid management and warming are important due to large irrigation fluid volumes.
Anesthesia for Genitourinary Surgery.pptxTadesseFenta1
This document provides information about anesthesia for genitourinary surgeries and procedures. It discusses considerations for cystoscopy, transurethral resection of the prostate (TURP), lithotripsy, and the lithotomy position. Regional or general anesthesia is typically used depending on the procedure and patient factors. Complications of TURP can include hemorrhage, TURP syndrome from fluid absorption, bladder perforation, hypothermia, septicemia, and disseminated intravascular coagulation. Careful monitoring is important to detect issues like fluid overload and hyponatremia.
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.
TURP is a procedure to relieve urinary symptoms from an enlarged prostate. It carries risks due to the elderly patient population and long duration. A thorough pre-op assessment helps determine anesthesia technique, with subarachnoid block preferred. Potential complications include hypotension, hemorrhage, bladder perforation, hypothermia, and the rare but serious TURP syndrome caused by excessive fluid absorption. Close monitoring is needed to rapidly identify and treat any issues.
TURP is a common procedure for treating enlarged prostate but it carries risks. Regional anesthesia is preferred to allow early detection of complications like fluid absorption. Irrigation solutions must be nontoxic if absorbed. Complications can include TURP syndrome from fluid shifts, leading to hyponatremia, seizures, or pulmonary edema. Treatment involves terminating surgery, diuresis, oxygen, and correcting electrolyte imbalances with hypertonic saline if needed.
This document provides an overview of basic principles of liver resection, including:
- A brief history of liver resection and techniques like hepatic inflow occlusion.
- Concepts of liver regeneration, surgical anatomy, and terminology as described by Couinaud.
- Surgical techniques for liver transection including finger fracture, water jet, CUSA, Ligasure, and vascular staplers.
- Methods of vascular control during resection like Pringle maneuver, liver hanging maneuver, and total hepatic vascular exclusion.
- Postoperative management considerations like fluid/electrolyte balance, nutrition, pain control, and monitoring for liver failure.
This document discusses extracorporeal shock wave lithotripsy (ESWL), a treatment for kidney and ureteral stones. It describes how ESWL works to fragment stones using shock waves, and compares older lithotripters that used water baths to newer generations that do not. It outlines factors affecting successful ESWL treatment and discusses preparations, potential effects of shock waves, and anesthetic considerations and choices for pain management during the procedure.
This document discusses urolithiasis and treatments for kidney stones such as extracorporeal shockwave lithotripsy (ESWL). It provides details on the history and technique of ESWL, noting that it was first used successfully in 1980. It also discusses anesthetic considerations for ESWL and other stone removal procedures like percutaneous nephrolithotomy.
TURP is a common procedure to relieve BPH symptoms by resecting prostate tissue. Key considerations for anesthesia include assessing cardiac, respiratory and renal function due to the elderly patient population. Regional anesthesia is preferred to allow early detection of complications like TURP syndrome. Potential intraoperative complications are hypotension, hemorrhage, bladder/capsule perforation, hypothermia, and infection. Careful fluid management and warming are important due to large irrigation fluid volumes.
Anesthesia for Genitourinary Surgery.pptxTadesseFenta1
This document provides information about anesthesia for genitourinary surgeries and procedures. It discusses considerations for cystoscopy, transurethral resection of the prostate (TURP), lithotripsy, and the lithotomy position. Regional or general anesthesia is typically used depending on the procedure and patient factors. Complications of TURP can include hemorrhage, TURP syndrome from fluid absorption, bladder perforation, hypothermia, septicemia, and disseminated intravascular coagulation. Careful monitoring is important to detect issues like fluid overload and hyponatremia.
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.
TURP is a procedure to relieve urinary symptoms from an enlarged prostate. It carries risks due to the elderly patient population and long duration. A thorough pre-op assessment helps determine anesthesia technique, with subarachnoid block preferred. Potential complications include hypotension, hemorrhage, bladder perforation, hypothermia, and the rare but serious TURP syndrome caused by excessive fluid absorption. Close monitoring is needed to rapidly identify and treat any issues.
TURP is a common procedure for treating enlarged prostate but it carries risks. Regional anesthesia is preferred to allow early detection of complications like fluid absorption. Irrigation solutions must be nontoxic if absorbed. Complications can include TURP syndrome from fluid shifts, leading to hyponatremia, seizures, or pulmonary edema. Treatment involves terminating surgery, diuresis, oxygen, and correcting electrolyte imbalances with hypertonic saline if needed.
This document provides an overview of basic principles of liver resection, including:
- A brief history of liver resection and techniques like hepatic inflow occlusion.
- Concepts of liver regeneration, surgical anatomy, and terminology as described by Couinaud.
- Surgical techniques for liver transection including finger fracture, water jet, CUSA, Ligasure, and vascular staplers.
- Methods of vascular control during resection like Pringle maneuver, liver hanging maneuver, and total hepatic vascular exclusion.
- Postoperative management considerations like fluid/electrolyte balance, nutrition, pain control, and monitoring for liver failure.
Percutaneous transluminal coronary angioplasty (PTCA) is a minimally invasive procedure used to open blocked coronary arteries and restore blood flow to the heart. During PTCA, a catheter with a deflated balloon at the tip is inserted into the blocked artery and inflated to compress the plaque and widen the artery. Stents may be placed to help keep the artery open. The procedure aims to improve blood supply and relieve symptoms caused by coronary artery disease.
Hydronephrosis is the dilation of the renal pelvis and calyces caused by urinary outflow obstruction. It can result from anatomical or functional issues anywhere along the urinary tract. Chronic or severe hydronephrosis can lead to permanent kidney damage if not treated. Treatment depends on the cause and severity but may include ureteral stents, percutaneous nephrostomy tubes, or open surgery to bypass or remove the obstruction. The goal is to relieve obstruction and preserve kidney function.
This document discusses the advantages and technique of robotic radical prostatectomy. It notes that robotic surgery results in less bleeding, less pain and scarring, shorter hospital stays, lower risk of incontinence and impotence compared to open surgery. The da Vinci robotic system is used, with precise 3D visualization enabling preservation of nerves for potency. The procedure involves developing the space around the prostate, ligating blood vessels, and precisely excising the prostate before reconstructing the bladder neck. With experience, robotic surgery achieves similar oncologic outcomes to open surgery with improved recovery of urinary control and sexual function.
This document provides an overview of intravenous urography (IVU), including indications, contraindications, technique, projections, and modifications. IVU involves intravenous injection of contrast medium to visualize the urinary tract. It is declining in use due to newer modalities like CT and MRI, adverse effects of contrast, and cost. The document outlines patient preparation, standard projections including nephrogram, 5-minute, compression, and post-void films. It also discusses non-routine projections, contrast agents, and radiation protection. Complications and aftercare are briefly mentioned.
This document discusses complications that can occur during and after hysteroscopy procedures. It begins by stating that the overall complication rate is around 2% according to studies. It then discusses specific direct complications like cervical injury, uterine perforation, hemorrhage, infection, and thermal damage. Indirect complications include reactions to anesthesia or distention media. The document provides details on managing three main complications - uterine perforation, hemorrhage, and injury to other organs like the bowel or bladder. It emphasizes the importance of proper training, experience, instruments and use of distention media like CO2 to reduce complications.
This document provides an introduction and overview of the transradial approach for neurointerventions. It discusses why the radial approach is preferable to the femoral approach, including lower bleeding risks and access site complications. It covers topics like assessing the radial artery, achieving arterial access using ultrasound guidance, administering a "radial cocktail" of medications, challenges that can be encountered, achieving hemostasis, and potential complications. The conclusion recommends embracing the radial approach as it offers safety benefits and improved patient outcomes and satisfaction compared to the traditional transfemoral approach.
This document provides information about tracheostomy including:
- A brief history and current uses of the procedure
- Indications and contraindications
- Anatomy of the trachea
- Surgical steps for performing an open tracheostomy
- Types of tracheostomy tubes and their uses
- Post-operative care considerations
The document serves as an educational guide for performing tracheostomies and tracheostomy tube selection and management.
Renal transplantation surgery and its complicationsد.محمود نجيب
This document discusses kidney transplantation, including:
1) Donor types can be living, deceased after brain death, or deceased after cardiac death. Living donors have advantages like better outcomes but risks to the donor.
2) Surgical technique involves removing the kidney and associated vessels laparoscopically from the living donor. For recipients, the kidney is implanted heterotopically in the pelvis.
3) Complications include vascular thrombosis, lymphoceles, urinary fistulas, and ureteral obstruction which are investigated and managed surgically or conservatively.
The document discusses complications that can occur during and after laparoscopic surgeries. Some common complications discussed include:
1. Anaesthetic complications such as inadequate muscle relaxation during the procedure, hyperventilation prior to surgery, and possible air embolism from carbon dioxide used for pneumoperitoneum.
2. Complications due to pneumoperitoneum such as respiratory acidosis, increased pressure on veins, and possible effects on renal function from increased abdominal pressure.
3. Surgical complications such as injuries to organs like the stomach, bowel, bladder from trocars or instruments. Thermal injuries from diathermy are also discussed.
4. Other complications mentioned include bleeding, infections, inc
Arterial bleeding during EUS-guided pseudocyst drainage stopped by placement...Enrique Moreno Gonzalez
Hemorrhagic complications during EUS-guided pseudocyst drainage can occur, because the vessels on the internal wall of the pseudocyst might be compressed by the fluid and thus not visible on color Doppler or even power Doppler EUS.
1) The document discusses considerations for perioperative management of patients undergoing thoracic endovascular aortic repair (TEVAR). It covers preoperative optimization, indications for TEVAR, neurological management including cerebrospinal fluid drainage and risks of stroke and spinal cord injury, hemodynamic management, and respiratory care.
2) Key aspects of management include preoperative optimization of comorbidities, use of cerebrospinal fluid drainage in high risk patients, maintaining adequate blood pressure and perfusion pressure postoperatively to prevent spinal cord injury, and lung-protective ventilation.
3) Complications of TEVAR like stroke, spinal cord injury, and paraplegia require multidisciplinary care including interventions to optimize
1. Injury to the ureter is a serious complication that can result in high morbidity and potential loss of renal function.
2. The ureter is most commonly injured during gynecological or abdominal surgeries, though trauma from blunt force or penetrating injuries can also cause damage.
3. Diagnosis of ureteral injury relies on imaging like CT scans and retrograde ureterography to identify signs of extravasation or deviation, though hematuria alone is a poor indicator.
1) Neutropenic sepsis or fever is a life-threatening complication of chemotherapy that requires urgent assessment and antibiotic therapy reflecting local sensitivities.
2) Spinal cord compression is an oncological emergency that requires immediate diagnosis and treatment with steroids and radiotherapy to limit neurological damage.
3) Cardiac tamponade presents with breathlessness and collapse, and requires urgent echocardiogram-guided drainage of pericardial fluid.
This document discusses complications that can occur during hysteroscopic procedures. It begins by defining various complications such as perforation, bleeding, fluid overload, and infection. It then discusses incidence rates and risk factors for complications. The remainder of the document provides details on specific complications, how to recognize them, and strategies for prevention and management. It emphasizes the importance of proper patient positioning, techniques such as gradual dilation to avoid false passages, and using distension media carefully to prevent fluid overload.
This document provides information about retrocaval ureter, including its etiology, diagnosis, and management. Retrocaval ureter is a rare congenital anomaly where the ureter passes behind the inferior vena cava. It occurs due to persistence of the subcardinal veins during embryonic development. Clinical presentations include flank pain, hematuria, urinary tract infections, and urolithiasis. Diagnosis involves imaging tests like intravenous urogram, CT urography, and renography. Surgical management includes open or laparoscopic pyeloplasty to reposition the ureter anterior to the inferior vena cava. Preserving the retrocaval ureter segment may be
This document discusses urinary catheterization. It describes catheters as plastic tubes inserted into the bladder via the urethra to drain urine or inject liquids for treatment or diagnosis. Critically ill patients requiring strict urine output monitoring are often catheterized. The document describes different catheter types including Foley, Robinson, Coude, and hematuria catheters.
This document provides an overview of chronic kidney failure (CKF), including its definition, classification, incidence, etiology, clinical presentation, investigations, management, complications, and references. Some key points include:
CKF is a progressive decrease in renal function over 3 months or more, leading to accumulation of waste and electrolyte abnormalities. Diabetes and hypertension are the leading causes of CKF. Treatment options for CKF include dialysis, renal transplant, or conservative management. Dialysis can be done through hemodialysis or peritoneal dialysis. Renal transplant provides the best outcomes for patients compared to long-term dialysis.
Percutaneous transluminal coronary angioplasty (PTCA) is a minimally invasive procedure used to open blocked coronary arteries and restore blood flow to the heart. During PTCA, a catheter with a deflated balloon at the tip is inserted into the blocked artery and inflated to compress the plaque and widen the artery. Stents may be placed to help keep the artery open. The procedure aims to improve blood supply and relieve symptoms caused by coronary artery disease.
Hydronephrosis is the dilation of the renal pelvis and calyces caused by urinary outflow obstruction. It can result from anatomical or functional issues anywhere along the urinary tract. Chronic or severe hydronephrosis can lead to permanent kidney damage if not treated. Treatment depends on the cause and severity but may include ureteral stents, percutaneous nephrostomy tubes, or open surgery to bypass or remove the obstruction. The goal is to relieve obstruction and preserve kidney function.
This document discusses the advantages and technique of robotic radical prostatectomy. It notes that robotic surgery results in less bleeding, less pain and scarring, shorter hospital stays, lower risk of incontinence and impotence compared to open surgery. The da Vinci robotic system is used, with precise 3D visualization enabling preservation of nerves for potency. The procedure involves developing the space around the prostate, ligating blood vessels, and precisely excising the prostate before reconstructing the bladder neck. With experience, robotic surgery achieves similar oncologic outcomes to open surgery with improved recovery of urinary control and sexual function.
This document provides an overview of intravenous urography (IVU), including indications, contraindications, technique, projections, and modifications. IVU involves intravenous injection of contrast medium to visualize the urinary tract. It is declining in use due to newer modalities like CT and MRI, adverse effects of contrast, and cost. The document outlines patient preparation, standard projections including nephrogram, 5-minute, compression, and post-void films. It also discusses non-routine projections, contrast agents, and radiation protection. Complications and aftercare are briefly mentioned.
This document discusses complications that can occur during and after hysteroscopy procedures. It begins by stating that the overall complication rate is around 2% according to studies. It then discusses specific direct complications like cervical injury, uterine perforation, hemorrhage, infection, and thermal damage. Indirect complications include reactions to anesthesia or distention media. The document provides details on managing three main complications - uterine perforation, hemorrhage, and injury to other organs like the bowel or bladder. It emphasizes the importance of proper training, experience, instruments and use of distention media like CO2 to reduce complications.
This document provides an introduction and overview of the transradial approach for neurointerventions. It discusses why the radial approach is preferable to the femoral approach, including lower bleeding risks and access site complications. It covers topics like assessing the radial artery, achieving arterial access using ultrasound guidance, administering a "radial cocktail" of medications, challenges that can be encountered, achieving hemostasis, and potential complications. The conclusion recommends embracing the radial approach as it offers safety benefits and improved patient outcomes and satisfaction compared to the traditional transfemoral approach.
This document provides information about tracheostomy including:
- A brief history and current uses of the procedure
- Indications and contraindications
- Anatomy of the trachea
- Surgical steps for performing an open tracheostomy
- Types of tracheostomy tubes and their uses
- Post-operative care considerations
The document serves as an educational guide for performing tracheostomies and tracheostomy tube selection and management.
Renal transplantation surgery and its complicationsد.محمود نجيب
This document discusses kidney transplantation, including:
1) Donor types can be living, deceased after brain death, or deceased after cardiac death. Living donors have advantages like better outcomes but risks to the donor.
2) Surgical technique involves removing the kidney and associated vessels laparoscopically from the living donor. For recipients, the kidney is implanted heterotopically in the pelvis.
3) Complications include vascular thrombosis, lymphoceles, urinary fistulas, and ureteral obstruction which are investigated and managed surgically or conservatively.
The document discusses complications that can occur during and after laparoscopic surgeries. Some common complications discussed include:
1. Anaesthetic complications such as inadequate muscle relaxation during the procedure, hyperventilation prior to surgery, and possible air embolism from carbon dioxide used for pneumoperitoneum.
2. Complications due to pneumoperitoneum such as respiratory acidosis, increased pressure on veins, and possible effects on renal function from increased abdominal pressure.
3. Surgical complications such as injuries to organs like the stomach, bowel, bladder from trocars or instruments. Thermal injuries from diathermy are also discussed.
4. Other complications mentioned include bleeding, infections, inc
Arterial bleeding during EUS-guided pseudocyst drainage stopped by placement...Enrique Moreno Gonzalez
Hemorrhagic complications during EUS-guided pseudocyst drainage can occur, because the vessels on the internal wall of the pseudocyst might be compressed by the fluid and thus not visible on color Doppler or even power Doppler EUS.
1) The document discusses considerations for perioperative management of patients undergoing thoracic endovascular aortic repair (TEVAR). It covers preoperative optimization, indications for TEVAR, neurological management including cerebrospinal fluid drainage and risks of stroke and spinal cord injury, hemodynamic management, and respiratory care.
2) Key aspects of management include preoperative optimization of comorbidities, use of cerebrospinal fluid drainage in high risk patients, maintaining adequate blood pressure and perfusion pressure postoperatively to prevent spinal cord injury, and lung-protective ventilation.
3) Complications of TEVAR like stroke, spinal cord injury, and paraplegia require multidisciplinary care including interventions to optimize
1. Injury to the ureter is a serious complication that can result in high morbidity and potential loss of renal function.
2. The ureter is most commonly injured during gynecological or abdominal surgeries, though trauma from blunt force or penetrating injuries can also cause damage.
3. Diagnosis of ureteral injury relies on imaging like CT scans and retrograde ureterography to identify signs of extravasation or deviation, though hematuria alone is a poor indicator.
1) Neutropenic sepsis or fever is a life-threatening complication of chemotherapy that requires urgent assessment and antibiotic therapy reflecting local sensitivities.
2) Spinal cord compression is an oncological emergency that requires immediate diagnosis and treatment with steroids and radiotherapy to limit neurological damage.
3) Cardiac tamponade presents with breathlessness and collapse, and requires urgent echocardiogram-guided drainage of pericardial fluid.
This document discusses complications that can occur during hysteroscopic procedures. It begins by defining various complications such as perforation, bleeding, fluid overload, and infection. It then discusses incidence rates and risk factors for complications. The remainder of the document provides details on specific complications, how to recognize them, and strategies for prevention and management. It emphasizes the importance of proper patient positioning, techniques such as gradual dilation to avoid false passages, and using distension media carefully to prevent fluid overload.
This document provides information about retrocaval ureter, including its etiology, diagnosis, and management. Retrocaval ureter is a rare congenital anomaly where the ureter passes behind the inferior vena cava. It occurs due to persistence of the subcardinal veins during embryonic development. Clinical presentations include flank pain, hematuria, urinary tract infections, and urolithiasis. Diagnosis involves imaging tests like intravenous urogram, CT urography, and renography. Surgical management includes open or laparoscopic pyeloplasty to reposition the ureter anterior to the inferior vena cava. Preserving the retrocaval ureter segment may be
This document discusses urinary catheterization. It describes catheters as plastic tubes inserted into the bladder via the urethra to drain urine or inject liquids for treatment or diagnosis. Critically ill patients requiring strict urine output monitoring are often catheterized. The document describes different catheter types including Foley, Robinson, Coude, and hematuria catheters.
This document provides an overview of chronic kidney failure (CKF), including its definition, classification, incidence, etiology, clinical presentation, investigations, management, complications, and references. Some key points include:
CKF is a progressive decrease in renal function over 3 months or more, leading to accumulation of waste and electrolyte abnormalities. Diabetes and hypertension are the leading causes of CKF. Treatment options for CKF include dialysis, renal transplant, or conservative management. Dialysis can be done through hemodialysis or peritoneal dialysis. Renal transplant provides the best outcomes for patients compared to long-term dialysis.
The document discusses disorders of the adrenal gland, including glucocorticoid excess (Cushing's syndrome), mineralocorticoid excess (Conn's syndrome), and adrenal insufficiency (Addison's disease). It covers the anatomy and function of the adrenal cortex and medulla, signs and symptoms, diagnosis, and anesthetic considerations for surgeries involving the adrenal gland.
ENT and Maxillofacial and Ophtha course.pptxsamirich1
This document provides an overview of ophthalmic anesthesia. It begins with discussing the anatomy and physiology of the eye, including structures like the orbit, eyeball, extraocular muscles and nerves. It then covers topics like the oculo-cardiac reflex and how certain ophthalmic drugs can impact anesthesia management. The learning objectives are to discuss anatomy/physiology of the eye, the oculo-cardiac reflex, effects of ophthalmic drugs, patient assessment, regional anesthesia techniques and anesthesia management for various eye surgeries.
Addison's disease is caused by damage to the adrenal cortex which leads to insufficient production of cortisol and sometimes aldosterone. This can disrupt homeostasis, impacting glucose metabolism, immune function, and stress response. It can also cause electrolyte imbalances if aldosterone is deficient. Cushing's syndrome results from prolonged high cortisol exposure due to adrenal tumors or medications. Excess cortisol causes metabolic disturbances. Congenital adrenal hyperplasia is caused by an enzyme deficiency, resulting in androgen buildup and health issues, especially in females. Adrenal tumors can disrupt hormones and cause conditions like primary hyperaldosteronism.
This document discusses several orthopedic trauma considerations for anesthesia. It compares general anesthesia (GA) versus regional anesthesia (RA) for orthopedic trauma, noting advantages and disadvantages of each. It also discusses risks like fat embolism syndrome, compartment syndrome, crush syndrome, and venous thromboembolism (VTE). For each condition, it describes causes, risk factors, signs/symptoms, diagnostic criteria, and treatment approaches. Throughout, it emphasizes the importance of early stabilization of fractures to prevent complications.
This document discusses acne vulgaris and provides information on its pathophysiology, clinical features, differential diagnosis, and treatment strategies. It defines the primary and secondary lesions of acne and explains the role of factors like increased sebum production, follicular hyperkeratinization, P. acnes bacteria, and inflammation in its development. Guidelines are provided for evaluating and initially managing patients presenting with acne based on lesion type and severity.
Blood transfusion involves introducing donor blood into a recipient's bloodstream. It is used to increase oxygen-carrying capacity, reverse tissue hypoxia, restore circulating volume, and provide clotting factors. Blood products include whole blood, packed red blood cells, platelets, fresh frozen plasma, and cryoprecipitate. Transfusions aim to treat anemia and coagulation disorders while minimizing complications like reactions, infections, or electrolyte abnormalities through careful screening, storage, and monitoring during the procedure.
This document discusses occupational hazards faced by anesthetists. It begins by outlining course objectives to understand hazards and minimize risks. It then explores various types of hazards including chemical (anesthetic gases), radiation, infectious diseases, and physical risks. Specific health risks from exposure like fatigue and effects on performance are examined. The document provides details on minimizing different hazards through techniques like gas scavenging and personal protective equipment.
This document discusses various topics related to professional ethics and medico-legal issues in healthcare. It begins by outlining the expected learning outcomes of understanding basic ethics concepts, analyzing medical ethics problems, avoiding malpractice, and understanding legal and ethical issues. It then covers the history of medical ethics from ancient times through the modern era. Key definitions are provided for morality, ethics, law, bioethics, professional ethics, and medical ethics. The main ethical theories and healthcare-specific topics like informed consent, competence, disclosure, and do-not-resuscitate orders are analyzed in detail. Special consideration is given to issues involving Jehovah's Witnesses, pediatric patients, maternal-fetal conflicts, and withdrawing or
Obesity is classified using BMI and is associated with increased health risks and diseases. Anesthesia for obese patients presents challenges including difficult intubation, reduced lung volumes, increased cardiac workload, and postoperative respiratory complications. Careful preoperative evaluation and positioning, adjusted drug dosing, and postoperative oxygen supplementation can help manage the risks of anesthesia for obese patients.
This document discusses the management of patients with obstructive jaundice undergoing surgery. It notes that jaundice results from increased bilirubin in the body due to obstruction of bile flow from the liver. Surgery in jaundiced patients carries risks, so careful preoperative assessment and perioperative management is needed to address nutritional deficiencies, cardiovascular and renal issues. The key is to maintain fluid balance and oxygen delivery while minimizing stress on the liver and kidneys.
TURP syndrome is a combination of fluid overload and hyponatremia that can occur after a transurethral resection of the prostate (TURP) surgery. It is caused by excessive absorption of irrigating fluid into the circulation during the procedure. Symptoms range from mild like headache and restlessness to life-threatening issues like pulmonary edema, hypoxia and coma if not promptly recognized and treated. Treatment involves discontinuing irrigation fluid, administering diuretics and hypertonic saline if sodium levels drop below 120 mmol/L, and monitoring electrolytes closely in intensive care. Overly rapid correction of sodium levels should also be avoided to prevent neurological complications.
The document discusses nerve blocks at various locations in the upper extremity including the elbow, wrist, and digits. At the elbow, the radial, median, and ulnar nerves can be blocked using bony landmarks like the medial and lateral epicondyles. Each nerve is blocked slightly differently depending on its location. Distal to the elbow, the radial, median, and ulnar nerves can also be blocked at the wrist. Intravenous regional anesthesia, or Bier block, provides surgical anesthesia for short procedures on an extremity using exsanguination and tourniquets with local anesthetic injected intravenously.
The document describes nerve blocks for the median, ulnar, radial, and musculocutaneous nerves. It provides details on locating each nerve, inserting the needle, and injecting local anesthetic. It also describes digital nerve blocks, an intercostobrachial nerve block, and intravenous regional anesthesia (Bier block).
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
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.
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
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
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
2. Procedures For Nephrolithiasis
The management of urinary stones has
progressed greatly since the introduction of
Extracorporeal shock wave lithotripsy (ESWL),
and surgical stone extraction has become a very
uncommon procedure.
3. Common Procedures For
Nephrolithiasis
Cystoscopic procedures
including flexible ureteroscopy with stone
extraction, stent placement, and
intracorporeal lithotripsy (laser or electrohydraulic),
along with medical expulsive therapy (MET), have
become first-line therapy.
ESWL:
is utilized primarily for 4-mm to 2-cm intrarenal
stones
Percutaneous and laparoscopic
nephrolithotomy:
4. MET has become the treatment of choice for
acute episodes of urolithiasis
for stones up to 10 mm in diameter,
administration of the α blockers tamsulosin
(Flomax), doxazosin (Cardura), or terazosin
(Hytrin) or
the calcium channel blocker nifedipine (Procardia,
Adalat)
lessens the pain of acute urolithiasis and
increases the rate of stone expulsion over a
period of several days to several weeks.
5. Extracorporeal shock wave lithotripsy (ESWL)
ESWL uses acoustic shockwaves to fragment
stones.
During ESWL, repetitive high-energy shocks
(sound waves) are generated and focused on
the stone, causing it to fragment as tensile and
shear forces develop inside the stone and
cavitation occurs on its surface.
The shock waves are then focused on the
target stone using an ellipsoid reflector(acoustic
lens).
6. A key element of all lithotripters is the coupling
that allows shockwaves to progress from the
site of formation to the surface of the patient’s
body.
Water or a conducting gel couples the
generator to the patient.
Because tissue has the same acoustic density
as water, the waves travel through the body
without damaging tissue.
7. Tissue destruction can occur if the acoustic
energy is inadvertently focused at air–tissue
interfaces such as in the lung and intestine.
However, the change in acoustic impedance at
the tissue–stone interface creates shear and
tear forces on the stone.
Subsequently, the stone is fragmented enough
to allow its passage in small pieces down the
urinary tract.
8. Electrohydraulic, electromagnetic, or
piezoelectric shock wave generators may be
used for ESWL.
With electrohydraulic units, the patient is
placed in a hydraulic chair and immersed in a
heated water bath, which conducts the shock
waves to the patient.
The generator is enclosed in a water-filled
casing and comes in contact with the patient
via a conducting gel on a plastic membrane
9.
10. Modern lithotriptors generate shock waves either
electromagnetically or from piezoelectric crystals.
Newer units allow both fluoroscopic and
ultrasound localization.
In the case of electromagnetic machines, the
vibration of a metallic plate in front of an
electromagnet produces the shock waves.
With piezoelectric models, the waves are the
result of changes in the external dimensions of
ceramic crystals when electric current is applied.
11. Contraindication
The inability to position the patient so that lung
and intestine are away from the sound wave
focus.
Urinary obstruction below the stone
Untreated infection
bleeding diathesis
Pregnancy
The presence of a nearby aortic aneurysm or
orthopedic prosthetic device
12. Complications
Ecchymosis, bruising, or blistering of the skin
over the treatment site is not uncommon.
Perinephric hematoma can develop: Severe
abdominal pain should alert this complication.
Gross hematuria- should recover within 1 wk.
13. Cardiac Arrhythmias
Shockwaves have the potential to trigger
ventricular arrhythmias when they coincide with
the repolarization period of the cardiac cycle.
For this reason, ECG synchronization and shock
delivery 20 msec after the R wave has been used.
Shockwaves can occasionally inhibit or reprogram
cardiac pacemakers.
Patients with a history of cardiac arrhythmias and
those with a pacemaker or internal cardiac
defibrillator (ICD) may be at risk for developing
arrhythmias induced by shock waves
14. To avoid this complication, the patient should
be positioned so the pacemaker is not in the
path of the wave, and resuscitation equipment,
including an external pacemaker, should be
available.
15. Effects of Immersion During
ESWL
Immersion in a water bath can have hemodynamic
effects.
Immersion into a heated water bath (36–37°C) initially
results in vasodilation that can transiently lead to
hypotension.
Arterial BP, however, subsequently rises as venous
blood is redistributed centrally due to the hydrostatic
pressure of water on the legs and abdomen.
SVR rises and cardiac output often decreases.
The sudden increase in IV volume and SVR can
precipitate CHF in patients with marginal cardiac
reserve.
16. Immersion in water also causes upward shifting
of the diaphragm, increased work of breathing,
and decreased arterial oxygenation.
Moreover, the increase in intrathoracic blood
volume reduces FRC 30–60% and may
predispose some patients to hypoxemia.
17. Other Complications
Patients with a high stone burden are prone to
obstruction by fragments after ESWL.
Fever and sepsis are possible after ESWL and
are more common in patients with an infected
urinary tract before the procedure.
Pneumothorax may occur if the wave path
crosses the lung and is more likely in children.
18. Choice of Anesthesia
Depending on the intensity of shock waves
patient may require sedation, RA or GA
High-intensity shock waves, which most
patients cannot tolerate, need GA or RA.
Lower intensity of shock waves usually require
only light sedation.
Supplemental oxygen by face mask or nasal
cannula
19. Continuous epidural anesthesia is preferred
Regional anesthesia with sedation greatly
facilitates positioning and monitoring in this
situation
A T6 sensory level ensures adequate anesthesia.
When using the loss of resistance technique for
placement of the epidural catheter, saline should
be used instead of air during epidural catheter
insertion; as air in the epidural space can
dissipate shock waves and may promote injury to
neural tissue.
20. A major disadvantage of RA or sedation is the
inability to control diaphragmatic movement.
Excessive diaphragmatic excursion during
spontaneous ventilation can move the stone in and
out of the wave focus and may prolong the
procedure.
This problem can be partially solved by asking the
patient to breathe in a more rapid but shallow
respiratory pattern.
Bradycardia also prolongs the procedure when
shock waves are coupled to the ECG, and small
doses of glycopyrrolate are often administered.
21. GA allows control of diaphragmatic excursion
during lithotripsy using older water bath
lithotriptors.
A light GA technique in conjunction with a
muscle relaxant is preferable.
The muscle relaxant ensures patient
immobility and control of diaphragmatic
movement.
22. Monitoring
Standard anesthesia monitoring
ECG pads should be attached securely with
waterproof dressing.
Oxygen saturation: Changes in FRC with
immersion particularly in patients at risk for
developing hypoxemia.
The temperature of the bath and the patient
should be monitored to prevent hypothermia or
hyperthermia.
23. Fluid Management
Intravenous fluid therapy is typically generous.
Up to 1000–2000 mL of LR with a small dose
of furosemide to maintain brisk urinary flow
and flush stone debris and blood clots.
24. Noncancer Surgery of the Upper
Ureter & Kidney
Indication
Laparoscopic urological procedures, including
Partial and total nephrectomy,
Live donor nephrectomy
Pyeloplasty
Open procedures for
Kidney stones in the upper ureter and renal pelvis,
and
Nephrectomies for nonmalignant disease,
25. Open procedures are often carried out in the
lateral flexed position.
Because of the potential for large blood loss
and limited access to major vascular structures
in the lateral flexed position,
Initial placement of at least one large-bore IV
catheter is advisable.
26. Arterial catheters are often utilized.
Proper ETT placement must be verified
following final patient positioning prior to skin
preparation and surgical draping.
Intraoperative pneumothorax may occur as a
result of surgical entry into the pleural space.
27. Surgery For Urological
Malignancies
Many urological procedures are carried out with
the patient in a hyperextended supine position
to
Facilitate exposure of the pelvis during pelvic lymph
node dissection, retropubic prostatectomy, or
cystectomy
Care must be taken to avoid putting excessive
strain on the patient’s back.
28. Prostate Cancer
Adenocarcinoma of the prostate is the most
common nonskin cancer in men
It is second only to lung cancer as the most
common cause of cancer deaths in men older
than 55 years.
29. Patients with prostate cancer may present for
laparoscopic or robotic prostatectomy
Pelvic lymph node dissection
Radical retropubic prostatectomy with lymph node
dissection
Salvage prostatectomy (following failure of
radiation therapy) or
Bilateral orchiectomy for hormonal therapy.
30. Radical Retropubic Prostatectomy
Is usually performed with pelvic lymph node dissection
through a lower midline abdominal incision
The prostate is removed en bloc with the seminal
vesicles, ejaculatory ducts, and part of the bladder
neck.
Following prostatectomy, the remaining bladder neck is
anastomosed directly to the urethra over an indwelling
urinary catheter.
The surgeon may ask for IV administration of indigo
carmine for visualization of the ureters, and this dye
can be associated with hypertension or hypotension.
31. There may be significant operative blood loss.
Direct arterial BP monitoring is useful.
Two large-bore peripheral IV catheters.
Factors influencing blood loss include
Positioning
Prostate size
Duration of operation, and
The skill of the surgeon.
32. T6 sensory level is required for neuraxial
anesthesia, but these patients typically do not
tolerate RA without deep sedation because of
the hyperextended supine position.
A multimodal approach to postoperative
analgesia is often optimal.
33. Postoperative complications
Hemorrhage
Deep venous thrombosis
Pulmonary embolus
Injuries to the obturator nerve, ureter, and rectum; and
Urinary incontinence and impotence.
Extensive surgical dissection around the pelvic
veins increases the risk of thromboembolic
complications.
34. Robot-Assisted Radical Prostatectomy
Most laparoscopic prostatectomies are
performed with robotic assistance
There is frequent use of steep (>30°)
trendelenburg position for surgical exposure.
Patient positioning, duration of procedure, need
for abdominal distention, and desirability of
increasing minute ventilation necessitate the use
of GA with ETI
35. When compared with open retropubic prostatectomy,
laparoscopic robot-assisted prostatectomy is
associated with
a longer procedure time but have a lower rate of
complications.
It is also associated with
Less blood loss and fewer blood transfusions,
Lower postoperative pain scores and lower opioid
requirements
Less postoperative nausea and vomiting, and
Shorter hospital stay.
36. Bilateral Orchiectomy
Bilateral orchiectomy is usually performed for
hormonal control of metastatic adenocarcinoma
of the prostate.
The procedure is relatively short (20–45 min)
and is performed through a single midline
scrotal incision.
GA with LMA or spinal anesthesia .
37. Bladder Cancer
Occurs at an average patient age of 65 years with a
3:1 male to female ratio.
Transitional cell carcinoma of the bladder is second to
prostate adenocarcinoma as the most common
malignancy of the male genitourinary tract.
The association of cigarette smoking with bladder
carcinoma results in coexistent coronary artery disease
and COPD in many of these patients.
Intravesical chemotherapy is used for superficial
tumors, and transurethral resection of bladder tumors
(TURBT) is carried out via cystoscopy for low-grade,
noninvasive bladder tumors.
38. Transurethral Resection of Bladder Tumor
(TURBT)
TURBT differs from TURP in that the surgical
resection is not necessarily carried out in the
midline.
Bladder tumors may occur at various sites within
the bladder.
Unfortunately, laterally located tumors may lie in
proximity to the obturator nerve.
In such cases, if SA or GA without paralysis is
administered, every use of the cautery
resectoscope results in stimulation of the
obturator nerve and adduction of the legs.
39. In contrast to TURP, TURBT procedures are
more commonly performed with GA and
neuromuscular blockade.
TURBT is rarely associated with absorption of
significant amounts of irrigating solution.
40. Radical Cystectomy
Is a major operation that is often associated with
significant blood loss.
It is usually performed through a midline incision
All anterior pelvic organs including
Bladder, prostate, and seminal vesicles are removed
in males;
Bladder, uterus, cervix, ovaries, and part of the
anterior vaginal vault may be removed in females.
Pelvic node dissection and urinary diversion are
also carried out
41. These procedures typically require 4–6 h
Frequently associated with blood transfusion.
GA with ETI provides optimal operating
conditions.
Controlled hypotensive anesthesia may
Reduce intraoperative blood loss and transfusion
requirements.
Improves surgical visualization.
42. Supplementation of GA with spinal or
continuous epidural anesthesia
Can facilitate the induced hypotension,
Decrease general anesthetic requirements, and
Provide highly effective postoperative analgesia.
43. Close monitoring of BP, intravascular volume, and
blood loss is always appropriate.
Invasive arterial BP monitoring is indicated in
most patients, and central venous catheters are
often placed.
Urinary output should be monitored and correlated
with the progress of the operation, as the urinary
path is interrupted at an early point during most of
these procedures.
The risk of hypothermia should be minimized
44. Urinary Diversion
Urinary diversion is usually performed immediately
following radical cystectomy.
Involves implanting the ureters into a segment of bowel.
The selected bowel segment is either left in situ, such
as in ureterosigmoidostomy, or divided with its
mesenteric blood supply intact and attached to a
cutaneous stoma or urethra.
Moreover, the isolated bowel can either function as a
conduit or be reconstructed to form a continent
reservoir (neobladder).
Conduits may be formed from ileum, jejunum, or colon.
45. Major anesthetic goals for urinary diversion procedures
include keeping the patient well hydrated and
maintaining a brisk urinary output once the ureters are
opened.
Neuraxial anesthesia often produces unopposed
parasympathetic activity due to sympathetic blockade,
which results in a contracted, hyperactive bowel that
makes construction of a continent ileal reservoir
technically difficult.
Papaverine (100–150 mg as a slow IV infusion over 2–3
h), a large dose of an anticholinergic (glycopyrrolate, 1
mg), or glucagon (1 mg) may alleviate this problem.
46. Prolonged contact of urine with bowel mucosa (slow
urine flow) may produce significant metabolic
disturbances.
Hyponatremia, hypochloremia, hyperkalemia, and
metabolic acidosis can occur following construction of
jejunal conduits.
In contrast, colonic and ileal conduits may be
associated with hyperchloremic metabolic acidosis.
The use of temporary ureteral stents and maintenance
of high urinary flow help alleviate this problem in the
early postoperative period.
47. Testicular Cancer
Testicular tumors are classified as either
seminomas or nonseminomas.
The initial treatment for all tumors is radical
(inguinal) orchiectomy.
Subsequent management depends on tumor
histology.
Nonseminomas include embryonal teratoma,
choriocarcinoma, and mixed tumors.
48. Retroperitoneal lymph node dissection (RPLND)
plays a major role in the staging and management of
patients with nonseminomatous germ cell tumors.
Low-stage disease is managed with RPLND
High-stage disease is usually treated with
chemotherapy followed by RPLND.
In contrast to nonseminomas, seminomas are very
radiosensitive tumors that are primarily treated with
retroperitoneal radiotherapy.
49. Chemotherapy is used for patients who relapse
after radiation.
Patients with large bulky seminomas are treated
primarily with chemotherapy.
Chemotherapeutic agents commonly include
cisplatin, vincristine, vinblastine,
cyclophosphamide, dactinomycin, bleomycin, and
etoposide.
RPLND is usually undertaken for patients with
residual tumor after chemotherapy.
50. Anesthetic considerations
Patients undergoing RPLND for testicular cancer
are typically young (15–35 years old) but are at
increased risk for morbidity from the residual
effects of preoperative chemotherapy and
radiation therapy.
In addition to bone marrow suppression, specific
organ toxicity may be encountered
Renal impairment following cisplatin,
Pulmonary fibrosis following bleomycin, and
Neuropathy following vincristine.
51. Radical Orchiectomy
Inguinal orchiectomy can be carried out with
RA or GA
Anesthetic management may be complicated
by reflex bradycardia from traction on the
spermatic cord.
Retroperitoneal Lymph Node Dissection
52. Patients receiving bleomycin preoperatively may
be particularly at risk for oxygen toxicity and fluid
overload, and for developing pulmonary
insufficiency or ARDS postoperatively.
Excessive IV fluid administration may be
contributory.
Anesthetic management should include use of the
lowest inspired concentration of oxygen
compatible with oxygen saturation above 90%.
PEEP 5–10 cm H2O may be helpful in optimizing
oxygenation.
53. Fluid replacement should be sufficient to
maintain urinary output greater than 0.5
mL/kg/h;
the combined use of both colloid and crystalloid
solutions in a ratio of 1:2 or 1:3 may be more
effective in preserving urinary output than
crystalloid alone.
Retraction of the inferior vena cava during
surgery often results in transient arterial
hypotension.
54. The postoperative pain associated with open
RPLND incisions is severe, and aggressive
postoperative analgesia is helpful.
Continuous epidural analgesia, extended-
release epidural morphine, or intrathecal
morphine (or hydromorphone) should be
considered.
55. Renal Cancer
Preoperative Considerations
Renal cell carcinoma(RCC) is commonly discovered
as an incidental finding in the course of working up a
supposedly unrelated medical problem, such as in an
MRI performed for evaluation of low back pain.
The classic triad of hematuria, flank pain, and
palpable mass occurs in only 10% of patients
The tumor often causes symptoms only after it has
grown considerably in size.
RCC is frequently associated with paraneoplastic
syndromes, such as erythrocytosis, hypercalcemia,
hypertension, and nonmetastatic hepatic dysfunction.
56. This cancer has a peak incidence between the
fifth and sixth decades of life, with 2:1 male to
female ratio.
Curative surgical treatment is undertaken for
carcinomas confined to the kidney, but palliative
surgical treatment may involve more extensive
tumor debulking.
In approximately 5–10% of patients, the tumor
extends into the renal vein and inferior vena cava
as a thrombus.
57. Preoperative evaluation of the patient with
renal carcinoma should focus on
Defining the degree of renal impairment,
Searching for the presence of coexisting systemic
diseases, and
Planning the anesthetic management
58. Pre-existing renal impairment depends upon tumor
size in the affected kidney as well as underlying
systemic disorders such as hypertension and
diabetes.
Smoking is a well-established risk factor for renal
carcinoma, and these patients have a high incidence
of underlying coronary artery and COPD.
Although some patients present with erythrocytosis,
the majority are anemic.
Preoperative blood transfusion to increase
hemoglobin concentration above 10 g/dL should be
considered when a large tumor mass is to be
resected.
59. Intraoperative Considerations
Radical Nephrectomy
The operation may be carried out via an anterior
subcostal, flank, or midline incision.
Hand-assisted laparoscopic technique is often utilized
for partial or total nephrectomy associated with a smaller
tumor mass.
Many centers prefer a thoracoabdominal approach for
large tumors, particularly when a tumor thrombus is
present.
The kidney, adrenal gland, and perinephric fat are
removed en bloc with the surrounding (Gerota’s) fascia.
GA is often in combination with epidural anesthesia.
60. The operation has the potential for extensive
blood loss because these tumors are very
vascular and often very large.
Direct arterial BP monitoring should be used.
Central venous cannulation is used for
pressure monitoring and rapid transfusion.
TEE should be strongly considered for all
patients with extensive vena cava thrombus.
61. Retraction of the inferior vena cava may be
associated with transient arterial hypotension.
Only brief periods of controlled hypotension
should be used to reduce blood loss because
of its potential to impair function in the
contralateral kidney.
Reflex renal vasoconstriction in the unaffected
kidney can also result in postoperative renal
dysfunction.
62. Fluid replacement should be sufficient to
maintain urinary output >0.5 mL/kg/h.
The postoperative course of open
nephrectomy is extremely painful, and epidural
analgesia is very useful
63. Radical Nephrectomy with Excision of
Tumor Thrombus
Commonly performed for tumor thrombus
extending into the inferior vena cava(IVC).
The anesthetic management can be challenging
Because of the degree of physiological trespass and
potential for major blood loss
A thoracoabdominal approach allows the use of
cardiopulmonary bypass(CPB) when necessary.
64. The thrombus may extend only into the IVC but below
the liver (level I), up to the liver but below the diaphragm
(level II), or above the diaphragm into the right atrium
(level III).
A preoperative ventilation-perfusion scan may detect
preexisting pulmonary embolization of the thrombus.
Intraoperative TEE is helpful in determining whether the
uppermost margin of the tumor thrombus extends to the
diaphragm, above the diaphragm, into the right atrium, or
to the tricuspid valve.
TEE can also be used to confirm the absence of tumor in
the vena cava, right atrium, and right ventricle after
successful surgery.
65. The presence of a large thrombus (level II or III)
complicates anesthetic management.
Invasive BP monitoring and multiple large-bore IV
lines are necessary because transfusion
requirements are commonly 10–15 units of packed
red blood cells.
Central venous catheterization should be
performed cautiously to prevent dislodgement and
embolization of tumor thrombus.
A high CVP is typical in the setting of significant
caval thrombus and reflects the degree of venous
obstruction.
66. Complete obstruction of the IVC markedly
increases operative blood loss because of
dilated venous collaterals from the lower body.
Patients are also at significant risk for potentially
catastrophic intraoperative pulmonary
embolization of the tumor.
Tumor embolization may be heralded by sudden
supraventricular arrhythmias, arterial
desaturation, and profound systemic
hypotension.
TEE is invaluable in this situation.
67. CPB may be used when the tumor occupies
more than 40% of the right atrium and cannot
be pulled back into the cava.
Heparinization and hypothermia greatly
increase surgical blood loss.
68. Renal Transplantation
The success of renal transplantation, which is largely due
to advances in immunosuppressive therapy, has greatly
improved the quality of life for patients with ESRD.
With modern immunosuppressive regimens, cadaveric
transplants have achieved almost the same 80–90% 3-
year graft survival rate as living-related donor grafts.
In addition, restrictions on candidates for renal
transplantation have gradually decreased.
Infection and cancer are the only remaining absolute
contraindications.
69. Preoperative Considerations
Current organ preservation techniques allow
ample time (24–48 h) for preoperative dialysis of
cadaveric recipients.
Living-related transplants are performed electively
with simultaneous donor and recipient operations.
The recipient’s serum potassium concentration
should be below 5.5 mEq/L, and existing
coagulopathies should be corrected.
70. Renal transplantation is carried out by placing
the donor kidney retroperitoneally in the iliac
fossa and anastomosing the renal vessels to the
iliac vessels and the ureter to the bladder.
Heparin is administered prior to temporary
clamping of the iliac vessels.
Intravenous mannitol administered to the
recipient helps establish an osmotic diuresis
following reperfusion.
71. Immunosuppression is initiated on the day of
surgery
Recipient nephrectomy (with a failed
transplant) is performed for intractable
hypertension or chronic infection.
72. Choice of Anesthesia
Most renal transplants are performed with GA,
although spinal and epidural anesthesia are also
utilized.
All GA agents have been employed without any
apparent detrimental effect on graft function.
Cisatracurium and rocuronium may be the muscle
relaxants of choice, as they are not dependent
upon renal excretion for elimination.
Vecuronium may be used with only modest
prolongation of its effects.
73. Monitoring
Central venous cannulation-
For ensuring adequate hydration while avoiding
fluid overload
Useful portals for the various infusions that these
patients require in the first few days after
transplant. Normal saline is commonly used.
A brisk urine flow following the arterial
anastomosis generally indicates good graft
function.
74. If the graft ischemic time was prolonged, an
oliguric phase may precede the diuretic
phase, in which case fluid therapy must be
appropriately adjusted.
Administration of furosemide or additional
mannitol may be indicated in such cases.
75. Hyperkalemia has been reported after release of
the vascular clamp following completion of the
arterial anastomosis, particularly in pediatric and
other small patients
Release of potassium contained in the preservative
solution has been implicated as the cause of this
phenomenon.
Donor kidney washout of the preservative solution
with ice-cold lactated Ringer’s solution just prior to
the vascular anastomosis may help avoid this
problem.
Serum electrolyte concentrations should be
monitored closely after completion of the
anastomosis.
Editor's Notes
Inadequate coupling, particularly when air is entrapped between the skin and the coupling membrane, may result not only in insufficient wave transmission but also in skin ecchymosis and breakdown.
Older water bath lithotripsy units require 1000–2400 relatively high-intensity shock waves, which most patients cannot tolerate without either regional or general anesthesia.
In contrast, newer lithotripsy units that are coupled directly to the skin utilize 2000–3000 lower-intensity shock waves that usually require only light sedation.
Bradycardia due to high sympathetic blockade also prolongs the procedure when shock waves are coupled to the ECG, and small doses of glycopyrrolate are often administered in this situation to accelerate the ESWL procedure.
Transrectal ultrasound is used to evaluate tumor size and the presence or absence of extracapsular extension.
Patients with large bulky seminomas or those with increased α-fetoprotein levels (usually associated with nonseminomas) are treated primarily with chemotherapy.