Bernhard Meier, MD

• Professor of Medicine
• Chairman, Department of Cardiology
• University Hospital Bern
• Bern, Switzerland

This technique was employed to not only remove tissue for pathologic analysis but also to aid delicate tissue resection around the apex and verumontanum acne face buy line acticin. Surgeon preference skin care products reviews by dermatologists order acticin 30 gm with amex, bias skin care for swimmers purchase acticin 30 gm line, and familiarity also play a large role and may have influenced these investigators to those conclusions acne x-ray treatments purchase acticin 30gm with mastercard. The vaporization technique is performed using the electrode in a nearcontact technique (so-called hoovering technique) acne fulminans cheap acticin 30 gm. No perioperative complications were noted acne zones and meaning buy acticin 30gm low price, no patient required a blood transfusion, and no postoperative electrolyte abnormalities were noted. Around half of the patients (53%) required continuous bladder irrigation postoperatively. Transient mild-tomoderate dysuria was present in four patients (13%) and resolved within 2 weeks postoperatively with antiinflammatory agents. First clinical experience with new transurethral bipolar prostate electrosurgery resection system: Controlled tissue ablation (Coblation technology). The provision of transurethral prostatectomy on a day-case basis using bipolar plasma kinetic technology. Plasma kinetic vaporization of the prostate: Clinical evaluation of a new technique. A prospective randomized trial comparing conventional transurethral prostate resection with plasmakinetic vaporization of the prostate: Physiologic changes, early complications, and long-term follow-up. A hybrid technique using bipolar energy in transurethral prostate surgery: A prospective, randomized comparison. Role of transurethral biopsy sampling of the prostate to diagnose prostate cancer in men undergoing surgical intervention for benign prostatic hyperplasia. Randomized trial comparing holmium laser enucleation of prostate with plasmakinetic enucleation of prostate for treatment of benign prostatic hyperplasia. Clearly, larger multicenter trials are needed with longer-term follow-up to assess long-term outcomes, specifically the reoperation rate and rate of urethral stricture occurrence. Transurethral electrovaporization of the prostate: A novel method for treating men with benign prostatic hyperplasia. More than 2000 years ago, surgeons began using a median perineal incision for the removal of bladder calculi and in the first century of the classical era, surgeons used a semi-elliptical incision in this same perineal location for partial removal of the prostate. Although there are infrequent records documenting its use for a few hundred years, this perineal approach continued to be applied until 1894 when Eugene Fuller performed the first suprapubic prostatectomy. It was not until 1912, however, that the procedure was popularized as a result of Peter Freyer reporting his results with this technique, which consisted of the enucleation of the hypertrophic prostatic adenoma through an extraperitoneal incision of the lower anterior bladder wall. In 20 patients he reported a technique by which he achieved complete enucleation of the prostatic adenoma through a transverse capsulotomy incision on the anterior surface of the prostate gland. Recent developments in laparoscopic simple prostatectomy Currently, despite the development of transurethral surgery and new technologies employed with this access, open surgery continues to be the ideal treatment for large adenomas in terms of its cost-effectiveness for this pathology. Minimally invasive ablative techniques have also been popularized and include transurethral needle ablation and thermotherapy [2]. Over the last decade, with the advent of laparoscopic and robotic surgery, new treatment alternatives have also begun to be used. This basically duplicates the techniques of open surgery and maintains the standard of open surgery in regard to the proportion of tissue extracted, but with all the benefits associated with this type of minimally invasive surgery [4, 5]. This alternative is the use of a single access point in to the abdominal cavity through the umbilical scar. This device has two particularly important qualities: first, is has multiple flexible valves that do not protrude in to the cavity and allow introduction of curved instruments; and second its valvular component is easy to open and does not need to be taken out to be changed, a crucial aspect in intraluminal surgery. We began to explore the possibilities of applying this new access method to our technique of laparoscopic simple prostatectomy, first through the umbilicus and later through a small suprapubic incision that is used to place the port directly in to the bladder. The operation was developed as a collaboration between Drs Gill and Desai and our group. In this chapter, we will describe the technique in detail, highlighting tips that may be useful in performing the surgery. This is challenging, because the bladder must be dropped and the finger cannot be used to assist the enucleation. Additionally, at the end of surgery, the cystotomy incision has to be closed laparoscopically in a water-tight manner. With the new double-bend instruments, this method has been made easier, but it is still inherently difficult to carry out. At the end of surgery, the cystotomy closure can be done in a standard open fashion. The laparoendoscopic transvesical simple prostatectomy is performed through a small incision of 2. Relative contraindications include the need for concomitant procedures such as hernia repair and bladder diverticulectomy. Preoperative preparation Preoperative evaluation must include history and physical examination. In cases where there is evidence of previous hematuria, acute urinary retention or urinary lithiasis, and cystocopy should be performed. Patients should stop taking Aspirin or any anticoagulant at least 8 days before surgery. The retractor has an interior ring, two exterior rings, and a plastic retractable sleeve. The valve has three openings (two of 5 mm and one of 12 mm) for laparoscopic instruments and a port for inflation. The valve contains a thermoplastic elastomer that allows for the proper introduction of the instruments, including needles, with insignificant air loss. Surgical technique the equipment and instruments required are listed in Table 135. The Triport is a multiport access device that allows several instruments to pass simultaneously. It consists Surgical steps the advantages and disadvantages of this procedure are summarized in Table 135. At first, enucleation is difficult, but the location of the suprapubic incision allows bimanual dissection if necessary. The index finger of the left hand in the rectum elevates the prostatic fossa and the index finger of the right hand through the ring of the Triport helps the mobilization of the adenoma 1620 Section 8 Lower Urinary Tract: Intra- and Trans-vesical Procedures Table 135. Patient position and endoscopic evaluation All procedures are performed under general anesthesia with the patient in a modified low-lithotomy position. The bladder wall is entered sharply between the stay sutures, and the inner ring of the Triport is inserted in to the bladder, being deployed with the help of an introducer. The inner and outer rings are approximated by removing the slack on the plastic sleeve, thus cinching the abdominal and bladder walls between the rings of the Triport in an airtight seal. The stitches serve as the anchor for traction and also facilitate the introduction of the trocar. Care must be taken that the incision in the fascia and the bladder is no more than 2. Mucosal incision and enucleation A large, bulging median lobe can be retracted anteriorly in an efficacious manner with a figure-of-eight stay stitch. The two ends of the stay stitch are retrieved and anchored outside of the anterior abdominal wall. Typically, a reddish zone of mucosa is seen immediately lateral to the internal meatus. The horizontal limb of the U-incision is made using a hook electrode and cutting current to reach the adenoma. The plane between the surgical capsule and the adenoma is created using a hook and suction cannula. Separate excisions of each mobilized lobe of the adenoma provide superior visualization of the remaining part of the adenoma, enabling better hemostasis. The pneumovesicum is re-established for incising the urethra at the prostatic apex and completing the procedure. The lateral pedicles of the prostate should be thoroughly checked and the pneumovesicum pressure diminished to ensure that there is no bleeding. In the event that there is slight bleeding, it can be controlled with a monopolar or bipolar unit. If there is still any doubt, stitches can be made with absorbable sutures and knotted extracorporeally. Trigonization and closure of the bladder After adenoma removal, trigonization of the prostatic fossa can be performed by suturing the cut end of the posterior bladder neck distal toward the apex of the prostatic fossa. The bladder opening is sutured with 3-0 Vicryl, and the fascia and skin are closed in a standard fashion. Thus, the first Vicryl stay suture, which was previously placed in the bladder, can be tied, along with any additional sutures, to give a water-tight closure. Postoperative management Close monitoring of urine drainage is important to ensure it remains clear. If significant hemorrhage is noted, the urethral catheter may be placed on traction so that the balloon can compress the bladder neck and prostatic fossa. On average, continuous irrigation is removed 12 h after verification that there is no bleeding. On the first postoperative day, the patient starts ambulation and a regular diet; oral analgesics can be given and parenteral narcotics are discontinued. Complications the overall rate of morbidity associated with single-port transvesical simple prostatectomy is extremely low; and to date no case of mortality has been encountered. Also, to date there have been no reports of stress incontinence, erectile dysfunction or thromboembolic events related to surgery. Stress incontinence and total incontinence are rare even for open surgery; with precise enucleation Usually the patient is discharged 24 h after the procedure with appropriate discharge instructions. The duration of hospitalization was 2 days on average, and the Foley catheter was removed on postoperative day 7 in most of the patients. All patients were voiding spontaneously without a significant postvoid residual volume and were fully continent. The incidence of urinary extravasation is practically zero with this technique because the incision through the bladder is very small, less than 2. Following surgery, urgency and urge incontinence may be present for several weeks, depending on the preoperative bladder status. Guidelines for the diagnosis and treatment of benign prostatic hyperplasia: a comparative international overview. Results Our early follow-up data show that prostatic adenoma was successfully enucleated in all of 23 patients using this novel single-port transvesical technique [8]. Complications were present in four patients, including the three who were transfused. This patient had a history of previous exploratory laparotomy through a full midline incision for colon cancer and subsequent incisional hernia repair. Additionally, patients with neurologic disorders, such as multiple sclerosis, myelomeningocele, and spinal cord injury, often experience voiding dysfunction. However, such receptors exist elsewhere in the body, including the brain, salivary glands, heart, gastrointestinal tract, and eyes, resulting in side effects: cognitive problems, dry mouth, tachycardia, constipation, and blurred vision. Almost half of patients discontinued medication as they felt it "did not work as expected," and almost one-fourth of patients blamed the side effects [13]. It was not until 1897 that the microbiologist van Ermengem discovered the culprit bacterium that he termed "bacillus botulinus" (from the Latin word botulus meaning sausage) after isolating it from the tissue of several people who died following a funeral dinner as well as the smoked ham served that day [17]. They demonstrated a statistically significant increase in bladder capacity over placebo at 6 and 12 weeks, and a decreased detrusor pressure and number of incontinent episodes throughout the trial. Additionally, patients treated with Dysport had a significant reduction in their use of tolterodine. Incontinent episodes were significantly decreased and QoL was improved in both treatment groups, but these parameters were unaffected in the placebo group. Cytometric measures also revealed a significant increase in bladder capacity and decrease in bladder pressures only in the treatment groups.

Hemodialysis this patient is profoundly uremic with clinical evidence of bleeding acne glycolic acid order generic acticin online. Bleeding in uremic patients is complicated by platelet dysfunction and is characterized by mucocutaneous bleeding and bleeding in response to injury or invasive procedures acne 6 days before period purchase acticin now. Prothrombin time and partial thromboplastin time may be normal skin care during winter purchase 30 gm acticin mastercard, and platelet counts are normal to slightly low skin care natural tips discount 30gm acticin overnight delivery. Unfortunately acne forum cheap acticin 30 gm otc, the effect is short lived acne help generic acticin 30 gm with mastercard, lasting 4 to 24 hours, and tachyphylaxis frequently develops after a second dose, limiting its use. Hemodialysis can correct the bleeding time in uremic patients, but is time consuming and may acutely prolong bleeding through platelet activa- tion on artificial surfaces. More prolonged control of bleeding in uremic patients can be achieved with conjugated estrogens, with peak control reached after five to seven days. If the effusion is found to be a hemothorax, or if there is alternative evidence of ongoing bleeding, a platelet transfusion should be given. A 58-year-old man sustained a fracture of the right humerus when he fell from a ladder. His past medical history is significant for coronary artery disease for which he underwent coronary stenting of the left anterior descending artery with a drug eluting stent 3 months ago. Stop aspirin and clopidogrel, for 5 days, then proceed with surgery the combination of aspirin and clopidogrel is commonly used following coronary stent placement. Placement of drug eluting stents has become increasingly common, and current recommendations are to continue dual antiplatelet therapy for 1 year following stent placement. Early admission to a neuro intensive care unit A protocol for the rapid evaluation, diagnosis, and treatment of anticoagulated trauma patients has been shown to significantly reduce the mortality of warfarin anticoagulated trauma patients with intracranial hemorrhage. Simultaneously, the blood bank is notified to thaw two units universal donor plasma followed by two units of type specific plasma. This protocol for rapid evaluation and treatment of warfarin associated intracerebral hemorrhage resulted in a reduction in mortality from 48% to 10%. Premature interruption in antiplatelet therapy is associated with a high risk of stent thrombosis with a resultant 64% rate of death or myocardial infarction. Perioperative management of antiplatelet agents is based on balancing the risk of surgical bleeding with the risk of stent thrombosis. In this situation, it is important to know the indication for stenting, the date of implant, the type of stent used, as well as the proposed duration of current antiplatelet therapy. When possible, surgery should be delayed until after the recommended period of dual antiplatelet therapy. If urgent surgery must be performed, the risk and consequences of surgical bleeding must be assessed. For procedures with a low bleeding risk, dual antiplatelet agents should be continued through the surgery. A 71-year-old woman taking warfarin for chronic atrial fibrillation arrives in the emergency department after a fall down a flight of stairs at home. She is confused, mumbling, and unable to follow commands, but withdraws to pain in all extremities. Two randomized controlled trials demonstrated a significant decrease in red blood cell transfusions for patients with severe blunt trauma, with a trend toward decreased transfusion in penetrating trauma. Immediately following surgical control of bleeding and massive resuscitation, aggressive resuscitation must continue addressing all potential causes of bleeding. Hypothermia 35 C has been shown to be a strong independent risk factor for mortality in trauma patients. Hypothermia contributes to coagulopathy through platelet and clotting factor dysfunction. If bleeding continues after aggressive warming and correction of clotting abnormalities, the patient must return to the operating room without further delay. A wound to the thoracic spine was difficult to control and was packed with sponges. He received 12 units of packed red blood cells, 10 units of fresh frozen plasma, and 1 unit of apheresis platelets in the operating room. Type specific blood 116 Surgical Critical Care and Emergency Surgery Advantages of using uncrossmatched type O blood include immediate availability before type specific blood becomes available and avoidance of errors in multi-casualty situations. The safety of type O blood has been improved by prescreening donor blood for anti-A and anti-B antibodies which can lead to hemolysis of native red blood cells. Crossmatched blood the described patient has hemoperitoneum and should be taken to the operating room for control of any surgically correctable sources of bleeding. Crystalloid resuscitation should be minimized and O negative or if unavailable, O positive blood transfused without delay. If uncrossmatched blood resources are limited, O negative blood is reserved for woman of child-bearing age to avoid the risk of Rh isoimmunization, while O positive or negative blood is used for men and women beyond childbearing age. O positive blood has been shown to be safe for transfusion in hemorrhaging trauma patients, with a very low rate of transfusion reaction. What physiologic abnormality is associated with an increased risk of analgesic toxicity Hypoproteinemia Patients with hypoproteinemia have less of the drug bound to proteins, leaving more of the drug free. Neither hypocalcemia, hypokalemia, hypomagnesemia, nor hyponatremia affect the binding of the drug. Propofol has a fast onset and clearance, and is indicated for short-term sedation. Side effects of propofol are hypotension, respiratory depression, hypertriglyceridemia, pancreatitis, and propofol infusion syndrome. Propofol is useful for patients with neurologic injury, as it decreases intracranial pressure, cerebral blood flow, and cerebral metabolism. Mirtazapine is an example of an alpha-2 antagonist, which is often used for its antidepressant effects. Mehta, S, McCullagh, I, Burry, L (2009) Current sedation practices: Lessons learned from international surveys. Alpha-2 adrenergic agonist Surgical Critical Care and Emergency Surgery: Clinical Questions and Answers, First Edition. Patients with head injuries have a lower seizure threshold, and are more likely to have seizures. Using meperidine in a patient who has suffered a head injury would be ill advised. It would less likely be sufficient for pain control in the immediate post-injury period. Its use would not be contraindicated but it effects would be short acting, making it an unlikely choice of analgesic. What combination of analgesia and sedation has been found to reduce the time of duration of mechanical ventilation Administration of analgesia and sedation at the same time In a technique dubbed "analgesia first," drugs used for sedation are administered after the use of analgesics. Studies have found that this technique has led to a reduction in amount of sedatives required, as well as a decrease in the duration of mechanical ventilation. Administration of analgesia alone would not allow for adequate comfort for the patient. Examination after being admitted to the hospital reveals an intracranial injury, fractured left humerus, two fractured ribs without pulmonary contusions, and multiple skin abrasions. Tetracaine Amides have an amide linkage between a benzene ring and a hydrocarbon chain, which is attached to a tertiary amine. The tertiary amine attached to the Analgesia and Sedation hydrocarbon chain makes the anesthetic water soluble. The important difference between amides and esters is that, in general, amides are metabolized in the liver, whereas esters are metabolized by plasma cholinesterases. Unconsciousness Toxicity of a local anesthetic results from the absorption in to the bloodstream. It first manifests in the central nervous system, and then the cardiovascular system. The symptoms progress from restlessness to tinnitus, slurred speech, seizures, and then unconsciousness. If the toxicity has progressed to seizure activity, administering a benzodiazepine or thiopental can treat it. Unless contraindicated, the optimal level of sedation is where the patient is alert, not agitated, and able to maintain brief contact, and follow simple instructions. This could lead to patient behavior that would be detrimental to their care, such as removing medical devices or thrashing in their bed. However, evaluating the mental status of patients with this level of sedation would be more difficult, as they would have a hard time participating. Answer: C Barr, J, Donner A (1995) Optimal intravenous dosing strategies for sedatives and analgesics in the intensive care unit. The target level of sedation for a patient not expected to require mechanical ventilation for greater than 48 hours is: A. Patients who receive a high dose of bupivacaine can 120 Surgical Critical Care and Emergency Surgery cord syndrome is a result of hyperflexion of the cervical spine. It results in the bilateral loss of motor function, pain, and temperature sensation in the upper extremities. It often occurs after a viral infection, surgery, inoculation, or mycoplasma infection. Using epinephrine as an additive to bupivacaine would allow for a greater amount of the drug to be used. Epinephrine is a vasoconstrictor that, when added to a local anesthetic, reduces bleeding, hastens the nerve blockade, lengthens its duration, and improves the quality of the nerve blockade. Epinephrine containing injections should not be used where there are end arteries, as they can lead to distal ischemia. A 25-year-old woman is undergoing preoperative preparation for a planned Cesarean section. After injection of a local anesthetic in to her dura sac, she complains of sensory and motor loss of her legs. It is seen in cases where there is an indwelling spinal catheter and high concentrations of lidocaine. It is associated with a penetrating injury, resulting in ipsilateral motor loss and contralateral loss of pain and temperature sensation. The anesthesiologist wants to use an induction agent that also has analgesic properties. It produces analgesia as well as amnesia, and is classified as a dissociative anesthetic. The use of a benzodiazepine, in addition to ketamine, has been shown to decrease the side effects of delirium and hallucinations, which are associated with ketamine. Which of the following opioids undergoes rapid hydrolysis that is not effected by age, renal function, hepatic function, or weight It is a synthetic opioid that differs from nonsynthetic opioids in lipid solubility, tissue binding, and elimination profiles. Remifentanil undergoes rapid hydrolysis and is unaffected by age, sex, weight, renal dysfunction, or hepatic dysfunction. An increase in pH favors the elimination process, whereas a decrease in pH slows down the process. Pancuronium is an example of a medication that is eliminated almost completely unchanged by the kidney. Vecuronium and rocuronium are examples of medications that are metabolized by both the liver and kidneys. The man has a past medical history of coronary artery disease, diabetes mellitus, hypertension, and hyperlipidemia. Which muscle relaxant should be used in order to decrease the risk of myocardial ischemia perioperatively Kidney and liver metabolism Succinylcholine is a depolarizing neuromuscular blocker, which binds to the post-synaptic acetylcholine receptor. It should be avoided in patients who have suffered burns or tissue injury, as it can result in a significant rise in serum potassium. Patients with low pseudocholinesterase levels have a delay in return of motor function. Succinylcholine Muscle relaxants with minimal or no effects on heart rate and blood pressure should be used in patients with high risk of myocardial ischemia. Rocuronium and vecuronium would be the most ideal choices for neuromuscular blockade in such conditions. The other neuromuscular blockers have a greater effect on the cardiovascular system, making them a less ideal choice. Adult patients are not good candidates for this type of induction for a number of reasons. This could lead to hypertension, tachycardia, laryngospasm, vomiting, or aspiration. Children would be better candidates for this type of induction because they progress through the second stage quickly. A 55-year-old man with hepatic cirrhosis is undergoing an intra-abdominal operation. Vecuronium Mivacurium is the only non-depolarizing neuromuscular blocking agent that is metabolized by plasma cholinesterase, similar to succinylcholine. Patients with cirrhosis are more likely to have decreased levels of plasma cholinesterase, resulting in a hypersensitivity to mivacurium. Of the choices, mivacurium should be avoided in a patient with significant liver disease. Cis-atracurium is eliminated by Hofmann degradation and would not be affected by liver disease. Pancuronium is eliminated almost unchanged by the kidneys, and would be unaffected by liver disease. While their elimination may be decreased in liver disease, this decrease would not be as significant as a drug exclusively reliant upon liver function. Utilizing the Mallampati scale in a patient with a Class 3 airway, the practitioner would be able to visualize A. None of the above Airway assessment should be conducted and is easily performed utilizing the Mallampati scale.

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Patients undergoing minor procedures should likely receive all or 50% of their home dose prior to operation acne 4 year old purchase acticin line, assuming a quick return to oral intake acne nodule order acticin 30 gm with mastercard. Patients poorly controlled or those with major operations are best managed on continuous insulin infusions until the stress response abates and home regimens can be resumed with reasonable control acne during pregnancy boy or girl generic 30 gm acticin overnight delivery. Issues related to hyperglycemia in the perioperative period include all of the following except: A acne drugs order acticin paypal. Prior to moving to the operating room for celiotomy acne breakouts cheap acticin american express, she relates a history of inflammatory bowel disease and prednisone 20 mg daily as her current therapy acne 7 dpo order 30 gm acticin amex. Excessive facial hair or beard In a minority of critically ill patients, even a well trained practitioner familiar with conventional intubation techniques will experience difficulty. This is particularly important for patients with acute hypoxemia, acidosis, or hemodynamic instability. While the presence of excess facial hair or a beard is often omitted from airway evaluation, it may result in difficulty obtaining a seal during bag-valve mask ventilation. Not administer any additional steroid but resume her home medication dose as soon as possible E. Not administer additional steroid, and hold her home dose to minimize wound complications the perioperative evaluation and management of patients on chronic exogenous steroid therapy remains controversial, with little literature to guide practice. Symptoms are extremely vague, and may include nausea, anorexia, weakness, and fatigue. For major emergency cases, administer hydrocortisone 100 mg before anesthesia induction and 100 mg every 8 hours for at least 24 hours. Supplemental steroids should then be tapered rapidly to avoid immunosuppression, altered wound healing, or other complications. The patient remains on mechanical ventilation through an orally placed endotracheal tube while the trauma team schedules a tracheostomy. Tracheostomy has many benefits over translaryngeal intubation for long-term mechanical ventilation, which may include all of the following except: A. All of the following Airway Management, Anesthesia, and Perioperative Management D. Decreased incidence of ventilator-associated pneumonia Tracheostomy improves comfort and potentially allows patients to eat, talk, and ambulate. Secretion management is much easier, and airway resistance, anatomic dead space, and laryngeal injury are minimized. However, tracheostomies have the highest associated risk of serious complications including bleeding, stenosis, dysphagia, and aspiration after decannulation. In the immediate postoperative setting, noninvasive ventilation has been demonstrated to be most effective at: A. A 72-year-old, non-obese woman undergoes a laparoscopic ventral hernia repair without incident. Similarly, ventral hernia repair that is performed laparoscopically is unlikely to result in abdominal compartment syndrome as patients who are suitable for a laparoscopic repair generally do not demonstrate significant loss of domain. Answer: A Jaber S, Chanques G, Jung B (2010) Postoperative noninvasive ventilation. A 19-year-old man undergoes an uneventful laparoscopic appendectomy for microperforated appendicitis. He is then extubated with a train-of-four of 4/4 twitches and shortly thereafter develops stridor as well as hypoxia despite vigorous respiratory efforts and gas movement. Clear lung fields this patient is demonstrating the classic presentation of negative pressure pulmonary edema. It primarily occurs in young, muscular patients who are able to move large volumes of gas using significant muscular effort. Hypoxia is common as is stridor as the patient tries to move gas through partly opposed cords. Westermark sign is consistent with pulmonary embolus and is inconsistent with this presentation. Change to pressure control ventilation the clinician must frequently assess rising peak airway pressures. In this scenario, slowly rising pressures indicate a different process than those that rise acutely. Given his multiple injuries he is likely to need large-volume fluid resuscitation and clotting factor dilution. He is at risk for failure of nonoperative management of his splenic laceration as well. Each of these factors can lead to an increase in intraabdominal pressure from visceral edema, hemorrhage, as well as acute ascites formation. The lack of change in other ventilator parameters is also suggestive of a process that is external to the pulmonary circuit. Thus, magnesium sulphate for bronchodilatation, as well as n-acetyl cysteine for mucolysis, will not address the underlying condition. Neuromuscular blockade may mask the underlying cause and should be used with caution. Paravertebral block placement Rib fracture management hinges on adequate analgesia to support coughing, deep breathing and maintenance of ventilation of the segments of lung that are contused and underlie the fractured ribs. Inadequate ventilatory efforts lead to widespread atelectasis and eventually an unsupportable work of breathing. Thus, an analgesic method that minimizes sedation is ideal, and placing a paravertebral block meets those needs. Inhaled agents designed to manage bronchoconstriction are useful adjuncts but not primary therapy for rib fracture management and diuresis is generally inappropriate immediately after acute injury because patients generally need fluid resuscitation to support macro- and microcirculatory oxygen delivery. Changing to a square waveform will provide a constant gas flow and will shorten Ti. Current data identifies that the invasive diagnosis of pneumonia is more cost effective than an empiric therapeutic course of antimicrobial management. Therefore, the best choice is to perform a flexible bronchoscopy and bronchoalveolar lavage to investigate for airway inflammation and to obtain a specimen for culture. This method allows one to culture directly from the involved airway segment, and to avoid culturing tracheal secretions that may be colonized with bacteria resident in the omnipresent biofilm that accompanies indwelling devices. A 72-year-old patient remains ventilated after a low anterior resection for malignancy. Increase in dead space: tidal volume Oxygenation most closely correlates with mean airway pressure and is a reflection of the area under the curve described by the gas-flow waveform. Which of the following interventions will prolong the inspiratory time in volume-cycled ventilation: A. In: Hedges J, Roberts J (2009) Clinical Procedures in Emergency Medicine, 5th edn, W. It is a superior recruitment mode and relies on a significant increase in mean airway pressure to match regional time constant variations, recruit atelectatic alveoli, and improve oxygenation. She sustained a large volume blood loss and was resuscitated and therefore left on mechanical ventilation. Which of the following findings is expected before the patient begins to take spontaneous breaths Increased expiratory time Intraoperative ventilator settings generally reflect neuromuscular blockade or deep sedation as well as the reduction in metabolic rate that accompanies inhalational or intravenous general anesthesia. The latter may be especially true in the patient with perforated diverticulitis who may have received significant fluid resuscitation to help manage her peritonitis associated capillary leak syndrome. Vieillard-Baron A, Jardin F (2003) the issue of dynamic hyperinflation in acute respiratory distress syndrome patients. A 35-year-old man is post injury day two following a collision with an automobile and remains mechanically ventilated on inverse-ratio pressure control ventilation for the management of severe bilateral pulmonary contusions. This would suggest that his ventilator settings may be optimally adjusted for his pulmonary mechanics, and he requires pressor support to help mange pulmonary flow. Once the airway is secured from above, the tracheostomy tube may be safely replaced in a controlled fashion. Many surgeons will place tracheal stay sutures to facilitate pulling up on the trachea and easing replacement should the tube become dislodged. A 68-year-old clinically severely obese woman is two days s/p a extensive head and neck resection with radial forearm free flap and tracheostomy. Diuresis is not acutely effective in reducing visceral edema immediately after injury and is generally contraindicated during resuscitation from hemorrhagic shock. Similarly renal support therapies are ineffective and not supported during resuscitation for total body salt and water removal. Pressor support is inappropriate when a simple maneuver, leaving the chest open, will more directly support perfusion without increasing myocardial consumption of oxygen. A 16-year-old patient is shot in the left chest, arrives with agonal vital signs, undergoes a transverse thoracotomy for resuscitation, and undergoes nonanatomic lingual resection, repair of a thoracic aortic tangential injury and a left-ventricle and right-ventricle laceration, as well as a nonanatomic right middle lobe resection. Thoracic packing and open chest management Compartment syndrome is not limited to an extremity or the abdomen as it may also occur in the chest. Treatment paradigms are similar in that the cavity to be closed is instead temporarily expanded to allow for visceral edema. Decompressive laparotomy Full-thickness circumferential burns over the torso can result in significant compromise of chest wall movement and hinder ventilation. Tobin index) obtained by dividing the frequency of respiration by the tidal volume. Since negative inspiratory force is effort dependent its validity is readily questioned. The definitive treatment is to incise the thick eschar that is limiting chest-wall excursion. Abdominal compartment syndrome may present similarly but would be associated with an elevated bladder pressure and an attributable organ failure. The clinician sets the amount of pressure during inspiration and expiration while the patient controls the respiratory rate and inspiratory 19. Two multicenter randomized trials have failed to show benefit in established respiratory distress although other smaller trials have demonstrated some benefit. Only negative pressure ventilation has been proven effective in enhancing expectoration of secretions in the cystic fibrosis patient population. Answer: E Jaber S, Chanques G, Jung B (2010) Postoperative noninvasive ventilation. Piperacillintazobactam, cefepime, cefoxitin, and meropenem are all -lactam antibiotics. Carbapenems are much more resistant to beta lactamses than the other beta lactams. Clindamycin-susceptible, erythromycinresistant Staphylococcus aureus can become clindamycin resistant. Antibiotics are recommended for abscesses in those with cellulitis and comorbidities. A 58-year-old remains in critical condition following omental patch repair of perforated duodenal ulcer. He is most likely adrenally insufficient with an inadequate response to vasopressors. Answer: D American Thoracic Society and the Infectious Diseases Society of America (2005) Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. The patient was previously in septic shock and steroids are currently being weaned. Severe sepsis causes immunological reaction that is proinflammatory and prothrombotic. Contraindications to drotrecogin alfa include trauma with increased risk of life threatening bleeding, active internal bleeding, hemorrhagic stroke within 3 months, platelets less than 30,000 per mm3, and bleeding diathesis; thus the best answer is D. Morning postoperative blood glucose level less than 200 mg/dL in cardiac patients E. Surgical care infection prevention performance measures include prophylactic antibiotics within one hour of surgical incision, two hours if vancomycin; the appropriate antibiotic for 6. A 42-year-old man suffers a severe traumatic brain injury after motor vehicle collision. Use of Xigris (drotrecogin alfaactivated recombinant protein C) would be absolutely contraindicated in this patient if: A. Prevention strategies include the following: use of the subclavian site, nonscheduled line changes, removing catheters when no longer needed, and maximum sterile barrier precautions with insertion. Antimicrobial-impregnated catheters can be used to reduce catheter related infections when the above efforts fail to satisfactorily reduce infection rates. Scheduled line changes may increase the incidence of infection, thus (b) is the correct answer. Hyperbaric oxygen therapy Appropriate therapy for necrotizing fasciitis includes: aggressive debridement, broad-spectrum antibiotics, treatment of pathogens including Streptococcus pyogenes, use of clindamycin (a protein synthesis inhibitor against toxin production), and physiologic support. The data for the use of hyperbaric oxygen therapy demonstrates variable results and based on current evidence should not be used. Discontinue all previous antibiotics and start fungal coverage this patient is at risk for developing tertiary peritonitis. With persistent fevers and lack of new culture results, starting an antifungal agent is the correct regiment. Common organisms in patients with tertiary peritonitis are Enterobacter, Enterococcus, Candida, and Staphylococcus epidermidis. Two or more of the following indicates severe disease: age greater than 60, temperature greater than 38. Addition of oral vancomycin or metronidazole could benefit if the drug would reach the site of infection-the colon. Some data exists regarding the use of rectal administration of vancomycin (intraluminal).

Errors in technique or positioning or nontraumatic causes of widened mediastinum should be diagnoses of exclusion acneorg purchase acticin 30gm without prescription. This will accurately diagnose aortic injury acne 5 weeks pregnant order acticin uk, associated pulmonary contusion acne facials discount acticin 30 gm without a prescription, as well as soft tissue and bony injuries skin care gift sets order generic acticin on-line. Outcomes are best with penetrating cardiac injury skin care discount 30gm acticin otc, followed by penetrating non-cardiac thoracic trauma acne cure discount acticin 30gm amex. Working Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons-Committee on Trauma (2001) Practice management guidelines for emergency department thoracotomy. A resuscitative thoracotomy is indicated in which of the following clinical scenarios Loss of vitals with cardiopulmonary resuscitation time greater than 15 minutes in penetrating trauma C. Loss of vitals with cardiopulmonary resuscitation time greater than 15 minutes in blunt trauma D. Loss of vitals with cardiopulmonary resuscitation time greater than 15 minutes in pediatric trauma E. It will allow evacuation of hemothorax/pneumothorax, release of tamponade, repair of cardiac and intrathoracic vessel 16. Which of the following is not an acceptable treatment for traumatic aortic injury Aortography was previously the gold standard; however, it is utilized now primarily for therapy as it is invasive and requires the presence of a specialty angiography team. Additionally, when open repair is chosen, bypass is frequently preferred to the clamp-and-sew technique. Open repair is generally performed via posterolateral thoracotomy, although anterolateral thoracotomy may be used for patients who are in extremis, and median sternotomy is used for injuries to the ascending aorta or arch. In addition to open and endovascular repair, nonoperative management with aggressive blood pressure control has become an acceptable treatment option, especially in the elderly patient with multiple comorbidities, or in patients with minor intimal tears. Shunting is also a viable treatment option in the unstable patient in a damage control situation, although data on patency rates and long term outcomes are lacking. Ding W, Wu X, Li J (2008) Temporary intravascular shunts used as a damage control surgery adjunct in complex vascular injury: Collective review. A 37-year-old man sustains blunt chest trauma requiring chest tube for drainage of a hemopneumothorax. Which of the following is an acceptable modality for diagnosis of traumatic aortic injury Chest x-ray has been utilized in the past as a screening exam; however, x-ray can be normal in up to 33% of patients with traumatic aortic injury, and positive findings are nonspecific. Retained blood may occur as a result of delay in presentation, delay in diagnosis/treatment, and thoracostomy tube malposition, migration, or occlusion. The options for treatment include open drainage, video-assisted thoracoscopic drainage, and intrapleural thrombolysis. Cardiothoracic and Thoracic Vascular Injury Several studies and a meta-analysis of intrapleural thrombolysis have revealed promising results with complete clinical and radiographic resolution in over 90% of cases in most studies. In contrast, postural drainage, chest physiotherapy and increased suction on the thoracostomy tube are unlikely to resolve retained hemothoraces. Not only is administration of antibiotics unlikely to resolve the hemothorax, but it is also unlikely to prevent infection of retained fluid collections. Which of the following is a contraindication to a trial of non-operative management in liver injury His abdomen is non-tender, his pelvis is unstable, and x-ray demonstrates a severe open book fracture. Bilateral needle thoracostomy If hypotension is present with pelvic fracture, the pelvic ring should be reapproximated as soon as possible. Binders or sheets are fitted over the anterior superior iliac spines superiorly, and the femoral heads inferiorly. If orthopedic surgeons are available an external fixation device can be placed to reapproximate the pelvic ring. Stabilization devices close the pelvic ring decreasing pelvic volume to tamponade bleeding. They also stabilize the broken ends of bone preventing further injury to nearby tissues and Surgical Critical Care and Emergency Surgery: Clinical Questions and Answers, First Edition. Hemorrhage associated with pelvic fracture can cause significant hypotension and carries a high mortality. In stable or semistable patients with pelvic hemorrhage, angiography should be considered for diagnostic and therapeutic purposes. If significant arterial bleeding is found, selective embolization can be performed. If no arterial bleeding is found, bilateral internal iliac artery embolization can be performed to decrease pelvic inflow. The rich collateral circulation in the pelvis prevents ischemic complications in most patients. Very rarely, complications such as necrosis of pelvic organs or glutteal compartment syndrome can occur. Transfusion of blood products are also a very important aspect of immediate therapy that can be initiated but stopping bleeding is the highest priority. Complications of embolization are not rare and include hepatic necrosis, abscess, and bile leak. Timing of angiography appears to affect morbidity and mortality, with better outcomes observed in patients undergoing early compared with late angiography. In this patient there is a second indication for angiography, as it can also be used to diagnose popliteal artery injury, which is associated with knee dislocation. Pelvis x-ray reveals bilateral pubic rami fractures and there is blood at the urethral meatus, which of the following should be the next step in management Laparotomy Stable patients with any injury grade and evidence of intraparenchymal extravasation of contrast are candidates for angiography and possi- E. Blood at the urethral meatus, perineal hematoma, high riding prostate on rectal exam, and inability to void or gross hematuria are all indicators of urethral injury. This can be done by placing a small foley catheter in the fossa navicularis and partially inflating the balloon, or using a non-crushing clamp on the end of the penis to prevent contrast leakage. Which of the following is a contraindication to nonoperative management of splenic injury Ultrasound retrograde cholangiopancreatography Answer: D Bile leak or biloma formation can complicate the course of 0. The incidence is slightly higher in operative compared to non-operative patients, and in patients with higher grade injuries. Symptomatic patients with fever, leukocytosis, pain, jaundice, or feeding intolerance, are best treated with image-guided drainage. Regarding seat belt signs on the abdomen which of the following statements is false They are associated with increased mortality Abdominal and Abdominal Vascular Injury B. Additionally, pancreatic injury is increased especially in the pediatric population. Lastly, the use of a lap belt without concomitant use of a shoulder restraint has been associated with chance fracture of the lumbar spine. Blunt mechanisms are far more common than penetrating, accounting for approximately 60% of injuries. Blunt trauma to the renal vessels is more likely to result in thrombosis, whereas penetrating trauma more often results in bleeding. Risk factors for failure include high-grade injuries, large perinephric hematomas, and urinary extravasation. The only absolute contra-indication to nonoperative management is hemodynamic instability. In the cases of renal artery thrombosis, warm ischemia time is the most important determining factor in renal salvage rates. Complications, including recurrence of bleeding, abscess, and urine leak are more common following nephrorraphy than nephrectomy. Late complications include Page kidney, renovasular hypertension and hydronephrosis. Acute renal dysfunction can occur after traumatic nephrectomy, but tends to be transient and self-limited. The utility of seat belt signs to predict intra-abdominal injury following motor vehicle crashes. After falling a patient is found to have a renal artery injury with thrombosis and ischemia. Injury is more common in adults than children 286 Surgical Critical Care and Emergency Surgery D. Post-phlebitic syndrome is an early complication Iliac vein injury can occur after blunt or penetrating trauma and as a result of iatrogenic injury following pelvic procedures. Minor lacerations can be repaired primarily, however more destructive injuries associated with gunshot wounds and blunt trauma most often require ligation. Complications following ligation include extremity edema, compartment syndrome, thromboembolic complications, and outflow ischemia. Leg edema is common after ligation but compartment syndrome is rare unless there is also arterial injury or prolonged hypotension. Post-phlebitic syndrome characterized by venous hypertension and incompetence, chronic edema, and ulceration can also occur in the late postoperative period. Transection following blunt trauma typically occurs near the mesenteric vessels E. Duct disruption is common following blunt injury Pancreatic injury following blunt trauma is uncommon, occurring in less than 2% of abdominal trauma cases. Because they tend to have less intraperitoneal and extraperitoneal abdominal fat, children tend to be at increased risk of pancreatic injury. Anterior-posterior compression of the pancreas against the lumbar spine results in transection at this location in twothirds of patients, adjacent and just to the left of the superior mesenteric vessels. While duct integrity is the main determinant of intervention and outcome, major duct injury is rare, occurring in less than 15% of pancreatic injuries, and is much more common following penetrating than blunt trauma. If the main duct is injured in the pancreatic tail or body distal to the neck, distal pancreatectomy is the best treatment. Blood transfusion >/= 4 units is associated with increased infectious complications B. Inappropriate choice of antibiotic is associated with increased infectious complications D. Several factors can significantly increase the rate of complications following surgical repair or resection. A large multicenter prospective observational trial identified severe fecal contamination, transfusion of 4 units of blood or greater, and inappropriate antibiotic prophylaxis as independent predictors of postoperative complications. It also found that the method of repair had no effect on the rate of complications. Several other studies have supported these findings, and additionally identified blood loss greater than 1 L, and hypotension as being risk factors for infectious complications. Lastly, several studies have found no additional benefit to continuing antibiotic coverage beyond 24 hours postoperatively regardless of the extent of contamination. Injuries due to blunt trauma in this area are unlikely to require surgical repair and hematomas should be left intact. Following penetrating trauma, major vascular or hollow viscous injuries are common and all hematomas should be explored. However this is less likely following blunt trauma and the risk of releasing venous hemorrhage is high. Most bleeding associated with pelvic fracture following blunt trauma is not amenable to surgical correction and is more likely to respond to interventional techniques or pelvic stabilization. Tamponade is possible even with major vascular injury in this area, and release of tamponade can result in exsanguinating hemorrhage. Stable hematomas resulting from both penetrating and blunt trauma in this area should not be explored. Retrohepatic trauma hematoma following penetrating Zone I hematomas are centrally located and contain the major abdominal vessels, because of this vascular injury is highly suspected and Zone I hematomas due to both blunt and penetrating trauma should be explored. Of the following, which is/are taken in to account when considering damage-control laparotomy and temporary abdominal closure It has since been applied to many surgical conditions including nontraumatic abdominal surgery, vascular surgery and orthopedic surgery. First, control of acute hemorrhage and contamination, second resuscitation, and third planned re-exploration for definitive treatment of surgical pathology. Which of the following methods is an option for temporary abdominal closure in primary damage-control surgery Additionally as there may be significant drainage from the abdominal cavity the closure method must have a means of collecting, removing and quantifying this drainage. Methods that reapproximate fascia or skin may create abdominal compartment syndrome and should be taken in to account. There are some surgeons that prefer to approximate the skin over a suction system as it avoids the loss of domain. The two most popular techniques are vacuum-assisted abdominal dressings and the Bogota bag. Vacuum-assisted closure can be performed with commercially available materials, or following the Barker method. The Bogota bag uses sterile plastic sutured to the skin to create an abdominal silo. There is also the option of skin closure, or placement of absorbable mesh with planned ventral hernia. Many physicians also combine methods using a combination of dynamic retention sutures with Barker or other type of vacuum closure system in order to decrease the loss of abdominal domain. The second stage of damage-control surgery is aimed at correcting which of the following values Following splenectomy for trauma, vaccinations should be sure to include which of the following organisms Pseudomonas aeruginosa the spleen produces tuftsin and properdin, postsplenectomy patients have diminished immunity and are most at risk for infection from encapsulated organisms. These include Streptococcus pneumonia, Hemophilus influenzae, and Neisseria meningitidis. Following splenectomy, patients should receive Haemophilus, meningococcal, and pneumococcal vaccinations.