Bailey & Loves SHORT PRACTICE OF SURGERY 24th Edition INTERNATIONAL STUDENTS’ EDITION Edited by RC.G. RUSSELL ss pecs Consultant Surgeon, The Middlesex Hospital, London, UK NORMAN S. WILLIAMS ws rcs Professor of Surgery and Cencte Lead, Centre for Academie Surgery, Barts and The London, Queen Marys School of Medicine and Dentistry, ‘The Royal London Hospital, London, UK CHRISTOPHER J.K. BULSTRODE wea rres(ont) Professor and Honorary Consultant Ozthopaedic Surgeon, Uni ‘Member of Counl, Royal Callege of Susgeons of Edinburgh: lecred Member of the General Medical Council ofthe UK Ameer ofthe Hodes Headline Group LONDONlion ube 2000, “Thc 20 dian pen 2008 by Amol meni af che Hacer Henle Group, 338 Eaton Road London NWI 38H ‘psf/earnldpuihes com Dist nthe ied Sate of Ame by ‘Oxford Uniensy Pe Ie, 198 Maton Asus New Yor NYI0016 Onoda reine ear of Onlrd Unies Pre (© 200 Ald Aig ed. No prof is pbiron maybe produced ot eam in any fora er by any mens doi oneal ‘clang poncoping coro ayers org ot el ‘ten ithe tor ie person wring rm te publsteor ‘ne ering eed cpying nthe ied Kingdon sch sexs 2d by de Copii Lteing Age: 90 Team Cows Re “Whi he avi nd infin cio ae eid re srrumtea edt of ging ope rater the non othe ble “an ape aye psy Tabi fray eas or omisions tae may be me In are nor ning te genera fe Peet dain eery fo haben made tcc dg dongs weer sil pb th rose ees mise. Fatma dg shu ne comand being vee nl ew se ls meted For those the ce ng ged com agcompanie? pe nsnicons be amerng any fhe gs coord es bck Br Ly Catlpig i Pabiaion Date Acalogue nandfortsbok huie fom e Bach Libay ita of Cones Cte ablion Dats cao ord rd ook ali oe the ivy of Congo ISBN 034080895 ISBN 0 340 son209 (nero Sets Edtion = tied el ii) 12345676910 Commisoning Edt: Georgina Ben Developmen aor Heater Sith ‘racton Conler Lindy Sith ‘Cover Doig: Anita Dahan “yest in 911.5 pe Gay by Peni hooting Chat, Kent Pied and oun in ii Pls end your comment back aroul@hadirsaakCONTENTS Sayings of he Great 10 2 Introduction REG Rosell Diagnostic and interventional radiology Ison Mi McLean and Maton Maton Preparing a patient for surgery [er Decl and Chast Kata Anoesthesia and pain management Riad M Lago fe support and critical care: fluid, eb re and acie Nutrition orden Caron ad Edn Clark Wounds, tissue repair and sears David Geman Basie surgical skills ond ‘anastomoses David | Leper Principles of laparoscopic surgery Wound infection Dona Achat. Pee Parasitic infections eer Chin 9 6 8 95 10 us rr 6 13 “ 15 v7 19 a 23 27 Acquired immunodeficiency ‘Tanrhy Allene Menh Transplantation || Anew Bley Cysts, uleers and sinuses Oheuni A. Osun Principles of oncology Rober} Sele and Amy Lec Day surgery Jems ilar ‘An approach to surgical audit “Mark Emerton an Jen van dee Men Clinical trials and statisties ig Whiman and fonoehan | Eashow Surgical ethics Len Boye Plastic and reconstructive surgery ee N-Haland Jono Chbbon Burns Mike Ter ‘Accident and emergency surgery Kenneth D. ofa ond Dash NO. Bewley Warfare injuries Jes NF Clinical examination in. musculoskeletal disorders (Christophe JK Baste Musculoskeletal imaging David} Wile and Gina Me Aen Fractures and dislocations ‘Ghitphe JK Bultoe ae Bi at 2166 a ns 40cowrents 28 29 30 32 35, 37 38 39 a a a3 Problems in the shoulder and elbow. ‘Aste J Caerad Jon C, Casper Pelvie and acetabular fractures Jahn Kessing Lower limb trauma (Chrstpr Salar an Anite innit Surgery for arthritis in the hip CGrstper JK, lst and lan K, Richie Diseases of bones and joints: infection Anthony Bese a Maria A. MeNally Bone tumours eer EM Chore Diseases of the bones, joints and connective tissues Baal Wordever Paediatric othopoedics: normal evelopment ond congenital dirorders “ Dane FLA Jos nd Robert At Paediatric orthopaedics: diseases ‘of the growing skeleton Dav THA Joes and Reber A Hi Sports medikine and biomechanics Jonathan Mesh and Christopher 1K: Balt Wrist and hand David) Warwick The foot lan Winson sd Pal Coke Neurological disorders and the musculoskeletal system Tim N. Theslogs ‘The spine, vertebral column and spinal cor Rehard CS. Ker and Jans Wikon MacDonald Nerves “Tint Ef Hans Craniocerebral trauma chan! © Kar and Nichols F Masrens Elective neurosurgery ‘Richa CS Ker and Nichols F Martens a Ke 49 #1 oo su 60s a3 46 a7 48 “9 50 51 32. 53. 35. 37 59. 60 or oe oa ‘The eye and orbit Jonndian Da Cleft lip and pelate: developmental soarmalir of the foe, mouth Sion PS ‘Maxillofacial inju Chars Pets on asl Ener ‘The nose and Raber W, Raley The ear Grant JEM. Bates Oral and oropharyngeal cancer Joba Bs Langton Disorders of the salivary glands Wills P Stahl ohn D Lama Pharynx, larynx and neck Dard Howat an Ver) Ld ‘The thyroid gland and the thyroglossol tract Zygmunt, Keskomet Parathyroid and adrenal glands Brand Has The breast ihnd Cy Sunbury ‘The thorax “Tom Tease Cordioe surgery [tan Be Aero al an Hat Arterial disorders Jon A Mase Venous disorders John Sune tymphoedeme ‘Ase We Beary The oesophagus John Bancewier Stomach and duedenum John Ponce The liv Bran The spleen (Jes Galen oo 4 co i 0s 4 er a on 5The gall bladder and bile duets ROC Basel 66. The pancreas o 6 oo n n 73 Red Rise ‘The peritoneum, omentum, mesentery and retroperitoneal Space rer Thompson ‘The small and large intestines Nal JM&C. Mortensen an live Jones Intestinal obstruction More Chaswpher Wiser ‘The vermiform appendix Rogan Conall ‘The rectum Nonman §. Wiis ‘The anus and anal canal Nonman'S Wiliars Hornias, umbilicus and abdominal wail Divi H. Benet and Anew N. Kingsnorth 1094 133 uss 1186 v0 74 75 76 7 78 Usinary symptoms, investigation of the urinary tract and anuria Ghrsonter 0. Fone The kidneys and ureters Christopher O. Fowler The urinary bled David E- Nelo Jon D. Kel The prostate and seminal vesides Davi E Neal nd John D Klly The urethra and penis CistopherC.Foner Testis and scrotum (Chstpher G. Roser Principles of paediatric surgery Mark Stanger Postoperative care Pacer Drcal, Anew D, Farmer ad Chsopher J. Bubs ‘Appendix Index 1294 14 bn 88 403 wait 1436LIST OF CONTRIBUTORS Gina M, Allen mx out cer ce eR ‘Citnattar Radiol, Royal Orthopaedic Hospi and Unies Hospi, Biinhr, UK “Timothy G. Allen Mersh so mS tout of Gaston! Sgr, peril Cole: SGhutf Meticne, Chebesand Westminses Hompital, Lemon, UK Jonathan R. Anderson mcs Coral Crtotor pita Landon, UK Surgery Hammersith Joh Bancewis Ws ct MS FRI eer in Surgery, Univer of Manchester Shoat of Dediing Covulent Surges, Hope Hospital Salo, UK Grant EM. Bates cs Ghnseat Losunen Unive f Oxford Schoo of Mein Ganaltant Ory, John Rail Hospital, Cntr ue ‘David Hs Bennet 6 cs etttener ef Songer The Repl Borneo Hospital Bournemouth, UK [Anthony Berende mi no rice Cottilr Physicain-Coarse, Bone Infection Ut and Deyury Medial Deter, Nfld Onbopoetic Cane Ost, UK Kenneth D, Boffad cs rs acs Protea Clint Hest, Department of Suge. [Jiannesbure Hopi anc University of Wivotessand, JPlionnesbrg, Sth Ain 1 M.G. Bowley mcs ‘Tr Fellow, Jhoneshung Heep Tem Unik and ‘Honay Lestret Deprunen of Suey, Univesity of ‘scan Jobat, Sot AS Andrew W. Bradbury 0 cs ‘Adin of Vaclr Sugg Universny Deparment of sul Seger, Linea Hoe, Bimirghaw Heamands Fingal rina, US J. Andeew Bradley m0 rs Ps Faster a Singer, Unset of Cambri nd Dic Taso, Adenbrooke* Hostal, Cambie, UK (Christopher LK, Bulstrode sen reson Fees raat Hooray Conslant Onaet Setseo, Usa of Onfa Mener of Counc Royal Colles of ‘Sup of Elihu Elst Meer othe Gener Medical Cone the UK. Gordon L- Carson ma 8 Mo rcs Peters Suro and Hencrry Senor acturet, Unierity (G Manchester, Deparment of Sgr Hepe Horta Slit UK Andrew J Care cot rcs Cixtioen Orpen, Noell Ohoraedc (Conte, Oxford UR Peter Chidini was fcr i RF REN ‘Comuttane Parsitelogst, Deparement of linia Panny Hospital fo Tepe Dias; Hono Pres, En Sealed Hygne and Teel Mecine London, UX Peter FM. Choong wi a0 ACS TH Peer Ontupeaicy, nverty of Melbomne Director EeSthpalicy Se Wincor Hepa, Meus Distr of Bante Peter Macau Cancer rote; Chirman, Seem Sevice Peter MacCallum Cane nate Atal ‘win C, Clark nm wns Reseic Fallewe Deporte o Super Hore Hest Silo, UK Jon C. Chaper reset por san Orchopmeic Sos, Milicey Wing Filey Park pital se, Cambeley, U Jonothan Ctibbon ws cas rst) AeCSibe Regetrarn Pla Stuer, Addenbrooke's Heit Cambs, UR David J. Coleman 6 rac Cantar Petit Recostoctie Sager, The Rael fn, Oxford, UKre Paul Cook rs Pa crot Fos Servic, Nufld Crhapeic Cente, nfo Uk Prono Surgery ard Head of Deparment, Deparment of ‘trea! Oncology and Tecnlog, mera Clee Laren, ux Brian R. Davidson ww cm pew est Pricoor of Sunger Royal Fee snd University iMedia, Londo, UK lege Schl Len Doyal a9 ‘Melia this St Bartholomew and The Roya, nom School of Medicine an Dry Queen Mary ed ‘ented Callge,Univenity of Lonlon, UK Peter Driscoll tin sm ene Stat Regrar n General Sune, Einbugh, UK Jonathan J- Earnshaw ox mcs Comte Suen, Glvcestenhie Royal Hospital, ‘Ghoceses, UK Mark Eanberton sa ‘Asstt Duet, Cincal Becynes Unt Royal Calo Sinn, Landon, OR Jon G Fairer 10 a4 9m Foemcly Ansethets, Cl Scho London, UK Andrew D. Farmery wo mca slant and Senor Lectern Anaesthetic, Nuleld Deparment of Ansesthetis, Users of sf, Ostend, UR (Christopher G. Fowler ssa sence rest rm Profesor of Sul Elucation, Bars and The London, Ques Mary School ef Medicine and Dest, University of Leon, and Honorary Consltane Urls, Bars tu “The London NHS Trt London, UK (©. James Garden ts ane a rec ERED PREM Regis Profesor of Clinieal Surgery Cina and Sura Sciences (Suey) Royal lamar, Elinbgh, UR ee N. Hall css Consent Pate Surgeon and Resastutve Sure Derm cf Paste Suey Addenbooke Howth Cambs, UK ‘Barnard J. Harrison eo es mess clean Ender Srsson, Nonhem General Hostal Shatield, DE ‘Timothy E- Hems ua po Res ewe) Constant Hand snl Orthopaedic Saree The Vitra Insrary, Glag, UK List af conteiberers ie Robert A- Hill srs CCanatant Othopanie Surgeon, Great Ormond Set, Hospi for Chien, Lond, UK David J. Howard vcs snes Serio Lecter tate of Largo and Oxy, Royal Frc and University College Seok of Medicine. a CGansltane Head andl Neck Surgeon Royal Notional Throat, [New nl Ear Hospital Loon, UR Tan Hunt us cs Sheva Reta in Caothorcke Sur, St hots’ Hospital Landon, UK Jonathan D. Jagger un ws rcs to rac) Cans Oplialae Sugeoe, Rojal Free Hosa, Leadon, UK David HAA, Jones rcs restos Gansta Orchopati Stason, Great Ormond Stee Hopital fr Sik Chien, London, UK Oliver M, Jones sex res Speciale Reyer Geel Surgery, Noth Hants Hospi Basingstoke, UK Richard P. Juniper ea snes eqisal Deter of Pstpute Dental Eatin, The Depurent of Pstgraate Medial and Dsl hist, Heading, Oto UK Joh E. Keating wna msn Console’ Orthopaete Surson, Edinburgh Rolly, linus, UK Job D. Kelly wo est Lecter, Honorary Contant Urologist, Deprtent of Oncology, Unieniy of Cate, UR Richard C.S, Kere ws ms ics Content Nese, Deptnent of Sugey, The Radel faery, and Hoary Sela Clin Lectre ta Nears, University of Oxf, Oxford, UK ‘Andrew N. Kingsnorth 15 ns rics Professor of Suge Pyouth Posture Medal School, Dereon Hosp Pytmouth, UK Andrew Kinniomonth x ci mesiio) CConsleanc Orthopaet Snase, Glen Tee Nace Hopital, Clydebank, Glasgow, UK ‘ygmuat H. Krakowski 0st CConalene Surgeon, Aberdeen Roa Irma, Fotessrof Surgery University of Abe, Abelcen, UK Joh D. Langdon wos roses mes asa re afteorof Orland Maile Spey. Ch King ard ‘Thoma! School ol Medic and Denty, Leadon, UREOS UST a conTaLBUraRS Richard M. Langford enc Pte Lercr St PanlemewS and The Royal London SEV Micine or sen Mary and West Coles Fee Canal Ansett, St Bartholomew's Hosp Lend, UK David J. Leaper Mo ct rcs RCH HES Pra of Suey, Pfesral Ut of Surgery, University lpia of Now Tees Stolton on Tes, Cleveland, UK ‘Amy Leslie na cs cs ined Resa Fellow, Univer of Duce, UK ‘Valerie Je Ld ns rcs FR Protenorin Rhinology Insti of Laryngol and Delay, Univerty College Landon, and Honorary Constr ENT Suom, Royo National Throat, Now AP pial and Mes Eye Hospital, Levon, UK [Nicholas Maastens un cn c=) Ciptulnt Netrourgeon, The Royal Mtboume Hospital ‘Melowane, Viton Astain ‘Alison M, MeLean scr Rc fen! Constant Radlog, Bars and The Landon, “Th Ral Landon Hostal Loran, UK “Martin Ax McNally 0 Pcs res) Catan nb Reconsuction, Nufeld Otbopadic Cetera one Snir Lsctaer in Onhopackics nina of Oxford, Oso, UK Mothew Matton scr Ginattane Rediloge, The Royal Hospital of Se Fanleaen, The Royal Laon Hosp, London, UK Jan van der Mealen wn sr Bates Clint Ectiveres Unt, Royal Calle of Srsors, Landon, UK Jean M. Millar cs 4 ‘Sana: Ansett ed Honorary Seni linia [atures Nuff Departnent of Anaesthetics, jn Radi emia, Oxo, UR Neil JIMcC: Mortensen vo mcs Profesor of Colorectal Steers, Departmen of Coles ‘Spry John Rodlife Hsp, Oxf, UK John A. Maro nso mes Toe tane Vasculr Sunon, The Royal nfmay of linurgh, Ebr, UE ‘Monty C. Mathen mc Dict Presse of Ameshosa and Cet Cate, Rov Fee University Collge Stool of Mascne, Landon, UK David. Neol wis as Res Ms Presa of Srsical Oneaoy, Unicity of Camby, Cambri, UK P. Ronan O'Connell rac RCH Tenn linc! Research Prefer, Univesity Collese Das Depument of Susy, Mater Micon Hosta Dublin, stand ‘Olagunju A. Ogunbiy mores Serer tre omsltant Cloectal Sanson, ive apartment of Surgery, jal Fre and Unirerty Colle SSeS ar Metin, Royal ree Hosp, London, UK ‘Anthony LG. Pel 1 nes PRC ‘Citar Surg, North Tees General Fost Seockoer oes, UR (Charles, Peis roanes oes Caen Orland Manilla! Sargeor, Chetan {Ganeral and Gkacestenbite Royal Hosp, UK Joh N. Proeose 0 rs Profesor of Surgery, Univerty of Southern Naleiv, Southampton Gener! Hospital Southampton, UK Tan K. Ritchie wes ms) Couto Orthopaedic Stageon, Deparment of Onbopactic soul Tina Suzy Seiting Roy Infirmary, Sting, UK Robert W. Ruckley wn cin rs TR Fr Nowe ad Tho and Head and Neck Surgeon, ENT [Exparmwee Darlington Mem esp, Darling, UK R.CG. Russell 6 GoraultantSagoon, The Madilsex Hogi, London, UK James Me Ryan oi Rc8 BCE PAB [ited Chote Prfece at Royal Fee and University (Gita School of Medicine, UK, tel Enatinal Prfesr ‘f Sagey at USUHS, Bethoxt, MD. USA [Richard C. Ssinabury os wo 78s Sisto Lecter and Canvtant Sargeon Royal Fee 2nd Galventy College Scola Medicine, London, UK Joho H. Sour as mcs Evatt Surgeon, The Liter Hogptal London, UK Willan Smith rosnes res Coralant Mail Sageon, Maxie Uri ‘Nontampion General Hostal, Nocharptan, UK Robert J. Stele vp vcs es end Surgeal Oncor, Departmen of Saas at Neca Oncelegy, Ninouels Hespaland Medical Schoo, Dundes, UK Mark D. Stinger wy rs mcr yes MEE Cee ent Pastare Sungeon Lets Thing Hesials NHS ‘Fe an Render In Pace Sogoy,svertyof Les, UK “Tim N. Theologs ms: mao mes Gonslant Orthopedic Suazon, Nats Ornopactic ‘Cente, Headington, Oso, UKJeremy Thompson ne ics (Spulant Gasrinetina Sarge, Clas and Westminster st, Londo, UK To Treasure ua Profesor of Canthorce Suc, Guys Hospi Londo, UK Mike Tyler na ese Diprrent of late Surgery, Seske Mandevile Hosp Ansty, UK David J. Warwick as eon Conan Hand Surgeon, Souhanpron Univer Hox, Soathrpton, UK Jonathan M. Webb rcs Consltane Onhopaedic Suscon, Suthmead Gene opal Bestl, UK Bigit Whitman bien Research Coerdinator, Gloucesteshie Royal Hsp ‘Gloves, UR [Norman $. Williams nce Prt of Sige and Cette Leal Cenc for Aesc Sige, Bars an The London, Quen Mary Scho Matsine sol Daas, The Royal Landan Hota, Lloe, UK Uist of centribeters a David J. Wilson ns ce nc (Canale Relist Null Ortopasdc Cte, Ont UK James Wilton MacDonalds cv mcs nett CGonsiant Othcpaedie Sngon, Nuekd Onhoyaedic (Gente, Headington, Oxford, UK Mare Christopher Winslet ns nes race Profesor of Sugery and Honorary Consult Seon, Royal Fe ad University Calege School af Medce, London, UR Tan G. Winson sca rs Cansultat Orthopaedic Suton, Avon Othopaiie Cente, ‘Scuthnead Hospital, Bol, UK aul Wordsworth sx Nilfeld Onhopredic Cente, Oxia, UK Editorial contributor Victoria Hunt ns 2 Skills Uae, Oxo, UKPREFACE eniton Bailey and McNeill Line wou! be honoured by the Comtinsng ces afthtrextbonk, we as row ben sed al ‘ve the mel for 7D yeu To many of wea Become an od Ferd i ispied our stant day, helped ws pas our ‘nacol exams and sow kee ur ght upto dste when we ae epg examinations fn the nes generation frees Tn his 2th etic, ws have eed to say wih the auiing prinils of cer txt tit fin red. However e have ly work fl toe the now eon eampehensve sd Fh elevant A chapters ow sc with larg jcc “These stances age threo Tend both anes ad amine what we thas che rl topes cat ned 1 Be Ln (and set) by acon tc We uve aso trast ‘te bine, which simaaiae the Key fat and concep ‘ntined nthe autour tex. These shoul pave wel or fevnon an shoul se provide otesom which raines an pan Conte an clear newer in examinations ‘No sunocal teat canbe efficent om sow. Ics rere co cenyplement the Teng whlch focal frees practising Sirgen the wand it ouepaiens and’ ia the operating these. Those ae sme enil e hapter Pfr Clon the Insiate of Tapia Duees in London reminds us that practic ducer are notconfine othe tps Peter Decal ha summa what sual ance neds odo wen looking cr rial pent Thi lads bing onsen, win a ‘perating nee nd ecrding ote on Gil ward onus These oe tis which ae econ icteasingy importa sang ‘onnere when checking that ealnes we se co pct “he Wstrcl nos have ben completely ove ar realy expands by Dr Dickie Fare This resp 0 feedback from our reer, who csely sae oir ewe the wh story of suey "Ne se lays gracile howe wh pnt ok mies roe important the easel acer (A textbook ives Thmagh te redereip) OF ene, we acre pe that this ‘lon he none but expeienee elu at thee aes difine tern he st cera fem cea fected bane Dest dee important changes wehope you wl sre hat Baley& Lie rene the sme fas peu etn. Surge Practise evlang et the undying pines rma {te have enfeaoured to bend dh ol wth the new and we hope eine Been ccna in tis emlevout ROG. Rall Noro S. Willsms ‘Chisopher 1K Base 004SAYINGS OF THE GREAT th amon Bale and MeN Lave, when medial sade, fered auch to St Robete Hutch, 1871-1980, who wa ‘Gonsuting Psion uo the London Hostal nd rodent of the Ral Calge of Physician, They never sed ting bit ‘rie lay’, wich is arproprate forall cnlns and, arto emeclly for the whe areaureally minded From abi oleae wal lo Fre lo ch el ra menor ‘oon fra od From puting hnowadge bore wadom, “elnce belo of, clea Elo From Weal pers os coves: od From molng te cue of «dase more (pierout han enduron, coed Lod dl To ich may headed The pian isthe cents of fe madi universe around wich alow work ee and loads whch eur efor ted 418, Mg, 1857-1216, Peso Surgery ‘Note Unive, Cheapo, USA on vachore so, wl oy books hou potent is SicViliom Os, 1849-1919, ‘A knowledge of helihy ond dcosed econs is not las recosory 19 be undesod than the pins of ther Science. By or veauitonce wih prnpes wo loan he ‘un of deans, Wout tha knowledge omar canna be {Ssurgeon. Tele prof surgery namely arto = ‘efeton athe hedge cached ‘the neocon fer. His Ek on med svogs whe ‘ere ge tha by fre obich @Gled ran wd by John Hurt, 1728-1793, Surge, ‘8 George's Hospi ladon UK ‘hatin very qudion hares th th whaevr or noone tray be. The sare props avery smo coriiaon ye ehonge how chon # tame be dregerdod. we hed nothing tt pecuniary renrds and wer hon ook ‘©, ou pofieon wold ot be one oe ied. Bt proton you wil fd t 10 be ofended wih pacibor Pulses) second 10 nena i ine intrest on pre Bleosres soe proud fet td the Bes tober be avid by unfetered ith ond love efigned In the burt ofthe noble ond hoy cling wh yor all God Ss. Promoter's oddecs, Graduation Medne, Uses of Eeinbwah, Avg, 1876, by Lord Use, th Founder ofHISTORICAL FOOTNOTES adel Lone abe he oats Tigi an nual wh os a dy or eirecil (o sugens, With chi eon, mapa ben fk one de omnes and ee rk ha hoe tlertaken by Dr Dickie Fale, A popu charac efoto each pate ANOTE ON SI UNITS Bec tat St (Syrtn Ieerarional Uni) units ave Pees Fahour thi texboak per ur sb nhohas sidan chock he ld toot the ner notes The los is ‘Seetbuign and to ehank hi fer proved eo bea suet (Bove ender nd the notes of tee For i holt and ba work yal ak Te eos horeINTRODUCTION CHAPTER LEARNING OBJECTIVES © Toundestond the procs of sarery © Toth abut he process of sy aking © Tocorsier inl exoninain ‘The undeuradvate or graduate approaching suger, as 2 stun atiched to sucaldepartnenc or aya he ner, may we wonder hat elfen about any, Why it seperate ‘Epartnene Thac questions bing conser ocean oe a8 the bees bstwcen the medial aa sual epee of subject ‘pects mete Inthe ps and tage extent isis re “hay he surgeon was prin a cor who teats atts by tipkal means undertaking exc and rep by hand ther than hy open nd pharmacclgsl means. Tht detain tow Kee lear in dt pbysela teat patents not only wk Siphicord phmacetials but do with thet andy fen ‘hing instrument such as eather and erdoecapen and ape Techniques to achleve therapeutic objective. The pin ‘aly Vener in the operating thar, but ay, te the tudoicopy ste or depen of ely pf procednes ‘Mul maggitade to those underaen by sige ‘Whar pets fcises dhe usa mid isthe question ‘Does ths palene need an cpeition or wl the diagno sagged by ‘he pants symp Ist be pve by sual seven thn nthe cpering rom, or hows o conservaiv approach ne apie to eevee mpm ae achieve ‘ehublaion and anomaly Me” Theabroptnes ofthe Sone question focuses he i ad demands «dai hae reques sctbn, which dstngusher the sural apprach. A Uscon roact cnor proces wahow intelectual inp To make thse, thesugeon must ance the alvaneges and dade ‘anagesandthe beets ad the i aswel asthe wisest Pen an he paint’ lave “The hats on which such a poces stats ithe simple procedure of king cna stor exci the patie and “ceating diferent dag fem fh he sutgon can see ‘he est investationsodeine and nies hse di: Once the dings hasbeen made, the daon to operate feces ‘elbevident onthe bs of evidence-based sey The data ot the knowledse opether wth experince, te aval to make ah aly | adtetteaehetdgeere einen bt the decbion forthe patient and, opel atin the best ‘utcme, es importan msasp that che sgn need ‘lagen in tentent an nde, in aftercare Never, the sangeet cle lnc confine othe psa? sd rhe Tong core, de tent managed by che psa oe ay ‘rate adage pot. The hyphens confi by he Scent radlogeal and abry tee Define the opt ‘ree tavstipione ares te and Cope, onl cables th Fotient to proceelon thereof the snl ep achieve (ie fark rhe nal complaint FURTHER READING Lune JS (197) Hard Bays Psa Ses: Aral, Lend INTRODUCTI CHAPTERCHAPTER 2 CHAPTER DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY oa LEARNING OBJECTIVES To recagise the impact imaging on the agnosis Te undestand he bc nls ofthe dfierentimoging modaies © Tobwonere fhe gol rouemens in relate theese afionsing rdiion © To ndastond th bic ecg need in ntervetionl rail procedures To gun an veri of nicl opaiansofner ventional echiues ‘abe fan ith he rental complications of ntervennd procedures od sags for hc prevention nd ietment INTRODUCTION een ro view the ima ns in conjneton with the ro ten the patent saber price. Over the Ses aside tng melee Ween hee one ee ae le yo signs and clad agement To achieve the optim logic posi ecesary eo unestan tes modern ein the os tothe inal cation ber ia ios retard te iia pe ten ‘engi an weaknetecs of the imag tes ‘eis Am alley to inter images ves a new dep of “Sucrundingo the dues ross ao the nacre and tin rose nial thous uncles al ese goa pret Tope tad Leseexpersive et eth il provide the anne For cxamel, the plan ania lr ais the caste cor festone fn aseseing the aie abdomen: na ptint witha lat Foy fay coli nl rsound eration ay be deteminemaragenet: However ss apatient with 2 Tncalpesraton i be mre peices [econ ‘rtp sds ay lead to 2 Tmnmgements nd potetilh as th more caper? home the ‘comes Sh procere. Ta ‘keenming. The see orca cntent hi ben ose m0 hanger in. exoing technology (helen Ct and now lie” sc the st iogatn for @ pari cpl by the pk aeelment of sal se of oral au senile Hgee 21 Bom flow-trugh ino potest wih Crobisdizom sow-maline, etalon) Dept th patnce of mullet the pnt wos en wrclogy and cal capers. It ta esmpemote vole guipmende comslation with che ptient lnk presentation (Fi. 21). Poser,» pene with finan cote may be cial tee, bur there may bec minimal on he plan ln Bee {Peres datas aaling eae nqaclon develo There general ere npc arenes ofthe aber ffi radon nthe induct cf cancer and genetic defers Hou the rece onsing rion comes fom the wn and fhecartscore Honceer nial sin acount or opp hotly 126 ofthe roel received by humans ‘Ase on-radatin-depende maging techniges bese nore widely avaibbl oultatoun, magnetic esonance ma {hy QHRD eatin nsdn ocressinly portance Influencing the selection of investigtn, parc hen youngpeopt- There aresaruter European regions requ inal those Involved i point ca to redoce the unnecesor {hfs a individu oration, The ect done inpared pa CT sc, resample equa eo 40 chest adgrphs [fc 11} Howevee thi cortical sk nt Bland en th icly igo yield of te exanaton ew oeneh the pent. Theslmastbe ores unneceayinvestiptns, inch nel al neds opine iadaton bral weste Tented sources an lncteze wag tines. Virus guidlines ate aval fx ivexigacons ot Huey se coniute othe cline digs and management in parti: tla clea siuations: One fom the Beta Royal College Radiologie highlights the chief cams of watt se of ‘adblgy (Bon 2.2), Other actors mut aia be eke ito con ‘Seridon when deciding on the apron investi, icing the ope eral confton ofthe paint and sor ber sey to ue dhe chosen investigation (Bx 23). DIAGNosTic IMAGING Imaging techniques Conventional radiology rvenionalraigrph depend on the dren absopion bys usse, ane, gnsand far of Xray pssng hous he od “The unatsobed rays Docken a photopic fim, contained Wii ight serie sens, which then procesed produce the hard copy. Moder tables involes the we of any technkal oistions to root the doe of Kaye 10 the parle, Panera oan th mary cage tol in the chest and some, andi eau and orthcpedis, With ‘el epretation courte Jigs an be abeved; and it eal hate plan lm not jetted is aur of moe co Fe and expense agin ecg. ‘When Xerye stake a Morescont screen, pst & emi, whic, by wean fan agin tenses canbe mooted en 3 Teevion sce. This the bai of flnacpy (teeing, ‘Typical elfective doses fram diagnostic medicel exposure inthe 1990s ops eee hk ec do adegaphic centers ines opp) Sar | year and 49-10% at Sea re ssponed ‘Transjugular intrahepatic portosystemic shunt ‘A rant we of exponng mata sens hs been i the koelopment ef onsite. Forte shunt (HPSS), which ini the poretanas eration of « coe Tricaton beeen the prt ad hepatic eas tens a the ‘eff pal peters F234) This procedure ws st per me fy Rc in 1988 ano eae a aller fe tovgey apatite wth recent vaca coin bo ate {aban toler or erecting The eh Con mit & oer 90% Tre mak compton beatc “teeruapothy, nich cn Sevelop fll the procedure. Shunt ‘etn may deepal oul fii perl Ts ny gue ence th loro eon sen, Tear patency reson be ckewd with cone sens. Pepacwn GASTROINTESTINAL INTERVENTION Enteric strictures, esophageal strictures Dilsati of enn or malignant cexageal strictures ean be [rb with ether endosopc oe Bsoronopie guidance, The hoe depends on loa exper, bc ctesing daring datos ‘Patbuatl to eluc thes of csopboged prorton.Bkon ‘Bluanon i aehieved bythe inmotion ofa allan ove ewe under orscope guidance aon isa the ‘Mhamtage of povidlng conta ria ating force wibout the loghunal shering frces acetal with conventions esophageal bout ton ducing the kof cesar ‘peur, Obierton the wait af the allan wth faon a [otered in eal ne and proves an ato of the Hey sce of the poe i paeny wth malignant setphagel dese conser incurable by ane Inercrio, cosa stent placement vies palin, ied plas tents(Celestinot Atkin [bes hive bees gal supe by sePexpnsing etd ‘tenes 25). Some of hee are covered wth pst, in Figue 2.6 Yoru ihepatc pore temic shut proces ‘MPS (o)_ Neal ‘Srecad fom tepateo pode vein ia Foe Svs oppo b) Caters posed teu foodie i, sypar reser ein (se Fapottga Now vig croney vin Fraley balloon ehene over we ord Coord fo erase @ peenal rok. Sioa ster ocd oe th ck bn Napoleon petal va ehepose Shr etd vo se Hoot ow cece wt Cicero wi: Mepadied om Chop Sen elie th 986) Cade Regie! Rcndvs, wth prs fom Eber ov eg Ca | amen Fn ia (ISL SOcT ent ma een edow chr paceman esl epacig plo overs mee er Ther ropd te Row tough in to io kgs Iubing tour ingroth ad sealing ny asi perforation o scl Placenta eleves stom allowing the tent torettm home ov elavely nore diet Pylore strictures and gustrie outflow obstruction en dense may be treated by ll itaon sng lon upto 1 um, ually inserted bythe al ute Malone dene toction o gtc ute 7 deer ma Be a th sclbexrnding acta sens, ogain ually ered lly abou trnspatie and srbcpetc approaches hve Seen esrbed, The eral st fel prose fe elapse Colorectal strictures Selfespandg metal sets inserted per sectum have exo main in colorectal malgsaney eausycotuction. They can be ‘ed pallaely apts with coring lon earns W tle obstruction in ptt it for eperation. They i lo be used athe tna state ia patents presenting wih maligne colonic ebstucton to ll medal opinion of he ant poet suey in an ater to mime surg ctaleyand allow a one-step sgl procedure Percutaneous gastrostomy and ‘gestrojejunostomy = grtentry Hucanene proves a mz confoabe slrative to longer taseate dg ia pients wh te “rae romaine rion thik Tis wally 2 revo wpe codes rat alin orn ally to sw fo doce pelos cntarectbe eae laa cement stontomy fesding bes can be ached sng chet vkecory rth Thochole gana deer os peri an bth eh ar tal sua Forocople plcement is een In pats i sespharyngal or caopbagel acon isch that even the Sat enncoecnaot ys the stot. Theda Technigucregutesierion fa nceassgetitub, Bara gen through tis the dy bee the procedure allows entiation a the tree con on famcapy lla fr though the tube tendts i necopcly earl dite the each aunt the aerial wall. Taner cr be wed a thewontach othe anterr abdominal wall Bg 26). The aims toininse the ik pron fe ea throws te stomach tall pci adhe fotenen ae removed fer 2 wels when heck ssahed. A ance ate mec er the ower bul the eamach, lly gudewize placement the tick Mlated coca +12 lo catheter aly pation witht ‘stents oop the stomach, nor ompicatons nade wound (ncn and tue dalodgement A modfication ofthe i technique & (9 ie a cared other w advance the guidewire thr the pon at the fourth pat of duodenum or dal tothe laren of Tie lloring placement ove th wir of wanotrojtoomomny tae PERCUTANEOUS RENAL INTERVENTION Percutaneous nephrostomy Frcazaneus nphrotomy (Boe 211) fone oft must com ‘ately erred tcrventions Thee ea numberof india ons, of ich by fr the mst common ree of ia lst 6 pretrve renal faetion or oslo accel est tnentofinfection The appecach vo neatnent nod tobe aloe Perevlonsous nephrostomy Indie tl ay tn = pee = teen ao rtm iin = aloe sea bc = fama je "avaleppeyod Wk = sation. mote — guioeg elon 1 ino dere cca Indies fe gent peso Span wy lr (rat ut ey 1 en tn low csie th soond demain % CHAPTER 2. |CHAPTER 2 | DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY DIAGNOSTIC AND INTELTENTIONAL RADIOLOGY Figere 136 jo emus a preoneais posted ® to the pin, For example, eaten of waemla may be ap Frepeste apr wth agranced maligne. H nepstomy TF pectamed fe hate magmantobstcson, 2 andatr pox ‘ie nly nh kidney sth Beterprenchyial Eke, ‘Say bc cm torasor neque rena fret, Thisapesach imines the numer external dans othe pinta ar al roe stent deaiage fot away, pole. x other tens lea Snage ma be areropee to mx real Fmecon "The prcedute i vaaly best pororned under combined esound aa fuoscepi 237) conta posterior clr ‘Behowen tet ower pole cas oa mille cal apo Song stencing fs be performed: I important that the nde ph though parenchyma Ico the fiery of the febcaleea! system ental punetares are anced wth Rekewel being Recune of the ite of rar renal vee ‘Bldg ocean ony (3% of pints nd is wally vee An slliiting, Are jury should he speed fk ‘eos pert Peon 3 aye: Avtergaphy Is shen ia “ed, with ie 9 embolarin a blessing pi foun, Sip Cmplcarions ae ial areal may be raced by Slur ath Ove the mutt te reported ‘eatound 02%. [Antegrade ureteric stent insertion ‘Alahouh Jocks sai cheers maybe lft for several ‘fees tele encenge rete, lngtem ueteie rina i Her achieved nrnally by doxble-pigal stent. dations Tce calc estan, fen x lain to extcxpores Hock wae linn ESWL), which pofaces many al ae hone at may Mock the ete; hengn or malignant eter ‘Mrctves and ureteric prfomtons Sten may be passe ‘Bekdy ae qyeemopy on 2 ettogrde sppecach fac com rindeteds then sn negra appract i pose, Following femataneus acs nthe evcalyeea yter,awie psd {poh the craton into the Node Mose trues can be tree wth 2 ecbleHylzopac lew, bic by hen ‘fchmpe fo a ewyary we co sper the inertia ofthe ‘ene Ballo ansoposy of wrteri sticures can Be pcre tthe sae tine ether teat a benignstrtre oF ate a lian sere enous wallow psp ofthe sen, ° igre 37 Prctaens racy wie.) guide fended ough neler ih ue Teak ltd A [ppl ect ith sock op el ine renal piINTERVENTIONAL VASCULAR TECHNIQUES A wie rmgeof inertial vec techniques ket deve Foe neuen ce ll Percutaneous transluminal angioplosty Feeutaneoe engopliny was intl deere’ by Dt an Julho in 96H anda by Great who nied the sy elon. The eng lesen the tec aon wth pide, ower which the deed halon fest an ined win th idly obey eater ial fe ila vex agony ts gear the Ft oppo ‘scunlccchnvelesimrequingtement: Ted ther seutasensdeotosclaonendoreaao with sugcalbpass paling depends on se length dene sent aa ave ial acs a Best ade a ine dso hereon er nal ncaa an star snon eho 13). The schnal ce te or eral and phil aly cen Stand 95% enone nih 20-7 pen test $ yea (Fg 238). Compton ince al hams and fake ncuron ae the puncture ae, ang cen alae pation, The secs of pened felon of atheromatous det oy repel been $end fei anderen clnkalyqparentechac, Vascular stenting (Box 2.12) I 1988, Plat topored the use of itravacula celeron For sul renal ery menses, stent haveleen down tobe superior aban angen Inthe art and Mac aterenIndkacos for sering ca scl ecarent stents ad owing duction, pot ‘lt fllovingbllomangeplisty Sins cendanto bess yor ninguna ds, oe He low slower, hee her te of oecaskon and evidence of uperily over balloon rope alone fom rndemnss sont trae lacking, thongh oe ep fom metsandyaes have ben fvounble Indications for vascular stants oo) 2 tote cel vii ed tein dno Tacs fi diss fers die wri ied pes tien ~ ses sees gy ona air sire one Soa WS pe es te Tran ieagutocoytian tommon ec erry oven are angola) Te ua 2 yea ‘ter arintny (Cai ery stenting develope aan endovacur altemave ‘0 carotid eatterectoany unde lini erleatin, ‘enous of cent vl ual pent ee malig we cnn sys, ten secondary 0 Franchi ac Tester reste ny ccc de 10 rogreion of wfcratnn dice, Radia Pesce dil ‘fsradbocty cuts ee Alem ere te hasbeen ed 1 ” CHAPTER 2————_—_—_ CHAPTER 2 | DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY DIAGNOSTIC AMD UNTER/ERTIONAL RADIOLOGY ste with an lating ata hiatal plierston or he {ecopnent ofberaable sen Covered stents and stent grafts ‘Gover tes are fore fe askeletn of a bare tent with an she covering nual made tome Goretex o ptt weiMlene PTFE). They ave depo in he save manner Sconce stents harm be set et pespheral cues Pyne pre eliwing sgn Larges and arsed Safe have fecn developed to teat aoe ancunens, Not ll acl artic aneunans te stable for endovscu epi Mae DD) The comfgurton of he ori nck an he fine dee agama some mone table than others. The del der re ere of ae ore ugk acest the GuNeTmey for neon fark eu fom easily is re dots have been enum but fer cla wale wa dk the pee ple orthese devices in he eaten ‘Freed and abdoninal cee neu BN ireerne ot onurysms untevourabe for Sraovesclar ret ere lege < mm (Gl -noaraon Ganbril enia Si ens tne > acres ‘al sre < Tam Pind radios Ney acres een ree dep! nan coe eon Intravaseuler thrombolysis "Thrombotic agents can ews eat acute tremor dea nthe Lowe in or optimal fis, he drug mus be ‘tied lel he theombus,chrugh mae (Meter iwenous shen feat ect Thrombobss an Sitematve tothe we ofa Ray balloon in patents resenting ‘acute eal oor, preculy for blow-koee throm. ae cre of serous pate se fects f emtbae and ues aoc generly recommended fr patents wid Kes ‘Sree echwemi suchas ose mith ciation, "Fhvontsiys nyo be wed to teat inkmoral venous hes an thomiy-cchsive Gaease of the central ure Ruy eine Hb an sltertve to saa thrombectomy and ult tcchenical thnsbectomy sn the easHent of ‘lade dole and alts Inferior vena cava flters Tercera cae (VC) filers are satis mader sematve (ees iano the IVC pte ath contain (ebE Srtcremenimiietc anticoagulant Grech SERS cron inca enor, br newer eves SST delved ecrnec om enor el oF Suu ein aprectTemporary, cenovable or teal Bast or permanente can Be wed, depen the ial inacon Where pst a nee psn peered over rea depen sto here oa ence of eal wc ees: 20% wih device etn tu Therapeutic embolisa Detnete vincolaremboliaton he ome ocladings veel Dene chived wang 8 wey o diferent atc lading ‘Sian grange Foner pin alcobol PVA) Kam pars veel mel ces Avra embalstion my he we he Fee tmuny varalconditins, scans act hero caacte therapy meres alates and hyper Gastrointestinal embolisation feat oper tintin hacsooge isi invest aa wae hy upper utinetnl endo Management of ‘Shout Heeling ely reqs ealtortin beeen end rar cup increta alot, tine at Sera can be essing Bleeding pot 60 rae sca be weed ih get ebhsaton,c the et aaa aralnaenalarerescan beempiicaly cclads. The aaa pyar the seomach donde and posts eee fern aivewent foes. Bleling enon ang aoe elyament Te eauisccefeectiveembal rar anexen lacs svar posihl inthe iat See A te surgen mt bel tothe development fens yiclucmnfembalacon sed asa fisene apna nd mest FORAS toupee ble nk potoninisnse Tein en mportane rechnigetn the mangement of rage hocornge om mle es plang ue [fora ypc Spleie aery emboli ca lo be wed toes ae toplenestomy sn che weatnent of hypersenim, Gonadal vein embolisation ‘Rreanber emf agers hae been we esi the ese Pea occas ype tobe he agente hace nthe eaten eee tsi ware, Enbuation van erative t on Agno orlgaosose cpg the vein The et ae ina Hee rma estent wed enblsion fuse aan- Tepe olay nave dys hap A sin techni os far thecal the ovarian einenpetcconpson symone. [Arteriovenous malformations ‘The maragenent-cf ateivenns malematios i cole “Ponr sears nla conserve agement see te ‘Tandon ee fom the ae utr by he die pert Sn etn: The choice eftcament tl depend the patent cea nl eh cara ofthe ion, sc de te Ea tn ofthe comrleiy anche hese problems {hy ane bo mame speci centes ith cam rpc FURTHER READING Among and Tad rm ese Daa Raber 1290) erevimal Rtas A Sei "Sue Church Lvngtne Landon ol ele ot Rare (999) Ma ie Uo Deprme "na ag aso Dt hc Ral Clee Rad, Ln sie a) Ct or doialeew nab Rai 05 97- ML Gk) 0D A Cc Tee ofCHAPTER PREPARING A PATIENT FOR SURGERY LEARNING OBJECTIVES © Tounderstand te pines inched in preparing potent fr heat «Tobe var of th common probs ofecing «pies iness for pation onthe prinles of management + Tokow hess equred when king informed consent fom an ad ‘Tobe cleo prepare an operat ist + Tokna the mprtneof on ptt note INTRODUCTION willl expected to recoun and jut your ever aon Ts wil 1 hey oxmute of + profesional le meticulous preparation ‘sey tno exception. Your resporshiy at sageon ing other and eon al relevant intrmatos GS eepere un cay ont ple bri tk ued caine et Gor the pte + prepare contingency plan fr pele vere events + Communist cctvely wth yor patient andthe rote Gathering and recording Information “This proces rt fon the moment ihe patient is nt efeed to the oor patient o emergency department. Alte inowedge ea ogerus thing (lake), bt mation overload ca alo sain probleme, The all fan experienced szson fn oy he com ewes fas ore ots bua er revit and ln. The ovat yu ste arent je for sey te bo oh ote Imembers a the tea, bod now ann te ie ‘Ava of amb, our ner shld + alow romeone ee to take ovr Your work a momen "econ onl weil facts, noe sje opinions seid ambigvus or unl abbreviate ‘Wie all your noes sifey maybe wed ce dy evidence yous profestnalcmpetence fcr fv By te ne 3 ore comes to at may be yaa the event and yet you rads | page eae eee ‘Sih atean nn 1s ete staan ‘aaa sor esos ek feta yo tence ae Ie dca odo witha notes retnind you. Remtrtha 8 ‘Gras acouof lam concern itisnoe wien dwn A nee appt Minimising risk, maximising success Pst euiting surgery maybe celia ves dhe tundeing endian, Despe this che operation mst nat bein tnt the prepetive conn ee ga ec he ales (epimistin). Anaesthetsts pospane suger no because the parent but Besse thir conto cold he ows Contingency plans sng in particular teve ae ne sch things vente ny poo planned ourey: What defines asiledsurscon isis tor her antipuion of potential problems and tha subseauent toance andor management Communication Area works ifveryone knows wha ppsting and what Isexgeced af then, Thisaples to the patient well “The nest ine you find ae expe onde recsve a omoplaine rat watt, analse why tis hs append. The {Stare wil onl be one of commuzntion wthin the ea, nat of rida ncompetence. Use earn how So ng in the ftire a to apportion lame INITIAL ASSESSMENT AND RESUSCITATION lel managment of he very il paint (Boe 3.1 moe fly overed in Chaps 23 bt should ll aie se down by Inital management ofthe vary ill patent 1 feu ited pad Peto mi th iro 1 Dintheteallreitne T FOR SURGERY G A PATI cHarten 3 | prerari—————— » A PATIENT FOR SURGERY CHAPTER 3. | PREPAR PRErAning A PATICNT FOR SURGERY thesunial andemergeney made colleges under the elstive a anced Timm nd Life Sappoet (ATL). nthe come Tre a ary. thntrothngand heaton. ete fase An an be geste ry re fo, lowed bY Ean of dbl nalexpose ofthe print, 0 allow Sona nd complete earn 8. Symes ae pile thus soc amount of ity ‘aking mination and vestigation may be pile whe ‘eh isang lace, this shold not dla he te ‘nent of fete comin hte srs of the eam soul Be ints ey ce al tesenheecalleapue= Thre shoul he ny shame aso cl tits norman or raring help fee so Sijtspues Most stale a trama’ ors ees, sho ‘fusldbe ead wo be call ear rather tha tee NEW OUT-PATIENT CONSULTATION YY wil se many new pants in cack lnc But, fr each of You va lan thy Hy eben event Pants ‘these apie ro he star ofthe consultation You Takacs youll to then expiring who you ae (Bex 3.2), te how they nish cote adresed and make ue thay ae cattle bette wating However by ce hn, you should SE premio tha ou Have all he cme the wood rd I ou ar poping ove them yur unde attention or {He Yona of their ineriews This means emaniing Your 1 ones ao ae hee equate ine fo ach pri ard eet he ceptor ding conan at REE C08 ole ni ‘The star of consttion rae ioe yr an Gate tne now ide othe 1 ase at etch 1 Hoven 1 be rate ut-patient history (Box 2.3) Listens what does the patient think fs wrong? “The fa pase of eakinghistoey Use the patent, The Fmt shen be tel 19 describe he role fH of et rate fe Thi theegvuie forthe pce, and wil ge yu gota cs he danas Clarify; what does the patient expect? Arc spn usin ey be ss at his ex stage 0 dete ae ey at he patent thinks song aswell ace et vr Un opng fo sie ad the oacome che sent Diagnosis: what cen you offer? Rose lowed quests node 1 coi exc the RRRA posi lanes hae you wil ready have teats Perea pm wl day ive eaced a dsiative agnosis Te he sage, Semen exomamaton ad vesgtons toe coin your ass ‘Taking @ history Yoo eon ape iin Nernst eh tr Tisserand pe ida dod Cotton — Opis carpdain tien, ‘pops oso pets unis Cal uss—_fhysin ie fofimer dre mes fandom eile Fimess for surgery: Is surgery the best option? reuse sapere the be pon fe this pain then ot ass Kr cstons te needed w determine f thee ae ee untcetrs ws anaesthesia ad surgery. Ths eels Plc any managment plan i neptined with the ‘out-patient examination Peres shu be warm and confab when they ae being ame un Ge th they are blag weaed respects A Seaman ofthese achieved when they are ade to le eee of al thir lobes. This could only fe done Freed when reed: However the part ofthe bay tere Sed mus be fay cxpsed ed in dhe ae of inks ee tad shoud sly be expaed to allow compari recat potun (a chaperone) oul be present when» wae fe beingcxamined. This eset fr real or vagal took Trp leaps best tases the ptt visa oll anges Meee Reon jour examinecin, computing ils whom Feel Fak the patio about areas of ender bre glpting 0 Peed Enmre dat your hand ce warm, ond arch the Perce fice toughen. There no excise foe uring raent unnecemly so he xamiation shold be ov gene rane Ser you fliegen, well avy fom ane Maer meas, Pocced to dope ealpeion ony iyo can avo veut unncresony dace. Pan can be an porate ENGR aoe otal mina. aber shan avid ot the epense of aan Tests eplat othe pint what yt ate ding and why ore pet ao Gh os ch ae peeasion or ws sabi Ter ty areal anion ter the explana, do che ax somevhere well way fon ie tender wet so thatthe enc at eet lows he ef dhe dying up When you have Gin your extn, thank nd cover the pave hen wah our Bade Let te patient get desc Bf four dicusing dau or ent pl Management plan Artheendofthe nerview Bax 3.4) themsnapemene pn fr lite by dco wth the pee esol be ito, oe tan explanation Thus the pte wll need 0b hat gow have found, what you thle wrong nd what you ebeeae the options fr abisuen investigations and teat pene This tut be couched i lnguage thar dhe pint wil tudes wit being patonsng the dion a dificult then agatha de pint gre home nd sso Spe all one with my or er, return with 2 Feros ed 10 provi port when mang he de Sn. Sater weiiagdown any quent ha none Ken fo the hem of the mument, Remember dt pints may ot else that doing nothing ial cn opt thaw they ‘tam thi shouldbe ncaa inthe pans that You so et ‘The end ofthe interview dre ‘ie ot nto ay eb in Gita et eek vo eps ba potas ig, Sts i don quest abuae Dane ete fia a al rt oan ot oe ode (eyelets er Writing up out-patient notes Ae geecral hy thr be take ding on ‘er they may dere fom pag allt to the patie ‘Thay rest mae ler the crv Bed andthe whole pcre canbe sees in penpective. Your aoe sould be le ence and ordered. Mae tre tit whocyer ‘meds to know ‘ecives a coy of yur notes the rekrring doctor an any her cena volved ing ft pain. PREADIMISSION CLINIC Rationale Movs units rage sce the: patents or2 week bine sunt peadmision lie (Box 5). The pape ft it ‘Sto mute that eveyene, selling the patient, knows what ting open and ates wath dela. eau Bal ope Tune tease that the patient a ta poe or the eh ovnng sre Tis mimises che sot tee, ad avoids the expense consequences of eancing the paces operon Jue befie surgery Tako lysine ws obtain ered coment fre the park in an enone hat ke tefl thaa the nighe efne or even the moun of dhe procedure For all Preeedunsy especialy compler one the pees of cng onsen wl stein the ike wher che patient put on to dhe Retionale for preedmistion clinics 1 uti apr nol oust opie os ape pois Gah te ede nin apt 1 Thee peda cb ene slg tell ony be comple! whe the patent ha ome infocoupey but beforehe ordeti scene any remediation. However nat ces the peal clin te Hel nef ‘he ai prt of ths conmenatn tae place The surgical history ‘The is esks w conren that you have the corre patent and hat dhe pinned pcre pyrene Check il ane, date offal there rll sme dub, the ome dren Check th hem he cen for bic they have en aited pa ‘ular noting the ef appin ‘A cael ene Hf general Snes for sims i alka rade The determinate othe fee ofthe pent fr the ‘arial pcre balance Fete hero praing ard the eof ot doing o,"The more tration tht can be keane ee ete the decison Hel to eT rl ccm piel inom ene who know when and wisn ro 0 pert, “Thea re thae need the ever are tin Tie 3 ‘The surgical examination The examiaon canbe dived inc thee set (Fox 3.6: + Agonerl medical examinations eset check fries foram ansenhes nd sere + Riawgerpepcti camino sees factored the tn fr which sumer ep + A'patenesperte cuminatin evlmres the pretence and ‘every oer probes in tot pont ‘System for examination ofthe patient * Gov it anon — ac ed gee Spal canian-cri es er oa Staonal oa al ‘mob General medical exemination “These that need tab covered ae ted in Ta 32. Mot of ‘hse checks wl reveal no probes your pin, but al ned tote exclade nevertheless fay pits repent Shen i ecu tv detsomine the sever and vo eour thot they are der opel cone ‘Specific examination: tallored to the Ssurgleal condition “Thea of thi examin i 4+ confirm previous iaings and heer he demos + Stermine severity = how mic this nom feting the “+ nip extent — ae other structures inode wil ct ‘gal planning? a CHAPTER 3 [PREPARING A PATIENT FoR SURGERY—————_—_—_——_—h 2 CHAPTER 3 | PREPARE 1G A PATIENT FOR SURGERY PREPARING A PATIENT FOR SURGERY able 31 Teron bite ed dates, cane, tment ol Taher ps digs ni ‘pes ip er de i roti es a ie io pny ntl estoy Sagi me ent ik ia rnc irr x0 etal Ges! ist ees Dress Prva dg pm oie iain an Fede Neral ts eden aco Sgilmesa evans Peon inion Fea omens Dros Fmt lion fom oh ie ins ‘ble 3:2 Te pape gel arian fen SC hte ew) edraits Pld was tcl on a ed ine Chin gs egy a ond ee, si, yn bos ruse [xr tenn, ‘emer agenda tne al xis sa ted! —_ Cede msl so rept ‘iw inns Ss a aos For example cn exainng a inguinal hernia, you shook co tna oe eo rom te seventy pln of anf Ed co chock whether the erin seduce a a cea asf bowel traction. When check eaten, you need know whsther the hem 0 ae tha i rt an xcilectry of even bel eet making ule tance be a soutine pee nto fr moe Tra underaking Perea memionct, thre are pcige complicaiont oe Se operon irs rorded that robe ae ere foe gery, hen ay suena by ead grit asco y the sey can be contend ioe ate ave caocs a fot op This ie ama dam fap suey has te fet ofthe foe a a be recone orien mete fer Individvel examination: medical ‘comorbiclties Srersce ar of she examination need to focus on checking pee nee Fa ical eontons that te patent oY hve, Fen hal depen cbse er 8) orate clo wl ss need © becarefuly examin Ec empathy or roves dese. Each of hese ey iin coma wb cond in the clevan ‘ton on peoperative etme bow Investigations (Box 3.7) Routine investigations ‘The oe of rine’ ess nora pfrme on most roi Fe pe eco ill aa ean basic Bechet ng eeaograhy)needs_caeil sl result ree Ta cee emenztan fr nfilent and expensive onl Hay rnd sme asc the pases sa ee to ie value fn ordering am tvetiton i the sea un here, ec the ote when sey Becone roe al sted up Al results oul be ocd ety re Sad baad The ue of a canine record i elo i ee oni epee rs nd eprop 0 Investigations romani red yal 1 Si estore lnhr s Feeble dros nee te eet seamed olan ed un Special investigations Sree onl be reais n casaion wth éhe spect Tet Tc adsingen the ean wth heaters who HSL whether the pane it x ur Writing « request card “Tha cad easton nfrarn forbs dhe ohn Te ng he tet theta erecting the ee er eee econ formation they need oP shone pat the tes. shld alo ave one went for tun oul fis estmay ae out mana cee amply exuding abet Thinsentence sald or a alan ma or you athe serie petrites toennre tha the indians ort are preprint, Domo fig dhe wor nee theend fs ees, engeted surgical tests (Table 3.3) Full blood c ‘Thistnt vena ide to anal but ter any posi of into or inde of any condo dt ag deplete ately ATptlet coun wil ak be rage All dct yas falpndecdlng how mich Mia eel tobe erate. reotinne ond elecrlyes ‘These tte ve gue to tts of deystion an of renal tesificieny, which might complied management ding finer. Asa ape, dey ae mabey in all poten oer 65 years inal pets whom sg ca lo spose wd al flats with 2 istry a ears palnany roomy of ficly wih previous saethtc Theseallow tintin of he prenencear dere ofhepaticinhiry rpc log it the pote hepa seve Tn neh thor a cate by oie, know ce erred pat he ‘hows malganey esa orsesoney and poalhyperrenso, ‘Albumin snd oe protein free may sve age to mutica Stour atl wan cf pele pcb vith hel postopera Aormal iver fae etsy al woof ting poten Teble 23 Gnomes fa ain pets Tadtine Fasc posal) Ned oc ni I ot sip Fes (ot pe) Novae owe dyer Ta lens wc uo nay ep) ‘reget! eb peta snows Novi pris ih eeponila ae Pain yon i eg oma oval es ih expan aan Paseo et pe) Neale ih persion eau ‘lerdc es Pane may et peta) ell al pny ac ‘imi anf may ep) eed al pens vibe pes ein alsin oi xen ‘eer xt tt tin cin io Medal see Pet magn om dar nig edge 6) wae Panny teeaduission clin lotng seroon he putin anicongulte, hascongrome ve fasta hav evidence of bes dates then cating wren wl la he requid Elecrocertography Every anaeschotiedepremene has guidelines on which pins Boul under elerocandinzaniy (ECO). Ass ingle ne ECG snarl tint oe 6 yeas all tint in ‘hon sigfcane Bod Me ose ad inal tics wih Hitory of eandxsnelrpumonary pce o ly ih a peri meri Chest radiography Ths sould never be rege a oti: Homeve, canine ue aroma and iypertnson ul ll eden fo ches alhgrophy as would spton of chet naton, ale tase oe severe conic estracive pulsnay dee (OOD) Remember tat che las st be avaiable forthe amaestbetist tthe dere ele pn taking dhe in the ist place Cardiac vation In gener the invcvemnt of cana aise ian ‘hing oes than se cadet lence Tem keermine functor calite reserve and terete, the Hey response tthe sess of sen In mos fen ere ECO toad the ist chic fet with alm casing estes chocarogaphy wed ia peas ule to compe the ex ‘he promod Resting ECs fale to demonstrate pore ‘ale fr haere petopcraive event, ldo a venticl ‘jeton exon of lee than 35% ime the peat vik of a thas complications Respiratory evuation Teves prediction of raptors Fil vlc cept in thse pant with eve COPD, in whom eevee mon may he inetd. Urine Bedside urinals aque 0 complet the inal examin ton alls the detection of rary tract nection, bln, con and iappropdate canola. Specie mice Facterisegal or Bochemical ena ie indicated oly fe pe fe mesial conditions. Tere ote no preoperative sual Snacsthede requirements. Sich investiga dow fuer warming nest thee alias wrth eecking the patents temperature one ‘ncountes uneapected bleding Hacnephila ques Propet tie emopretpee,betes fresh naen plasma oe renee baels wed mcaer fo Wilrane' daca Theombopilia isa teseney Tovar thrombosis. Several ete mts inca defences of anton I ten Sand Cand ancanlpin antisera now econo, whe tv pases with malgnney ar abo ata erst sk tbo venous and artral trem Pete with Ene lotng tendency shouldbe considered to be a high rk for thomiopephysss and_ may eequire femal heparin srr longterm waren (Box 313). ‘loting problems fo ents ing seo ae © iti Sn pss wha deed ea atom anyon dig Obesity ‘The clinkally obese (> 30% above Kel weigh?) sual patent rns nresed ka postopera ceebrovaclaccde ad ‘chaemic heart kewe (Box 314),DVTandsubeuan ulonary "snl ae cman, making tremkopepylas poe ‘ant, Serous estat rblens rel fr inate entry !ncchats and pecperatesoeherapy mye nstitd Oba atentvarealo more fede tonurse and ch alr iin "ence of reste soe, Thy also have poe wou Fels Tete bese to delay clei rocedtes whe the pane sxe tose weigh Problems of surgery in the obese ils of palin sek ay shen) ‘dpe 1 eer ange 1 Donoso ey sie Fervent Jaundice Two Key roles need wo be ated in the juiced patent: tren a sess (Box 3.15). The cause of the olsruction fan be diagrsed lo combination of har (i wine, ple Sool), echomicl measwreent of ve faneton ard ain tthe iat oe show yp dataon. ‘Astor of fevers ral gy log with penn an rade hie cll count, wool support the ale prscce af eps (Ge. cholo) This reqs rap external or eral ny dainge ln combination with tevenon ld renchaton aad stoi, ‘Clog ctr I, VV EX and X, dependent en wenn K, may be decent in cstucrive june soa cougiion pote ‘hould he peronned.Signticantaknormaliies shou be ated ning feheoeen plasmin andr viemin K preuperatvey A hacmataogst should be volved Problems of surgery inthe jaundiced petient 1 hc Inpers g kl le ig om hyn 1 inert CHAPTER 3 [PREPARING A PATENT FoR SURGERY——_— CHAPTER 3. | PREPARING A PATIENT FOR SURGERY PREPARING A FATICNT FOR SURGERY ‘All ounce patients mu he well hydrated avoid eon oman ena ae hepato yd. Intravenous ses reuled, and shou be admits wahout fal tthe de pene sa by mou St nice paren shoul ceive ante proba as such patents ase at reset of infection. Hypertension Inte absence frnate ane dysfunction, sual iin tally fete by mu hyperssion Teepe with a Bod fre pene than Ibm sec of 95 ml dnsolie REEL have elt procedes deere nl the fesse i See nt Newly damon ypertenson need tobe invest ped athe fore surgery (3:10) ‘las potas ds cock hfe sure atts ‘eng uted wth lareto, BY Fie ponte wt corovosular problems for surgery Fives adie ser bps des own iiue Sake sm Cre rn i ol Sein nit be cn Hoortfeilure Carne flr shoud feted ond sabi elo en unger if (Sasa In urgent ese ign and esis may be necesy Foor adc The ammeiei team shoul Be involved ata ‘Sree to low any fad balance to Be comeced. iets Sat Sonal dpicesonhopncea and parojenal octal GOSS ne ae wey fig ak The cro team should be inoue at al pose Urinary traet infection ‘Uncompicited urine fete are sen mos commonly trot ‘Snel i enke pte Male prints with outflow oor Gon mest inv, bave chronically infested ne ‘Teaaene sald be stated preperatvely with anproprine ‘ores Bex 3.17) la ake shouldbe increased 0 sh {Re eae Cie ch reparations may be ver oa the Me Urgent peocedure rely lye by uncomplicated an May actneson but gent ei pcs oul be {bse oe 24-45 hos depesingon the staf the potent "A patent aupeced o having teal cole oper ret ultion must undergo epi scoen co exclae Stu palomitas con tht rues ugent desempeson of Fe tcc bee ever kid damage ress BY ie, reatintetion 1 Seton rae {ait ri 1 homesiaeser ‘Routine medications Tes mow Been shown that ourine medias (Box 3.18) (Betta Reve mrad om ee Jay of sxgey wich rial aan tr if neceaary Obviow exceptions iach ani [Suns ral hypodyesee dug (sabe). Aspin maybe (Sera i Heedng Hy 0 be prolonged eg pti sresbing eaaurtaresetion of he prsate (TURD), bough fore ea clear indaon (Gch im pas wt see ne dase nding rors schaemic tac) ‘yb comes Thee ema some deat around the aus: Job of whether or not angtnsin-convering ensyne (ACE) inks how be stopp Te ie male opmion to consul the anaesthetic members of ea athe on yada const Routine medications ‘anki 1 open none 1 Dutmges-onarig cee Chis nea do irom Informed consent ‘Spey technically an asa wolss (be pent as sven See penn dis to aca This permission val al he asennad and then apes wih thereon couse faction In aaa sve consent es a aacrraning in scoutaf law iste poe aking food eas econ tot ths has ae ace which the wo ees an change fal and baer, Mawes re foot Solop aera chaperone’ tht wl be le all exon Simon er thing the baling oF nfonmed onset ut un Tree ade doce ermine th key. The stges of Intel conse at given Table 34. Introduvetion| Yo soul ineatice yourself, check the patent's name and pin what i hat you ae poping to do, and by wha eRe jo are doing has Caren st eomered hat nl ‘fern yerfrming the surgery a depury wt abo apa TN ofestnming the soy, sould ain consent Background Tearworh chek beste wat de yates ares eel {GLEE yd not wan to dpe inormtion ce wore sti (itary ace. You shi alo ches ow ach he isto st wlleny beupetng pave unvanced n Manse However oor ex to ence inthe teste pl fin pce eine to cle ful ace, Whar is wrong FF she grin does not apart nw hs or er diagnosis {fisnfometan shuld be conmeyed char and single nen Action ‘nce ain, dhe patent neds to know in spe terns cx (Ghat dc epetion tvs Te now red tha you en ‘ether our cate ln confor tan nana ul [Wehee arguing and your wcatmers ders rm them theil 34 Flo hr rth ied oat lores anyone (prom iets ‘odie hm Sotgned daca pak es ‘ip mer steo wesow Mats Chine apc lt in Wore ppd Do iron inva? aay aoe at ii lgtmtones ‘| ‘rab lve aes egg tig | coptas ‘hin cor ela ros elas od thw a> ste ibs pr olan orton li adie ‘oar ded Wri ee da pte on ito ne hk abt ion a ompte Cpe aeons ey sane ad ‘cose ln pe ee ‘eden Thc adele tte nT eve Forno oe yeeuaun nap qe eh se hina ota ie ea? Mord vo eld a wget ou will need 10 expsin why. cho nose ens ances Irie to sugery, of empliations woul ada change the tego lam he options each pssity mst be explained at thistage Likely outcome (short end Fong term) Some pavens havea touching lle that mee they have a Suge, everthing ping be ab righ Ths ral the {lta ei ortant forthe paene o be cea exact what Cin reincally be expected inthe roe and eg tem i he ents expectations ae foo hh, te the outcome Bound tebe doppeintment, ixapeccve of the scandal of the Choices Ty ae an fformed decison, 2 pent must be amare of che hhices svnlaly inching the open of dong "othng sue th Each hie meds be deverbed ogee witht iy Sattome. "The pen then need To make an ce deekion 1 te fe sngeny Te maybe eceery trem patient they ice an ascii etse spe, Complications All minor comics with an idence of mone than 1% Should mento. Al eos Teatening compli, however rey must al He mented You soul give she mrprnimate vel of ey desc wa actos have Ben taken ‘Sreduce this ik and hut wl fe dane the une event of {hishappening One abeanage ofthis descipon 0 eves Sra aclance to ensue the pen boot your sl sn pros: Sonali, For etary you should explain thor there 6a sal ik ofthe pent sufi heat ak dating sage, ro mat (ex how mise The tk forall bat she most seour operation {fa blow 1100, 20 you might explain tat you ony ce ‘ne or emo cases in your hospital a whole Yea Tou ean 30 ‘nwo cali dat prt the work fee peeadmision live feo idcnify anyone who ie at parsiular sk, and that the onary eae unit ofthe hospital whic is pes day and ih, tava to manage any patient who des safer & hear aac ‘competence “Tove consent pase mat be abl tn tak in dhe formation wovided, retain and coer, then ates the decison. ‘Those for stapes ean be ested a the same tne by sing the lee to repea hottie ot shear undestnd fom the onverson ha sgn bee the patient eanot remem Feral the iicematon then shoud be reese eyou shout teeon! what could not be remembered. I is cla that che cones evil sate such that noe pol 1 cain {tore const den isl posible o proceed with sey ttder the comet os tlatve oe y acing in“ nee Fever the eons for dig this acd toe eared caeuly inthe mee Recording Tes important 10 teond what exactly took place when consent ‘ashen ths contemporaneous evidence ad wl be npr Tancevidenee fhe coment conestd pen question “The intervie should rsh with an open question tthe patent Gn whthor they have sy alone prs they woul Uke to oa ‘OPERATING LISTS Day-cne procedures shouldbe perform at cry posible in thelist li plenty fine for patents cover bere ing Fe fo 319) Mine inpatient procedures shoud be schel> tied flow ate mak perros as dy ate fr ee to reseed thoy have ob postponed abet patents sh be schededcnly inthe dy to mini nis pcos, been iy eases fh fakes) and Foren nh presen igh’ ther patents oa [eof Ticinecsotne See (MRSA) or HIV infection oc BN Sporn tt order apt Smet rte ar om CHAPTER 3 | PREPARING A PATIENT FOR SURGERYfo PREPARING A PATIENT FOR SURGERY epi shoul be placed ra the cri ofthe i to faite ‘Ring the there pret the next ‘lace. “nn completing the epeaton Bi, poe to ts publkaon, onesheuld emer tht poser! eset nukes and os tle ae cet (Box 3.20) cases where ie of operation is eu check the noes and eck with the patent. nal check hall he patent are mated i pyvopeate) and come. Make sie Hat the ring afte cee about mings sing Ensure the notes, eats ard aera Iie present and cmplte, and eh any Blood that has een tered ead ‘Operating lists fnel check ese ntl oot Sie inom Toso sre Bd armel raed os Theat ald PREPARATION ON ARRIVAL FOR SURGERY ‘The patient + Canim that you fine the correct patient a hat the Planned procedure appre + Gheck ee pen fl ame and dae ofbih, Check, with the pent andthe nes the problem or wich the paint fh been cited io parclar ning the side apo pre. + Blake sce tht al tes, mages ae west ets re aa he + npr hat ln, fre svalae ‘The operating theatre ond team “There sal wll prec lpn setting up, expecially there {Bir of work to be dons Yow sould check thar any pea ‘auimene requ ch a a bage intense) rah ‘Teac ard thot allthe struments you wll need are ow the {ray Good surgeons abo range for adel traps hey Tra nec he operation ds not 891 plan, eo be bought £0 theare tht hot opened), Sending = renner our ofthe erent {heats wo fetch annum tray inthe mid fa oreo ‘cates poor mipton of onal probes "Yr anes collage reeset for nest al fom of cpcrtve teatinent and fhe ete of he ental aga frertYou shuld deveep and ain profesional lato ‘hi among good twewny commutation, In che teste Tul tis otays appoint forthe son tobe she eam Tener I during 4 ute rosedre anaesthetic problems are rcotnterd iis cntely appropiate fe the anesthetist ae ‘Sage tap ure In nay actly be ee peop. Ste Bethe date ster Ben chase eo coordinate the ap ‘echange of patens end eupment. The complied ‘Miguanecogics thee bated gute wing toe dicted rpopae operation expected tobe anyehing ter than routine inv any way the aaeathee need o be warned, 20 that ANP Pit plane my be made del with the nti, CHAPTER 3. | PREPARING A PATIENT FOR SURGERY OPERATING NOTE “Tis san mporane dunt I shoul elle, compeche ‘inc and signed my ince grams chs lps co ein {he cur, cs conterporineows sc! ad theres ‘este weit in any rbuaen ogy ino compiations oe ‘tiene come Tes ao an inptantsoor of ifoortion fr medical aad pring st who subsequent mana YA ena er subseuent aie ‘Avuageted sts fash docamentason given Table 35, Names “The nugco, asisant() and snaesthest should all be named Pek ug copiers 0 thatthe names ean ets be Feed the fir Indication Iris good peoctice to snte Ee the remo wh te opera ts undertaken, or example cme mal ae Operation Tbe operation fs name tec soul be wien in apa lean help angen pening an ai in the fate, ‘sample ares pea Position “The positon othe patent maybe important or ending ou ‘Eitapie ay clans arg om compitions. The Js ‘Som oul hte che a desc of ny ping se event nese ors datoge, cess we to ected print ‘Sr ehe tbl fr example pine wi sda nde il ack ling Approach ‘Some inebons and appmaches have eponymous names, fe eampleHaydinge acl cers is best ro dese the ‘Ste thape and eat of de ieson andthe tact hat wa ‘Tuidedt obeain ness A drawing ay etl hers Findings These should hovefuly comin the diagnos, or example Tle bc ro eer pein ih ae fst should “drive hove scutes thc were sented nd pote hing he pocee for example Yee ag nerve ee fala pot. Procedure Describe fe was done, tp by sep there ae sansa wie ten proce your uni nd ese we allowed thes ths cal Pee Te example nce expn ang stmdand prc {pov cars wer keno poect important strates tes ‘Reni be deed, fo example howe rls lps Fehon nace. Recon ny secon tha ad to be la rape crament hat mee wed Nove any rhesus {GlSutcaton libel canbe stack woe aperation note) ant fenton when the procedure wns compet, for exanle Paling lm les aaa tan | 4-1 tp Fanclosure ‘This section should include a deseigtin feecks made wo peo- fects ony worhout ned th et hat were closed nd (hese wed for eamele Sate eee ace Wid weed hc whale xcs eatached wt 20 Ver, Test led wth [70 Vent eonracs No far sees Sin cle wh spe Postoperative care Intrusions realing postoperative create a most important ut ofthe note and mst be lea ete. They sould ay ot See eae plan. These ron are very ipo the feo athe eam. Avoid malig umessonatde demands om the efor pce, butemare hac al the eed ato are cle fecored The instructions should tr wth med pester ve cae, for example cack ub eal sre al rein ipa ard checks on fanction, or example hack motemer showy for 4 hs There shal be clear isesctons on ‘und cave, arcu change drs aul das, fora pie 'Dreous to be then dou or tnoron's wand wand. ras nea 1 ha ‘A provisional lan shoud be ad for mbitation, cha, renting stiches a lle tes are al going ‘Neurinthe nee ture and need be orn, oe oxample Te plvoes sacs da ot. Prva diharge iy tac Sato cat 10 dee Cheats 4 wc Complications Complications nay cur lowing ll operations These shold elise albag withthe actions you vant the tem oak they ecu fr example heck esto ashe tet cae ort call dtr call mney Signature and date An operation noe is lve ro being algal document. eis con terpieuneous cord of leensed seat Ie abou thereto be Operati ‘ent poopercve hypeaheacmi, Consent for surgery and fenaesthesia Feed conse shou he taney she sual ear, eke Ay the epraing ngs, ele ay seston given bt the sonshetst shuld sillexpin amaechatie procedures opectaly ‘esol and spinal techniques, and discuss peal sequelae ‘Where aed Wis pertain he putin shold Be ire oe sample potential nage © vulatble crowned o bridged ‘eth Preoperative drugs and treatment Preoperative sedative and anlgese madiewion i becoming touch fs common. Hey salt, angemei, aniease anede medcaton was previously sed fat indation Saestota wih dor pangent ilasnal agents, which po Yokel coughing snd slat. Except fr pacts fo ar lead in pain, op anal as ae generally se gen “ling ndeton of amaestheaa, amieredinerveniay Fo Taped onset of action pir othe ar of sarery For etn Ivete shoreacting Bealispines arrow more com only wed 1-7 hous preperavely expec chien. Oa trneprasine abo sl poplar dren, For the increasing numbers of daycase proces, poorer tine sedation i avolded so as 0 promote rap merece fam next al mobilen “The atichlinenge agent atone, gycopyeonia, ad hice ate we to reduce repr and cel seretions They ote wich moder abuethe ages but ane stl se {al any singer and endorcope Atopine and shy: um ako preset agate vagal athyimise, fr which ‘dmineraton a induction ss asec Hyecine iplea sul sedtve wibout the ara fees of acpine, but Ke can ‘se excenieatn in nfns ore der ‘Anthromboreprophyans maybe nated propel aor sumer comraony by sukctaneus Pept nection, rear attention mut he gwen tise ik potent sh women ting contcepaive and Irmone replacement Ss, Su tho underpin peli iy ke and cance ute Low ie progesterone preparationt mar be efecto covered by ‘ubcutanens hepain, bu other lsoennonly pec ems of contacepive hormone resumen ay ne te be ppd 1 ‘month before major suey Preaperadve ches pysoerpy poly with roehiator ‘eae, ay be requed fata another monary con Alone If tact, prophylactic ance agents are even by ‘the anaiteti in concert with the surgeon, ete ws premod etn or inary ding anesthe GENERAL ANAESTHESIA Induction of anaesthesia Tnavenoss injection i all the ent commen methad of aanthtc Induction in contemporary practic, lous the Telly recent ttradcton of nowepungent sree os lado renewed ie of ilar induction, Fr anravenos Induction propedal, wih fx ral recovery replacing the lengetnding bariwrate agent thiopentone Inbalcaal Inconel i your crn. or cdl phobia, tna may alo bea in patients who area i of pany Aspiration (ex. ef Mod), whic cae the patio pt the lateral pon with ned-down ee odin te fed ay free he tachen Intonation & aw one of the reds wed fr paint ra of detloping ary obi “Aralgesic agents ate Fequnely a inject tthe tine of anesthetic inten to rede the eardiowsclr respon £0 trachea ntti and to be efeciive by the tine of eps Maintenance of anaesthesia Flowing the induction of anaethesia,inhalataal volute or fneavenou enacthe capes we contin sddntered 6 ‘inn ands depth of anaesthesia ce ‘Struts analgesic and weak aracthee fet hich rece ‘he concentration of volte anaesthetic gent end oral: terance. To povie a safety mang at east 30% crys rade tothe need mixture. Although sl cmpkyed inser parts of ‘he wrk ether has geal een replaced by bh, en zane an! fume: Desane and sewflrane we he moet {ecru inteuced agra conring Gh avenge of ver Sideefectr ad more rap ever ‘The se of mitour oxide i slowly waning a1 onsen (eebel eau nts eee lene eee lees pale. Tf compresed sources of oxygen, trou axe of at are scare the at uy be dene iis the anmcthee cui ether bythe anparated) pusen’s owe rapintcey et or By 8 mechani retain "Taal iottarenons saaeheria a techni undergoing con- teripontysenmgence, void the we of nkalationl anesthe gens and came wo prvi enhanced ality nl rapa of ‘ecinery Iris also wed when inhalational anthem be npr, sich as ding way laser surgery or esdencopy, ac ' popular erdopsinonary bypass india pia surgery during neuopytkcl metring of ol mea ‘evoked penta sigtale ar uppese by nhl anesthe Sh Invenous anaesthesa avd amonp eric places, aa is ‘sly conde hy infxing propofol and shreacting pid fags agent, suchas fentanyl oe alfenal neonietion ‘wh newemuscolar Nock and pulmonary venti with a ‘itue or aod aye 6 MANAGEMENT CHAPTER A [ANAESTHESIA AND PA“ CHAPTER 4 [ANAESTHESIA AND PAIN MANAGENENT ANAESTHESIA AND PAIN MANAGEMERT ‘Management of the eirway during anaesthesia, (Genera anaesthesia ducsthe onect dhe muses hat sere Sirwoy patency ard ence thre »reqement for seo Schema echnigus gj hes) or devices sch ae the ‘Guctelorayncea mask wy orendrrchea tbe to peer the a Mail develope the endotracheal ube ding dhe Fase ‘Woe Wart facie plac sng azo the mouth without pce mak. The eiton 9 et dhe tbe lowe al of the emhea to pec the ngs ee spin of blood or ere ths, and lace to face mechanical posive-pemue pl woman sent Ti fllocng can of way cntolin the anaesthetised ox nconsioptlent re wed (hg 4.1) Fire errr arson af ha ao. Desa fom he truth oe bonds fe monk on aroptannga iw oy (rol ess oto er nnctchel Nee et if cd We “lsozony ibe; dole unen rt endaborcha be eoewa nd enc cl eter Bowen Wea ey St ani in tn (Br | We ana n ed Positioning of the tongue an jaw “The anesthe thre the fra feo Behind he tem ocmanibulr on shereby ing he ongue off the poser neal wal which may alo Be chi y ietng an ate tal oropharyngeal sway sch ete Gide. The amaetete thc re ven hoop a Tce mask The laryngeal mask airway The large ask irway (veloped the 1980s by Archie Bin, UE anesthetist) also sete vi the mouth a tone 0 hat mack covers the Bryne ine, which ‘ale yan notable ell. I provides a lable means of mai ‘Sng the airwoy andres the anew’ hands or ling {he tents jor fice musk, plcement fe simulating ‘Bow endombed ination ee teque ea at omamestheats fer emengey airway nasagenent an the ‘huquncy tea, wry usfilaltenatve tothe face mk {trimmed cate poor tn eadotochel intubation The endotracheal tube The entrees abe maybe passed no dhe cache ia the The mouth or he seis aly placed by erlang, ‘Biagafargitope- Occ isp ovis the Ey cise and fibveopek ecbrique maybe employ it TERI the rachel tube alonded cer de exible rag ‘Ropes nce thei as been tered intothe ches. "Raed endotached ee sed cae afi vent Taso pay aound the face sway and 1 protect the Tang there ak of lmonary xpi id ay obec te he uth er above an st pe) 2 hoat rack seed nthe ropa “Alda crowacheal incubation is general sraihto: wand complications do occu cident and ness esophageal incbaton Seiden neva of amin tochus, rua to ay trachea or eth topo of ren daring intbasons Fle oie te aches, coven incubation of he epg and los fairway contol + Teetenectio or lockage of he ibe: 1) liye thea stenoiinchdeno afer reolonged int tater ‘Cael chueration of rss and constant vince sala! ly pole oxiety, nogrphy of the exper {fapiory omen conection menacment and vent {Eetooncevo alarms ane mado forum dese ks Trochea! tubes “eal des for laser sey the ary ae pci dese {he monflamabl, wo to aol pete ft resin te fares away and may be of Rose mera constuction “Ten eal Tracheostomy tube ‘Anmestbesiycan safely be condcted dough 9 racheostoa fuk bat shoul ive an lable co for aray corral Sve Sato+ fread emeboscmny tubes shld theefre be replaced by sculls ot cco of noe. Endobronchial ube In glmnary and open oesophageal agen sete intubation {cher roto unl oa Seaton ofthe lng onthe rte side Is use eaten poet che oral angi the [roseee of troachopleral Fl Ventilation through @ bronchescope The hing can ke vested during hnnchosopy by neem tof omgen down ncannola within he ronchrcoge: The xy [venti ny the Ventura generate enghpsute teu ow to inflate the lng. The wechniue demands consant ‘heranon othe patents chest movers Neuromuscular blockade during surgery Parmacologcal Nockade of neuomuscuar tani pro ‘ide elasaton of muscles to litte surgery and neha phat resre venlaten, Musk tne may alo be reduce by ferv deep anaesthesia but may compromise the creation ‘Neuron Hock deste conocer ofthe airy mod venation by the anaeithetit. The depobriing maecle ‘esxant sxanethoniun pil previles exellent stu, Tenino nef diac, but commonly cams poatpeacive Sse msl ans and ey may ene peolonged Hecke fate i defclent n plana oewochalinsere "The compeitve neurornceuar Hocking agzaty, aoch ot cure td todemn sucess, pace prolonged tard ene equ cael no vss tht the pins miele fiver ie tenoed ad malaained inthe ptapertive every Fol. Atcha, catracaro, neurontin dram ‘hare more preictabe atv ple and alex dependent ot tepeitrenalfenettn Gx fruinatin of artim. Apert ve eatr is slsn weed o chk Gr awa depth of Heckade daring srry and tx carn entacny corey of ‘eurmuscalt finn eta enumptin of ontancon n> ttn and extubation athe aca, The advent of scuromesc ler Mocha ia the 1990 fitted many ances ora ad thoracic age, bt intaduced the ak of cles paest Svarens wile peaoed doing mse Hoomostasis and blood pressure control Aldough the dager of profund hypotension ae nomads well ‘cepted, a 20-30% redoton of man arterial Mond pre from the ava preoperae evel eG patents ial ord seep nl Ean ety improve he quly ofthe operative fel and duce al Balas Reds of venous preset the ound by eotect patient petining and avoidance a a ‘uses venous lection Fg 4.2, and maintenance of i faery dep anuethsi and sghiy reduced arial carbon lose ens further conti the pons of dy call Hpotcsive degs ay be ese proce deliberate con tole typotenson i there ct surged enero be sane, although preservation of cerebral prison and cx ‘ation remains paramount. The srgom must be aware of the ‘Sone van | DO Poo do ab Fig 42 Poon for evopbe potato. good operat fl ‘th contol poston aie by poston hs opus “ener C8, eval ll rere, particu athe He of Sia hee enteees weer ee eam ‘heel trempt Bote Her pressure act the oral Teel ses geo the procedare Management enaesthesia Hypothermia develops quickly during anesthese and surgeey «due tnvsaaatony col inons of kd anos cy het iyjatenae RE epee a SE an copia haan in hen cae of the ih rat of by Stnfce are Boy mas. The elder are as tpl ska Ipohermia and shivering inereesxqeen cannon aad Se eeeee erie eles eine ee pink eee patie oe oreeees se eileen ‘warming blankets sold be wan efor reno "Hon option of oy eaves or crane (hc the Nader ‘at cal peli) shoul Be wed toa tempers Catefil {nwopeativeemperntre cone gesty reduces postopera rb f temperature during ‘Monitoring during anaesthesia Accurste monitoring of sl fnctons ding stein (Box 44 stow reddy inal paso the wor. Sas shoul not be rtd where prope iis for meting ad ey ae eee ee ‘meters omen ore ngrtny gen comcention eh Seaaton by ple execpt carbon die reson smearement, blood prmire sad che sleercstingram. For ‘hajr aunry, favsve ect lrg of the eedaion ‘wes a eee ane FEST Pl rb swighed agate publ dangers of placing a amen ot Peroperative monitoring sexo megs hice olmtie 1 opts tb segs eo) carters |CHAPTER ANAESTHESIA AND FADE MAWAGEMEN nach In the USA, slometry ding arses regal Recovery from general anaesthesi wat stk be eal aval ee seco pate on fo ced inti with velar supp spn ak whe resprstey ates or obstuct The common cues of fare 9 + barton af the awe + Iyponinor peri oy ex ‘ ncuromuecla beac : hora fom pleural damage ding anscthesia Management of blood pressure in the recovery room rythm ot hyporemnia, Managerene by eeaunent ofthe Hypertension "Hyperion ts common postopera wal of fiitand i asccined with pepe vacconste fn fee col shiv ot pe-exitng ypetenave dives Figpenensonpedopowes to sesbral nd myer i yes active ranagerc ft prot i the presence fa {Gente pat cle wblingul pine nd sravencus beta Fesine ae we, Rarely catol ath move power General anaesthesia for day-ease surgery Dayrese management scaly scours fr abou 4% of pose sen demanding hig eat anseatosia sri civ wales Steps (Bos 43). Teal sclectin of patents iste with ard cess ¢ dae the naturel the propel urge the wala titel ec: nd transport heme dam vel Knrlled on-delesting chro: eases do ox pec dasugery but» age pero of postoperative supervision ay be rested blir he pin echo ‘Gener anesthesia combi with regional anaesthesia or inguinal hemi epi cen tas Ansestheck that pom tani every sch a propo severe and dese, ar (Sod, Drag wth rokoged depressant ental acon, neludng freedcane drag, ae sole and where publ, alge {foul et peripherally ore of soreduation cel cing ‘When possbl paints are managed witha laryngeal mask or ce nul hough endotracheal inubaon tthe neces airway ‘tel forma day-case rode suchas ol oe ose rd thar (ENT ster and is yenetalhunconpeted "With che pace eave Wola fom immediate medic serio ad ale, postopera mst be cantly falbed (0 the procedie,especaly inthe ce of the moe peinfl pccshaes Gch as hela “pi, hacnuidectom fu sao enscecto), for whieh stoge anaes ond ‘reba should be provided. Repl pstopertive dog recommended to avo beakough pan as may psc cer floving th lil tence focal onwetete Day-case surgery 1 fulpegoetar si ‘ea eile ie reds 2 toate * Cauca Thr a no shoe General anaesthesia and cerdiopulmonary bypass ‘Th echnigue i dscused in Chae 52 “Amaethece agents a en exanot he deiveedo the c alain through the lange en eh ange ae ype, 0 al ‘kp are sven cay tu win onto the Hood we t es through the cypeaston LOCAL ANAESTHESIA Choice fa eal anaesthetic technique depends up fei ‘fr a particular procure and te patients wlinanes and ‘Day to eoperate, a wel the agen and sneer et Greace, Lol ansehen may be te rlble and tata Inelod be soae mance sera procedures tha do not rat (eral anaes Box 4.8). One othe ra vantages ithe ition of pin eliint he postoperative pers cher By ‘rg dap ath pene drt steno by ater Inglarher al snueheteincremert in cee However local anaesthesia notifies may be con- tented lle lal inti, Erdal nd natal asoosthesa ile smpetie Hodes, wich may soe soliton and stern yptenson al may conker eter Inpertve ik dan crea managed general amet. Complications may be lel sich nection or haemstom, or sstemic If overdosage ce ectentl inteaasclr ineeson ‘esd tne Blood level, The le ay mania depres ‘onscaus level, convulions andr cade atest (party Fupenein) acd may he hetled by creme paresthesia en ligh-henes, Alton of adrenaline oth cal anaes the solution nerene the ak of ena: anythin ected Ww secKenal itrvacalr injection. Prone overdose ‘oust eethernaglbinaenia, Recenyinrcced loa ancy thes such as opiacin ad lac bipecaine Cline wo Inve enhanced wary roles “Adio f arene (commonly :200000 1125090 on cura) tothe eal aaesthee wlasn het ots and felon the darsion of action nd permits ih dee fds, { be tual as ie more slowly aber fen he cheaton, ‘ArealneshoulSnothewdnypertenive patent inp ‘aking ther moncamine onde biter ee eycle ange ‘Sordhupyasitscardvaclar eects pentinted Kou nt ke won endarterl catins where there no clr lion, sich finger al eso aon the realty. “The potenti ik of Me-iveateningseqclse mands the slay of appropri shld personnel and resco ‘augment, nce oxygen Tea naethesspractd “The fallow exempt sce pp dove Um sua for a TO-kgadele + Ligweain 200g (10 lof 28) ce gncaine wit aes ine 1200000) 50 mg Lgncane 1 flee for mane sersory blk, and addon of atenaline ens restr Sokime tobe wed Thus, up 4030 af lgvocine wth ‘aenain (7200000) can einfleated ito te see + Bigicave 1500 (Om of 058). Addn of ales wonkdenhanoe theses ih hve Bupoaines more Candee han leneaine Bypiacalne 029% sft fo ferry blck aan modrce sinus, Bupa mae cer be inject int ve aa solace fee we nner nal rashes Bers Hoek, con tony wed roe ach seduction of Ces tre tndcapal ume! dconpresce), Dupcane banging ‘ug wth dustin often of about ts Recent ‘col the neve tupvscsine seeone ce to have fnmeovedcarovasculr typo + Rapnacaie 25 ng 30m of075%). Aso a seen ao, ropiactne cuted to have an npoved idan ‘sfery protean ta provide rebel rete vemoy th tot Hacke + Prfocaine C0 mg 40a of 18). The presence ef Hue-beowe stan colou neat mthaerngabn toxic. teal esthetic techniques * ton = pal Pass faba 1 meen the shia! Tool Terre specs een ‘age Ca Bar| 8 eae me a tea ‘Sha ley | Eee eget ‘rime or ” MENT CHAPTER 4 | ANAESTHESIA AND PAIN MANAG:CHAPTER 4 | ANAESTHESIA AND PAIN MANAGEMENT AWAESTHESIA AND TALK MANAGEMENT ‘Topical anaesthesic “Topeal annette agents are wed on the skin the urethra ‘com, asl mucosa the corner. The agen wed are tnethocsine, bee wll bored by mucosa, cocnne for [senmcinstiv propetie,lgnocie ad peloeine. A To Chine aad piocane evocic mature (EMLA eres) 1 comme non wed thes of ure foe venepunct. Local infiltration “This she method enn omtony ae by Bo spent and sans enor nese to are the pen preoperatively fries the provedne cies a hgh rake of bnovacuar of itethecalihjeton, Intron offal anaestetc dog may be ing ox arund 9 wound, ea wt parla atenon tome ronstomial terse and undaresConaindications att Teel inecoon and eloig dkrdee Noe oly does leis th pend the nto but Toa ances evs ae ine tee tn condtions of sity 8 prodoeed by infection. Loca Inflrtion inthe prseree of cloting dorder may rs in cmorage or may pduce haematoma, which I poteniay fain the sey, a mr ocr dental sure Regional anaesthesia (without general anaesthesia) Region anacthes involves blockale of major nerve urls thor Innere these of surgery Ue wally peso by 29 Suesthest wih the nsw: However, oth inate (Gina) a epidural rsesthenshoul Be conducted ony by ‘Speinced practioner sng il svepi techniques Teisin any cise requted that a doctor oder than the operator is poset continu monitor amd susie the patent if feces eepinal ancetcers Ea general anaestesta may be fecesry Compensation for an nadequnt resol Hock by fesny sedation cures gat danger nladngatrayobsrccion fn pulmonary natin of gas conten These ay ea 0 tnteconsed bya sage banded operate All ptens chou be Starved pesperatvely un monitored. In emergency suger, ‘een anoetbees cares the advantage of preservation of the protective lange e-es patel eerpeney obstetric actos fr whch pl or pial elon rachis Smnon the meted ef hos, The redaction i blo pes Sich apna sad ep anne can be advantageous in ‘ecg tranperative Hod but onl the sorgeon ties to schive hacrtse lr to wound closure and restrain of oma ood! pressure ‘When sation fas bor wha for surgery under ceil amoestheriy retory cerstion may occ postoperatively then the saga stil hay easel. Onyen stration mes Slrement by pub one segue for monitoring ding teponal sachs Reyna anasthess bad ery clear advange over ener anaesthesia wher gone anaes ages cate high morbid ityand moray resin contemporary pect, this advange isle pronounced or even revered. Honever rol anaesthe= ‘maybe advange for patents who ave deiliating resp ‘auoy eas Inconliovanclr das, general amestesta with Sart of the clcaton and pulnooay vention fen Inu alvantogeous thas feng hyfenson and tachyarchyt nas cacti cheese here dee and tala ang, ‘uch may occur with enal anaesthesia: Reloal anaesthesia does provide excelent anaes ine the pestoptasive period Fed the ed fcc acting snalpstc agent "The lets indications for pn an depderal anaesthesia te in elotewe practice sane the mother fom the ik of ple onary spin bee te fill ac wally presenti Thur und als tose the newborn fe the depres ction tthe rene anger aed nage dup, General and regionel anaesthesia: combined ‘Combining the two meth of nats in well-balanced me Stree pent orceve ight pneral anaesthetic and towed advantage of god potenti orale, As fst the inflation of sabia woud wis cal anaes thetic agent wl fate enfrtabe breathing inthe recovery Regional local anaesthetic techniques Spinal less and nor ere local anesthetic locke maybe ‘rmloqed lone oi combination withsedaton o gener ate {hes mou conumon ed fre absninal thoracic gery and obstee ales and sme tisimperrv tha accord med proctioney and not the sual opto egonstefrsupetison ard mowing a the pen ding the ocd Frepertive poi proortion elective regional amas theta nclade hat seule for pen sachs wih xpi tion eth oel anasto pees. Tn an emergency is ‘Str to oe royal anostiain onan unsaved pent ther {hon gent anseaes, the rk apation of ase cane {ents b much reficedlthouch no absent Some forms fepal anoethra wich fng-cin, dru, suc eid ‘piaclne result prolonged moor black and may be nse the the patent expected robe an abut dy case. "The recent intrdaced sana low-molecule weight heparin (LMWH) fc prophase deep venous thromboss longer ting thas pain and ape to hae incense the ‘akin arnt, Epa asp injects (and alaeter itn or etoval) should only Be performed least 12 hous fer a LMWH dose, a the exe EMWH dove should te dyed a ast 2 hours, The LMWH doves must theeore Be tied apport. Ax with many peopeative management tues, opal sare depends upon eve lon betwen mae ‘het and sno "lectocantogeny, pulse oxmety anal Mood peste mete surements shoul be performed ring regional anacses ‘Srygen by face mak should Be gwen alo slated patents during. ‘common local anaesthetic techniques Tanke patos the nerve blocks must provide comprehen ‘umes tcphoot the sural el The falling eld osks recommonly wed + Brahe Bock for ugey a dear oe hand {ld Nock for inguinal Berta eae The Hoyo tal fsingunal nerves ae Blocked inmeditely nce {dal othe areror supe dac spine The gentler err & ited the midiaguial point anal at the ub taberle fs lg volume foal anaesthetic we The pttonol sac ean be anasyeted Reloe the nes,uc cre mut be taken to ao ng tow Lace anaes thee with 1200 000 adrenal poor the dao of secon ad rades tot ty trod vacation. The ne ofthe ak Inc had lee wth the + Reglnal Mock ofthe ankle This canbe we or sngey on the tos and minor rer of heft Intravenous regional anaesthesia ‘The arm co be operated is exsanguated by elevation andor fonoreson, and then holed fromthe general creslaton by ‘heapplcaton of ourniget late oa resure wellinexcnt ee zl aera posure. The weno str then il Wich hal anaesteieagemt inject vin 9 previously paced Irweling venous earmula The day dilfses fom the Non Stem atthe aoves to produce a efctive Hock, The a frome stable for this procedure (Bers lock) than the lee enue the age value of rue fr the ater at ea Ie o voit The torque mat ely be define esl {inte time ar eyed (st eme 2 mre) tallow bee ta hl venous da ee fills alee bee msl back Ino the general crcuation Candie ses o cnvulns ty srl cceur if he wuniquce is tecklnallyelese bee the ras fed particlarty ened wth bopeacnne hich was been banned fom inhi proce fer boc eons et sf dens and desl to eters onthe hear Prlacine 5% Upto 30m recommended thems agent fo eA bone searate eed pacts shel siperse the Heck rd ‘onor the patient whe the srgcon operates Intrathecal anoesthesia. Spl anaebeaa in he awake rte ie wf oem fens seri the ple cr lower ihe perc slo of ae ‘ese are injec ssn shot ft the creep had ‘o poce a mpl mene Hock, lly hla 5 te ‘Atoncni ympatherc oclade resin byputeskn, ce ting poe tavenons fund ing ond ration of vasocon- seco drape I the pear ali lle to ser os Tigh seers hypotension and venta re oct Th ct lite the ae opin naethosaosgey flow he ental lewlof TiO esopentive headache, dve to cshospinal dil Kakage throth he dal pefetion fr nowodays much ess cmon, a ‘rule the suricion of moe tees (very ne wth ‘ound ur penelpoie ip and sie-apscre), whi te despa ‘spt rather han cut he da es ‘Sina ammethesamach wel orCacstan sto, gos ‘ccm ad lowe mb urge (A Cvsean section te pe Seon of delivering the fru an inion in the utes, usually hgh the abdominal wall) Ital pd drug se sed 0 Iroluce postoperative alpine Ha aca ek "sity depen, Epidural anaesthesia purl anaesthesia slower in onetthan neha nace stot has the advantage of emling lie devine and ace longa vs, aan ndwelig eather aye hed nthe ‘idralsoce. Ths epsral ane can prove go pl ‘et evtndg inthe postoperative pro. Ua een ‘common, netesating eatherristin ofthe Hace Epc ‘sachs ao ices yates Hocade but of dower Vine pain celiel (acute pois mesogement) ont a he resuking hypotension, which ay ab be air 0 ‘er fet that can be ws to advantage dag sarge tolcton of bl os, Ia wes soto of apa od ewer ropivacaine i chosen plural anesthe ean be ued 9 Prodce predominantly sensory Hock Sr alge fer oper tional or thocesugery. The current wend io combine ‘real slucions fll anesthe with pi gers uch athe Tp-sluble dumoyphin rental which pone analgesia by thei aecoa on pid ceptor i the pial con Howeve the erent cmplation of epidural opi nage delayed ee [ator ates fom rt pend and ental depen te 1524 hous afer the as ene. Hence, el niin of a Seiounes level and rept ite and the ft sn ftehy reve the pod wih irre nekwone or reuscate are pregites rural amerthsn ith bunineaine or ropivacaine) semains the stndard meth of anaesthesia dn abou ‘etervenional elven fn comtast with cal anaes age, «plural ood gens alone don sic yperse,sohe ‘epee for ations who ae bl, For this eto thet {tend tgaed thir ein toe but aloe dey wn nt pr hee alge adoqat or sual nerves, Couch epalural ansehen pedicel hy incon of oa ansethtc agent thrugh the serocccysa tan, tui ses ate wo suplemen yencal amestei an 6 provide tery eetiveponoperative pam lick This anakeaetechnigee ‘sme ined pen sae POSTOPERATIVE PAIN RELIEF (ACUTE PAIN (MANAGEMENT) (Optinal managemen of sete postoperative pi ies pln ng potent and staff eduction and tang tothe typeof Surgery athe ness ofthe nde patient. Eecve peop crate in ch has mero ri (Boe 47) sl be ‘Matera secording 0 protocol of nce stent ‘commend by the Wisk! Health Organon (eae [er Bor 48), Pints vary rest (op igh) in thi equrement oe analcss, even afer Hlentclsuicel pocedes. Under treatment rosin unaccptal eee of pin wth aches, Iypetemion, scons ad splinting ofthe ced pat Pan abominal and ons unde esc pt eal ing eo tachypnoes, sal rl volumes anal Iiton othe pation fm elev ccuphing aa mat. Th pie frees to chest infection, dyed mediation, ceep venous "ra, micle wasting ad peste te However analguic admisrcon above the peients resucent incene thers faders suc os nausea, tensling samlonce and dasnct of eatin cen sere anal fects ielang deposed consents ind ep ttn. Rona thi w ve an can be aved by vcore Ita dining flo by eration unl the pate combo able sagged feof opi ndaced cent ders ‘lion fave le ll woo soon to inhibin among ell fom prscebing and adminstrng aeguate doe of opis Inert vamaser desing ao lad delay adr ton ofthe ‘orl pe cmpneded By the noo of "Ata real of thse common deficiencies,» Jont Winking Pony ofthe The Royal Colleges of Anaentherbes sad Surgeons a CHAPTER 4 | ANAESTHESIA AND PAIN MANAGEMENTCHAPTER 4 | ANAESTHESIA AND PAIN MANAGEMENT ANAESTHESIA AND PAIN MANAGEMENT Benefits of effective postoperative pain relict 1 eyed ne ocd ating std may a wp ose 1 Psaltis ncty Nn su sense du Caliah = thn ps le oi) 1 acl omesiio ond ee \yasconven al ub! the ep afer Sager in 1980. Terewmmendel the eaatiment of acute pin teams ot Sr ‘ice comeing dial and noring petals, vo oversee the Insimentation of puelns for pect, including vowcine tevning of pin level andes of bork sea and patents In owl pace dhe USA, a rocent nto ave as ‘stable pin ho ih al sp eat mae be ely es red, an nae therapy must be acted y sal rte by ih scores "The Jat Woking Paty Repor lo encouraged weynead se of combined tetment (ened anced oe ‘ind lwleesi), competing kcal antethesa and now sera an inflammation dng toll Simple analgesic agents Following minor surgery and when the patient ale 0 et afer nor sre api and grscetamel ae often the only dass ects tocol pal Feat of metabo aide ad hep ‘oy and Reye syne in hie, has made prseetatol prefer ro pan in the younger age ep Parcel ‘rinse eeommenda ons yy ae and efctv ana {sc Pareto mec now Eruwe to Bethe inhib thn of eyl-enygenare (CK) 3 inthe ental neous ester, Inubece esate acto spp we cmblton with ules ating diferent ter Cane phoohate the al ese favoured sternal urgeybeease oes nat have poe esprtary Sopa flee st must Hever be gen intravenous set cases fund Iypoteson on inaveneus Now terial ani-iflaaiory anagee drags (NSAIDS) are etl the main nage for moderate pa, o a vane theta with ool or rere pine These action, con-spece ‘Seloaystore inhibin raul insides due to COX'L isto, inlaing leo ani eyoprerecson, renal home nth and platelet” fneton, Rectal and Incavenous ABckfenacy ce sntavenses ketorlae te common ed NSAIDs in the perpeatice pao. Palents wth a tendency i Dash as | 8.97 ara abi ema a (to che to pepe eration may need cover wth proton, pup inubtors or moped dung analgesic teatment with ance flame "The recently eced spectic CON inborn nary anaes ae beter flersted thas NSAIDs any the proper per dy have the parr aantage of mae thie pel neon, Stronger onalgesics fective posopertve pin clef encourge eaty melas fh hospital dha Canned with deat aralgess, gu ler neamosclar morphine nection can owe tive pox operative pa ri che tary of seal patients. Nowe Shara meds of in managers wh parca aden: apes) when se fr manag tpn of rae an, hn bon acct Patient-controled analgesia Parents my selFadminster po analgesia by avenous ice tion or epidural The pan sane ive a bar doe of ‘hag by pressing corel button ona main, the fetons of rich have bon eel by che medal staf The stent, {oency and oa Se of din ten ine ar allied by “Spr Tis meth pp with pate athey se able ‘cn thelr pin and delay kn admiration of does ae vada Local anesthetic blocks Leal ammestesc Hacks prove excl shore-erm anaes ‘teh airaon gues skill apd there asl alse fate Continuous catheter techniques provide prkonged ‘sift re general nl arreopte f-patkets Other methods Spec athods of pin rele may be usa under cos per + Coins all anaes wih opiate oF Leal anes thetic drs Spa a gery very flor peop peso Strgery bt, pny thot adinstreon regan sll ad thas wa fs liad hy concerns oer severe sspears Sepresion + Ghnimunt bvvenns oF scans isis of oped mls cary the tk of overdoage nthe more sone ent hut ane safe the conten of contin mon fore high-dopendency rvicoment and cartel dose Ut CHRONIC PAIN MANAGEMENT aul prac, the pant with chronic pln may resent treatment of the came fog panereatts ce Ive concomitant Fooly. Surgery hl nay have ben dhe cause ofthe ow {Tce renotom, ae ace pain ay pet's to chic pat “Thor a developing Debt tht sadequate wcatmen of Cte uy make this more ‘Chon, incactable pain may he of wallgnant 0 non-mai san in at of eer pes + Nese pai. Nosieptive pain may sok om sc Tene doce reancersthacnewancous sceProlongalchaen orale roe rein ens kaon of peep noesptom alae esi in the ‘eral nervous stem, dg soemxgerated repenssin the oval han ofthe spl cor The waned aes hyper: Sis and recedes (lls) has been strut Inerecd ananiion of alee pin ips comet gon thisspnl cord dame plat + Nant r nay) pu. Tis deo dsinction peripheral or cena nerves (echaing the ‘Bhylopeal fu due to noxious stinalation of the nee termina) “Neurpethlc pun ictal Temaing, shoving re ting andy be aocated wih lly rambo tnd minted thermal sesaion Tee pods repo is Examples ioelade tsomial nels mettle Sd porcherpeve ad dhe newopaiy Moneaminers, Teele antepeesant and aeionvolsne dri ne the ‘mas of tees + Bicone ft Pca tor play a retro lsc, role nan come pin syuenes Whatever the pinay Cause may have ben depres iinet and hone alt tmapexcetate cach oer ‘Malignant disease The ereuemene fain of malgnne og dies ott of pain fa benign ate, which may e the more dificult cvereome Drag shoul pera be taken y owt, the potent mu te regu renoned to enue hata eas a se the dneae proce canes In the cae of ntl pin, sh undehing principle of rretmene fo eneoumge independ of the pent and an scve Ife dete the syapom Thy nin guide tothe macy nosnent of cancer pain i the Wrld Heath Onision [le (now int second edo) sich ports chic levels 1 reent The “pain stele aches the flowing + fist ung: single suieses ~ apn, pracetaol, non steroidal atnammatory agents cyte antidepres ‘or andconvulene dg Scand eng heed sents odin, ama ‘rdexacpropontene: + ch ung eng os ~ morphine (etidine witha fram second edt), al pat analgesia neesary von the es ome nal {gsi agents no lnge contol pam on movement, or eral the acne dep eather he paaen nay develop a icon paes wualy ot joted n malian dee (Oral marine can he prescribed in shoreacig gd oF tube form ad sould be administer ely every 4 hous val an adequate de of dru ae fen tated 0 conto the foun over 24 hour. Once di eats, the dl se cn Feed sgto exo separate aminarations of enter: Sted, slowzelewe morphine tablex (MST morphing) every 12h. Allinalsboreaesng expine can then be ined to cover epider of “rake pi Nasa es poem cy in the ase of mrpine teament and mayne to Be ‘cooled hy antiemetic agent for example. Ralopede, rcthotinepeine, metoopramiie or ondanston. Naa doer not all” per, but cneition i equenty a enaent complication, euurng mar prevention by baat Infusion of subcutaneous, inravenous, Intrathecal or epidural oplare drugs “The infin of pat nessa) ia paren enable to rake coral drug, Sobcatanens neon of dxmorpie single and ‘fc to aimiaser pido takasons of disomhine con te tied on mle patents eth an external pun. Intec Infos ate prone to nection, bt ional srw with pamge propamed by exenal computer ae bing wed ot Kinwern strate! anal. Intravenous nace agents sity then be recved for ocate criss such mr pathologie ‘tre, ‘Neurolytc techniques in cancer pain ‘Thee should ony be sed theif expectancy nite and he agonist The wef proces ae 1 Subcosal pena injecton fa ih metas 2 Coxhoe plenus nett Hock with alcool pin of pan ‘ead gute or put cancer Image neste conta ‘sec 3 Tnuathecl newt injeion of byperbre pho: Tis technique WF uefl only i fit. peeutnecs fordotomy ae not aval, a ica damage mote pth 4 ercutaneou anteater condtomy dvds te spinthal tie ascending pin pathway fi a highly efecave rch: ‘ge fe expetnced band wletvely lian pain and temperature senton ina specie ined ne Alernative sates ieades 1 “The dole of nity harness ih Inmoefn nour nl efece farrlgg Calne pu of cel mets ted fry Stoney 2 Raley coat ma beech the fof in ineasare dace 3 Ratan dng sch nck omic eb elem tanto nad cmc are ein SSmpton contol Tce morn ncn ‘idtccnaly cae ea od ce hein Sten Pain control in benign disease Sarl patents may have persistent pin fom aware of di tii, thing hrs nmetey ewe, Trent x Son, degenertive Fone or jt diese, neve ny aad Smpathee drtony. Chromic pin may elt rm pest ‘ett ofthe ociepive pwns in the cnt nervous tne inaling mechs rch wponteacos fring of pat nal at N-setby-anpurate esos in the exanding eth ways, Suc civ is poor sponte to opts; euroablatse Surgery unico produce pongo benef ard my make the pte were ‘Asis el Known, amgration of Lin may ean phantom lin pate Welbod being fare nese the il mos pln befre surgery, Contato eal anaes Uocade feral or brachial pleas), ease More oper tn and cena postopera far ae days, + Eelieved to tflsctively educe theese pnt pi fn CHAPTER 4 | ANAESTHESIA AND PAIN MANAGEMENT4 | ANAESTHESIA AND PAIN MANAGEMENT CHAPTER 4 WAESTAESIA AMD PAIR MANAGEMENT The fling are ernment for crenie pan of benin Leal euch nd som jects. These ean be efotve ‘cud a ned ere an they rece the eee of an tant ain trnsniocn th consequent muscle spas, Eau njcthow ae wed forthe psf nerve oo ‘on aaciaed weh minor de pegs. Tas weacmene Should be in sociation wth atv patra to po ‘pate moby. [Now simain proces. Acupuncture, transcutaneous ‘ee stilton andthe nega! pation of ‘Jona coun cts im to nce endorphin poe tio i de ental nevus ster aleing pin earns Nore destin, Decanpression ofthe wien nerve 2 crnotomy i sow peed fe geminal nel, father tha prcutnncotscongbton of the ign thon, in pare wh ref or canken Teton of a dercie ot empath neous yee azn. Even ino au and suger fen of ib) ean frovok chronic busing pai, topic cans tnd estan de, Thayne as een atte to reette sympathetic aber acti inducing acon” fineton and ahnornd noccepeve — anamieson Managment may incl A est opens wo ssenie eairenegc Heckade wing Intravenous phentolamine bb eal anaes ington of lle ganlion oar spt cai © intmvenous elem sympathee Hocknle using ‘rencthadine, wader eoumiguet, cow conrovere Sr cominent eidene to coi ficacy as. not ‘Shere anducme etertavesbundne thse Percancoas cheer spthectomy wth phenol ‘under morphic conte prt by bth san ad wcsthen for elit cat pl In adanced ohne Ainge of the Leg I can ali. promote che healing of Schacter by improving perierHood ow 5) Drugs av cone non-maiet pan. ractamol andthe [NSAIDs ae the masta of museuoskdtl pin rearment, but NSAIDw are handicapped by gsteieestinal ntaleanee nd peptic eeaten. These cary sunicane eves of non mplance, eamtrandeations and roti Specie (COX? inion, with peeservaton protective COX-1 fein, prmber co improve tletlty an my Ia NSAID remem. The whe annepresane drags and Anvcnvulent agents a often us dinning the Taino ere inary although e-efces ean rove cull Some and vedace comple. In pets wth mor svete Sint dcilsting ‘owsmligaant clonic pln, opid thalgede dagr are more commonly pes nce th ‘Ment of domelewse oral preparation of merphine std “nyendhne and tamcatanes fates deleting fea tn buprenorphine, Combination of digs cite pote we: fale achieve optimum ciency wah ana sleet, Jn the management of con pain of kez case aul ciliary aprrcocny a eamof cla ting sta work ing with, peyhelogis, nstherpiss ad ceeuptional ‘erp cam fen achieve much ore beet thn she we of Pre ds To a wh ch ein ho ft repond to cinwentonl means, ala anssenent po: fram’ have teen devsed comrsing 2 moldscpinary Approach of pain specials, aycholost, ayers and ‘ception herp. They help 2 urbe of patents cope ‘tthe pin and ahve hier quay fie FURTHER READING Rol, Nal) (988) Manas of Ace a Ce Ra 4 Tok, Lene ‘nt Led Arno, EN, Ge) (190) fms nd Pe pn Anncha, Chal iron, EiCHAPTER ACUTE LIFE SUPPORT AND CRITICAL CARE: FLUID, ELECTROLYTE AND ACID-BASE BALANCE AND BLOOD TRANSFUSION, LEARNING OBJECTIVES To appreciate the critical role of uid bolance in surgery ‘To understond ocié—base balance in relation to surgery To manage blood lass ond restoration of blood volume Tourdesond sk’ on is menogement ‘Te be able to resuscitate « hypovelaemic petient ‘nlm espns syne FLUID BALANCE Fluid intake Fi ita sds rm two sores (1) exons and (2) cnogenon. Exe water elther drunk origi info (Te 1), ‘The gute vay win wide Kit tut vera 2-3 ie pe 24 hous f which neta contin is od Ting into consleackn thie body weak, the water sepia of tants and eho ae lately rete a Sh falls Because of (1) the yer sure aes po ni of Indy weight 2) thee greater metalic ay te to prow 1.3) dhecomparativey por concentasing aby ofthe ina weekly End water ie eleaned dig the oxidation of ingested forthe amoune nora es han SOD! per 24 hows Howeres during arrtin the mount is supplemented by ote eae om the reo obo sae Fluid output otras fo the dy by ou tes 1) Vin the as Abo 400e of water xen expe aie ery 24 hour In ey sempre, ad when the rest. tony te incre the os eoresgodly geste hi ai apples othe pane whee trachea net Toll 1 org dai wor bln oe wey aia onprte sini) inka ‘oi Se 130 a Yow oni 0 ol Aselashonsinad ig 00 Newtemeson 0 ol Fae ts “To opr mule organ failure syndrome, mule sysems organ faire, multiple gon dystuncon syndrome od systemic 2 ates. When he bdybecomes oprhctedehee ile esplaton bt thous, Insble esplaon walays Proved, Cancou fd ks vanes ain ne en Aconlance with the emerge temperate acd fui ‘maculata andbedytmprcie a emrce dinate the average les betwee Oa TOD lpr 24 as. 5 Infaas: Betacen 60 and L50r ofwater ot ty toute dfn daboe, cham rey ued 4 nine, The oar of une under he cool mle indunoe, uh Hood volume and oro ad nervoue Inlunce, among whch the ane hone pags 2 ajo vole conoling tony of te bly fas» Kineton that peroens by sting the tebsepioned waters thera aul ths yang the anon exceadafte the reaueenes of theft dee rote hve teen mt. The Pema unary ouput eappenimaely 1500 ot 24 hours an, pode the kidneys are hel, the spec wai of the rine bears dierent othe Fine, A mi mur nay utp fapponimatel 0 lpr 24 rs required w excrete thee products of prtelt metab, Water depletion Pare ter dpeton usu eto dined ine, This may sul fam lck of aval o difculy ce nb sallow cause of psf condo of he mouth and shares or sloeruccon fo the sesophag. Exton and pte of he areal miscls wl pradce a sin peru Pre mater pletion may abo follow ieremc Ise fom te nes ater teachostm This may be ch 500 i exces of he noel sense las. Aer racheosomy, humidicaton of he Ines a import preventive messi (Clinical features ‘The main symptoms ae weakest and inteee thi. The winary utp diminihed andy pce gravid. The cuarrers |“% CHAPTER 5 [ACUTE LIFE SUPPORT AND CRITICAL CARE ACUTE LIFE SUPPORT AND CRITICAL CARE lncrmed scram osmos presure causes water to eae the calls (insert dyetoo} and thus delay the onset of overt coord bypclcr ue belo), Water intoxication ‘Water ntoiaton cin ceurwhen excetve oun of wate of lomeanium or ypotnse stone are tan ot en by 99) route. The commonest case om sri ward the overpe ‘ening of intavenou 5% loess suns to postoperative patents. Caorectal wah with plan wate sted fain, ‘hn tral Bowel wash ahmagh peor wo clone surgery have sl reed in wnte inexeaton. Aaj component ofthe TURD (ansretrl eset of the pest) syone tthe voter sna ced by eaceive uptake of water (ond hein) fom rption a ‘Shr water ieoeason can ecco the boy retains water In emer to pln aden This can be ses in the sy Ake of appropite atvaiehoemne (ADH) secret {SIADH), which mot commonly assisted ith lng cond tone sch lobar peumora empyema anon eel acho ‘fbonchus wel bea ne Clinical feotures “These include dowsnes weakest and emeines, conven an con. Noten an voting clear fs recommen, au, with che nomile excep of patents veh SIADH, those lscied usualy pose a considenble amount of dite wine Laon nestgtione my show fling haestoent, en solu and aber lcrlye concentrations Treatment “The intake of wate having xen stopped the best cours i water retin: the patent fro improve) nse toa neve ‘eo hl- dependency unt wil be neceway fr more save ‘nonitringandconolled snips de andleta. ‘The adminsation ofirees or hypertoni saline oul oe be Uneraen wiehoutreseritin, a xpd changer serum Sodium concentration may ese n terol desjlnatin sd Sal outcome ELECTROLYTE BALANCE ‘When ice salts are i sohtion a nthe exter oe sonal of he boy they sce om. ons ae ewok (cans which ate ectroponie and(2) ar, Sthich are eletroneptive Colcivey hase are te lectrlts “The mos accurate way of desrbing the chemical concen thon, resets and otc omer af theses ia Sl st illmols per lige fmm F). The eations ila soir, Tots, clean and magne the anon include coe Floshat, biarboate ane alphate. The dtibton th sas ‘nigh dhe Ea compares fhe body conus the passage of Woter hgh the cll walls aint ad-bse equi its excntal to optine oth sodas bance (Bow 51) and eens bance (oe 5.2) nepal pores and know the ‘ones imbulence fee let Sodium balance Sd the principal eatin conten ofthe excell Hu The stl bay sli amount to apposite 8000 aa of which 496 dhe extracel fl 9% fh the irae ued il done 1 iy eon his iit eo pet sg Potassiom belance vu ie = eeu ass se Tone ce sas ‘etesiomsiiskan pty dee fu anc the rmaning 47% 6 bone. The wu housed one mers spec comment alte mre than half scam ily nave an vquites sid for sain he remainder ster soluble nd exchangeble, Thus the sale storehouse ‘fsa ely co compensate aba som he Boy. The ‘hyn of sadn ncnstane On srrae ti Lmal ig Sodium cherie of SOO mt of onc 09% sine soliton. A ‘spivlen amount sexteted dalla inthe wrne bat some inthe ces The sin persion coral i neaBes hme ser in pero ot aclated to opt het, longed poe Fi eating aul ina conde ee four chs [Sana (Ni), I ater soe geno counterbalance the fluid Tvs, sees soda depletion can occur orn ecesie sweating ice ao Chapter 67). Control by adrenal corticoids ‘The output of sai, severed by dhe vation in the aviiy set which he renal als Fels scum from he lame lar filtrate and the amoune of slim crete by the seit inde, under dhe contol of heated oral herons the most rowed conservator of sou being aldosterone ‘When the areal lads have Ben destojed by disease or ext pd theres ar baled ow of wen nthe wine. ‘The sodium excretion shutdown of Following eaumarsry, chore la varie period of rede ‘accion of solu For thi tease, It nay be inavile « ‘incr ge qt of ron (09%) saline slant Sr operation. The pid of saum excretion shutdown ca la fee gpto hour and isd to ceased abenocatal et ‘Sodium depletion (synonym: yponatraemio) ‘The muntfequent cause of soln depson seen in sui practice station ofthe sal teste, wth it pi os tian ee an elect ane Sind een, beter hy vomiting or apation. Duodenal ‘orally pancreatic and high intestilexteral fists “ap eh | NS bn ee ht | ‘atv Orm aber Seated erga