Mrcs part a essential revision notes book 1 pdf


 

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Mrcs Part A Essential Revision Notes Book 1 Pdf

'In a nutshell' sections highlight important lists and vital points, and the text is clearly laid out with illustrations to aid understanding. Vital for. MRCS Part A Essential Revision Notes Book 1. MRCS Part A Book 1. 12 MB PDF I'd like to thank you for clicking like and G+1 buttons. MRCS PART A ESSENTIAL. REVISION NOTES. BOOK 1. Edited by. Claire Ritchie Chalmers. BA PhD FRCS. Catherine Parchment Smith. BSc MBChB FRCS.

The book covers every major subject in the MRCS syllabus; works systematically through every general surgical topic likely to appear in the exam; highlights important principles of Surgery; contains important lists and vital points; is clearly laid out with illustrations to aid understanding. Chapter 1 Perioperative care Chapter 2 Surgical technique and technology Chapter 3 Postoperative management and critical care Chapter 4 Infection and inflammation Chapter 5 Principles of surgical oncology Chapter 6 Trauma Chapter 7 Evidence-based surgical practice Chapter 8 Ethics, clinical governance and the medicolegal aspects of surgery Chapter 9 Orthopaedic Surgery Chapter 10 Paediatric surgery Chapter 11 Plastic Surgery. Essential Revision Notes Book 1 PDF by using our direct download links that have been mentioned at the end of this article. This is a genuine PDF e-book file. We hope that you find this book useful in your studies. DMCA Disclaimer: Please keep in mind that we do not own copyrights to these e-books.

If you feel that your copyrights have been violated, then please contact us immediately. You may send an email to pickapdf [at] gmail. Monday, April 15, Pick A PDF. Medical MRCS. Free Books For Everyone. Clinical Anatomy: Please enter your comment! Please enter your name here. You have entered an incorrect email address! Common surgical conditions under the topics of gastrointestinal disease; breast disease; vascular disease; cardiovascular and pulmonary disease; genitourinary disease; trauma and orthopaedics; diseases of the skin, head and neck; neurology and neurosurgery; and endocrine disease Module 3: Basic Surgical skills including the principles and practice of surgery and technique Module 4: The Assessment and Management of the Surgical Patient decision making, team working and communication skills Module 5: Perioperative care preoperative, intraoperative and postoperative care, including the management of complications Module 6: Assessment and management of patients with trauma including the multiply injured patient Module 7: Surgical care of the paediatric patient Module 8: Management of the dying patient Module 9: Organ and tissue transplantation Module Professional behaviour and leadership skills including communication, teaching and training, keeping up to date, managing people and resources within healthcare, promoting good health and the ethical and legal obligations of a surgeon.

Assessment of fitness for surgery 1. Preoperative management of coexisting disease 2. Care of the patient in theatre 4. In a nutshell Before considering surgical intervention it is necessary to prepare the patient as fully as possible. The extent of pre-op preparation depends on: Classification of surgery: Common factors resulting in cancellation of surgery include: Patients may be: Preassessment clinics The preassessment clinic aims to assess surgical patients 2—4 weeks preadmission for elective surgery.

They assessed over 19 surgical cases prospectively and identified four key areas for improvement see overleaf.. Improved use of postoperative resources: Identification of the high-risk group preoperatively. Preassessment is timed so that the gap between assessment and surgery is: Improved pre-op assessment. Improved intraoperative care: A review of the perioperative care of surgical patients in response to concerns that. Preoperative preparation of a patient before admission may include: History Physical examination Investigations as indicated: Presenting complaint In one simple phrase.

Ask if he or she has had this complaint before. Ask about risk factors for having a general anaesthetic. History of presenting complaint a The story of the complaint as the patient describes it from when he or she was last well to the present b Details of the presenting complaint.

Taking a surgical history 1. Introductory sentence Name. The protocol-led system has several advantages: Do not include irrelevant previous operations here.

Try to ask open rather than leading questions. Taking a history also gives you an opportunity to assess patient understanding and the level at which you should pitch your subsequent explanations.

In summary. Preoperative history A good history is essential to acquire important information before surgery and to establish a good rapport with the patient. This involves direct questioning about every aspect of that system and recording the negatives and the positives d Relevant medical history.

Preassessment is run most efficiently by following a set protocol for the preoperative management of each patient group. Ask about risk factors relating to the complaint. Physical examination Detailed descriptions of methods of physical examination can only really be learnt by observation and practice.

Drug history and allergies List of all drugs. Family history 8. Who is at home with the patient? Who cares for them? Social Services input? Stairs or bungalow? How much can they manage themselves? Ask directly about the oral contraceptive pill and antiplatelet medication such as aspirin and clopidogrel which may have to be stopped preoperatively.

Do they have characteristic facies or body habitus eg thyrotoxicosis. Physical examination General examination: Are they in pain? Look for anaemia. Full review of non-relevant systems This includes all the systems not already covered in the history of the presenting complaint. Are they obese or cachectic? Look at the hands for nail clubbing. Vascular bruits carotids. List allergies and nature of reactions to alleged allergens.

Social history Smoking and drinking — how much and for how long. Essential Revision Notes for details of surgical examinations for each surgical system. Recreational drug abuse. Past medical and surgical history In this section should be all the previous medical history. When deciding on appropriate investigations for a patient you should consider: When to perform a preoperative FBC In practice almost all surgical patients have an FBC measured but it is particularly important in the following groups: All emergency pre-op cases — especially abdominal conditions.

Patients should be counselled before testing to facilitate informed consent. Emergency pre-op cases likely to result in significant surgical blood loss. An exercise test is preferred.

KUB kidney. All emergency cases with abdominal or pelvic pain All elective cases with diabetes mellitus All pre-op cases with thoracic.

When to perform a lead ECG: Patients with a history of heart disease. Note that the resting ECG is not a sensitive test for coronary heart disease. Electrocardiography A lead electrocardiogram ECG is capable of detecting acute or long-standing pathological conditions affecting the heart.

Plain films: A urine pregnancy test should be performed in all women of childbearing age with abdominal symptoms. Surgical technique and technology. Microbiological investigations The use and collection of microbiological specimens is discussed in Surgical microbiology.

Investigating special cases Coexisting disease A chest radiograph for patients with severe rheumatoid arthritis they are at risk of disease of the odontoid peg. Suspicion of obstruction Suspicion of perforated intra-abdominal viscus Suspicion of peritonitis The role of radiological investigation in diagnosis and planning is discussed further in Chapter 2.

All treatment options. Withholding information: You may not withhold information from a patient at the request of any other person including a relative. If a patient insists that he or she does not want to know the details of a condition or a treatment. This helps to prepare the patient for surgery. Responding to questions: Ensure that the patient has an opportunity to review the decision nearer the time.

You must record in the medical records if you have withheld treatment and your reasons for doing so. In some specialties. The decision to undertake surgery must be based on all available information from a thorough history. Counselling Medical staff spend most of their working life in and around hospitals. It is important to recognise that all patients are different — in their ages.

This helps to establish a timeline and keeps other members of staff informed as to what the patient knows.

General concerns of the surgical patient Is this the first time the patient has been in hospital? Never forget that all surgical procedures are significant to the patient. Sometimes asking the patient to explain back to you. Social network What support does the patient have? Ask patients whether they have understood the information and whether they would like more before making a decision. What responsibilities does the patient have.

Good communication is essential so that the patient knows what to expect beforehand and can make an informed decision: What are the risks of anaesthetic and surgery? Colostomy Transplantation Amputated limbs What if things go wrong?

How long will I stay in hospital? Will I die? Specific considerations of the individual Knowledge How much does the patient know and understand? Complications What potential complications may result in readmission eg wound infection. The legal right to consent The ability to give informed consent for different patient ages and groups is discussed fully in Chapter 8.

Patient identification is checked by the nursing team on admission to theatre. All entries to the notes should be written clearly and legibly. Always write the date and time and your name and position at the beginning of each entry. He or she should also be given a separate red wristband documenting allergies. All patients should be given an identity wristband on admission to hospital.

Clinical Governance and the Medicolegal Aspects of Surgery. Documentation Medical documents medical notes. Obtaining consent Provide sufficient information: Individual comorbidities are discussed later in the chapter. Documentation often starts with clerking.

Discussion between surgeon and anaesthetist before theatre Adequate preoperative investigation Optimisation of surgery by ensuring: Accurate documentation should continue for each episode of patient contact. Do not forget that this includes nutrition. Optimisation should be undertaken in a timely fashion as an outpatient for elective surgery.

Most emergency patients fall into one of two categories: In extreme and life-threatening conditions this may not be possible eg ruptured abdominal aortic aneurysm or AAA. This is important to protect both the patient and yourself. The management of haemorrhage and sepsis are dealt with in detail in the Chapters 3 and 4 of this book respectively.

File documents in the notes yourself. The source of information should also be stated eg from patient. Malnourished patients do badly and a period of preoperative dietary improvement eg build-up drinks. Record as much information as possible in the format described above for history and examination.

From a medicolegal point of view. Marking is essential to help avoid mistakes in theatre. If anaemia is acute. Marking while the patient is conscious is important to minimise error.

Establish good IV access. Preoperatively prophylaxis should include: Stopping potentially harmful factors: Preoperative marking is especially important if the patient is having: The anaemia may be acute acute bleed or chronic underlying pathology.

Consider the effects of massive transfusion and order and replace clotting factors simultaneously. General principles of resuscitation are: Optimise circulating volume: Severe renal impairment may require dialysis before theatre. Insertion of a urinary catheter is vital to monitor fluid balance carefully with hourly measurements. IV rather than oral. If a patient is having surgery: Review pre-existing medication: If in doubt ask the anaesthetist. There are some essential medications eg anti-rejection therapy in transplant recipients that may be withheld for 24 hours in the surgical period but this should only be under the direction of a specialist in the field.

This is important.

MRCS Part A Essential Revision Notes [2 books PDF]

Prescribe preoperative medication Medication for the preoperative period Pre-existing medication see above for those drugs that should be excluded Prophylactic medication For example. DVT prophylaxis For example. Indications for perioperative corticosteroid cover This includes patients: Anticoagulants and fibrinolytics Consider the risk of thrombosis augmented by postsurgical state itself vs risk of haemorrhage. Minor use: IX and X as well as protein C and its cofactor.

Warfarin Inhibits vitamin K-dependent coagulation factors II. DVT prophylaxis in the perioperative period is covered in Chapter 3. Surgical haematology. The European Society of Cardiology has published guidelines to cover the preoperative risk assessment and perioperative management of patients with cardiovascular disease. Special care must be taken with pacemakers and implantable defibrillators.

Investigation of patients with cardiac disease Investigation of patients with previous cardiac disease aims to look at three cardiac risk markers myocardial ischaemia.. Cardiac comorbidity increases surgical mortality includes ischaemic heart disease..

Patients with an index of 0. In a nutshell. In general it is necessary to: Avoid changes in heart rate especially tachycardia Avoid changes in BP Avoid pain Avoid anaemia Avoid hypoxia give supplemental oxygen In addition. Patient-specific factors are more important in determining risk than the type of surgery but. Blood tests. The Lee Index is a predictor of individual cardiac risk and contains six independent clinical determinants of major perioperative cardiac events: A history of ischaemic heart disease IHD A history of cerebrovascular disease Heart failure Type 1 diabetes mellitus Impaired renal function High-risk surgery The presence of each factor scores 1 point.

FBC Correction of anaemia is essential because it compromises cardiac and respiratory function and is not well tolerated in patients with ischaemic disease May require iron supplements or even staged transfusion. CT detection of coronary vessel calcium and MR angiography can also be performed. Look for previous infarct. Dobutamine stress testing or cardiac perfusion scanning may also be used for specialist investigation. Acts as a baseline for comparison in the future.

Exercise testing: Assessing myocardial ischaemia ECG: Assessing LV function Echocardiography: It assesses peak oxygen consumption and anaerobic threshold and provides an objective measurement of functional capacity.

Always bear in mind that a patient may need his or her cardiac condition optimised by a cardiologist.

It may be necessary to arrange angioplasty. Intraoperative considerations for patients with cardiac disease Cardiac effects of general anaesthesia GA include: Vasodilatation blocks sympathetic outflow May be combined with GA for pain control Ischaemic heart disease Preoperative considerations Known risk factors must be identified in the history eg smoking.

Remember that ischaemia may be silent. Combined cardiopulmonary testing CPET: Obviously the risk must be balanced against any potential benefit of a surgical procedure. A careful examination of the heart and lungs must be performed.

Clinically look for mitral facies. Symptomatic aortic stenosis AS produces syncope. Must be given prophylactic antibiotics for invasive procedures. Poorly controlled hypertension in the immediate pre-op period predisposes the patient to perioperative cardiac morbidity and must be avoided. Newly diagnosed hypertension must be assessed for possible reversible aetiological factors eg renal disease. Minimise fluid overload and changes in cardiac rate. On examination there may be an ejection systolic murmur radiates to the carotids.

After appropriate pain relief take three separate BP readings. Prophylactic antibiotics are important. Chronic long-standing hypertension puts the patient at increased risk of cardiovascular disease.

These patients are also at higher risk of hypertensive crises. LVH whether clinically. Mitral stenosis May predispose to pulmonary hypertension and right cardiac failure. These conditions need to be excluded or optimised. They may also be on long-term anticoagulation. Valvular disease Patients with valvular disease are susceptible to endocarditis if they become septic.

Indication of the need for and the speed of intervention. Continuous or demand model? If continuous. Due to short-circuiting of the electrical impulses of the atria resulting in disorganised muscle contraction. Arrhythmias Atrial fibrillation Common arrhythmia giving an irregularly irregular beat. Causes reduced efficiency of the atria to pumpprime the ventricles.

AF predisposes to thrombotic events blood in the auricles of the atria moves sluggishly and forms clots which are then expelled into the systemic circulation — commonly causing a cerebrovascular accident [CVA] Pacemakers and implanted ventricular defibrillators Problems during the surgical period include: Interactions with diathermy current: Respiratory disease commonly includes chronic pulmonary obstructive disease COPD.

Unipolar diathermy current may pass down pacing wires. Chronic obstructive pulmonary disease and asthma COPD is pathologically distinct. Always use bipolar diathermy if possible and check for deleterious effects. Cardiac failure Due to acute or chronic ischaemic or valvular disease Exercise tolerance is a good indictor of cardiac reserve.

Patients should have the pacemaker evaluated by cardiology before and after surgery because they will be able to assess and advise on any changes required to the settings. It may be difficult to determine the importance of each condition in an individual. Generalised airflow obstruction is the dominant feature of both diseases..

Input from respiratory physicians is advisable.

Postoperative physiotherapy at least three times per day is essential. Bronchiectasis and cystic fibrosis Preoperative sputum culture and ABG are needed to act as baseline information. They may require preoperative chest radiography. Smoking Short-term effects of smoking Nicotine increases myocardial oxygen demand.

This is not usually a problem. Active TB should be considered in recent immigrants from areas where TB is endemic. Tuberculosis Many patients have evidence of old TB disease or previous anti-TB surgery on chest radiography. Active physiotherapy. Analgesia Optimise analgesia using a combination of local and regional techniques to allow deep breaths and coughing as required.

In patients with known respiratory disease. Remember local infiltration intraoperatively. Diabetes mellitus Thyroid problems Parathyroid problems Preoperative management of diabetes mellitus.. Infiltration of local anaesthesia LA. Anaesthetic agents Anaesthetic agents have the following effects: Reduce muscle tone and thus functional residual capacity Increase airway resistance and reduce lung compliance Cause atelectasis in dependent zones of the lung.

Postoperatively monitor BM regularly and institute a sliding scale of intravenous insulin if the patient is unable to tolerate an oral diet immediately. Restart regular insulin once the patient is eating and drinking normally and observe closely for sepsis. This is a syndrome of excessive and uncontrolled thyroxine release which may result in hyperthermia. Preoperative management of thyroid problems For more details of thyroid physiology. Myocardial ischaemia Hypotension Hypothermia Hypoventilation.

Problems associated with thyroid disease include: Local effects: Restart patients back on their normal oral hypoglycaemic regimen as soon as an enteral diet is recommenced. Only discharge the patient once his or her control is within recognised limits because the insulin requirements may well increase transiently after a stressful stimulus such as surgery. Management of type 1 diabetes mellitus Achieve good pre-op control and admit the patient the night before surgery.

Book 2. Hypoglycaemia Hyponatraemia Acidosis Preoperative management of parathyroid problems For more details of parathyroid physiology. Endocrine surgery. Increased risks of: Renal impairment needs careful rehydration and fluid balance. Typical symptoms include tremor. Perioperative issues include: Compromised respiratory function Urinary retention Confusion. Consider individual special needs when arranging analgesia eg may not cope with patient-controlled analgesia..

They are at risk of drug interactions. Preoperative management of epilepsy Aim to avoid seizures in the perioperative period by minimising disruption to the maintenance regimen of medication: Patients with cirrhosis and liver disease do badly and have a high mortality rate with elective surgery. Problems to anticipate include: Domperidone is a good antiemetic because it does not have significant antipyramidal effects.

Hypoalbuminaemia impairs drug binding and metabolism and may lead to elevated serum levels. Bleeding due to coagulopathy Encephalopathy Increased risk of infection Increased risk of renal failure Hypoglycaemia Acid—base and electrolyte imbalances Underlying cause eg malignancy. Hepatorenal syndrome has a very poor prognosis. Drug metabolism Many drugs. IX and X. Clotting Due to a decrease in vitamin K absorption in cholestatic jaundice. There may be sodium retention and hypokalaemia due to secondary hyperaldosteronism.

This will cause the oxygen dissociation curve to shift to the left and decrease oxygen delivery to the tissues. Acid—base balance A combined metabolic and respiratory alkalosis may occur.

Hepatorenal syndrome Renal failure may be precipitated by hypovolaemia. Details of the causes. Patients in established renal failure pose specific problems in perioperative care. Fluid and electrolyte. Severe uraemia can directly affect the cardiovascular. Orthopaedic Surgery.

Essential Revision Notes for Intercollegiate MRCS Book 1 - PasTest

Veins on the hands can be used. Rheumatoid arthritis RA is a common relapsing and remitting autoimmune condition resulting in progressive joint swelling and deformity see Chapter 9. Fluid overload. Peripheral neuropathy: Respiratory disease: Renal impairment: Avoid nephrotoxic drugs in those with borderline or impaired renal function. Increased risks at time of surgery for RA patients Cardiac: Classification of renal failure Prerenal. Nutritional depletion pre- and post-surgery increases morbidity and mortality.

Subluxation can result in: Malnutrition may be due to: Decreased intake Increasingly catabolic states Impaired digestion or absorption of nutrients Nutritional support improves outcome and follows a hierarchy: Therefore it is not an absolute marker for nutritional status.

Nutritional requirements Daily nutritional requirements are shown in the table. B series. The postoperative catabolic state and the stress inhibition of the normal ketotic response can cause muscle metabolism and weaken the patient. K Trace minerals: Many patients especially those with chronic disorders. Malnutrition in hospital patients is common: Poor wound healing and dehiscence Immunocompromise leading to infection chest and wound Organ failure Causes of malnutrition in the surgical patient Decreased intake Symptoms such as loss of appetite.

Surgery may induce anorexia and temporary intestinal failure. Hypercatabolic states Figure 1. Increasingly catabolic state Due to disease process.

Obesity Obese patients are at increased risk of surgical complications for many reasons. Surgical risks of obesity. Respiratory Decreased chest wall compliance. Aspiration Increased gastric volume and high intra-abdominal pressure predispose to gastric aspiration. Nutritional support Tailored to the protein. Enteral tube options include: Hyperglycaemia insulin resistance Hypertension and ischaemic heart disease Gallstones Osteoarthritis For elective surgery in obese patients. It follows a hierarchy.

If the patient cannot take enough nutrients in orally. Oral supplementation Can be used between or instead of meals Variety available milk- or fruit-juice-based High in protein and calories Not all contain micronutrients Examples include Complan Enteral tube feeding Enteral feeding is the best route because it preserves GI mucosal integrity. This may be useful in patients who. Polymeric whole protein.

Catheter complications Risks of insertion Thrombosis Infection. Feeding may be cyclical or continuous. Feeding is via venous access. Peripheral vein long line. Postoperative Management and Critical Care Complications of enteral feeding tubes Feeding tube displaced or blocked Metabolic hyperglycaemia. Metabolic complications Hyperglycaemia Electrolyte and fluid imbalance Hepatic dysfunction Immunocompromise Metabolic bone disease Nutritional planning in surgical patients Preoperative considerations Dietitian pre-op assessment of high-risk patients Encourage increased oral intake Oral supplementation high-protein and high-calorie drinks.

Colorectal surgery Traditionally the postoperative feeding regimen for bowel surgery was a stepwise progression guided by improving clinical signs eg passing of flatus thus: This has changed in recent years. This has lead to a number of different models for predicting risk: There have been some reports of overprediction of mortality risks which has led to specialty-specific modifications: Online gives an estimate of reduction in the risk of death from breast cancer in patients undergoing chemotherapy.

Many surgeons will then do a water contrast swallow on day 10 of high-risk anastomoses before allowing oral feeding. The POSSUM score uses 12 physiological and 6 surgical variables for its calculation and can be used pre- and postoperatively to give an initial estimate and calculation of individual risk. Increasingly risk assessment has been tailored to combine underlying comorbidity with the type of surgery proposed.

Upper GI surgery Oesophageal and gastric resections are typically combined with a feeding jejunostomy placed intraoperatively. SECTION 3 Principles of anaesthesia Anaesthesia is the rendering of part local anaesthesia or all general anaesthesia of the body insensitive to pain or noxious stimuli.. Adrenaline may be used with LAs to slow systemic absorption and prolong duration of action. Dosage of local anaesthetic agents: Local toxicity Inflammatory response Nerve damage from needle or intraneural injection Systemic toxicity Allergy May occur from overdosage.

Topical local anaesthetic This is in the form of a cream or a spray and is used for routine procedures where only superficial anaesthesia is required. Procedure box: Give IV fluids and consider inotropic support. EMLA cream before cannulation in children Lidocaine gel before urethral catheterisation Xylocaine spray before gastroscopy Infiltration of local anaesthesia This is used typically for removal of small skin lesions.

Remember that even lidocaine takes 10—20 minutes to take full effect Use leftover local to infiltrate if the patient reports sensation. Drug toxicity can be local or systemic. This may involve blocking a nerve that supplies the area. An entire finger or toe can be made completely numb by injecting a millilitre or two of LA just to either side of the proximal phalanx at the level of the web space.

Brachial plexus blocks may be performed at different levels: These blocks are good for postop pain relief because they last for several hours. A ring block is a type of field block where the area to be blocked is a digit or the penis. Brachial plexus block The brachial plexus is formed from the nerve roots C5—T1 which unite to form the main trunks upper.

These subdivide into cords as they enter the axilla. Figure 1. A ring block can be used for manipulation of dislocated fingers. The cords subdivide as the plexus passes through the axilla.

The nerve runs here with the digital artery and vein. Deep infiltration of LA at this point will produce a femoral block note: The femoral nerve then divides in the femoral triangle and supplies the muscles of the anterior thigh. It lies on the iliopsoas as it passes under the inguinal ligament to enter the thigh.

It undergoes early organisation into common peroneal and tibial portions. The femoral nerve lies at a point that is 1 cm lateral to the pulsation of the femoral artery as it exits from under the inguinal ligament and 2 cm distal to the ligament. They usually divide in the distal third of the thigh.

Sciatic block The sciatic nerve arises from the lumbosacral nerve roots L4—S3 and exits under the biceps femoris muscle. This is suitable for analgesia covering the anterior thigh. Sciatic nerve blocks may be of slow onset up to 60 minutes so be patient with your anaesthetist. The intercostal nerve runs with the vascular bundle under the overhanging edge of the rib.

Essential Revision Notes for Intercollegiate MRCS Book 1 - PasTest - PDF Drive

The sciatic nerve block can be performed by a lateral. Inject local anaesthetic note: Exsanguinate limb eg Eschmark bandage Apply double-cuff tourniquet with padding Inflate upper cuff to approximately mmHg Inject approximately 40 ml 0.

It is contraindicated in patients who are anticoagulated or septic. Spinal anaesthesia Useful for lower abdominal. The sciatic nerve lies 2 cm lateral to the ischial tuberosity at the level of the greater trochanter.

Level is controlled by: Initial level of placement Patient positioning eg head-down tilt Volume and concentration of anaesthetic Level is described by the dermatome affected: Nipples T5 Umbilicus T Situated at level of nerve roots supplying surgical site lumbar for pelvic surgery.

Inguinal ligament T12 High block may cause respiratory depression. Allows for rapid recovery and avoids GA. Supplemental oxygen mask or nasal cannulae Cardiovascular: ECG leads and monitor Respiratory: Sedation is the administration of drug s to alleviate discomfort and distress during diagnostic and therapeutic interventions..

Be prepared for adverse reactions by ensuring the following: Sedation can be used: ASA grading estimation of risk for anaesthesia and surgery Class 1 Normal healthy individual Class 2 Patient with mild systemic disease Class 3 Patient with severe systemic disease that limits activity but is not incapacitating Class 4 Patient with incapacitating disease that is a constant threat to life Class 5 Moribund patient not expected to survive. General anaesthesia induces Narcosis unconsciousness Analgesia Muscle relaxation It does this in a controlled and reversible manner.

Stages of general anaesthesia Pre-op assessment and preparation Induction and muscle relaxation Maintenance and monitoring Recovery Postop monitoring and transfer Preoperative anaesthetic assessment The anaesthetist will assess the patient fully preoperatively.

ECG monitoring and resuscitation facilities available. It may be intravenous or inhalational. It is a negative inotrope and can result in a drop in BP. There is often associated respiratory depression. Steroids Prophylactic antibiotics Anticoagulants Immunosuppressants eg if undergoing transplantation Induction of general anaesthesia This is the administration of drug s to render the patient unconscious before commencing surgery.

Thiopental sodium is a commonly used induction agent. It is a phenol derivative that appears as a white aqueous emulsion. IV induction agents are also used for maintenance of anaesthesia. It causes a smooth and rapid induction but has a narrow therapeutic window and overdose may cause cardiorespiratory depression. It sensitises the pharynx and cannot be used with laryngeal airways Propofol is more expensive than thiopental but has the advantage of a slight antiemetic effect.

It is given in an alkaline solution pH It causes vasodilatation and is a negative inotrope. IV induction agents are liquid-soluble. The IV route is quicker. It is a barbiturate that appears as a pale-yellow powder with a bitter taste and a faint smell of garlic. Inhalational anaesthetics may also be used for induction and are discussed later in this chapter. It is the most rapid-acting of all the muscle relaxants and is therefore useful when rapid tracheal intubation is required crash induction.

For a discussion of intubation see Chapter 3. The main example is suxamethonium. As it acts on the acetylcholine receptor there is an initial period of muscle fasciculation that may be painful and distressing to the patient.

It has a duration of 2—6 minutes in normal individuals. Its action cannot therefore be reversed. Complications of induction agents Complications include: Hypotension Respiratory depression Laryngeal spasm Allergic reactions Tissue necrosis from perivenous injection The effects are especially pronounced in hypovolaemic patients.

This has a structure similar to two acetylcholine molecules and acts in the same way as acetylcholine at the neuromuscular junction. Muscle relaxants Depolarising muscle relaxants Depolarising muscle relaxants work by maintaining muscle in a depolarised or relaxed state.

Contraindications include previous allergy and porphyria. The rate of hydrolysis by plasma cholinesterase is. Complications of depolarising muscle relaxants Muscle pain Hyperkalaemia Myoglobinaemia Bradycardia Hyper- or hypotension Malignant hyperpyrexia. Other benzylisoquinoliniums include cisatracurium and gallamine Vecuronium is an aminosteroid of intermediate duration. It does. Maintenance of general anaesthesia Inhalational anaesthetics are usually used for maintenance of anaesthesia.

Atracurium undergoes non-enzymatic metabolism independent of hepatic or renal function and thus has a safety-net advantage for critically ill patients. Contraindications of depolarising muscle relaxants Patients prone to hyperkalaemia. Atracurium or benzylisoquinolinium provides intermediate duration. Similar to all inhalational anaesthetics. Airway management and intubation may be difficult because of: Abnormal anatomy eg small mouth.

This usually settles spontaneously but a search for other causes eg Candida spp. Trauma to structures in the mouth. Failed intubation with inability to ventilate necessitates an alternative airway eg surgical or needle cricothyroidotomy. Apnoea common Patient monitoring during anaesthesia Patient monitoring during anaesthesia These are the recommendations for standards of monitoring of the Association of Anaesthetists of Great Britain and Ireland.

Optimal head position Pressure on the larynx Bougie Fibreoptic intubation may be performed awake Alternatives such as laryngeal mask Failed intubation may require the procedure to be abandoned. Dislodged teeth may be aspirated. Minor complications include: Death 1 in Gastric content aspiration Hypoxic brain injury MI Respiratory infection Problems with anaesthetic drugs Anaphylaxis This is a severe allergic reaction to an epitope which is characterised by massive release of histamine and serotonin.

Commonly occurs as a reaction to muscle relaxants.. IV administration of chlorpheniramine 10—20 mg. Signs include hyperthermia. Pathology of malignant hyperpyrexia This condition may be triggered by all inhalational anaesthetics. It is a rare life-threatening condition 1 in which requires recognition and treatment.

There is an increase in oxygen demand and CO2 production leading to a metabolic acidosis. Hyperventilation will help reduce PaCO2. The patient will need to be nursed on ITU and carefully monitored for signs of renal failure. Surface cooling and cool IV fluids may be administered. The patient and family must be counselled as to further risks and the possibility of genetic inheritance.

Even patients undergoing a regional block should be starved preoperatively in case there are complications and the anaesthetic has to be converted to a full GA. Respiratory complications Airway obstruction May be due to: Postoperative Management and Critical Care. Surgical Technique and Technology. The three Ps of patient care in theatre are: Muscle injuries Pressure-area injury Risk factors: Pressure injuries on the sphere itself which can result in blindness are more likely if the patient is placed prone and measures should be taken to ensure that all pressure is transmitted through the bony prominences of the orbit Nerve injury Risk factor: Try to imagine that the patient is your relative and deal with him or her in a way that you feel is acceptable.

Place tape over rings or body piercings to protect site and ensure that there is no patient contact with metal parts of the operating table. In particular: The epidermis is supported and nourished by a thick underlying layer of dense.

These natural tension lines lie at right angles to the direction of contraction of underlying muscle fibres. All skin has the same basic structure. The external surface of the skin consists of a keratinised squamous epithelium called the epidermis. Hair follicles. The dermis is attached to underlying tissues by a layer of loose connective tissue called the hypodermis or subcutaneous layer. The skin is an enormously complex organ. A core knowledge of skin anatomy and physiology is essential to understand fully the processes involved in wound healing.

It is constantly regenerating. See Figure 2. The four main functions of the skin Protection: Figure 2. On the limbs and trunk they tend to run circumferentially.

Near flexures these lines are parallel to the skin crease. Wounds can be classified in terms of: Surgical procedures and accidental injuries may be classified according to the risk of wound contamination: Epithelial cells including those from any residual skin appendages such as sweat or sebaceous glands and hair follicles proliferate and migrate across the remaining dermal collagen. Examples of superficial wounds: Superficial burn Graze Split-skin graft donor site Deep wounds Deep wounds involve layers deep to the dermis and heal with the migration of fibroblasts from perivascular tissue and formation of granulation tissue and subsequent true scar formation.

Wounds are categorised as follows: Incised wounds: Although the skin may be intact. This occurs when. If a deep wound is not closed with good tissue approximation. Depth of wound Superficial wounds Superficial wounds involve only the epidermis and dermis and heal without formation of granulation tissue and true scar formation. It is usually associated with adjacent soft-tissue damage.

Mechanism of wounding The mechanism of wounding often results in characteristic damage to the skin and deeper tissues. Negative pressure dressings eg Vac can facilitate secondary intention healing when large wound defects are present Wounds that may be left to heal by secondary intention: Extensive loss of epithelium Extensive contamination Extensive tissue damage Extensive oedema leading to inability to close Wound reopened eg infection.

The wound usually heals by rapid epithelialisation and formation of minimal granulation tissue and subsequent scar tissue.

This inevitably takes longer. Scar quality and cosmetic results are poor. The principles of wound management are concerned with providing an optimum environment to facilitate wound healing. The wound is left open and allowed to heal from the deep aspects of the wound by a combination of granulation. There are three ways in which wound healing can take place: First primary intention Second secondary intention Third tertiary intention First primary intention This typically occurs in uncontaminated wounds with minimal tissue loss and when the wound edges can easily be approximated with sutures.

This may well follow a period of healing by secondary intention. Wound healing consists of three phases: Acute inflammatory phase see Chapter 4. The inflammatory phase Tissue damage starts a typical acute inflammatory reaction by damage to cells and blood vessels.

All surgeons deal with wounds and it is essential to understand fully the exact pathophysiological mechanisms involved in wound healing.

Epithelial cells: The aims of wound healing are a rapid restoration of tissue continuity and a rapid return to normal function. The inflammatory phase of wound healing involves: The cross-linkage of collagen fibrils by formation of covalent bonds aided by the action of vitamin C increases the tensile strength of the scar. It has a characteristic pinkish. Multiple molecules orient to form a fibril. It consists of a rich network of capillary vessels and a heterogeneous population of cells fibroblasts.

Endothelial cells Figure 2. In addition the wound contracts due to the action of myofibroblasts. Superficial skin wounds require minimal support and so can be closed with a quickly absorbable suture material or by interrupted sutures or staples that can be removed within days. Nervous tissue possesses very limited regenerative capacity — partial function may be regained through slow neuronal growth in peripheral nerve injuries.

Closure is therefore performed with either loop nylon that will persist in the wound. Inflammatory cells.

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