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By: M. Falk, M.B.A., M.B.B.S., M.H.S.

Medical Instructor, Alpert Medical School at Brown University

While the triad of anaesthesia (hypnosis earliest signs diabetes buy genuine duetact on-line, analgesia diabetes type 2 kaneel duetact 16mg with mastercard, and muscle relaxation) remains the fundamental principle behind general anaesthesia (GA) for surgery managing diabetes 911 buy duetact american express, the role of the anaesthetist has expanded to encompass not only the provision of ideal operating conditions for surgery diabetes mellitus and neuropathy purchase duetact overnight delivery, but also intensive care, resuscitation, alleviation of acute and chronic pain, obstetric anaesthesia, and anaesthesia for diagnostic procedures. A detailed knowledge of general medicine, physiology, pharmacology, the physical properties of gases, and the workings of the vast array of anaesthetic equipment are essential in order to practise well. We emphasize that this short chapter is no substitute for a specialist text or for experience on the ward and in theatre or clinic. We thank Dr Melanie Osborne, our Specialist Reader, and Dillon Horth, our Junior Reader, for their help with this chapter. What to do about preoperative medication Ask about allergy to any drug, antiseptic, adhesive bandage, & latex. Suxamethonium serum K+ by ~1mmol/L, and can lead to ventricular arrhythmias in the fully digitalized. Check the INR, if needed switch warfarin to heparin preoperatively, leaving sufficient time for the INR to drop to < 2 before surgery. It is a controversial area so involve the interventional cardiologist (needed if stent thrombosis occurs), surgeon, and anaethesist if urgent non-cardiac surgery is needed. If possible, defer surgery for at least 6 weeks after bare metal stents and 6 months after drug-eluting stents. Stop alpha-blockers as they can cause floppy iris syndrome making cataract surgery challenging. It requires an understanding of the proposed surgery and the particular anaesthetic techniques to suit both the patient and surgeon. Assess car- MI or IHD diovascular and respiratory systems, exercise toler- Asthma/COPD Hypertension ance, existing illnesses, drug therapy, & allergies. Does the patient have any spe- GI reflux or vomiting Past anaesthesia/ cific worries The ward doctor assists with a good history and examination, but should not be responsible for consent1 (OHCM p570), though can discuss postoperative complications-both general (OHCM p578) and specific (OHCM p582). Tests Be guided by age, history, examination, proposed surgery, finding the safe balance between too many investigations and too few. Be guided by NICE, which grades the surgery, from grade 1 (eg abscess drainage) to grade 4 (complex+) and beyond: cardiovascular and neurosurgery. Other issues: Perioperative antibiotics (OHCM p572) Bowel prep (OHCM p572) Frozen section (tell pathology) Post-op physio. Ensure he believes your facts and can retain pros and cons long enough to inform his decision. A patient may complain if: He is unaware of what will happen He has not been offered all options He was sedated at the time of consent He changed his mind He was not told a treatment was experimental A 2nd opinion has been denied Details of prognosis were glossed over. Anaesthesia Risk factors associated with perioperative morbidity 5 Age: the risk of dying doubles every 7 years from the age of 10. When functional capacity is high, the prognosis is excellent, even in the presence of other risk factors. A functional capacity of < 4 METs has been associated with poorer outcomes in thoracic surgery, although it has less predictive power with non-cardiac surgery. Angina (without MI) and transient ischaemic attacks increase risk to a lesser degree. Britain & Ireland 2010 5 Great Pulmonary aspiration of even 30mL of gastric contents is associated with significant mortality and morbidity; minimize this risk by aiming for an empty stomach. Patient safety: the WHO Surgical Safety Checklist the WHO published their surgical checklist in 2008 and worldwide implementation has been associated with a reduction of postoperative complications and mortality. Anaesthesia 1 2 3 4 5 6 ASA = American Society of Anesthesiologists Normally healthy Mild systemic disease, but with no limitation of activity Severe systemic disease that limits activity; not incapacitating Incapacitating systemic disease which poses a threat to life Moribund. However, through increased Anti-emesis (see BOX) use of day surgery, newer short-acting agents of in- Antibiotics duction, and enhanced recovery programmes (see Anti-autonomic p630) the use of routine premedication is no longer clinically advocated. It is really only those patients with special requirements (such as a patient with autism) or particular phobias that would require anxiolytics. Timing: ~2h preop for oral drugs but this is difficult to plan on a busy surgical ward. Topical anaesthetic creams are frequently used: Tetracaine 4% (Ametop; apply 45min before inserting I VI) is more popular than EMLA, as it does not vasoconstrict. The presence of a parent and play therapist at induction is more powerful than any premedication8 and relaxing music may be as effective as anxiolytics in reducing anxiety. Major operations: 50mg hydrocortisone IV at induction, then repeat 3 times (8-hourly before restarting oral); ditto if adrenal insufficiency or adrenal surgery, or steroid therapy within last 3 months with over 10mg of prednisolone per day. Day surgery is becoming more common, accounting for approximately 70% of all surgery performed in the UK. Avoidance of a stressful preoperative night has helped mitigate the need for preoperative anxiolytics in the majority of patients. The most common reasons for admission after day surgery include post operative nausea and vomiting (PONV; p631), uncontrolled pain, and lack of social care at home. Common reasons for cancellation Insufficient ITU/ward beds, staff, theatre, time or other logistical problems. Anaesthesia Sedation Definition Sedation is a range of depressed conscious levels from relief of anxiety (minimal sedation) to general anaesthesia (see BOX).

Diseases

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It is hypothesized that there is abnormal regulation of blood vessels and extracellular matrix expression that produce tortuous abnormal blood vessels in the leptomeninges diabetes type 2 soap note purchase cheap duetact on-line, with sluggish blood flow that results in progressive ischemia to the underlying cortex19 diabetes insipidus zentralis generic duetact 17 mg mastercard. Calcification of the meningeal arteries and cortical and subcortical veins underlying the angioma is present diabetes usa order duetact 17 mg visa, as is laminar necrosis of the cortex (232) diabetes medications recalled cheap duetact master card. Neuronal loss and gliosis occur, with progression of the condition and recurrent thrombi due to venous stasis. Leptomeningeal angioma and cortical injury is more common in the occipital pole of the brain, but can involve the entire hemisphere. Postcontrast axial MRI of the brain, showing enhancement of temporal, parietal, and occipital gyri (arrows) in the left hemisphere, with some left cortical atrophy. Developmental delay is commonly appreciated after initially normal milestones in approximately twothirds of patients. Hemiparesis and hemiatrophy of the contralateral extremities are present in the majority of patients. Recurrent transient focal deficits occur, usually hemiparesis or visual deficits, that last for hours or days. The pace of problems seems to decrease after childhood, and adults with SW can be remarkably stable. This can usually be seen within the first year of life, but may not be easily visible initially. CT demonstrates calcification of the underlying cortex relatively early, usually within the first 2 years of life. Positron emission tomography (PET) imaging may be useful in demonstrating decreased metabolism in the affected areas. EEG, particularly prolonged recordings, are essential in characterizing seizures and detecting subtle subclinical activity. Diagnosis the diagnosis is usually straightforward in patients with all three characteristic features: facial angioma, leptomeningeal angioma, and the presence of glaucoma. However, in the first few months of life, the leptomeningeal angioma may be hard to detect and glaucoma can have a later onset. Some may only have the leptomeningeal angioma, so that repeat imaging of patients with recurrent focal seizures in infancy is important. Radiologic studies suggest that seizures are associated with ischemic injury to the cortex underlying the leptomeningeal angioma because of abnormal regulation of blood flow in these vessels. Glaucoma should be treated (with beta blockers, carbonic anhydrase inhibitors, or trabeculectomy). Educational assessment is useful to identify learning difficulties and provide appropriate support. The most severely affected patients are those with bilateral disease who are not good surgical candidates. Laser treatment of the face is effective in eliminating the facial angioma and usually begins in the second to third year of life. Prognosis Prognosis varies widely because the extent of the leptomeningeal angioma can vary significantly. The pace of the clinical course of SW seems to be faster in early childhood and often stabilizes thereafter. SW can present difficult problems and devastating complications in some patients; however, in others the course is much milder. Patients with seizure disorders can be seizure-free for many years with minimal deficits. In some patients, while intractable, seizures can also be quite mild and relatively infrequent. Half of patients graduate from secondary/high school and a significant percentage live independently. HHThis often complicated by ateriovenous malformations (AVMs) in the brain, lung, GI tract, and liver. Prevalence of HHThis variable: 1 in 1331 in Netherlands Antilles to 1 in 39,000 in northern England. While telangiectasias appear in childhood, the manifestations are primarily in adults. The genes for HHT encode proteins that modulate transforming growth factor (TGF)-b superfamily signaling in vascular endothelial cells. TGF-b modulates several processes of endothelial cells, including migration, proliferation, and adhesion, and the composition and organization of the extracellular matrix. Pulmonary and hepatic AVMs create a right-to-left shunt that may lead to cerebral hypoxia and polycythemia, and may allow the passage of emboli (thrombotic, septic) from the systemic venous circulation or right heart to the brain causing stroke and cerebral abscess. Telangiectases range from small, focal dilatations of post-capillary venules to large, markedly dilated and convoluted venules which extend through the entire dermis, have excessive layers of smooth muscle without elastic fibers, and often connect directly to dilated arterioles. Telangiectases are commonly found in skin, face, nares, tongue, oral mucosa, conjunctiva, trunk, and GI tract (234, 235). Spontaneous and recurrent nosebleeds are the most common and earliest manifestation, often in early childhood. Pulmonary and cerebral AVMs may be more common in HHT1, whereas hepatic vascular malformations may be more common in HHT2, but these differences are not substantial enough to influence screening. A rare form of HHT linked to a defect in the SMAD4 gene is associated with juvenile polyposis. Telangiectases these are bright red or violaceous, ranging in size from that of a pinhead to 3 mm.

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In developed countries there has been a steady reduc tion in mortality from stroke during the past 40 years; trends in developing countries are less certain diabetes insipidus blog trusted 17 mg duetact. The most plausible explanation for the reduction in mortality in western countries is a decline in stroke incidence due to improved control of stroke risk factors (especially high blood pressure and cigarette smoking) combined with a parallel improvement in living standards diabetes in dogs red eyes order duetact line. TIA Stroke Incident cases 274 2000 0 00 0 0 60 0 0 0 600 600 0 Recurrent First-ever Prevalent cases 25 700 Deaths (incident cases) Deaths (prevalent cases) 274 Epidemiology of ischemic stroke diabetes symptoms when sugar is low buy discount duetact. In a population of one million people blood sugar ranges for diabetics safe 17mg duetact, there are about 2000 new (incident) cases of ischemic stroke each year, of which 1400 (70%) are first-ever and 600 (30%) are recurrent, who are added to a pool of at least 12,000 prevalent survivors. Of the 2000 incident cases, about 600 (30%) are likely to die during the year, and 700 (35%) remain dependent. Of the 12,000 (or more) prevalent cases, about 1200 are likely to die during the year. Strokerelated disability was the sixth most common cause of reduced DALYs in 2002. The proportions of etiologic subtypes of ischemic stroke shown in the Tables also vary among populations of dif ferent ethnic groups and ages; for example, intracranial atherosclerosis is more common in Asians and Blacks than Caucasians, and embolism from the heart is more common in the very elderly and young (due to atrial fibrillation [AF] in the elderly, and congenital and rheu matic heart disease in the young)5. Cerebral infarction (ischemic stroke) Sites of cerebral infarction: Wedgeshaped cortical/subcortical infarcts in the cerebral and cerebellar hemispheres (275): usually due to large or branch artery occlusion by in-situ thrombosis or embolism from a proximal source in the heart, aortic arch, or extracranial carotid and vertebral arteries. Note the low-density area (infarct) runs along the border between the middle cerebral artery and anterior cerebral artery territory, and the border between the middle cerebral artery and posterior cerebral artery territory. Courtesy Professor BA Kakulas, Department of Neuropathology, Royal Perth Hospital. The most common diseases of the large cerebrovascu lar arteries are atherosclerosis and dissection. Atherosclerosis the major sites of large artery atherosclerosis are large and mediumsized arteries. Individuals with atheroma affecting one artery almost always have atheroma affecting several other arteries, either with or without clinical manifestations. Consequently, occlusion of a branch of the middle cerebral artery (MCA) is more likely to be due to embolism than local thrombosis on an atheromatous plaque. A band of fibrous tissue (the fibrous cap) separates the lipid core (the atheroma) from the lumen of the vessel. The main cause of atherosclerosis is prolonged exposure to causal risk factors, such as high blood pres sure, high blood lipids (lowdensity lipoprotein [LDL] cholesterol and apoB lipoprotein), high blood glucose (diabetes), and cigarette smoking in individuals geneti cally predisposed to form atheroma in response to these exposures. Hyperhomocysteinemia is an uncommon hereditary cause of atheroma, predisposing to it by injuring endo thelial cells and increasing smooth muscle proliferation. Reproduced with permission from Hankey GJ and Warlow CP [1994]; Transient ischaemic attacks of the brain and eye. Dissection is characterized by a tear in the intima or media, leading to bleeding within the arterial wall, which tracks or dissects longitudinally and circumferen tially between the intima and media, or media and adven titia, of the arterial wall. The dissection can tear through the intima allowing the partially coagulated intramural blood to enter the lumen of the artery. Thrombus can also form on the intimal flap or any subendothelial col lagen, and later embolize to the brain. Most carotid dissections occur at the base of the skull and extend prox imally (towards the bifurcation of the common carotid artery into the internal and external carotid arteries) and distally (towards the intracranial internal carotid artery (282); common carotid artery and intracranial carotid dissections are rare. Most vertebrobasilar dissections occur at the C2 level, possibly reflecting increased suscep tibility to mechanical torsion and stretch at this location. It is a rare connective tissue disorder inherited as an autosomaldominant trait, characterized mainly by arterial dissection, intracranial aneurysm, and the spon taneous rupture of large and mediumsized arteries, and a gravid uterus or intestines. The higher cir cumferential wall stress is probably a major risk factor for the dissection and rupture of fragile arterial tissue. The fragility of the arterial wall in mice with mutations affect ing type I and type III collagens has been attributed to a large decrease in the number of collagen type I fibrils in the aortic media and adventitia. Marfan syndrome is a connective tissue disorder inherited as an autosomaldominant trait and is charac terized by abnormalities involving the skeletal, ocular, and cardiovascular systems. It results from mutations in the gene encoding fibrillin1 (FBN1), leading to abnor malities in the assembly of elastic fibers. A clinical hall mark and the major cause of morbidity and premature death from this syndrome is aortic root dilatation and associated aortic regurgitation, dissection, and rupture. The exact mechanisms leading to dilatation are not fully understood, but steady and pulsatile stresses are probably important, leading to the mechanical fatigue and ultimate failure of abnormal elastic fibers to sustain physiologi cal pulsatile stress. Fibromuscular dysplasia (FMD) is a group of non atherosclerotic, noninflammatory arterial diseases that most commonly involve the carotid and renal arteries, and can be complicated by arterial dissection and intra cerebral aneurysms with a risk of subarachnoid or intra cerebral hemorrhage. Histologic classification discrimi nates three main subtypes, intimal, medial, and peri medial. Intimal FMD, is characterized by irregularly arranged mesenchymal cells within a loose matrix of sub endothelial connective tissue and a fragmented internal elastic lamina.

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Those with medical conditions associated with hypoxia or reduced oxygen carrying capacity (eg anaemia managing diabetes type 2 with diet order cheapest duetact, respiratory/cardiac conditions) may not tolerate the reduction in barometric pressure without support diabete zuccheri purchase 17mg duetact with amex. Cardiovascular disease the majority of patients with cardiac conditions can travel safely managing diabetes zyprexa buy discount duetact on line. Symptomatic valvular heart disease relative contraindication (individual assessment required) diabetes juicing generic duetact 16mg without prescription. Treated hypertension OK to fly; pacemaker/ICD may travel once stable; CVA advised to wait 10 days (within 3 days if stable). Diabetes Air travel should not pose significant problems if diabetes is well controlled. Insulin treated diabetes patients must carry adequate equipment and all insulin in hand baggage. Temperatures in the hold may degrade insulin (+ there is the potential for lost luggage). General guidelines: If travelling east (shorter day): fewer units of intermediate or long-acting insulin may be required. If travelling west (and day extended by >2 hours): supplemental short-acting or intermediate-acting insulin may be required. Haematological Anaemia: Hb 80g/L may travel without problems, assuming there is no co-existing cardiovascular/respiratory disease. Sickle cell anaemia patients may need supplemental O2 (+ delay travel for ~10 days following a sickling crisis). For this reason, most airlines do not allow travel after 36 weeks for a single pregnancy and 32 weeks for multiple pregnancy. Most airlines require a certificate >28 weeks confirming EDD and that the pregnancy is progressing normally. Respiratory If able to walk 50 metres at a normal pace or climb one flight of stairs without severe dyspnoea, it is likely they will tolerate flying. COPD: Supplemental O2 may be required (some airlines charge for this; some allow passengers to carry their own O2). Bronchiectasis /cystic fibrosis: Appropriate antibiotic therapy, adequate hydration, and O2 may be required. Pneumothorax: Contraindicated until 2 weeks after successful drainage with full expansion of the lung. Respiratory infection: Postpone travel until infection has resolved and exercise tolerance is satisfactory. Ear problems Flying with otitis media or sinusitis may result in pain and perforation of the tympanic membrane. Surgery Patients should not travel <10d after surgery to the chest, abdomen or middle ear. Laparoscopy or colonoscopy patients may travel >24hrs; Neurosurgery patients may travel >7d. Fractures Flying should be delayed 24h (if flight <2h) or 48h (for flights >2h) after application of a plaster cast. If needing to fly sooner, the airline will usually require the cast to be split along its full length. Amount depends on: Age: Whether >25yrs and is single/has a partner Children: One rate for first child; lower rate for additional children Childcare costs: Up to 70% of childcare costs (criteria apply) Inability to work: Higher rates for those in the support group Carer status: If caring for a severely disabled person for >35h/wk Housing: If paying rent or a mortgage. Certain benefits are excluded when calculating the cap (eg Cold weather payments, Free school meals). The cap does not apply in certain circumstances (eg if anyone in the household is claiming Attendance Allowance, Disability Living Allowance, Personal Independence Payments, or either partner is unfit for work after Work Capability Assessment). Both unemployed and working people can claim Universal Credit to supplement low income. Volunteering: People claiming Universal Credit can do voluntary work for a maximum of half the hours they are expected to seek work for. Primary care UK benefits for disability and illness 497 Employment and Support Allowance Eligibility Age 16yrs and under state pension age Not entitled to Statutory Sick Pay (p491) Unable to work due to sickness or disability-SC1 certification for the first 7d then Med3 certification until work capability assessment (p491) Sufficient NI contributions Unable to work and claiming ESA for <1yr. Disability Living Allowance (DLA) Eligibility Disability >3mo and expected to last >6mo more <16yrs at time of application Mobility component: Help needed to get about outdoors. Two levels; age restrictions apply Care component: Help needed with personal care.

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