https://surgopaedia.org/w/api.php?action=feedcontributions&feedformat=atom&user=SurgopaediaAdmin 2026-07-30T20:18:18Z User contributions MediaWiki 1.45.1 https://surgopaedia.org/w/index.php?title=Trauma_-_initial_assessment&diff=1003 2026-07-26T04:45:52Z

<p>SurgopaediaAdmin: </p> <hr /> <div>== Preparation ==<br /> Pre-hospital:<br /> <br /> * Notify hospital of incoming trauma so team can be mobilised<br /> * Prioritise airway, bleeding control/shock, immobilisation, immediate transport<br /> * Field Triage Decision Scheme ---&gt;<br /> <br /> Hospital:<br /> <br /> * Smooth handover between team leader and paramedics<br /> ** Hands off handover - &quot;MIST&quot;<br /> ** Mechanism<br /> ** Injuries found and suspected<br /> ** Symptoms and signs<br /> ** Treatment initiated<br /> * Critical aspects:<br /> ** Resus area available<br /> ** Airway equipment accessible - tracheostomy, video laryngoscopy<br /> ** Warmed crystalloid solution<br /> ** Protocol to guide rapid response by medical, pathology, radiology<br /> ** Idea of transfer processes to trauma centre<br /> ** Standard precautions for all attendees<br /> ** Equipment - RIC lines, collar, binder, blood<br /> * Mass casualty events:<br /> ** Suspend elective activity<br /> ** Mobilise resources<br /> ** Pre-empt injuries based on mechanism and prepare<br /> ** Ensure staff safety including PPE<br /> ** Establish command structure<br /> ** Redistribute juniors<br /> ** On-site triage - START<br /> ** Damage-control approach<br /> ** Establish communications and pathways for transfer<br /> <br /> == Triage ==<br /> <br /> * ?activate trauma team<br /> ** Airway<br /> ** Circulation<br /> ** Lines<br /> ** Drugs<br /> ** Scribe<br /> ** Team leader<br /> * See separate topic<br /> == Primary survey ==<br /> <br /> * &lt;blockquote&gt;Goal: is the patient shocked, and what is the cause of shock?&lt;/blockquote&gt;<br /> * Rapid primary survey with simultaneous initial resus, followed by detailed secondary survey, then definitive care<br /> ** Introduce yourself<br /> ** Ask the patient's name<br /> ** Ask what happened<br /> ** If appropriate answers - ABCD is ok<br /> <br /> ==== '''Airway maintenance, restriction of C-spine''' ====<br /> ** Keep neck still for now - can clear C-spine later<br /> ** Oxygen<br /> ** Inspect for foreign bodies/facial and neck fractures<br /> ** Clear airway<br /> ** Suction<br /> ** Open/secure airway<br /> *** Jaw thrust/chin lift<br /> *** If GCS&lt;8, early intubation, with exact timing depending on other factors including sats<br /> **** Or surgical airway if intubation can't happen for whatever reason<br /> *** If unconscious with no gag reflex, NPA can be helpful<br /> <br /> ==== '''Breathing and ventilation (adequate gas exchange)''' ====<br /> ** Expose neck and chest<br /> ** Inspect neck: tracheal deviation and jugular venous distension and absent unilateral breath sounds = tension PTX -&gt; needle decompression and chest tube<br /> ** Inspect chest: injuries and symmetrical rise<br /> ** Auscultate lungs<br /> ** Specifically exclude and immediately treat<br /> *** tension PTX<br /> *** Massive haemothorax<br /> *** Open PTX<br /> *** Tracheal/bronchial injuries<br /> ** Give oxygen and monitor oximetry<br /> <br /> ==== '''Circulation with haemorrhage control''' ====<br /> ** Hypotension is due to blood loss until proven otherwise<br /> *** Can look at pulse pressure<br /> ** Level of consciousness<br /> ** Skin perfusion<br /> ** Pulse<br /> ** If bleeding externally<br /> *** Direct pressure<br /> *** Tourniquet if direct pressure not working and life is in danger<br /> ** Internal bleeding<br /> *** Chest<br /> *** Abdomen - FAST scan<br /> *** Retroperitoneum<br /> *** Pelvis<br /> **** Needs stabilisation device?<br /> *** Long bones<br /> ** Get vascular access<br /> *** FBE, UEC, LFT, COAG, bHCG, ?TROP, XM/G+H, VBG<br /> ** 1L IV crystalloid if any sign of shock<br /> *** If unresponsive, blood<br /> ** IV tranexamic acid if uncontrollable bleeding<br /> <br /> ==== '''Disability (neurologic)''' ====<br /> ** GCS<br /> *** If low, immediately re-evaluate ABC<br /> *** Assume CNS injury until proven otherwise<br /> *** Consider drugs/alcohol<br /> ** Pupils<br /> <br /> ==== '''Exposure/environmental control''' ====<br /> ** Completely undress patient then warm<br /> <br /> ==== '''Adjuncts to primary survey''' ====<br /> ** ECG<br /> ** ?IDC<br /> *** Need to examine perineum/urethral meatus<br /> *** If concern for urethral injury, need retrograde urethrogram prior to IDC<br /> ** X-rays<br /> *** Even in pregnant patients<br /> *** Don’t interrupt resus<br /> ** ?NGT<br /> ** FAST/DPL<br /> <br /> * Obesity<br /> <br /> == Secondary survey ==<br /> * Wait until primary survey is complete, resus is under way, and patient is improving/stable<br /> <br /> ==== History ====<br /> ** Allergies<br /> ** Meds<br /> ** Past hx/pregnancy<br /> ** Last meal<br /> ** Events leading up to injury<br /> * MVA:<br /> ** ?seat-belt<br /> ** ?steering wheel deformation<br /> ** ?airbags<br /> ** ?direction of impact<br /> ** ?damage to car<br /> ** ?patient position in vehicle<br /> ** ?ejection<br /> <br /> ==== Examination ====<br /> ** Head<br /> *** Scalp - ?lacerations, contusions, fractures<br /> *** Eyes - VA, pupils, conjunctival haemorrhage, penetrating injury, contact lenses (remove before oedema occurs), lens dislocation, ocular entrapment)<br /> ** Maxfacs<br /> *** Palpate all bony structures<br /> *** Intra-oral exam<br /> *** Assess soft tissues<br /> *** These can all be managed later<br /> *** Be wary of cribriform plate fractures<br /> ** C-spine/neck<br /> *** Assume injury until cleared if maxillofacial or head trauma<br /> *** Can use Nexus low-risk criteria to clear spine if<br /> **** No focal neurologic deficit<br /> **** No midline tenderness<br /> **** GCS 15<br /> **** No intoxication<br /> **** No distracting injury<br /> *** Inspect neck<br /> **** Subcutaneous emphysema<br /> **** Tracheal deviation<br /> **** Laryngeal fracture<br /> **** Palpate carotids - ?seatbelt mark or bruise<br /> *** Do not explore wounds that penetrate platysma<br /> *** Any active bleeding, expanding haematoma, arterial bruit or airway compromise requires operative evaluation<br /> ** Chest<br /> *** Visual inspection and palpation<br /> **** Entire chest cage<br /> *** Auscultate high anterior (PTX) and low posterior (HTX)<br /> *** Consider tamponade (distant heart sounds, low pulse pressure, tachycardia, distended neck veins)<br /> ** Abdo/pelvis<br /> *** ?Pelvic fractures - ecchymosis over iliac wings, pubis, labia, scrotum<br /> **** Pain on compression of pelvic ring<br /> **** FAST or DPL if unexplained hypotension, neurologic injury, impaired sensorium, or any abdo findings<br /> *** Seatbelt sign - often a/w mesenteric laceration or small bowel perforation or pancreatic injury<br /> ** Perineum/rectum/vagina<br /> *** Contusions<br /> *** Haematomas<br /> *** Lacerations<br /> *** Urethral bleeding<br /> *** Rectal exam - blood, sphincter tone<br /> *** Pregnancy test<br /> ** MSK<br /> *** Palpate long bones<br /> *** X-ray anything odd<br /> *** Consider compartment syndrome<br /> ** Log roll<br /> *** Each vertebra<br /> *** Check for bruising<br /> ** Neurological<br /> *** Motor and sensory evaluation of extremities<br /> *** Re-evaluation of pupils and GCS<br /> *** If deterioration neurologically - reassess oxygenation, adequacy of ventilation and perfusion of the brain<br /> ** Adjuncts<br /> *** X-rays<br /> *** CT<br /> *** Contrast urography/angiography<br /> *** TTE/TOE<br /> *** Bronchoscopy<br /> *** Oesophagoscopy<br /> ** Reassess need for transfer<br /> [[Category:Trauma]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Trauma_-_initial_assessment&diff=1002 2026-07-26T04:44:58Z

<p>SurgopaediaAdmin: </p> <hr /> <div>== Preparation ==<br /> Pre-hospital:<br /> <br /> * Notify hospital of incoming trauma so team can be mobilised<br /> * Prioritise airway, bleeding control/shock, immobilisation, immediate transport<br /> * Field Triage Decision Scheme ---&gt;<br /> <br /> Hospital:<br /> <br /> * Smooth handover between team leader and paramedics<br /> ** Hands off handover - &quot;MIST&quot;<br /> ** Mechanism<br /> ** Injuries found and suspected<br /> ** Symptoms and signs<br /> ** Treatment initiated<br /> * Critical aspects:<br /> ** Resus area available<br /> ** Airway equipment accessible - tracheostomy, video laryngoscopy<br /> ** Warmed crystalloid solution<br /> ** Protocol to guide rapid response by medical, pathology, radiology<br /> ** Idea of transfer processes to trauma centre<br /> ** Standard precautions for all attendees<br /> ** Equipment - RIC lines, collar, binder, blood<br /> * Mass casualty events:<br /> ** Suspend elective activity<br /> ** Mobilise resources<br /> ** Pre-empt injuries based on mechanism and prepare<br /> ** Ensure staff safety including PPE<br /> ** Establish command structure<br /> ** Redistribute juniors<br /> ** On-site triage - START<br /> ** Damage-control approach<br /> ** Establish communications and pathways for transfer<br /> <br /> == Triage ==<br /> <br /> * ?activate trauma team<br /> ** Airway<br /> ** Circulation<br /> ** Lines<br /> ** Drugs<br /> ** Scribe<br /> ** Team leader<br /> * See separate topic<br /> <br /> <br /> == Primary survey ==<br /> <br /> * Goal: is the patient shocked, and what is the cause of shock?<br /> * Rapid primary survey with simultaneous initial resus, followed by detailed secondary survey, then definitive care<br /> ** Introduce yourself<br /> ** Ask the patient's name<br /> ** Ask what happened<br /> ** If appropriate answers - ABCD is ok<br /> <br /> ==== '''Airway maintenance, restriction of C-spine''' ====<br /> ** Keep neck still for now - can clear C-spine later<br /> ** Oxygen<br /> ** Inspect for foreign bodies/facial and neck fractures<br /> ** Clear airway<br /> ** Suction<br /> ** Open/secure airway<br /> *** Jaw thrust/chin lift<br /> *** If GCS&lt;8, early intubation, with exact timing depending on other factors including sats<br /> **** Or surgical airway if intubation can't happen for whatever reason<br /> *** If unconscious with no gag reflex, NPA can be helpful<br /> <br /> ==== '''Breathing and ventilation (adequate gas exchange)''' ====<br /> ** Expose neck and chest<br /> ** Inspect neck: tracheal deviation and jugular venous distension and absent unilateral breath sounds = tension PTX -&gt; needle decompression and chest tube<br /> ** Inspect chest: injuries and symmetrical rise<br /> ** Auscultate lungs<br /> ** Specifically exclude and immediately treat<br /> *** tension PTX<br /> *** Massive haemothorax<br /> *** Open PTX<br /> *** Tracheal/bronchial injuries<br /> ** Give oxygen and monitor oximetry<br /> <br /> ==== '''Circulation with haemorrhage control''' ====<br /> ** Hypotension is due to blood loss until proven otherwise<br /> *** Can look at pulse pressure<br /> ** Level of consciousness<br /> ** Skin perfusion<br /> ** Pulse<br /> ** If bleeding externally<br /> *** Direct pressure<br /> *** Tourniquet if direct pressure not working and life is in danger<br /> ** Internal bleeding<br /> *** Chest<br /> *** Abdomen - FAST scan<br /> *** Retroperitoneum<br /> *** Pelvis<br /> **** Needs stabilisation device?<br /> *** Long bones<br /> ** Get vascular access<br /> *** FBE, UEC, LFT, COAG, bHCG, ?TROP, XM/G+H, VBG<br /> ** 1L IV crystalloid if any sign of shock<br /> *** If unresponsive, blood<br /> ** IV tranexamic acid if uncontrollable bleeding<br /> <br /> ==== '''Disability (neurologic)''' ====<br /> ** GCS<br /> *** If low, immediately re-evaluate ABC<br /> *** Assume CNS injury until proven otherwise<br /> *** Consider drugs/alcohol<br /> ** Pupils<br /> <br /> ==== '''Exposure/environmental control''' ====<br /> ** Completely undress patient then warm<br /> <br /> ==== Additional factors for primary survey ====<br /> '''Adjuncts to primary survey'''<br /> ** ECG<br /> ** ?IDC<br /> *** Need to examine perineum/urethral meatus<br /> *** If concern for urethral injury, need retrograde urethrogram prior to IDC<br /> ** X-rays<br /> *** Even in pregnant patients<br /> *** Don’t interrupt resus<br /> ** ?NGT<br /> ** FAST/DPL<br /> '''Consider need for transfer'''<br /> <br /> '''Special populations'''<br /> * Paeds<br /> ** Abundant physiological reserve - don't crash until late<br /> * Pregnancy<br /> * Geriatrics<br /> * Obesity<br /> <br /> == Secondary survey ==<br /> * Wait until primary survey is complete, resus is under way, and patient is improving/stable<br /> <br /> ==== History ====<br /> ** Allergies<br /> ** Meds<br /> ** Past hx/pregnancy<br /> ** Last meal<br /> ** Events leading up to injury<br /> * MVA:<br /> ** ?seat-belt<br /> ** ?steering wheel deformation<br /> ** ?airbags<br /> ** ?direction of impact<br /> ** ?damage to car<br /> ** ?patient position in vehicle<br /> ** ?ejection<br /> <br /> ==== Examination ====<br /> ** Head<br /> *** Scalp - ?lacerations, contusions, fractures<br /> *** Eyes - VA, pupils, conjunctival haemorrhage, penetrating injury, contact lenses (remove before oedema occurs), lens dislocation, ocular entrapment)<br /> ** Maxfacs<br /> *** Palpate all bony structures<br /> *** Intra-oral exam<br /> *** Assess soft tissues<br /> *** These can all be managed later<br /> *** Be wary of cribriform plate fractures<br /> ** C-spine/neck<br /> *** Assume injury until cleared if maxillofacial or head trauma<br /> *** Can use Nexus low-risk criteria to clear spine if<br /> **** No focal neurologic deficit<br /> **** No midline tenderness<br /> **** GCS 15<br /> **** No intoxication<br /> **** No distracting injury<br /> *** Inspect neck<br /> **** Subcutaneous emphysema<br /> **** Tracheal deviation<br /> **** Laryngeal fracture<br /> **** Palpate carotids - ?seatbelt mark or bruise<br /> *** Do not explore wounds that penetrate platysma<br /> *** Any active bleeding, expanding haematoma, arterial bruit or airway compromise requires operative evaluation<br /> ** Chest<br /> *** Visual inspection and palpation<br /> **** Entire chest cage<br /> *** Auscultate high anterior (PTX) and low posterior (HTX)<br /> *** Consider tamponade (distant heart sounds, low pulse pressure, tachycardia, distended neck veins)<br /> ** Abdo/pelvis<br /> *** ?Pelvic fractures - ecchymosis over iliac wings, pubis, labia, scrotum<br /> **** Pain on compression of pelvic ring<br /> **** FAST or DPL if unexplained hypotension, neurologic injury, impaired sensorium, or any abdo findings<br /> *** Seatbelt sign - often a/w mesenteric laceration or small bowel perforation or pancreatic injury<br /> ** Perineum/rectum/vagina<br /> *** Contusions<br /> *** Haematomas<br /> *** Lacerations<br /> *** Urethral bleeding<br /> *** Rectal exam - blood, sphincter tone<br /> *** Pregnancy test<br /> ** MSK<br /> *** Palpate long bones<br /> *** X-ray anything odd<br /> *** Consider compartment syndrome<br /> ** Log roll<br /> *** Each vertebra<br /> *** Check for bruising<br /> ** Neurological<br /> *** Motor and sensory evaluation of extremities<br /> *** Re-evaluation of pupils and GCS<br /> *** If deterioration neurologically - reassess oxygenation, adequacy of ventilation and perfusion of the brain<br /> ** Adjuncts<br /> *** X-rays<br /> *** CT<br /> *** Contrast urography/angiography<br /> *** TTE/TOE<br /> *** Bronchoscopy<br /> *** Oesophagoscopy<br /> ** Reassess need for transfer<br /> [[Category:Trauma]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Trauma_-_initial_assessment&diff=1001 2026-07-26T04:43:19Z

<p>SurgopaediaAdmin: </p> <hr /> <div>== Preparation ==<br /> Pre-hospital:<br /> <br /> * Notify hospital of incoming trauma so team can be mobilised<br /> * Prioritise airway, bleeding control/shock, immobilisation, immediate transport<br /> * Field Triage Decision Scheme ---&gt;<br /> <br /> Hospital:<br /> <br /> * Smooth handover between team leader and paramedics<br /> ** Hands off handover - &quot;MIST&quot;<br /> ** Mechanism<br /> ** Injuries found and suspected<br /> ** Symptoms and signs<br /> ** Treatment initiated<br /> * Critical aspects:<br /> ** Resus area available<br /> ** Airway equipment accessible - tracheostomy, video laryngoscopy<br /> ** Warmed crystalloid solution<br /> ** Protocol to guide rapid response by medical, pathology, radiology<br /> ** Idea of transfer processes to trauma centre<br /> ** Standard precautions for all attendees<br /> ** Equipment - RIC lines, collar, binder, blood<br /> * Mass casualty events:<br /> ** Suspend elective activity<br /> ** Mobilise resources<br /> ** Pre-empt injuries based on mechanism and prepare<br /> ** Ensure staff safety including PPE<br /> ** Establish command structure<br /> ** Redistribute juniors<br /> ** On-site triage - START<br /> ** Damage-control approach<br /> ** Establish communications and pathways for transfer<br /> <br /> == Triage ==<br /> <br /> * ?activate trauma team<br /> ** Airway<br /> ** Circulation<br /> ** Lines<br /> ** Drugs<br /> ** Scribe<br /> ** Team leader<br /> * See separate topic<br /> <br /> <br /> == Primary survey ==<br /> <br /> * Goal: is the patient shocked, and what is the cause of shock?<br /> * Rapid primary survey with simultaneous initial resus, followed by detailed secondary survey, then definitive care<br /> ** Introduce yourself<br /> ** Ask the patient's name<br /> ** Ask what happened<br /> ** If appropriate answers - ABCD is ok<br /> * '''Airway maintenance, restriction of C-spine'''<br /> ** Keep neck still for now - can clear C-spine later<br /> ** Oxygen<br /> ** Inspect for foreign bodies/facial and neck fractures<br /> ** Clear airway<br /> ** Suction<br /> ** Open/secure airway<br /> *** Jaw thrust/chin lift<br /> *** If GCS&lt;8, early intubation, with exact timing depending on other factors including sats<br /> **** Or surgical airway if intubation can't happen for whatever reason<br /> *** If unconscious with no gag reflex, NPA can be helpful<br /> * '''Breathing and ventilation (adequate gas exchange)'''<br /> ** Expose neck and chest<br /> ** Inspect neck: tracheal deviation and jugular venous distension and absent unilateral breath sounds = tension PTX -&gt; needle decompression and chest tube<br /> ** Inspect chest: injuries and symmetrical rise<br /> ** Auscultate lungs<br /> ** Specifically exclude and immediately treat<br /> *** tension PTX<br /> *** Massive haemothorax<br /> *** Open PTX<br /> *** Tracheal/bronchial injuries<br /> ** Give oxygen and monitor oximetry<br /> * '''Circulation with haemorrhage control'''<br /> ** Hypotension is due to blood loss until proven otherwise<br /> *** Can look at pulse pressure<br /> ** Level of consciousness<br /> ** Skin perfusion<br /> ** Pulse<br /> ** If bleeding externally<br /> *** Direct pressure<br /> *** Tourniquet if direct pressure not working and life is in danger<br /> ** Internal bleeding<br /> *** Chest<br /> *** Abdomen - FAST scan<br /> *** Retroperitoneum<br /> *** Pelvis<br /> **** Needs stabilisation device?<br /> *** Long bones<br /> ** Get vascular access<br /> *** FBE, UEC, LFT, COAG, bHCG, ?TROP, XM/G+H, VBG<br /> ** 1L IV crystalloid if any sign of shock<br /> *** If unresponsive, blood<br /> ** IV tranexamic acid if uncontrollable bleeding<br /> * '''Disability (neurologic)'''<br /> ** GCS<br /> *** If low, immediately re-evaluate ABC<br /> *** Assume CNS injury until proven otherwise<br /> *** Consider drugs/alcohol<br /> ** Pupils<br /> * '''Exposure/environmental control'''<br /> ** Completely undress patient then warm<br /> <br /> ==== Adjuncts to primary survey ====<br /> ** ECG<br /> ** ?IDC<br /> *** Need to examine perineum/urethral meatus<br /> *** If concern for urethral injury, need retrograde urethrogram prior to IDC<br /> ** X-rays<br /> *** Even in pregnant patients<br /> *** Don’t interrupt resus<br /> ** ?NGT<br /> ** FAST/DPL<br /> <br /> ==== Consider need for transfer ====<br /> <br /> ==== Special populations ====<br /> * Paeds<br /> ** Abundant physiological reserve - don't crash until late<br /> * Pregnancy<br /> * Geriatrics<br /> * Obesity<br /> <br /> == Secondary survey ==<br /> * Wait until primary survey is complete, resus is under way, and patient is improving/stable<br /> <br /> ==== History ====<br /> ** Allergies<br /> ** Meds<br /> ** Past hx/pregnancy<br /> ** Last meal<br /> ** Events leading up to injury<br /> * MVA:<br /> ** ?seat-belt<br /> ** ?steering wheel deformation<br /> ** ?airbags<br /> ** ?direction of impact<br /> ** ?damage to car<br /> ** ?patient position in vehicle<br /> ** ?ejection<br /> <br /> ==== Examination ====<br /> ** Head<br /> *** Scalp - ?lacerations, contusions, fractures<br /> *** Eyes - VA, pupils, conjunctival haemorrhage, penetrating injury, contact lenses (remove before oedema occurs), lens dislocation, ocular entrapment)<br /> ** Maxfacs<br /> *** Palpate all bony structures<br /> *** Intra-oral exam<br /> *** Assess soft tissues<br /> *** These can all be managed later<br /> *** Be wary of cribriform plate fractures<br /> ** C-spine/neck<br /> *** Assume injury until cleared if maxillofacial or head trauma<br /> *** Can use Nexus low-risk criteria to clear spine if<br /> **** No focal neurologic deficit<br /> **** No midline tenderness<br /> **** GCS 15<br /> **** No intoxication<br /> **** No distracting injury<br /> *** Inspect neck<br /> **** Subcutaneous emphysema<br /> **** Tracheal deviation<br /> **** Laryngeal fracture<br /> **** Palpate carotids - ?seatbelt mark or bruise<br /> *** Do not explore wounds that penetrate platysma<br /> *** Any active bleeding, expanding haematoma, arterial bruit or airway compromise requires operative evaluation<br /> ** Chest<br /> *** Visual inspection and palpation<br /> **** Entire chest cage<br /> *** Auscultate high anterior (PTX) and low posterior (HTX)<br /> *** Consider tamponade (distant heart sounds, low pulse pressure, tachycardia, distended neck veins)<br /> ** Abdo/pelvis<br /> *** ?Pelvic fractures - ecchymosis over iliac wings, pubis, labia, scrotum<br /> **** Pain on compression of pelvic ring<br /> **** FAST or DPL if unexplained hypotension, neurologic injury, impaired sensorium, or any abdo findings<br /> *** Seatbelt sign - often a/w mesenteric laceration or small bowel perforation or pancreatic injury<br /> ** Perineum/rectum/vagina<br /> *** Contusions<br /> *** Haematomas<br /> *** Lacerations<br /> *** Urethral bleeding<br /> *** Rectal exam - blood, sphincter tone<br /> *** Pregnancy test<br /> ** MSK<br /> *** Palpate long bones<br /> *** X-ray anything odd<br /> *** Consider compartment syndrome<br /> ** Log roll<br /> *** Each vertebra<br /> *** Check for bruising<br /> ** Neurological<br /> *** Motor and sensory evaluation of extremities<br /> *** Re-evaluation of pupils and GCS<br /> *** If deterioration neurologically - reassess oxygenation, adequacy of ventilation and perfusion of the brain<br /> ** Adjuncts<br /> *** X-rays<br /> *** CT<br /> *** Contrast urography/angiography<br /> *** TTE/TOE<br /> *** Bronchoscopy<br /> *** Oesophagoscopy<br /> ** Reassess need for transfer<br /> [[Category:Trauma]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Pruritis_ani&diff=1000 2026-06-01T05:36:28Z

<p>SurgopaediaAdmin: </p> <hr /> <div>'Unpleasant itching and burning of perianal skin'<br /> <br /> * Typically worse at night or in warm, moist climates<br /> <br /> == '''Secondary pruritus ani''' ==<br /> <br /> * '''Infectious'''<br /> ** Bacterial<br /> ** Fungal<br /> *** Candida responsible for up to 15%<br /> *** Especially in immunosupressed, on Abx, on steroids<br /> *** Diffuse, erythematous, macerated plaques<br /> *** Dermatophytes<br /> *** Treat with topical or systemic antifungals<br /> ** STI<br /> *** Gonorrhoea<br /> *** Chlamydia<br /> *** Syphilis<br /> ** Parasites<br /> *** Esp nocturnal symptoms in children - pinworms<br /> *** Scabies<br /> *** Crabs<br /> ** Viral<br /> *** HSV<br /> *** HPV - condyloma<br /> *** HZ + shingles<br /> * '''Anorectal'''<br /> ** Chronic inflammation<br /> *** Pilonidal disease<br /> *** Perianal Crohns<br /> *** Hidradenitis suppuritiva<br /> ** Faecal contamination<br /> *** Haemorrhoids<br /> *** Fistula-in-ano<br /> *** Anal fissures<br /> *** Faecal incontinence<br /> *** Skin tags<br /> *** Chronic diarrhoea<br /> * '''Dermatologic'''<br /> ** Contact dermatitis<br /> *** Ask about cleaning products/hygiene<br /> ** Atopic dermatitis<br /> *** Ask about other atopy<br /> ** Perianal psoriasis<br /> *** Scalp, flexor surfaces<br /> ** Lichen sclerosis<br /> **** Commonly perimenopausal women, but can be associated with other autoimmune conditions<br /> **** Probably also have vulvovaginal pruritis<br /> **** Can give topical steroids - betamethasone topical (Diprosone 0.05%) daily for two weeks, then not more than twice a week to avoid skin atrophy<br /> **** Barrier ointment like vaseline<br /> **** Avoid harsh toilet paper, microtrauma of any form<br /> **** Beware of malignant transformation into SCC - 5% lifetime risk<br /> ** Seborrheic dermatitis<br /> ** Radiation dermatitis<br /> * '''Malignant'''<br /> ** Anal canal cancer<br /> ** Anal margin cancer<br /> ** Rectal cancer<br /> ** Bowen's disease<br /> ** Extramammary Paget's (cutaneous adenocarcinoma in situ)<br /> * '''Systemic disease'''<br /> ** Diabetes<br /> ** Leukaemia<br /> ** Lymphoma<br /> ** CKD (uraemia - only cure is kidney transplant)<br /> ** IDA<br /> ** Hyperthyroid<br /> ** Hyperbilirubinaemia - ?cholestyramine<br /> <br /> == Idiopathic ==<br /> <br /> * '''Diagnosis of exclusion'''<br /> * Likely caused by faecal contamination leading to local irritation<br /> ** Chronic diarrhoea<br /> ** Poor hygiene or overzealous hygiene<br /> ** Faecal incontinence<br /> ** Mucus leakage<br /> ** ?Pruritogenic foods<br /> * 'Itch-scratch cycle' likely feeds into the chronic nature of this condition<br /> <br /> == History should be thorough ==<br /> <br /> * Onset and duration<br /> * Toileting behaviours<br /> * Mucus leakage or perianal moisture<br /> * Travel history<br /> * Medications and allergies<br /> <br /> == Workup ==<br /> <br /> * Biopsy suspicious lesions<br /> * Bacterial and fungal swabs<br /> * Tape test for pinworm?<br /> <br /> == Simple management suggestions ==<br /> <br /> * Shower after opening bowels and pat dry with unscented TP<br /> * If moist area, consider talc powder<br /> * Treat any chronic diarrhoea with fibre supplements<br /> * Avoid tight-fitting garments and perfumed products<br /> * Try to avoid scratching<br /> * Can trial topical steroids<br /> <br /> == Second-line therapy: ==<br /> <br /> * Topical capsaicin (0.006%) TDS for 4 weeks - desensitises skin - seems to work up 70% of patients<br /> * Topical tacrolimus has been tried<br /> * Intradermal methylene blue - directly toxic to sensory nerves<br /> <br /> <br /> [[Category:Colorectal]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Main_Page&diff=998 2026-05-02T11:09:01Z

<p>SurgopaediaAdmin: </p> <hr /> <div>== Introduction ==<br /> [[File:Surgopaedia Logo Large.jpg|right|frameless|257x257px]]<br /> Surgopaedia.org is a free, unreferenced, point-of-care resource designed to help residents and registrars training in General Surgery in Australia. It's written at the level of fellowship exam study and follows the curriculum quite closely, pulling together lots of different resources. <br /> <br /> There is enough breadth and depth of knowledge here to survive a night shift, a sub-specialty rotation, or pass the exam. The core surgical topics are very detailed (like [[breast cancer]] or [[acute pancreatitis]]), and the peripheral topics (like [[shock]] or [[empyema]]) are less detailed. <br /> <br /> Start by searching for an article or clicking 'categories' below.<br /> <br /> '''While every effort has been made to ensure accuracy of these pages, clinicians should independently verify information before applying it. This is intended as a general study resource, not to provide medical advice on a specific patient.'''<br /> <br /> == Categories ==<br /> [[Special:Categories|List of article categories]]<br /> <br /> [[:Category:Intern education|The most useful articles for interns]]<br /> <br /> [[:Category:FEX|Common fellowship exam topics]]<br /> <br /> == Editing ==<br /> Edits can be suggested on each page, but all changes are reviewed to maintain accuracy. <br /> <br /> == Contact ==<br /> Created by Dr Simon Bennet based on fellowship exam study notes. No AI.<br /> <br /> admin@surgopaedia.org</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Ventral_rectopexy&diff=996 2026-04-02T22:24:28Z

<p>SurgopaediaAdmin: </p> <hr /> <div>== Set-up: ==<br /> <br /> * Lithotomy with left arm out (potentially both arms tucked would be helpful)<br /> * Skin on gel mat - extended head down is required for basically the whole procedure<br /> * IDC<br /> * Assistant stands on left <br /> <br /> == Technique: ==<br /> <br /> * Infra-umbilical Hasson, 5mm ports in RIF x2 and LIF<br /> ** RLQ port needs to be above level ASIS to allow it to get across pelvic brim<br /> ** RUQ port needs to be more medial to allow triangulation on pelvis<br /> ** Left lateral port at level of umbilicus, doesn't really matter exactly where<br /> * Straight needle to stitch uterus out of the way<br /> * Assess abdomen, particularly for redundant sigmoid<br /> * Use endoloop brought out through the left port on an epiploic appendage to hoist up sigmoid<br /> * Identify landing zone on sacrum - look for the flat shelf<br /> * Use hook to create peritoneal flap from sacrum to peritoneal reflection, curving on the right of the rectum through to anterior to rectum<br /> * Dissect rectovaginal/rectoprostatic plane<br /> ** DRE to confirm reached just above pelvic floor<br /> ** Use assistant with an A-trak lifting upwards, look carefully for SV/prostate in man and vagina in woman<br /> ** Bleeding indicates wrong plane<br /> * Ti-mesh - cut a diagonal strip, 15cm long or so, along the line that doesn't stretch. The distal end should flare slightly. <br /> ** Other mesh options - BioDesign rectopexy graft; Phasix; BioA<br /> ** 6x distal sutures in two rows<br /> ** A mid-rectum suture may be required too<br /> ** 2x AbsorbaTacks (ideally protacks) to hold mesh in place, then a big deep suture (can use the big needle Prolene, I think it was 0 Prolene on a big chunky needle)<br /> * Suture peritoneal flap closed with 2/0 absorbable V-lok <br /> <br /> == Post-op ==<br /> <br /> * Keep stool soft<br /> [[Category:Colorectal]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Ventral_rectopexy&diff=995 2026-04-02T22:24:10Z

<p>SurgopaediaAdmin: Created page with &quot;== Set-up: == * Lithotomy with left arm out (potentially both arms tucked would be helpful) * Skin on gel mat - extended head down is required for basically the whole procedure * IDC * Assistant stands on left == Technique: == * Infra-umbilical Hasson, 5mm ports in RIF x2 and LIF ** RLQ port needs to be above level ASIS to allow it to get across pelvic brim ** RUQ port needs to be more medial to allow triangulation on pelvis ** Left lateral port at level of umbilicus...&quot;</p> <hr /> <div>== Set-up: ==<br /> <br /> * Lithotomy with left arm out (potentially both arms tucked would be helpful)<br /> * Skin on gel mat - extended head down is required for basically the whole procedure<br /> * IDC<br /> * Assistant stands on left <br /> <br /> == Technique: ==<br /> <br /> * Infra-umbilical Hasson, 5mm ports in RIF x2 and LIF<br /> ** RLQ port needs to be above level ASIS to allow it to get across pelvic brim<br /> ** RUQ port needs to be more medial to allow triangulation on pelvis<br /> ** Left lateral port at level of umbilicus, doesn't really matter exactly where<br /> * Straight needle to stitch uterus out of the way<br /> * Assess abdomen, particularly for redundant sigmoid<br /> * Use endoloop brought out through the left port on an epiploic appendage to hoist up sigmoid<br /> * Identify landing zone on sacrum - look for the flat shelf<br /> * Use hook to create peritoneal flap from sacrum to peritoneal reflection, curving on the right of the rectum through to anterior to rectum<br /> * Dissect rectovaginal/rectoprostatic plane<br /> ** DRE to confirm reached just above pelvic floor<br /> ** Use assistant with an A-trak lifting upwards, look carefully for SV/prostate in man and vagina in woman<br /> ** Bleeding indicates wrong plane<br /> * Ti-mesh - cut a diagonal strip, 15cm long or so, along the line that doesn't stretch. The distal end should flare slightly. <br /> ** Other mesh options - BioDesign rectopexy graft; Phasix; BioA<br /> ** 6x distal sutures in two rows<br /> ** A mid-rectum suture may be required too<br /> ** 2x AbsorbaTacks (ideally protacks) to hold mesh in place, then a big deep suture (can use the big needle Prolene, I think it was 0 Prolene on a big chunky needle)<br /> * Suture peritoneal flap closed with 2/0 absorbable V-lok <br /> <br /> == Post-op ==<br /> <br /> * Keep stool soft</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Anastomosis&diff=994 2026-04-02T22:08:48Z

<p>SurgopaediaAdmin: </p> <hr /> <div>== '''Techniques''' ==<br /> <br /> * Layers<br /> ** Single-layer has a lower risk of stricture<br /> ** Single layer is favoured by many surgeons when the bowel is unhealthy or access is harder<br /> * Configuration<br /> ** End-to-end and isoperistaltic anastomoses are easier to scope through, so may be favoured in IBD<br /> * Tools<br /> ** Surgeons should be comfortable choosing either stapled or sewn depending on the situation<br /> ** Sutured and stapled have the same incidence of leak<br /> ** Multi-layered sutured has a higher risk of stricture<br /> ** Braided sutures cause more inflammation and can 'saw' through tissue, therefore most use monofilament (PDS, Monocryl or Prolene are acceptable)<br /> ** Reasons to favour sutured:<br /> *** Non-healthy bowel or difficult circumstances, according to Schein's (oedematous bowel more likely to leak if stapled)<br /> *** Cheaper<br /> *** Single-layer continuous isn't MUCH slower than stapled<br /> *** Easier to subsequently scope through an end-to-end anastomosis<br /> ** Reasons to favour stapled:<br /> *** Faster<br /> *** Better in difficult-to-access areas (oesophageal and rectal)<br /> *** Laparoscopic<br /> *** Possibly lower leak rate in IBD<br /> * Disparity in size<br /> ** Cheatle slit can be done in the antimesenteric border of the narrower segment<br /> ***<br /> ** If &gt;2cm disparity, end-to-side anastomosis could be considered - e.g. low colorectal join<br /> * In summary:<br /> *** Deep in pelvis, use the circular stapler<br /> *** For small bowel, I prefer single-layer interrupted with PDS<br /> **** Colonic hand-sewn can be done in the same fashion<br /> *** Normal bowel in an elective right hemicolectomy or small bowel resection can also reasonably have a stapled functional end-to-end anastomosis<br /> *** For oedematous bowel, use single layer interrupted sutures with PDS. Invert the mucosa with big seromuscular bites and tiny mucosal bites, and suture inside the lumen where possible. Take bigger bites (up to 1cm) when the bowel edges are not perfect.<br /> *** To occlude bowel, use a stapler (Hartmann's or small bowel transection in ischaemia)<br /> <br /> == '''Contraindications''' ==<br /> <br /> * Multifactorial, requiring consideration of the holistic situation<br /> * Consider whether the patient can survive a leak<br /> * For small bowel, do not anastomose if two or more factors. For large bowel, do not anastomose if one or more factors.<br /> ** Diffuse established peritonitis or intra-abdominal infection<br /> ** Post-operative peritonitis<br /> ** Leaking anastomosis<br /> ** Mesenteric ischaemia<br /> ** Extreme bowel oedema/distension<br /> ** Extreme malnutrition with low serum albumin<br /> ** Chronic steroid intake<br /> ** Unstable patient<br /> ** Irradiated bowel<br /> <br /> == '''Sutured''' ==<br /> <br /> === '''Single layer end to end''' ===<br /> <br /> ** Continuous<br /> *** Two anchor sutures - mesenteric and anti-mesenteric<br /> *** Close the entire backwall with a single running suture (generally Lembert sutures - see below)<br /> **** Options for sutures -  Lembert, Cushing, seromuscular<br /> **** Seromuscular inverts the least, and may be useful when the lumen is small<br /> *** Flip and close the other side<br /> *** Test lumen size by invaginating the wall<br /> ** Interrupted<br /> **** ''Use good seromuscular bites throughout and only pick up a small amount of mucosa''<br /> **** The back wall (mesenteric side) is done with vertical mattress sutures - all full-thickness with knots inside. Mesenteric stay suture first, then work alternately around in each direction.<br /> **** Posterior wall interrupted until get to 3 and 9 o'clock - leave these untied and clipped as stays<br /> **** Flip anterior<br /> **** The 3 and 9 o'clock 'corner' sutures are simple interrupted full-thickness, directed back behind the previous stays. Knots on outside. Flip the previous stays up in front of them, then tie. Then you can tie the previous stays on the inside and cut them. Leave the new stays long.<br /> **** Complete the anterior wall with seromuscular sutures with knots outside - use bisecting method.<br /> **** Leak test with betadine on blunt needle before tying last knot<br /> <br /> === '''Double layer end to end''' ===<br /> <br /> ** Most commonly the inner layer is continuous and outer layer interrupted<br /> ** Holding sutures on either end (seromuscular at anti-mesenteric and mesenteric borders)<br /> ** Third seromuscular suture to bisect the posterior wall<br /> ** Complete the posterior wall with seromuscular sutures<br /> ** Retain the two holding sutures long, but cut the others<br /> ** Flip the bowel<br /> ** Close the mucosal layer of the posterior wall (from anterior) with a running suture (Chassin's says use a double-ended suture)<br /> ** Complete anterior mucosal layer using either Connell technique or a continuous Cushing suture<br /> ** Anterior seromuscular layer<br /> ** Inspect for leak/patency<br /> <br /> === '''Side to side double layer''' - full thickness inner layer, seromuscular outer layer; good for bypasses. ===<br /> <br /> ** Lay the two segments side to side for 8cm with a continuous posterior seromuscular suture<br /> ** Incise the anti-mesenteric borders for 5cm<br /> ** Inner wall left - continuous over-and-over technique plus Connell suture for the corners.<br /> *** Start in middle of back wall with over-and-over technique towards left side<br /> *** In to out on near side corner, then out to in on far side<br /> *** Now do the true Connell stitch, out-to-in then in-to-out on the same side before crossing over to the other side<br /> *** Go about halfway then stop and leave long<br /> ** Inner wall right - start again on the posterior wall, coming around the corner with another Connell, then meeting for the front wall and tying<br /> ** Outer front layer seromuscular continuous - Lembert<br /> **<br /> <br /> <br /> <br /> == '''Types of sutures''' ==<br /> <br /> === '''Seromuscular suture technique''' ===<br /> <br /> * This allows inversion of the mucosal layer<br /> * The suture should only penetrate as far as the submucosa<br /> * Interrupted sutures only<br /> *<br /> <br /> === '''Lembert stitch''' ===<br /> <br /> * This can be applied in a continuous fashion<br /> * Catch about 5mm of tissue and emerge 1-2mm proximal to the cut edge of the serosa<br /> * Can be used for single-layer anastomosis<br /> * Idea is to invert the bowel edge<br /> * Should be seromuscular bites<br /> <br /> === '''Cushing stitch''' ===<br /> <br /> * Similar to Lembert, but inserted parallel to and 2-4mm from the cut edge of bowel<br /> * Catches about 5mm of bowel<br /> * Can be either interrupted or continuous<br /> *<br /> <br /> === Connell stitch ===<br /> <br /> * Originally for performing a single-layer end-to-end anastomosis<br /> * Also often used for the outer layer of a double-layered anastomosis, because it is intended to invert/bury and to be water-tight<br /> * 'Go into the bar, then out of the bar, then cross the street and go into the bar, then out of the bar, then cross the street…' etc<br /> * Not extremely effective as a haemostatic suture<br /> <br /> === Halsted stitch ===<br /> <br /> * A variation of the Cushing stitch with seromuscular depth<br /> * Provides seromuscular apposition in a bowel anastomosis<br /> * Excessive tension can cause strangulation of a larger bite of tissue<br /> <br /> <br /> == '''Stapled''' ==<br /> <br /> === '''Functional end-to-end extracorporeal''' ===<br /> <br /> ** Ask for - 2x soft bowel clamps, GIA 80 blue stapler with one reload available; other stuff should be on set-up already.<br /> ** Divide mesentery between the two points where you will be inserting the stapler<br /> *** Ligasure/Harmonic - score mesentery then directly across, double burning<br /> *** Ties - score mesentery with diathermy; thin out a window 2 inches away between two fingers; clamp above and below with Roberts forceps; cut across with scissors<br /> ** Downstream soft bowel clamps - one click<br /> ** Protect the wound with packs<br /> ** Position the bowel so that anti-mesenteric borders are in apposition<br /> *** Optional - suture near the planned enterotomies to hold the bowel in apposition, if having trouble keeping it still<br /> ** Create small enterotomies at the anti-mesenteric edge with cutting diathermy and insert a linear cutting stapler (usually blue GIA 80). Check mesentery is free at each end. Be sure to support the bowel well, so it doesn't get any tension from the weight of the staplers.<br /> ** Fire the stapler<br /> ** Remove the stapler and apply Babcock clamps to two lips of the enterotomy, offsetting the opposing staple lines. Check for intra-luminal bleeding, and oversew if with 3/0 PDS if needed.<br /> ** Close the defect by firing a new stapler cartridge transversely across the top<br /> *** Haemostasis by very conservative diathermy or interrupted PDS figure-of-eight<br /> *** Underrun the staple line with 3/0 PDS continuous, and consider inverting/imbricating the ends of the staple line<br /> ** Crotch suture x2<br /> ** Close the mesenteric defect with interrupted 3/0 PDS<br /> ** Cover the anastomosis with omentum if feasible<br /> <br /> <br /> <br /> == '''Anastomotic leak''' ==<br /> <br /> === '''Incidence''' ===<br /> <br /> ** Ileocolic anastomosis: 1-3%<br /> ** Colo-anal anastomosis: 20%<br /> ** Majority become apparent between day 2 and 7 (median 5.5), but up to 12% can appear 1 month after surgery<br /> <br /> === '''Risk factors:''' ===<br /> <br /> ** '''Patient factors:'''<br /> *** Patient nutritional status<br /> **** Often use albumin as a proxy for nutritional status<br /> **** However, the difference is probably small unless profound malnutrition is present<br /> *** Microbiome<br /> **** E.g. some species may favour production of certain proteins<br /> **** Unanswered questions around the role of pre-op Abx and the role of topical Abx at anastomotic site<br /> *** Medications<br /> *** Radiotherapy to area<br /> *** Male gender<br /> *** Obesity<br /> *** ASA score III or IV<br /> *** Emergency operation<br /> *** Use of oral anticoagulants<br /> ** '''Operative factors:'''<br /> *** Tension<br /> **** Unsubstantiated at individual patient level<br /> *** Hypoperfusion<br /> **** Especially any vasopressor requirement<br /> **** ?diminished oxygen tension - hypoxia may impair collagen synthesis<br /> **** Coronary artery disease<br /> **** Radiotherapy to pelvis prior<br /> *** Multiple stapler firings<br /> *** Needs to be water- and air-tight, and technically sound, regardless of specific technique used<br /> *** Mesentery<br /> **** Kono-S anastomosis may help by excluding diseased mesentery<br /> *** Geometrical anastomosis construction<br /> *** Low extraperitoneal anastomosis<br /> *** Surgeon experience<br /> *** Diverting stoma<br /> **** Does not decrease incidence of leak, but does reduce severity and lower risk of re-operation<br /> <br /> === '''Presentation/evaluation:''' ===<br /> <br /> ** Clinically - fever sepsis, abdominal pain, prolonged ileus, leucocytosis, CRP, raised pro-calcitonin<br /> ** Using CRP<br /> *** Probably worth doing daily CRP up to day 5<br /> *** If there are two &gt;50 increases in a row, pretty specific for leak<br /> *** If do all five days and never increases by &gt;50 between any two, sensitivity 0.85 for leak<br /> *** Increase &gt;50 between two days on day 3 or later is &gt;0.90 specific for leak<br /> *** Mean values from a 2023 meta-analysis comparing leak/no leak. Note multiply mg/dl by 10 to reach mg/L.<br /> **** CRP &gt;159 on D3 is 77% sp/74% se/LR+ 3.21/LR- 0.29<br /> **** CRP &gt;114 on D4 is 76% sp/78% se/LR+ 3.29/LR- 0.24<br /> **** CRP &gt;109 on D5 is 80% sp/76% se/LR+ 3.81/LR- 0.26<br /> <br /> * CT - intra-abdominal or peri-anastomotic fluid collections and gas, or based on Gastrografin enema<br /> <br /> === '''Treatment''' ===<br /> <br /> ** Subclinical (minimal discharge from drains, no systemic signs) - conservative management with close observation, antibiotics, bowel rest, TPN<br /> *** If there are no drains, likely get enteric contents leaking, leave it as a controlled fistula, apply SNAPS principles<br /> *** Large proportion will close spontaneously<br /> *** If it hasn't closed by six weeks, elective re-operation to make a new anastomosis<br /> ** Abscess<br /> *** Small peri-anastomotic abscess - percutaneous drainage with medical management<br /> *** Complex intra-abdominal abscesses not suitable for or responding to percutaneous drainage - surgery<br /> ** Peritonitis or sepsis (even if minimal) - re-operation as soon as possible<br /> *** Only resect and re-anastomose in VERY select patients - stable patient, minimally compromised, minimal peritonitis, good-quality bowel<br /> *** Leak involves less than a third of anastomosis and minimal contamination: diverting stoma or directly exteriorise the leak<br /> *** Leak is larger or the anastomosis is disrupted: dismantle the anastomosis and create a terminal stoma (can consider just redoing the anastomosis for an ileocolic anastomosis, but safer to bring out as end ileostomy)<br /> <br /> == '''Anastomotic stricture''' (4-10% of circular anastomosis) ==<br /> <br /> * Risk factors<br /> ** E-E configuration with circular stapler<br /> ** Small circular staplers (25mm or smaller)<br /> ** Multi-layer<br /> ** Leak<br /> ** Radiation<br /> ** Ischaemia<br /> * Treatment<br /> ** Balloon dilatation, radial incisions, or endoluminal stents<br /> ** Redo may be necessary if endoscopic treatment doesn't work<br /> <br /> == '''Bleeding''' ==<br /> <br /> * Minor - very common - observation<br /> * Major bleeding requiring transfusion (4%)<br /> ** Generally caused by small arterioles at the staple line<br /> ** Treat endoscopically in most cases - place clips, adrenaline, or diathermy<br /> ** Angiographic treatment is possible but dangerous for the anastomosis<br /> <br /> == '''Twisting''' ==<br /> <br /> * Rare but serious<br /> * Occurs in extracorporeal ileocolic anastomosis - caused by suboptimal visualisation of the mesentery and mesocolon through the mini-laparotomy<br /> * Causes immediate oedema of the small bowel that leads to ischaemia and gangrene unless treated with prompt redo<br /> <br /> [[Category:Colorectal]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Rigid_sigmoidoscopy&diff=993 2026-03-24T09:58:01Z

<p>SurgopaediaAdmin: Created page with &quot; == Equipment == * Rigid sig - get from OT or CSSD - with light source * Lube (lots of packs) * PPE: bluies, long-sleeved gown, mask with eye shield, double long gloves * Rectal tube, drainage bag, flexitrak * Fleet enema to put up tube? == Set-up == * Nurse assistant * Positioning: left lateral with knees up, like colonoscopy; bottom near edge of bed; bed at comfortable height, assistant on opposite side supporting patient/holding them still * No analgaesia usually r...&quot;</p> <hr /> <div><br /> == Equipment ==<br /> <br /> * Rigid sig - get from OT or CSSD - with light source<br /> * Lube (lots of packs)<br /> * PPE: bluies, long-sleeved gown, mask with eye shield, double long gloves<br /> * Rectal tube, drainage bag, flexitrak<br /> * Fleet enema to put up tube?<br /> <br /> == Set-up ==<br /> <br /> * Nurse assistant<br /> * Positioning: left lateral with knees up, like colonoscopy; bottom near edge of bed; bed at comfortable height, assistant on opposite side supporting patient/holding them still<br /> * No analgaesia usually required<br /> <br /> == Insertion ==<br /> <br /> * DRE to maximum<br /> * Light source on <br /> * Lube up and insert scope, aiming towards umbilicus<br /> * Insert under vision to navigate rectal folds - insufflate with trapdoor at back closed, with lowest pressure that allows you to see mucosa<br /> * Insert to hilt<br /> * Stand back and flick open trapdoor<br /> * Place rectal tube through channel and use the trochar to push it all the way up, holding it there as you remove the tube itself<br /> * Attach to bag and secure with flexitrak<br /> * +/- fleet<br /> * Check abdomen for improvement, useful to get a baseline AXR after decompression<br /> * If inadequate decompression, needs OT<br /> <br /> *</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Open_chest_drain&diff=992 2026-03-24T09:50:36Z

<p>SurgopaediaAdmin: </p> <hr /> <div>== Equipment ==<br /> <br /> * Chest tube pack or similar (sterile field, kidney dish, gauze)<br /> * Sterile gloves and glown<br /> * Prep<br /> * Skin marker<br /> * Local anaesthetic, drawing up needle, syringe and needle<br /> * Scalpel<br /> * Suture (0 or 1 silk or ethibond or similar) and suture kit<br /> * 28Fr chest tube (by default)<br /> ** Do wide-bore chest drain for traumatic injuries<br /> ** Small drain for spontaneous PTX or thin fluid<br /> * Underwater seal drain and tape to secure<br /> * 2x Roberts forceps<br /> <br /> == Set-up ==<br /> <br /> * Doctor to manage sedation and nurse to help with sterile setup<br /> * Procedural sedation/analgaesia (ketamine is ideal in ED)<br /> * 45 degrees, ipsilateral arm behind head<br /> * Palpate and mark landmarks when in position<br /> <br /> == Procedure ==<br /> <br /> * Find 5th intercostal space in midaxillary line (triangle of safety)<br /> ** Palpate sternal angle (space inferolaterally is second intercostal space)<br /> * Prep, drape, LA (skin then deeper down to parietal pleura)<br /> * Incision (3cm)<br /> * Blunt dissect with arteries down to parietal pleura (Under vision)<br /> * Puncture parietal pleura with arteries and use finger to free up pleural surface<br /> * Pass chest drain into cavity with 2x Roberts, one on end and one middle<br /> ** PTX - towards apex<br /> ** HTX - towards base<br /> ** Empyema - to most dependent part<br /> * Should see either fogging of tube (PTX) or fluid (HTX)<br /> * Connect tube to UWSD and check for swinging<br /> * Suture in place and occlusive dressing<br /> * CXR<br /> <br /> == Complications ==<br /> '''Table 1: frequency of complications for large bore chest drains (Reproduced with permission from [5])'''<br /> {| class=&quot;wikitable&quot;<br /> |'''Complication'''<br /> |'''Frequency'''<br /> |-<br /> |Injury<br /> |1.4%<br /> |-<br /> |Malposition<br /> |6.5%<br /> |-<br /> |Empyema<br /> |1.4%<br /> |-<br /> |Drain blockage<br /> |5.2%<br /> |}<br /> <br /> <br /> If &gt;1.5L blood loss initially, or &gt;200mL/hr for first 2-4 hours, probably needs thoracotomy<br /> [[Category:Thoracics]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Main_Page&diff=991 2026-03-15T04:40:46Z

<p>SurgopaediaAdmin: </p> <hr /> <div>== Introduction ==<br /> [[File:Surgopaedia Logo Large.jpg|right|frameless|257x257px]]<br /> Surgopaedia.org is a free, unreferenced, point-of-care resource designed to help residents and registrars training in General Surgery in Australia. It's written at the level of fellowship exam study and follows the curriculum quite closely, pulling together lots of different resources. <br /> <br /> There is enough breadth and depth of knowledge here to survive a night shift, a sub-specialty rotation, or pass the exam. The core surgical topics are very detailed (like [[breast cancer]] or [[acute pancreatitis]]), and the peripheral topics (like [[shock]] or [[empyema]]) are less detailed. <br /> <br /> Start by searching for an article or clicking 'categories' below.<br /> <br /> '''While every effort has been made to ensure accuracy of these pages, clinicians should independently verify information before applying it. This is intended as a general study resource, not to provide medical advice on a specific patient.'''<br /> <br /> == Categories ==<br /> [[Special:Categories|List of article categories]]<br /> <br /> [[:Category:Intern education|The most useful articles for interns]]<br /> <br /> [[:Category:FEX|Common fellowship exam topics]]<br /> <br /> == Editing ==<br /> Edits can be suggested on each page, but all changes are reviewed to maintain accuracy. <br /> <br /> == Contact ==<br /> admin@surgopaedia.org</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Main_Page&diff=990 2026-03-15T04:01:51Z

<p>SurgopaediaAdmin: </p> <hr /> <div>== Introduction ==<br /> [[File:Surgopaedia Logo Large.jpg|right|frameless|257x257px]]<br /> Surgopaedia.org is a free, unreferenced, point-of-care resource designed to help residents and registrars training in General Surgery in Australia. It's written at the level of fellowship exam study and follows the curriculum quite closely, pulling together lots of different resources. <br /> <br /> There is enough breadth and depth of knowledge here to survive a night shift, a sub-specialty rotation, or pass the exam. The core surgical topics are very detailed (like [[breast cancer]] or [[acute pancreatitis]]), and the peripheral topics (like [[shock]] or [[empyema]]) are less detailed. <br /> <br /> Start by searching for an article or clicking 'categories' above.<br /> <br /> '''While every effort has been made to ensure accuracy of these pages, clinicians should independently verify information before applying it. This is intended as a general study resource, not to provide medical advice on a specific patient.'''<br /> <br /> == Categories ==<br /> [[Special:Categories|List of article categories]]<br /> <br /> [[:Category:Intern education|The most useful articles for interns]]<br /> <br /> [[:Category:FEX|Common fellowship exam topics]]<br /> <br /> == Editing ==<br /> Edits can be suggested on each page, but all changes are reviewed to maintain accuracy. <br /> <br /> == Contact ==<br /> admin@surgopaedia.org</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=File:Surgopaedia_Logo_Large.jpg&diff=989 2026-03-15T03:59:28Z

<p>SurgopaediaAdmin: </p> <hr /> <div>Surgopaedia Logo Large</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=File:SurgopaediaLogo.png&diff=988 2026-03-15T03:34:20Z

<p>SurgopaediaAdmin: </p> <hr /> <div></div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Stomal_complications&diff=987 2026-03-11T20:35:26Z

<p>SurgopaediaAdmin: </p> <hr /> <div>== In general: ==<br /> <br /> * End ileostomies and end colostomies have the lowest complication rate<br /> * Loop ileostomies have the highest complication rate<br /> <br /> == Very early (days) - often require return to OT ==<br /> <br /> * LBO due to twist in bowel<br /> <br /> == Early (&lt;3 months) ==<br /> <br /> === '''Stomal ischaemia/necrosis''' ===<br /> <br /> ** Incidence 14%<br /> ** Preventative factors:<br /> *** Adequate mobilisation of bowel<br /> *** Preservation of blood supply<br /> *** Adequate trephine size<br /> ** Risk factors:<br /> *** Emergency surgery<br /> *** Obesity<br /> *** IBD - especially Crohn's<br /> *** Occurs more often in end stomas due to more tenuous blood supply<br /> ** Pathophysiology<br /> *** Hypotension or a technical problem<br /> *** Occurs as a result of either venous congestion or arterial insufficiency (tight fascial opening, excessive mesenteric stripping)<br /> *** Mostly limited to mucosa above the fascia<br /> ** Assessment<br /> *** If it appears black, then it is black - don't shy from the truth!<br /> *** Usually evident early in the post-op period<br /> *** Extent of necrosis - insert test tube, or alternatively and flexible sigmoidoscope<br /> *** Severity - varies from minor mucosal hypoperfusion to a black, completely necrotic stoma<br /> *** Sabiston - a viable stoma transilluminates bright red, even in the face of venous congestion; failure to transilluminate indicates ischaemia<br /> *** Can also check bleeding<br /> ** Management:<br /> *** Necrosis extends to proximal bowel below anterior fascia, immediate revision required<br /> *** Proximal bowel viable and necrosis limited to stoma: observation may be appropriate. This can lead to a stricture in the future, though.<br /> **** If necrosis progresses, revise it.<br /> **** If sloughing occurs, only gentle debridement may be necessary. Can result in stomal retraction and pouching challenges but may not require re-intervention.<br /> <br /> === Stomal bleeding ===<br /> <br /> ** Uncommon - usually indicates either a stomal laceration from a poorly-fitting appliance, or the presence of peristomal varices in the patient with portal HTN.<br /> ** Minor bleeding can occur early with overly vigorous stomal cleansing.<br /> ** Initial management: direct pressure and local cauterisation (diathermy or silver nitrate) or suturing of the bleeding vessel, if identifiable.<br /> ** Peristomal varices are most often seen in patients who underwent a colectomy for UC in the setting of PSC. Can also develop in patients with other causes of portal HTN. Management with direct pressure + injection sclerotherapy or direct suture. Recurrence is frequent, and may even need other interventions e.g. TIPS.<br /> <br /> === Stomal retraction ===<br /> <br /> ** Defined as 0.5cm or more below the skin surface within 6 weeks of construction<br /> ** Typically occurs as a result of tension on the stoma.<br /> ** Can be intermittent (posture-dependent) or fixed - generally worse lying down<br /> ** Leads to leakage and difficulties with pouch adherence, resulting in peristomal skin irritation.<br /> ** Risk factors:<br /> *** Obesity<br /> *** Initial stoma height &lt;10mm<br /> ** Management:<br /> *** Retracts below fascia: immediate revision to prevent contamination<br /> *** Retracted, but stays above fascia: local wound care, convex pouching system, and the use of a belt or binder. Revise only if improved outcome expected, and not if the root cause hasn't been addressed. Lose weight prior to revision.<br /> *** If non-operative management of a retracted stoma fails, needs revision/re-siting. Re-siting to upper abdominal wall, which is thinner, may be helpful.<br /> <br /> === Mucocutaneous separation ===<br /> <br /> ** Results in leakage and skin irritation<br /> ** Incidence 12-24%<br /> ** Prevent it with meticulous technique.<br /> ** Assess<br /> *** Partial<br /> *** Circumferential - stomal stenosis can occur as the tissue heals by secondary intention<br /> ** Manage<br /> *** Usually heals with conservative management<br /> *** Re-suturing is usually not helpful<br /> *** Circumferential - strongly consider revision<br /> *** Partial - fill defect with kaltestat or barrier powder/paste to protect it from effluent and allow healing<br /> <br /> == '''Late (&gt;3 months)''' ==<br /> <br /> === Parastomal hernia ===<br /> <br /> ** Risk factors<br /> *** Colostomy<br /> *** Obesity<br /> *** Poor abdominal muscle tone<br /> *** Conditions with chronic cough<br /> *** Placement outside rectus muscle<br /> *** Large fascial opening<br /> ** See separate topic under 'abdo wall'<br /> <br /> === Stomal prolapse ===<br /> <br /> ** The telescoping of the intestine out from the stoma<br /> ** Can lead to intestinal oedema, and even incarceration/strangulation<br /> ** Risk factors<br /> *** Loop transverse colostomy and end descending colostomies<br /> *** Large abdominal trephine<br /> *** Increased intra-abdominal pressure<br /> *** Redundant loop of bowel proximal to the stoma<br /> ** Management:<br /> *** Uncomplicated: cool compresses and application of an osmotic agent (sugar/honey) to reduce oedema, followed by manual reduction of the prolapse and application of a binder with a prolapse over-belt to keep the bowel in the abdomen, or pouching modifications to accommodate the prolapsed bowel if reduction can't be established or maintained<br /> **** Manual reduction: press gently at the very tip of the prolapse, with gentle slow invagination, allowing the prolapse to intussuscept back into the abdomen.<br /> *** Complicated: full-thickness resection with reconstruction at the original site. Relocation may be necessary.<br /> ** Operative for revision:<br /> *** Circumferential dissection down to fascia<br /> *** Divide at new level, appropriate for skin height<br /> *** Refashion stoma<br /> <br /> === Stomal stenosis ===<br /> <br /> ** Narrowing sufficient to interfere with normal function<br /> ** Most common with end ileostomy<br /> ** Pathophysiology:<br /> *** Secondary to scarring or tightness of the mucocutaneous junction<br /> *** Peristomal sepsis<br /> *** Retraction<br /> *** Ill-fitting pouch<br /> *** Suboptimal surgical technique<br /> *** Crohns<br /> *** Malignancy<br /> ** Most likely to develop months later<br /> ** Early stenosis - manage conservatively, should improve as the oedema settles - insert a large 36Fr soft-tipped Foley catheter just beyond the fascia, without inflating the balloon<br /> ** Later stenosis<br /> *** Mild - dietary modifications - avoid insoluble fibre. Gentle routine dilatation of stoma may help but not evidence-based.<br /> *** Significant - cramping pain followed by explosive output. Usually requires surgical correction. Local revision may be preferred to dilatation. Enlargement of the skin opening may be useful in some situations.<br /> <br /> == Peristomal skin complications (any time) ==<br /> <br /> * Mechanical trauma<br /> * Dermatitis<br /> * Parastomal ulceration<br /> * Granulomas<br /> **<br /> * Peristomal pyoderma gangrenosum<br /> **<br /> * Parastomal varices<br /> ** Usually seen in cirrhotics/portal hypertension<br /> ** If bleeding, can under-run the varix with a deep locking Vicryl suture<br /> **<br /> <br /> == '''Ileostomy-specific''' ==<br /> <br /> === Dehydration ===<br /> <br /> === '''High ostomy output''' ===<br /> <br /> ** '''Background:''' <br /> *** A fully-adapted end ileostomy has an output of 500mL/24 hours. Initially post-op, it is usually 1000-1800mL/24 hrs, but usually comes down after a few days.<br /> *** High-output stoma defined as &gt;1.5L per day<br /> ** '''Pathophysiology'''<br /> *** Coupled absorption of sodium and glucose in jejunum via SGLT1 symporter<br /> **** If chyme is hypotonic, reduced ability to absorb glucose given sodium is working against a concentration gradient, so glucose will remain in lumen, leading to osmotic/secretory 'diarrhoea'<br /> **** If chyme is isotonic (&gt;90mmol/L sodium), glucose and sodium can both be absorbed from lumen, and the water will follow, thus reducing ileostomy output<br /> ***<br /> *** Standard sport drinks are not suitable - Gatorade only has 500mg sodium but 60g glucose per litre (23mmol/L sodium) - it may be called 'isotonic', but doesn't work well for optimising intestinal absorption of fluid because it's lower in salt and higher in sugar than St Mark's<br /> *** Tea, coffee, juice all count as free water<br /> *** To improve the taste of St Mark's:<br /> **** Drink chilled<br /> **** Turn into ice cubes<br /> **** Drink through a straw<br /> **** Add a little juice/soda<br /> ** '''Risk factors:'''<br /> *** Proximal stoma<br /> *** Intra-abdominal sepsis<br /> *** Following resolution of post-op ileus or SBO<br /> ** '''Classification'''<br /> *** 1-1.5L/24 hours: 'pre-high'<br /> *** 1.5-2L: mild high<br /> *** 2-3L: moderate high<br /> *** &gt;3L: severe high<br /> ** '''Evaluation''' of suspected developing high stoma output<br /> *** Observe stoma output for 48 hours before intervening<br /> *** Rule out other causes:<br /> **** Intra-abdominal sepsis<br /> **** Intermittent obstruction<br /> **** Infectious diarrhoea<br /> **** Medications (prokinetics, metformin)<br /> *** MDT involvement<br /> **** Stoma nurse<br /> **** Dietician<br /> **** Daily weights<br /> **** Accurate fluid balance<br /> **** Patient education<br /> *** Urinary sodium levels can be used to guide level of hydration - aim for &lt;20mmol/L<br /> ** '''Management:''' after 48 hours of high output<br /> *** Use a combination of interventions to match the severity of the insult<br /> *** Escalate to next level (add interventions from that stage) if not seeing improvement<br /> *** Always consider early stoma reversal<br /> *** For a new stoma, if unable to get control of outputs with moderate doses of stoppers (~10mg daily loperamide), ensure there are no contributing factors before increasing further - review medications, strongly consider CT to exclude partial obstruction/collections and stool PCR for infection <br /> *** Stage 1: Establish stability<br /> **** Pre-high<br /> ***** Stop free water<br /> ***** St Mark's solution for total hydration needs<br /> ***** Oral electrolyte replacements<br /> ***** Low-residue diet, with thickening foods (starchy foods, soluble fibre including Fybogel/psyllium husk/Metamucil; avoid insoluble fibre)<br /> ***** Low-dose loperamide - 2mg QID<br /> **** Mild high<br /> ***** Oral St Mark's up to maximum of 1L per day. No water.<br /> ***** Add IV hydration and IV electrolytes<br /> ***** Loperamide 4mg QID (open capsules, have 30 minutes prior to meals)<br /> ***** Pantoprazole 40mg BD<br /> **** Moderate high<br /> ***** Loperamide 8mg QID<br /> ***** Codeine 15mg TDS<br /> **** Severe high<br /> ***** Loperamide 12mg QID<br /> ***** Codeine 30mg TDS<br /> ***** Consider diphenoxylate/atropine (Lomotil) for additional anti-motility<br /> ***** Consider TPN if concerns for malnutrition - high stoma output can compromise absorption<br /> ***** Consider chyme reinfusion pump<br /> *** Stage 2: stability and transition to discharge<br /> **** Home when:<br /> ***** Self-managing<br /> ***** Stable output, ideally &lt;1L<br /> ***** Nutritionally ok<br /> *** Stage 3: long-term<br /> **** Link in with dietitian<br /> **** Long-term nutritional deficits in B12, zinc, selenium, and vitamins A, D, E, and K can result<br /> <br /> '''Antimotility agents used for high-output fistulas'''<br /> {| class=&quot;wikitable&quot;<br /> |'''Drug'''<br /> |'''Initial dose'''<br /> |'''Route'''<br /> |'''Frequency'''<br /> |'''Titration'''<br /> |'''Max dose'''<br /> |'''Cost*'''<br /> |'''Special considerations'''<br /> |-<br /> |Loperamide<br /> |4 mg<br /> |PO<br /> |Three times daily with meals or every 6 hours with enteral nutrition<br /> |By 2 mg<br /> |16 mg/day<br /> |$<br /> |Avoid liquid due to propylene glycol content<br /> |-<br /> |Diphenoxylate/atropine (Lomotil)<br /> |2.5 mg/0.025 mg (1 tablet)<br /> |PO<br /> |Three times daily with meals or every 6 hours with enteral nutrition<br /> |By 1 tablet<br /> |2 tablets four times daily (20 mg diphenoxylate)<br /> |$$<br /> |Avoid liquid formulation due to sorbitol content<br /> |-<br /> |Pantoprazole<br /> |40 mg<br /> |IV<br /> |Twice daily<br /> |None<br /> |40 mg twice daily<br /> |$$$<br /> |Discontinue as soon as feasible<br /> |-<br /> |Codeine<br /> |15 mg<br /> |PO<br /> |Three times daily with meals, up to four times daily<br /> |By 15 mg<br /> |45 mg four times daily<br /> |$$<br /> |Monitor for CNS effects<br /> |-<br /> |Octreotide<br /> |100 mcg<br /> |SC<br /> |Three times daily<br /> |None<br /> |None<br /> |$$$<br /> |Discontinue if output not decreased after 3 to 5 days<br /> |-<br /> |Clonidine<br /> |0.3 mg<br /> |Transdermal<br /> |Every 7 days<br /> |None<br /> |0.3 mg every 7 days<br /> |$$$$<br /> |Monitor HR and BP<br /> |}<br /> <br /> === Food blockage ===<br /> <br /> === Drug malabsorption ===<br /> <br /> == Colostomy-specific ==<br /> <br /> === Colon irrigation ===<br /> <br /> <br /> <br /> <br /> [[Category:Colorectal]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Main_Page&diff=986 2026-03-10T11:11:47Z

<p>SurgopaediaAdmin: </p> <hr /> <div>== Categories ==<br /> [[Special:Categories|List of article categories]]<br /> <br /> [[:Category:Intern education|The most useful articles for interns]]<br /> <br /> [[:Category:FEX|Common fellowship exam topics]]<br /> <br /> == Introduction ==<br /> Surgopaedia.org is a free, unreferenced, point-of-care resource designed to help residents and registrars training in General Surgery in Australia. It's written at the level of fellowship exam study and follows the curriculum quite closely, pulling together lots of different resources. <br /> <br /> There is enough breadth and depth of knowledge here to survive a night shift, a sub-specialty rotation, or pass the exam. The core surgical topics are very detailed (like [[breast cancer]] or [[acute pancreatitis]]), and the peripheral topics (like [[shock]] or [[empyema]]) are less detailed. <br /> <br /> Start by searching for an article or clicking 'categories' above.<br /> <br /> '''While every effort has been made to ensure accuracy of these pages, clinicians should independently verify information before applying it. This is intended as a general study resource, not to provide medical advice on a specific patient.'''<br /> <br /> == Editing ==<br /> Edits can be suggested on each page, but all changes are reviewed to maintain accuracy. <br /> <br /> == Contact ==<br /> admin@surgopaedia.org</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Immunosuppression&diff=985 2026-03-07T02:30:14Z

<p>SurgopaediaAdmin: </p> <hr /> <div><br /> Must constantly weigh risk of rejection against risk from immunosuppression<br /> <br /> * No real way to measure an individual's need for immunosuppression<br /> <br /> <br /> Corticosteroids<br /> <br /> * Common in induction, maintenance and rescue therapies<br /> * '''Prednisone''' most common<br /> * May need stress dosing in emergencies<br /> * Suppresses lymphocyte activation and promotes lymphocyte apoptosis<br /> * Reduces production of cytokines and suppresses inflammatory response<br /> <br /> Rabbit anti-thymocyte globulin (rATG)<br /> <br /> * Polyclonal Ab against human T cells<br /> * Depletes T cells<br /> * Effectively reduces the risk of acute rejection<br /> <br /> Basilixumab<br /> <br /> * Alternative to rATG<br /> <br /> <br /> Antimetabolites - inhibit lymphocyte clonal expansion<br /> <br /> * '''Azathioprine''' (Imuran)<br /> * '''Mycophenolate mofetil''' (Cellcept)<br /> ** Don't need to stop if patient has another surgical condition e.g. appendicitis<br /> ** Can be given IV<br /> * '''Cyclophosphamide'''<br /> <br /> Calcineurin inhibitors<br /> <br /> * Mainstay of most multimodal immunosuppressive regimens (used in 95% of patients)<br /> * Inhibit calcineurin, which has downstream affect of limiting T cell activation<br /> * '''Cyclosporin'''<br /> * '''Tacrolimus'''<br /> *** Especially liver transplant<br /> *** Don't need to stop if patient has another surgical condition e.g. appendicitis<br /> *** Needs close monitoring if giving IV<br /> *** The IV dose is approximately one third of the oral dose<br /> *** Target concentration varies significantly depending on patient and transplant factors. Trough concentrations are used. Steady state is reached after 3-5 days.<br /> *** Be careful of risk of AKI if dosing is slightly wrong during acute illness - use levels if necessary<br /> <br /> Lymphocyte-depleting agents<br /> <br /> * Often used as induction<br /> * Antilymphocyte globulin<br /> * OKT3<br /> * Anti-Il2 receptor antibodies<br /> <br /> Inhibitors of mammalian target of rapamycin (mTOR)<br /> <br /> * Alternative to calcineurin inhibitors<br /> * Prevents IL-2 stimulated proliferation of T cells<br /> * Significant impairment of wound healing<br /> * No IV equivalents<br /> * '''Everolimus'''<br /> ** Stop 5 days before elective surgery<br /> ** In emergencies, stop on admission and restart when wound heals<br /> * '''Sirolimus'''<br /> <br /> <br /> == Induction ==<br /> <br /> * Aim is to prevent acute rejection<br /> * Give at the time of transplant<br /> <br /> == Maintenance ==<br /> <br /> * Start at the time of transplant, and continue for the life of the graft<br /> * Suppress multiple pathways with subtoxic doses of medications<br /> <br /> == Complications of immunosuppression ==<br /> <br /> * Malignancy<br /> ** Mechanism<br /> *** Impaired immunosurveillance of neoplastic cells<br /> *** Reduced antiviral immune activity<br /> *** Direct mutagenic effects<br /> ** Types<br /> *** Skin - primarily SCC, but also BCC/melanoma<br /> *** Kaposi's sarcoma<br /> *** Lymphoproliferative disease (related to EBV)<br /> *** Lymphoma<br /> *** Cervical cancer<br /> *** Anogenital cancer<br /> *** TVV<br /> *** HCC<br /> *** Lung cancer<br /> ** Management<br /> *** Treat malignancy as required<br /> *** Avoid carcinogens carefully<br /> *** Switch immunosuppressant to mTOR, especially for skin cancers<br /> * Infection<br /> ** Atypical presentations, opportunistic, reactivation of chronic infections<br /> ** C diff<br /> ** CMV<br /> ** Viral gastro<br /> * Metabolic<br /> ** Diabetes<br /> ** Hypertension<br /> ** Dyslipidaemia<br /> ** CVD<br /> ** OP/osteonecrosis<br /> <br /> == Screening in immunosuppressed patients ==<br /> <br /> * Skin exam annually<br /> * Pelvic exam and pap smear every 1-3 years<br /> * Mammogram same as population<br /> * HCC annual USS and AFP if cirrhosis present<br /> * FOBT/CRC same as population<br /> <br /> [[Category:Transplant]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Immunosuppression&diff=984 2026-03-07T02:29:21Z

<p>SurgopaediaAdmin: </p> <hr /> <div><br /> Must constantly weigh risk of rejection against risk from immunosuppression<br /> <br /> * No real way to measure an individual's need for immunosuppression<br /> <br /> <br /> Corticosteroids<br /> <br /> * Common in induction, maintenance and rescue therapies<br /> * Prednisone most common<br /> * May need stress dosing in emergencies<br /> * Suppresses lymphocyte activation and promotes lymphocyte apoptosis<br /> * Reduces production of cytokines and suppresses inflammatory response<br /> <br /> Rabbit anti-thymocyte globulin (rATG)<br /> <br /> * Polyclonal Ab against human T cells<br /> * Depletes T cells<br /> * Effectively reduces the risk of acute rejection<br /> <br /> Basilixumab<br /> <br /> * Alternative to rATG<br /> <br /> <br /> Antimetabolites - inhibit lymphocyte clonal expansion<br /> <br /> * Azathioprine (Imuran)<br /> * Mycophenolate mofetil (Cellcept)<br /> ** Don't need to stop if patient has another surgical condition e.g. appendicitis<br /> ** Can be given IV<br /> * Cyclophosphamide<br /> <br /> Calcineurin inhibitors<br /> <br /> * Mainstay of most multimodal immunosuppressive regimens (used in 95% of patients)<br /> * Inhibit calcineurin, which has downstream affect of limiting T cell activation<br /> * Cyclosporin<br /> * Tacrolimus<br /> *** Especially liver transplant<br /> *** Don't need to stop if patient has another surgical condition e.g. appendicitis<br /> *** Needs close monitoring if giving IV<br /> *** The IV dose is approximately one third of the oral dose<br /> *** Target concentration varies significantly depending on patient and transplant factors. Trough concentrations are used. Steady state is reached after 3-5 days.<br /> *** Be careful of risk of AKI if dosing is slightly wrong during acute illness - use levels if necessary<br /> <br /> Lymphocyte-depleting agents<br /> <br /> * Often used as induction<br /> * Antilymphocyte globulin<br /> * OKT3<br /> * Anti-Il2 receptor antibodies<br /> <br /> Inhibitors of mammalian target of rapamycin (mTOR)<br /> <br /> * Alternative to calcineurin inhibitors<br /> * Prevents IL-2 stimulated proliferation of T cells<br /> * Significant impairment of wound healing<br /> * No IV equivalents<br /> * Everolimus<br /> ** Stop 5 days before elective surgery<br /> ** In emergencies, stop on admission and restart when wound heals<br /> * Sirolimus<br /> <br /> <br /> == Induction ==<br /> <br /> * Aim is to prevent acute rejection<br /> * Give at the time of transplant<br /> <br /> == Maintenance ==<br /> <br /> * Start at the time of transplant, and continue for the life of the graft<br /> * Suppress multiple pathways with subtoxic doses of medications<br /> <br /> == Complications of immunosuppression ==<br /> <br /> * Malignancy<br /> ** Mechanism<br /> *** Impaired immunosurveillance of neoplastic cells<br /> *** Reduced antiviral immune activity<br /> *** Direct mutagenic effects<br /> ** Types<br /> *** Skin - primarily SCC, but also BCC/melanoma<br /> *** Kaposi's sarcoma<br /> *** Lymphoproliferative disease (related to EBV)<br /> *** Lymphoma<br /> *** Cervical cancer<br /> *** Anogenital cancer<br /> *** TVV<br /> *** HCC<br /> *** Lung cancer<br /> ** Management<br /> *** Treat malignancy as required<br /> *** Avoid carcinogens carefully<br /> *** Switch immunosuppressant to mTOR, especially for skin cancers<br /> * Infection<br /> ** Atypical presentations, opportunistic, reactivation of chronic infections<br /> ** C diff<br /> ** CMV<br /> ** Viral gastro<br /> * Metabolic<br /> ** Diabetes<br /> ** Hypertension<br /> ** Dyslipidaemia<br /> ** CVD<br /> ** OP/osteonecrosis<br /> <br /> == Screening in immunosuppressed patients ==<br /> <br /> * Skin exam annually<br /> * Pelvic exam and pap smear every 1-3 years<br /> * Mammogram same as population<br /> * HCC annual USS and AFP if cirrhosis present<br /> * FOBT/CRC same as population<br /> <br /> [[Category:Transplant]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Main_Page&diff=983 2026-03-05T10:38:14Z

<p>SurgopaediaAdmin: </p> <hr /> <div>== Categories ==<br /> [[Special:Categories|List of article categories]]<br /> <br /> [[:Category:Intern education|The most useful articles for interns]]<br /> <br /> [[:Category:FEX|Common fellowship exam topics]]<br /> <br /> == Introduction ==<br /> Surgopaedia.org is a free, unreferenced, point-of-care resource designed to help residents and registrars training in General Surgery. It's written at the level of fellowship exam study and follows the curriculum quite closely, pulling together lots of different resources.<br /> <br /> There is enough breadth and depth of knowledge here to survive a night shift, a sub-specialty rotation, or pass the exam. The core surgical topics are very detailed (like [[breast cancer]] or [[acute pancreatitis]]), and the peripheral topics (like [[shock]] or [[empyema]]) are less detailed. <br /> <br /> Start by searching for an article or clicking 'categories' above.<br /> <br /> '''While every effort has been made to ensure accuracy of these pages, clinicians should independently verify information before applying it. This is intended as a general study resource, not to provide medical advice on a specific patient.'''<br /> <br /> == Editing ==<br /> Edits can be suggested on each page, but all changes are reviewed to maintain accuracy. <br /> <br /> == Contact ==<br /> admin@surgopaedia.org</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Category:Intern_education&diff=982 2026-03-05T10:36:12Z

<p>SurgopaediaAdmin: </p> <hr /> <div>The most useful pages for interns on a general surgical rotation, covering common surgical conditions, common ward procedures and basic peri-op management.</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Category:Intern_education&diff=981 2026-03-05T10:35:09Z

<p>SurgopaediaAdmin: Created blank page</p> <hr /> <div></div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=IDC_insertion&diff=980 2026-03-05T10:34:46Z

<p>SurgopaediaAdmin: </p> <hr /> <div>== Anatomical considerations ==<br /> <br /> * Average male urethra accomodates<br /> ** Meatus: 24Fr<br /> ** Prostatic urethra: 32Fr<br /> ** Bladder neck: 28Fr<br /> * Female urethra - normal calibre is 22Fr<br /> <br /> == Indications ==<br /> <br /> * Retention<br /> * Therapeutic eg bcg<br /> * Etc<br /> * Extraperitoneal bladder injury and SOME intraperitoneal bladder injury<br /> * Small vesicovaginal fistulae<br /> <br /> == Contraindications ==<br /> <br /> * Absolute<br /> ** Suspected or confirmed urethral injury<br /> ** History of bladder neck closure or repair<br /> * Relative<br /> ** Recent urethral surgery <br /> ** Urethral stricture<br /> ** Artificial urinary sphincter - needs special technique, need to discuss with urologist<br /> <br /> == Size selection ==<br /> <br /> == Difficulties ==<br /> <br /> * Prostatic obstruction<br /> ** Often gets stuck with BPH and a smaller (14 or 16Fr) catheter. Try 18Fr ideally with a coudé tip (point the tip anteriorly) - normally goes through with gentle sustained pressure.<br /> * Urethral stricture<br /> ** Occasionally, gentle pressure will dilate the stricture<br /> ** Beware strictures at level of membranous urethra - more likely to lead to false passage due to angulation<br /> ** Either pass a guidewire or go straight to cystoscopy for guidewire placement, then dilators would be passed over the guidewire. Dilation is needed to one size higher than the planned catheter (i.e. dilate to 18Fr if planning 16Fr catheter)<br /> ** I think a stricture at the meatus could be dilated under vision, or perhaps a urethrotomy<br /> * Urethral trauma<br /> ** Posterior injury - one gentle passage of catheter may be permitted, but stop if ANY resistance<br /> ** You could consider using guidewire<br /> * Blood in catheter - suspect false passage - probably needs endoscopic insertion<br /> * In children, especially male, there is often intense urinary sphincter contraction - normally resolves with gentle steady pressure and deep breathing<br /> * Don’t force foreskin to retract if it won't go easily<br /> <br /> <br /> <br /> [[Category:Urology]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Pleural_effusions&diff=979 2026-03-05T10:33:41Z

<p>SurgopaediaAdmin: </p> <hr /> <div>An increased (clinically significant) volume of fluid in the pleural space<br /> <br /> == '''Epidemiology''' ==<br /> <br /> * Breakdown according to Shields:<br /> ** 40% CCF<br /> ** 20% parapneumonic effusion<br /> ** 10% malignancy<br /> ** 8% PE<br /> ** 5% viral disease<br /> ** 2.5% post-cardiac surgery<br /> ** 1% GIT pathology<br /> ** 0.1% TB<br /> ** 0.1% malignant pleural mesothelioma<br /> ** 0.1% asbestos-related benign pleural diseases<br /> <br /> == '''Aetiology''' ==<br /> <br /> * Pleural infection (parapneumonic effusion - about 40%) and CCF (about 25%) are the most common causes, followed by things like chronic liver disease, renal disease, asbestosis, RA, SLE pleuritis, pancreatitis, PE and cardiac surgery.<br /> * '''Transudative'''<br /> ** Left heart failure (marked increase in permeability of '''visceral''' pleura, and interstitial lung oedema - not seen commonly in RHF)<br /> ** Cirrhosis/hepatic failure<br /> ** Nephrotic syndrome/renal failure<br /> ** Hypoalbuminaemia<br /> ** Fluid retention/overload<br /> ** Pulmonary embolism (usually occupies less than one third of hemithorax and can be bilateral in 46% of cases, with dyspnoea out of proportion)<br /> ** Lobar collapse/trapped lung (pleural dead space is filled by effusion fluid)<br /> ** Meigs syndrome<br /> * '''Exudative'''<br /> ** Malignant<br /> *** Primary lung<br /> *** Metastatic<br /> *** Lymphoma<br /> *** Mesothelioma<br /> ** Infectious<br /> *** Bacterial (parapneumonic)/empyema (see separate topic)<br /> *** TB<br /> *** Fungal<br /> *** Viral<br /> *** Parasitic<br /> ** Collagen vascular disease related<br /> *** RA<br /> *** Wegener granulomatosis<br /> *** SLE<br /> *** Churg-Strauss syndrome<br /> ** Others<br /> *** Chylothorax<br /> *** Uraemia<br /> *** Sarcoidosis<br /> *** After CABG<br /> *** Radiation/trauma<br /> *** Dressler syndrome<br /> *** PE with infarction<br /> *** Asbestosis related<br /> * Benign effusions (sometimes also called hydrothorax)<br /> ** Systemic disease<br /> *** Generally cause bilateral effusions<br /> ** Local disease<br /> *** Inflammation leads to both increased fluid filtration and decreased lymphatic drainage<br /> *** Often causes unilateral moderate to large effusions<br /> <br /> === '''Causes of transudative pleural effusions''' ===<br /> {| class=&quot;wikitable&quot;<br /> |'''Causes of transudative effusions'''<br /> |'''Comment'''<br /> |-<br /> |'''Processes that ''always'' cause a transudative effusion'''<br /> |<br /> |-<br /> |Atelectasis<br /> |Caused by increased intrapleural negative pressure<br /> |-<br /> |Cerebrospinal fluid leak into pleural space<br /> |Thoracic spinal surgery or trauma and ventriculopleural shunts<br /> |-<br /> |Heart failure<br /> |Acute diuresis can result in borderline exudative features<br /> |-<br /> |Hepatic hydrothorax<br /> |Rare without clinical ascites<br /> |-<br /> |Hypoalbuminemia<br /> |Edema liquid rarely isolated to pleural space<br /> |-<br /> |Iatrogenic<br /> |Misplaced intravenous catheter into the pleural space; post Fontan procedure<br /> |-<br /> |Nephrotic syndrome<br /> |Usually subpulmonic and bilateral<br /> |-<br /> |Peritoneal dialysis<br /> |Acute massive effusion develops within 48 hours of initiating dialysis<br /> |-<br /> |Urinothorax<br /> |Caused by ipsilateral obstructive uropathy or by iatrogenic or traumatic GU injury<br /> |-<br /> |'''Processes that ''may'' cause a transudative effusion, but ''usually'' cause an exudative effusion'''<br /> |<br /> |-<br /> |Amyloidosis<br /> |Often exudative due to disruption of pleural surfaces<br /> |-<br /> |Chylothorax<br /> |Most are exudative effusions <br /> |-<br /> |Constrictive pericarditis<br /> |Bilateral effusions<br /> |-<br /> |Hypothyroid pleural effusion<br /> |From hypothyroid heart disease or hypothyroidism per se<br /> |-<br /> |Malignancy<br /> |Usually exudative, but 3 to 10 percent transudative possibly due to early lymphatic obstruction, obstructive atelectasis, or concomitant disease (eg, heart failure)<br /> |-<br /> |Pulmonary embolism<br /> |Most are exudative effusions<br /> |-<br /> |Sarcoidosis<br /> |Stage II and III disease<br /> |-<br /> |Superior vena caval obstruction<br /> |May be due to acute systemic venous hypertension or acute blockage of thoracic lymph flow<br /> |-<br /> |Coronavirus disease 2019 (COVID-19)<br /> |Limited data profile the nature of pleural fluid in COVID-19-related pleural effusions, although transudative effusions have been reported <br /> |-<br /> |Nonexpandable lung*<br /> |A result of remote or chronic inflammation<br /> |}<br /> <br /> === '''Causes of exudative pleural effusions''' ===<br /> {| class=&quot;wikitable&quot;<br /> |<br /> {| class=&quot;wikitable&quot;<br /> |'''Infectious'''<br /> |-<br /> |Bacterial pneumonia<br /> |-<br /> |Tuberculous pleurisy<br /> |-<br /> |Parasites<br /> |-<br /> |Fungal disease<br /> |-<br /> |Viral pneumonias (eg, influenza, coronavirus disease 2019 [COVID-19])<br /> |-<br /> |Nocardia, Actinomyces<br /> |-<br /> |Subphrenic abscess<br /> |-<br /> |Hepatic abscess<br /> |-<br /> |Splenic abscess<br /> |-<br /> |Hepatitis<br /> |-<br /> |Spontaneous esophageal rupture<br /> |-<br /> |Cholecystitis<br /> |-<br /> |'''Iatrogenic or trauma'''<br /> |-<br /> |Central venous catheter misplacement/migration<br /> |-<br /> |Drug-induced (eg, nitrofurantoin, dantrolene, methysergide, dasatinib, amiodarone, interleukin-2, procarbazine, methotrexate, clozapine, phenytoin, beta blocker, ergot drugs)<br /> |-<br /> |Esophageal perforation<br /> |-<br /> |Esophageal sclerotherapy<br /> |-<br /> |Enteral feeding tube in pleural space<br /> |-<br /> |Radiofrequency ablation of pulmonary neoplasms<br /> |-<br /> |Hemothorax<br /> |-<br /> |Chylothorax<br /> |-<br /> |'''Malignancy-related'''<br /> |-<br /> |Carcinoma<br /> |-<br /> |Lymphoma<br /> |-<br /> |Mesothelioma<br /> |-<br /> |Leukemia<br /> |-<br /> |Chylothorax<br /> |-<br /> |Paraproteinemia (multiple myeloma, Waldenstrom's macroglobulinemia)<br /> |-<br /> |Paramalignant effusions<br /> |-<br /> |'''Other inflammatory disorders'''<br /> |-<br /> |Pancreatitis (acute, chronic)<br /> |-<br /> |Benign asbestos pleural effusion<br /> |-<br /> |Pulmonary embolism<br /> |-<br /> |Radiation therapy<br /> |-<br /> |Uremic pleurisy<br /> |-<br /> |Sarcoidosis<br /> |-<br /> |Postcardiac injury syndrome<br /> |-<br /> |Acute respiratory distress syndrome (ARDS)<br /> |-<br /> |Immunoglobulin G4-related disease (fibroinflammatory)<br /> |}<br /> |<br /> {| class=&quot;wikitable&quot;<br /> |'''Increased negative intrapleural pressure with accompanying pleural malignancy or inflammation'''<br /> |-<br /> |Lung entrapment<br /> |-<br /> |Cholesterol effusion (eg, due to tuberculosis, rheumatoid arthritis)<br /> |-<br /> |'''Connective tissue disease'''<br /> |-<br /> |Lupus pleuritis<br /> |-<br /> |Rheumatoid pleurisy<br /> |-<br /> |Mixed connective tissue disease<br /> |-<br /> |Eosinophilic granulomatosis with polyangiitis (Churg-Strauss)<br /> |-<br /> |Granulomatosis with polyangiitis (Wegener's)<br /> |-<br /> |Familial Mediterranean fever<br /> |-<br /> |'''Endocrine dysfunction'''<br /> |-<br /> |Hypothyroidism<br /> |-<br /> |Ovarian hyperstimulation syndrome<br /> |-<br /> |'''Lymphatic abnormalities'''<br /> |-<br /> |Malignancy<br /> |-<br /> |Chylothorax (eg, yellow nail syndrome, lymphangioleiomyomatosis, lymphangiectasia)<br /> |-<br /> |'''Movement of liquid from abdomen to pleural space'''<br /> |-<br /> |Pancreatitis<br /> |-<br /> |Pancreatic pseudocyst<br /> |-<br /> |Meigs' syndrome<br /> |-<br /> |Chylous ascites<br /> |-<br /> |Malignant ascites<br /> |-<br /> |Subphrenic abscess<br /> |-<br /> |Hepatic abscess (bacterial, amebic)<br /> |-<br /> |Splenic abscess, infarction<br /> |-<br /> |'''Miscellaneous'''<br /> |-<br /> |Endometriosis<br /> |-<br /> |Drowning<br /> |-<br /> |Electrical burns<br /> |-<br /> |Capillary leak syndromes<br /> |-<br /> |Extramedullary hematopoiesis<br /> |}<br /> |}<br /> <br /> <br /> == '''Pathophysiology''' ==<br /> <br /> * Disrupted balance between fluid production and absorption<br /> ** The amount of pleural fluid is controlled by a balance of oncotic and hydrostatic pressure within the pleural space and pleural capillaries<br /> ** Under normal circumstances, the net pressure moves fluid from the parietal pleura into the pleural space<br /> ** Pleural space normally contains 0.3mL/kg of fluid<br /> ** Normal turnover is about 0.15mL/kg/hour<br /> ** Most pleural fluid is reabsorbed through lymphatics of the parietal pleura - protein cannot re-enter the relatively impermeable visceral pleura<br /> * Causative factors:<br /> ** Increased input:<br /> *** Increased hydrostatic pressure<br /> *** Increased negative intra-pleural pressure<br /> *** Increased capillary permeability<br /> *** Decreased plasma oncotic pressure<br /> ** Decreased output:<br /> *** Strong reduction in lymphatic drainage<br /> * A pleural effusion represents a new equilibrium point between pressures acting across compartments - hence a larger imbalance will lead to a larger effusion<br /> * Characterise as transudate or exudate<br /> ** Transudates are protein-poor and result in change in fluid balance in the pleural space<br /> ** Exudates are protein-rich and may be related to disruption of pleural or lymphatic reabsorption<br /> * Volume<br /> ** 300mL of fluid causes blunting of costophrenic angle on upright CXR<br /> ** 500mL of fluid can be detected clinically<br /> <br /> == '''Symptoms:''' ==<br /> <br /> * Dyspnoea (effusion causes compression and collapse of adjacent lung - most commonly lower lobe)<br /> ** Volume of effusion<br /> ** Degree of compression and collapse<br /> ** Underlying lung function<br /> * Chest pain<br /> * Cough<br /> * Massive pleural effusion can cause tension effusion - mediastinal shift and tension physiology (requires 1-3L)<br /> <br /> == '''Examination''' ==<br /> <br /> * Asymmetrical decreased expansion<br /> * Dullness to percussion<br /> * Diminished or inaudible breath sounds<br /> * Effusions &lt;300mL will not show on physical exam<br /> <br /> == '''Diagnosis''' ==<br /> <br /> * Pleural fluid only 3-test combination (favoured by UTD)<br /> ** Any one of the following means exudate:<br /> *** Pleural fluid protein &gt;30g/L<br /> *** Pleural fluid cholesterol &gt;1.42mmol/L<br /> *** Pleural fluid LDH &gt;0.67 * serum LDH ULN ''(LDH ULN is typically ~280U/L)''<br /> * Light's criteria<br /> ** Any one of the following means exudate:<br /> *** Pleural fluid to serum protein ratio &gt;0.5<br /> *** Pleural fluid to serum LDH ratio &gt; 0.6<br /> *** Pleural fluid LDH &gt; 0.67 * serum LDH ULN ''(LDH ULN is typically ~280U/L)''<br /> ** High sensitivity but only moderate specificity for exudates<br /> ** 25% of transudates are incorrectly classified as exudates, particularly those due to heart failure when diuretics are given, or where erythrocytes are present in pleural fluid, which release LDH<br /> * Visual characteristics<br /> ** Serous<br /> ** Bloody<br /> ** Milky<br /> ** Turbid<br /> ** Frankly purulent<br /> * Cytology (sensitivity and specificity 65-90%)<br /> * Cell counts<br /> * Gram stain and MCS<br /> * TB testing<br /> * Pleural and serum protein, glucose, LDH and pH<br /> <br /> == Other investigations ==<br /> <br /> * Exclude medical conditions<br /> ** BNP<br /> ** eGFR<br /> ** LFTs<br /> ** TTE<br /> * CT chest<br /> <br /> == Management: ==<br /> <br /> * Treat the underlying disorder<br /> * Drainage for symptomatic effusions<br /> * Drainage for diagnostic purposes if complication is suspected<br /> <br /> == Treatment ==<br /> <br /> * Benign effusions<br /> ** Most benign pleural effusions are transudates, free-flowing, without loculation<br /> ** Treat underlying cause (CCF, ascites, malnutrition)<br /> ** Completely drain for diagnosis and treatment (14Fr or smaller if leaving a drain in)<br /> ** CXR to confirm complete drainage<br /> ** 'Trapped lung' may require decortication, especially if remaining symptomatic<br /> ** If no improvement in symptoms, look for alternative causes<br /> ** Recurrences<br /> *** Consider repeat thoracentesis, tube thoracostomy or pleurodesis (mechanical vs chemical)<br /> *** Don't need to continuously drain unless significant respiratory compromise is present<br /> * Unilateral effusions<br /> ** Parapneumonic, empyema, inflamed parietal pleura, chylothorax, haemothorax, pleural infection<br /> ** Drain effusion and correct consequences<br /> ** Indications for VATS:<br /> *** Recurrent effusion following earlier drainage<br /> *** Trapped lung (lack of re-expansion following drainage)<br /> *** Loculated or multiloculated effusions<br /> *** Parietal pleural tissue biopsies are required for diagnosis<br /> *** Very large unilateral effusion (consider VATS vs drainage - higher recurrence rate and malignancy rate)<br /> ** Role for VATS<br /> *** Complete drainage of effusion<br /> *** Parietal pleural biopsies<br /> *** Re-expansion of lung and de-cortication if necessary<br /> *** Pleurodesis<br /> * Malignant pleural effusions<br /> ** An effusion with positive cytopathology<br /> ** Median survival 90 days (5 months in breast cancer, and longer in lymphoma)<br /> ** Not all effusions associated with malignancy are caused by direct or metastatic pleural involvement (consider bronchial or lymphatic obstruction, hypoproteinaemia, and accumulation from infra-diaphragmatic involvement)<br /> ** Consider pleurX catheter or pleurodesis<br /> * Tension pleural effusion<br /> ** Drain immediately<br /> * Drainage<br /> ** Need CT or USS prior to drainage, since CXR can get it wrong<br /> ** Typically needle thoracocentesis under USS-guidance, with a catheter sometimes being left in <br /> ** Dogma states don't remove more than 1-1.5L in one sitting to prevent re-expansion pulmonary oedema, however the veracity of this is unknown. Larger volumes can be removed if the benefits of symptom improvement are thought to outweigh the risks.<br /> ** Those who respond well to drainage should also respond well for drainage of reaccumulations<br /> ** Drain on the larger side, or the right side if both are equal<br /> <br /> '''Survival with malignant pleural effusions according to cancer type'''<br /> {| class=&quot;wikitable&quot;<br /> |'''Cell type'''<br /> |'''Median survival in days (95% CI)'''<br /> |'''n'''<br /> |-<br /> |Mesothelioma<br /> |339 (267 to 422)<br /> |170<br /> |-<br /> |Hematological malignancy<br /> |218 (160 to 484)<br /> |35<br /> |-<br /> |Gynecological malignancy<br /> |230 (97 to 279)<br /> |59<br /> |-<br /> |Breast cancer<br /> |192 (133 to 271)<br /> |140<br /> |-<br /> |Renal cell carcinoma<br /> |114 (33 to 334)<br /> |22<br /> |-<br /> |Adenocarcinoma of unknown primary<br /> |87 (13 to 286)<br /> |11<br /> |-<br /> |Lung cancer<br /> |74 (60 to 92)<br /> |215<br /> |-<br /> |Other<br /> |71 (46 to 102)<br /> |33<br /> |-<br /> |Gastrointestinal cancer<br /> |61 (44 to 73)<br /> |61<br /> |-<br /> |Sarcoma<br /> |44 (19 to 76)<br /> |12<br /> |-<br /> |Melanoma<br /> |43 (23 to 72)<br /> |23<br /> |-<br /> |Urological cancer (bladder, prostate, testis, penile)<br /> |33 (22 to 168)<br /> |8<br /> |-<br /> |Overall<br /> |136 (119 to 167)<br /> |789<br /> |}<br /> <br /> <br /> '''LENT score'''<br /> {| class=&quot;wikitable&quot;<br /> | <br /> |'''Variable'''<br /> |'''Score'''<br /> |-<br /> |'''L'''<br /> |'''LDH level in pleural fluid (IU/L)'''<br /> |<br /> |-<br /> |<br /> |&lt;1500<br /> |0<br /> |-<br /> |<br /> |&gt;1500<br /> |1<br /> |-<br /> |'''E'''<br /> |'''ECOG PS'''<br /> |<br /> |-<br /> |<br /> |0<br /> |0<br /> |-<br /> |<br /> |1<br /> |1<br /> |-<br /> |<br /> |2<br /> |2<br /> |-<br /> |<br /> |3 to 4<br /> |3<br /> |-<br /> |'''N'''<br /> |'''NLR'''<br /> |<br /> |-<br /> |<br /> |&lt;9<br /> |0<br /> |-<br /> |<br /> |&gt;9<br /> |1<br /> |-<br /> |'''T'''<br /> |'''Tumor type'''<br /> |<br /> |-<br /> |<br /> |Lowest risk tumor types<br /> <br /> ** Mesothelioma<br /> ** Hematological malignancy<br /> |0<br /> |-<br /> |<br /> |Moderate risk tumor types<br /> <br /> ** Breast cancer<br /> ** Gynecological cancer<br /> ** Renal cell carcinoma<br /> |1<br /> |-<br /> |<br /> |Highest risk tumor types<br /> <br /> ** Lung cancer<br /> ** Other tumor types<br /> |2<br /> |-<br /> | <br /> |'''Risk categories'''<br /> |'''Total score (median survival in days)'''<br /> |-<br /> |<br /> |Low risk<br /> |0 to 1 (319)<br /> |-<br /> |<br /> |Moderate risk<br /> |2 to 4 (130)<br /> |-<br /> |<br /> |High risk<br /> |5 to 7 (44)<br /> |}<br /> LDH: lactate dehydrogenase; ECOG PS: Eastern Cooperative Oncology Group performance score; NLR: neutrophil to lymphocyte ratio.<br /> <br /> <br /> == '''Management of malignant and paramalignant pleural effusions''' ==<br /> {| class=&quot;wikitable&quot;<br /> |'''Option'''<br /> |'''Comment'''<br /> |-<br /> |Observation<br /> |For asymptomatic effusions; most will progress and require therapy<br /> |-<br /> |Therapeutic thoracentesis<br /> |Prompt relief of dyspnea; most effusions recur unless underlying tumor responds to chemo- or radiotherapy<br /> |-<br /> |Chest catheter drainage only<br /> |Most effusions will recur after catheter removal<br /> |-<br /> |Chest catheter drainage with chemical pleurodesis (eg, talc slurry)<br /> |Variable response rate with 60 to 90 percent of patients responding to talc pleurodesis<br /> |-<br /> |Thoracoscopy with talc insufflation<br /> |Control of effusion with similar frequency as chest catheter drainage with talc pleurodesis<br /> |-<br /> |Long-term indwelling pleural catheter<br /> |Control of effusion and improved symptoms in most patients. Some patients may experience pleurodesis after two weeks (median 11 weeks) of catheter drainage, which allows catheter removal.<br /> |-<br /> |Long-term indwelling pleural catheter with talc instillation<br /> |Control of effusion and symptoms with successful pleurodesis in 43 percent of patients without hospitalization<br /> |-<br /> |Pleural abrasion or pleurectomy<br /> |Requires thoracoscopy or thoracotomy. Effectively controls effusions in nearly all patients.<br /> |-<br /> |Pleuroperitoneal shunt<br /> |When other options have failed or are not indicated; may be useful for chylothorax<br /> |-<br /> |Chemotherapy<br /> |May be effective in some tumor types, such as breast cancer, lymphoma, and small cell lung cancer<br /> |-<br /> |Radiotherapy<br /> |Mediastinal radiation therapy may be effective in lymphoma and lymphomatous chylothorax<br /> |}<br /> <br /> <br /> <br /> Traditional criteria for indwelling pleural catheter removal - &lt;50mL drainage for three consecutive days<br /> <br /> [[Category:Thoracics]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Pneumothorax&diff=978 2026-03-05T10:32:51Z

<p>SurgopaediaAdmin: </p> <hr /> <div><br /> Accumulation of air in the pleural space, between lung and chest wall. This causes partial or complete collapse of the lung.<br /> <br /> == Epidemiology ==<br /> <br /> * Two peaks - 20-30 years (primary) and 60-70 years (secondary)<br /> * M:F 4:1<br /> * Cigarette smoking OR 20<br /> <br /> == '''Aetiological classification''' ==<br /> <br /> === '''Spontaneous''' ===<br /> <br /> ** Primary spontaneous<br /> *** Definition<br /> **** Spontaneous pneumothorax in a patient without an immediately obvious underlying lung disease<br /> *** Risk factors<br /> **** Occurs between 20-30yo, mostly men<br /> **** Smoking<br /> **** Ectomorphic habitus<br /> **** Genetics<br /> **** Nitrous oxide canisters - inhaled under pressure<br /> *** Pathophysiology<br /> **** Rupture of small subpleural blebs (&lt;2cm collections of air contained within visceral pleura), mostly found at apex of upper or lower lobes<br /> **** Blebs result from ruptured alveoli - well-demarcated from normal lung, being located between elastic interna and externa of the visceral pleura<br /> **** May be associated with apical fibrosis<br /> **** PSP can also occur in the absence of blebs<br /> ** Secondary spontaneous PTX<br /> *** Aetiology<br /> **** COPD (marker of severe disease with poor prognosis)<br /> **** Bullous disease<br /> **** Cystic fibrosis (marker of advanced disease)<br /> **** Pneumocystis-related<br /> **** Congenital cysts<br /> **** IPF<br /> **** Pulmonary embolism<br /> **** Asthma<br /> **** TB and other mycobacterial infections<br /> **** Other infections<br /> **** AIDS<br /> **** Bronchogenic carcinoma<br /> **** Metastatic lung disease (especially metastatic sarcoma)<br /> **** Radiotherapy<br /> **** Marfan syndrome<br /> **** EDS<br /> **** Histiocytosis X<br /> **** Sarcoidosis<br /> **** Scleroderma<br /> **** Lymphangiomyomatosis<br /> **** Pregnancy - usually around 26 weeks<br /> *** Management<br /> **** Refer to respiratory physician if not already known<br /> ** Catamenial (occurs with 48-72 hours of onset of menstruation; part of thoracic endometriosis syndrome (TES) and in fact the most common presentation of that syndrome)<br /> *** TES - haemothorax, haemoptysis, lung nodules. Growth of endometrial glands and stroma in the lungs, pleura, diaphragm and tracheobronchial tree. Mostly unilateral right PTX.<br /> ** Neonatal<br /> <br /> === '''Traumatic''' ===<br /> <br /> ** Generally sharp stumps of fractured ribs directed inwards, which can also cause HTX.<br /> ** Barotrauma from diving<br /> <br /> === '''Iatrogenic''' ===<br /> <br /> ** Mechanical ventilation<br /> ** Needle puncture (thoracentesis, FNA lung nodule, central line insertion<br /> ** Post-surgical<br /> <br /> == '''Pathophysiological classification''' ==<br /> <br /> * Closed PTX - no communication between pleural space and outside of thorax. Amount of air is usually small, and it is usually reabsorbed in a short period of time.<br /> * Open PTX - presence of open communication between pleural cavity and outside of the chest. Air enters during inspiration and exits during expiration. Most commonly the hole is in chest wall, but can also occur with rupture of the airway or parenchymal lesions. Repeated shifts of mediastinum during the respiratory cycle can cause refractory bradycardia or even cardiac arrest.<br /> * Tension PTX - air freely enters chest cavity but does not exit. The lesion through which air enters acts as a unidirectional valve. See below.<br /> <br /> == Pathophysiology ==<br /> <br /> * Introduction of air causes partial or complete collapse of the lung with consequent modifications in respiratory mechanics potentially affecting ventilation and gas exchange<br /> <br /> == Presentation ==<br /> <br /> * Chest pain, dry cough, dyspnoea<br /> * Pain predominant in younger patients, dyspnoea in older<br /> * Decrease chest wall movement, tympanic resonance, reduced air entry<br /> * Tachycardia almost always present<br /> * Tension physiology: respiratory distress, anxiety, cyanosis, hypotension, fixed hyperexpanded hemithorax.<br /> <br /> == Imaging ==<br /> <br /> * Standard erect CXR in inspiration. Expiration films can help to diagnose a small PTX (decreases lung volume, but doesn't decrease the volume of air, so relative increase in size of PTX)<br /> * Signs of PTX on supine films<br /> ** Air collects anteriorly, in front of the lungs<br /> ** Relative lucency of ipsilateral lung<br /> ** Deep sulcus sign<br /> ** Increased sharpness of adjacent mediastinal margin and diaphragm<br /> ** Double diaphragm sign, from visualisation of the anterior costophrenic sulcus<br /> ** Depression of ipsilateral hemidiaphragm<br /> * CT for uncertain cases, to assess aetiology<br /> * Quantifying PTX<br /> ** Size is less important than degree of clinical compromise<br /> ** Complicated formulas are available, but impractical, requiring CT<br /> ** Best is to describe 'small PTX' as one with the surface of the lung &lt;3cm from the chest wall<br /> ** Large PTX &gt;3cm to chest wall<br /> <br /> == Complications ==<br /> <br /> * 'Early tension'<br /> ** Any evidence of volume gain, including increased rib spaces on ipsilateral side, tracheal deviation, depression of diaphragm, deep sulcus sign<br /> * Tension<br /> ** When air continues to enter the pleural space without decompression, resulting in positive intra-thoracic pressure causing compression of the lung and mediastinum, shift of the mediastinum into the contralateral chest, and decrease in ventilation and venous return<br /> ** Produces a shunt with reduced oxygenation and cardiac output.<br /> ** Cardiopulmonary collapse and death ensue, primarily from low preload due to kinked IVC<br /> ** Must decompress immediately with needle or chest tube<br /> * Haemopneumothorax<br /> ** Usually rupture of a vascularised pleural adhesion or vascularised bleb or bulla<br /> * Rarely<br /> ** Pneumomediastinum<br /> ** Pneumoperitoneum<br /> ** Subcutaneous emphysema<br /> ** Need to rule out airway/oesophageal/abdo visceral injury when these are present.<br /> <br /> == Management ==<br /> <br /> * Options: bed rest and observation; aspiration; small-bore catheter; tube thoracostomy; VATS; open thoracotomy.<br /> * Simple, small, uncomplicated, clinically stable, asymptomatic PTX: more conservative treatment, perhaps even just bed rest and observation, with oxygen (oxygen favours healing by increasing the gradient for nitrogen absorption from the pleural space). Should hospitalise for at least 24 hours.<br /> ** Needle aspiration may be appropriate in this population (don't repeat if it doesn't work)<br /> ** Especially applies to small PTX from biopsy needle<br /> ** Progression in size requires drainage with small-bore chest tube such as Rocket 14Fr<br /> * Symptomatic: tube thoracostomy with UWSD is mandatory<br /> ** Tailor the size of the tube to the risk of substantial air leak<br /> ** Direct tube towards apex<br /> ** Reasonable to leave off suction initially (risk of re-expansion oedema), check re-expansion, then apply -10 to -20 cm H2O if needed. Use minimum suction to re-inflate lung.<br /> ** Remove chest tube when air leak has stopped for at least 48-72 hours<br /> * Persistent air leak - defined as &gt;48 hours<br /> ** Much more common with SSP as opposed to PSP (40% at 7 days compared to 5% at 7 days)<br /> ** ACCP guidelines suggest surgical intervention at 4 days for PSP and 5 days for SSP, since a longer waiting time does not seem to substantially modify outcome<br /> * Indications for surgery in primary spontaneous pneumothorax<br /> ** Rationale<br /> *** Prevent recurrence (30% without intervention, 2-3% with intervention)<br /> ** First episode<br /> *** Prolonged air leak (4 days)<br /> *** Non-re-expansion of the lung<br /> *** Bilateral pneumothorax<br /> *** Haemothorax<br /> *** Tension pneumothorax<br /> *** Complete pneumothorax<br /> *** Occupational hazard<br /> *** Absence of medical facilities in isolated areas<br /> *** Associated single large bulla<br /> ** Second episode<br /> *** Ipsilateral recurrence<br /> *** Contralateral recurrence<br /> * Lifestyle modifications if not had surgery<br /> ** No scuba diving, piloting planes<br /> <br /> === Surgery - resect the cause and obliterate the pleural space ===<br /> <br /> * Mostly need recurrent primary spontaneous PTX before considering VATS<br /> * If blebs or bullae &gt;1cm are seen, wedge resection is necessary<br /> * Controversial as to whether VATS or limited thoracotomy are better. In bilateral disease, VATS is also reasonable.<br /> * Mechanical abrasion of the parietal pleura<br /> * Pleural space should be obliterated with apical parietal pleurectomy, pleural abrasion or chemical irritation<br /> ** Apical parietal pleurectomy - surgical fixation of the lung to the endothoracic fascia - good long-term results<br /> ** Pleural abrasion preferred for patients likely to need further thoracic surgery as it preserves the extra-pleural plane of dissection. Recurrence rate 2.3%<br /> ** Chemical pleurodesis - mostly talc (powder of hydrous magnesium silicate. Commercially available talc is free of asbestos. <br /> * Pleurodesis with talc is good in older patients or patients with malignancy, but surgery would be preferred in most patients.<br /> <br /> === Talc pleurodesis: maximum of 5g introduced as a slurry through chest tube ===<br /> <br /> * Common reactions:<br /> ** Low-grade fever<br /> ** Local pain<br /> ** Local infection - very hard/impossible to cure<br /> ** Respiratory distress<br /> <br /> == Discharge advice: ==<br /> <br /> * Consider respiratory physician follow-up<br /> * Air travel should be avoided until full resolution<br /> * Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and CT scan post-operatively<br /> <br /> [[Category:Thoracics]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Shock&diff=977 2026-03-05T10:32:22Z

<p>SurgopaediaAdmin: </p> <hr /> <div>''Shock is acute circulatory failure, with inadequate tissue perfusion causing cellular hypoxia''<br /> <br /> * ''Can't be defined using systemic parameters, as it is possible to have inadequate perfusion with normal blood pressure''<br /> <br /> == Aetiology ==<br /> <br /> === Hypovolaemia ===<br /> <br /> ** Haemorrhage<br /> ** Fluid loss<br /> ** Dehydration<br /> <br /> === Cardiogenic ===<br /> <br /> ** MI<br /> ** Heart failure<br /> ** Arrhythmia<br /> <br /> === Obstructive ===<br /> <br /> ** PE<br /> ** Cardiac tamponade<br /> ** Pneumothorax<br /> <br /> === Distributive ===<br /> <br /> ** Sepsis<br /> ** Neurogenic<br /> ** Anaphylaxis<br /> ** Adrenal insufficiency<br /> <br /> == '''Pathophysiology''' ==<br /> <br /> === '''Haemorrhagic/hypovolaemic''' ===<br /> <br /> ** Tachycardia and increase in cardiac contractility - attempt to preserve cardiac output (usually first signs)<br /> ** Endogenous catecholamines increase PVR, which increases DBP and reduces pulse pressure, but does not increase tissue perfusion<br /> ** Vasoconstriction of cutaneous, muscular and visceral circulation - preserve flow to kidneys, heart and brain - increases PVR<br /> ** Contraction of volume of blood in venous system<br /> ** Shift to anaerobic metabolism - lactic acid forms, and metabolic acidosis - which can progress to end-organ damage/MODS<br /> ** Stress hormone activation<br /> ** Systemic inflammatory response from wounds, treatment, stress hormones<br /> <br /> === '''Cardiogenic''' ===<br /> <br /> ** Primary cardiac disorder characterised by low cardiac output resulting in end-organ hypoperfusion and tissue hypoxia<br /> ** Myocardial ischaemia results in depressed myocardial contractility, reducing cardiac output and blood pressure<br /> ** Compensatory action of the SNS leads to peripheral vasoconstriction, preserving coronary perfusion at the cost of increased afterload<br /> ** Tachycardia increases myocardial oxygen demand<br /> <br /> === '''Obstructive''' ===<br /> <br /> ** Tamponade<br /> *** Rapid accumulation of pericardial fluid results in compression to cardiac chambers and subsequent diastolic failure (reduced preload)<br /> *** Cardiac output reduces<br /> *** Compensatory tachycardia to attempt to overcome the reduced output<br /> ** Tension pneumothorax<br /> *** Increased intra-thoracic pressure compresses the mediastinal structures and prevents filling of SVC and IVC, leading to reduced preload<br /> *** There is also increased pulmonary vascular resistance<br /> *** Cardiac output is compromised<br /> ** PE<br /> *** Increased pulmonary vascular resistance due to a combination of mechanical obstruction and hypoxic vasoconstriction<br /> *** Increased right ventricular afterload compromises right-sided output, and prevents downstream left ventricular filling, which results in reduced overall cardiac output<br /> <br /> === '''Distributive''' ===<br /> <br /> ** Sepsis/anaphylaxis<br /> *** Inflammatory cytokines induce systemic vasodilation and capillary leak, and sometimes a direct cardiomyopathy<br /> *** See separate topic 'Sepsis/SIRS'<br /> ** Neurogenic<br /> *** Loss of sympathetic outflow beneath the level of injury means reduced catecholamine delivery and subsequent vasodilation<br /> *** Similar condition can be seen with epidurals<br /> *** ''Differentiate from spinal shock - a neurological phenomenon where there is immediate temporary loss of power, reflexes and sensation below the level of the injury''<br /> ** Adrenal insufficiency<br /> *** Decreased alpha-1 receptor expression on arterioles secondary to cortisol deficiency, resulting in vasodilation<br /> *** Seen with sudden withdrawal of chronic steroids<br /> ** Common pathway<br /> *** Reduced venous return and reduced cardiac output<br /> *** Reduced perfusion to vital organs<br /> <br /> == Clinical features of subtypes of shock, in addition to generic features of hypo-perfusion ==<br /> <br /> * Cardiogenic<br /> ** Similar to hypovolaemic shock<br /> ** Elevated CVP or JVP and pulmonary oedema, but low arterial pressure<br /> * Obstructive<br /> ** Tachycardia<br /> ** Elevated JVP<br /> * Septic<br /> ** Warm peripheries early<br /> ** Lower SVR meaning lower diastolic pressure<br /> ** Tachycardia<br /> ** Confusion<br /> * Hypovolaemic<br /> ** Tachycardia<br /> ** Cool peripheries<br /> ** Decreased pulse pressure<br /> <br /> == Clinical features of decreased tissue perfusion ==<br /> <br /> * Cool peripheries<br /> * Poor filling of peripheral veins<br /> * Increased RR<br /> * Increased core-peripheral temperature gradient<br /> * Prolonged CRT<br /> * Poor signal on pulse oximeter<br /> * Poor urine output (&lt;0.5mL/kg/hr)<br /> * Anxiety/restlessness<br /> * Decreased consciousness level<br /> * Metabolic acidosis or raised serum lactate<br /> <br /> == Treatment ==<br /> <br /> * Diagnose and treat the underlying cause<br /> * For hypovolaemic/vasodilatory shock:<br /> ** 10mL/kg crystalloid if normotensive<br /> ** 20mL/kg crystalloid if hypotensive<br /> ** Oxygen in high flow via non-rebreather bag<br /> * Venous access<br /> * IDC<br /> * ECG monitoring<br /> * Pulse oximetry monitoring<br /> * CVC<br /> * Assess response after 30 minutes, and change plan if the patient is not improving<br /> <br /> <br /> <br /> [[Category:Critical care]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Abscess&diff=976 2026-03-05T10:32:04Z

<p>SurgopaediaAdmin: </p> <hr /> <div><br /> A pus-containing, confined structure within an inflammatory wall, which requires drainage by whichever means available.<br /> <br /> * Contrast that to contaminated peritoneal fluid or loculated collections, which do not have a wall<br /> <br /> == Pathophysiology ==<br /> <br /> * Abscesses represent an intermediate natural outcome of infection - not quite cleared, not quite progressive<br /> * Natural history is progression to overwhelming sepsis unless drained<br /> * Microbiology<br /> ** Typically poly-microbial<br /> ** Secondary abscesses usually have mixed aerobic-anaerobic flora<br /> ** Obligate anaerobes are usually involved with late abscess formation, such as Bacteroides fragilis<br /> ** Primary abscesses are often mono-bacterial, especially Staph<br /> <br /> == Classifications ==<br /> <br /> * Visceral vs non-visceral<br /> * Primary vs secondary<br /> * Spontaneous vs post-operative<br /> * Intra-peritoneal vs retroperitoneal<br /> * Simple vs complex (multiple, multi-loculated, communication with bowel, associated with necrotic tissue, associated with cancer)<br /> * Anatomical location<br /> <br /> == Presentation ==<br /> <br /> * Post-operatively, often presents as sepsis and ileus<br /> <br /> == Diagnosis ==<br /> <br /> * CT provides the best anatomical information, but USS is also good, especially for RUQ<br /> * Imaging during the first post-operative week cannot distinguish between a sterile fluid collection and an infected fluid collection - would need to do a diagnostic aspiration in this context<br /> * CT features suggestive of abscess are a contrast-enhancing, well-defined rim, and the presence of gas bubbles<br /> <br /> == '''Management''' ==<br /> <br /> * Clinical context is key for detected post-op fluid collections<br /> * True abdominal abscesses should be drained by the least invasive method possible<br /> ** '''Factors favouring percutaneous:''' hostile abdomen, accessible location, source already controlled, visceral location, single abscess, thin viscosity, stable patient<br /> ** '''Factors favouring surgery:''' easy abdominal access, interloop, multiple abscesses, loculated, bowel communication, associated necrosis, associated malignancy, thick debris, critically ill patient, failed percutaneous drainage<br /> * Complex abscesses are more likely to require true surgical drainage - although can still temporise with percutaneous.<br /> * Clinical improvement should be seen within 24-72 hours. Ongoing sepsis indicates treatment failure.<br /> * Catheter drainage, as opposed to just aspiration, is probably more effective. Small simple abscesses containing thin fluid or within solid organs are more likely to be manageable with just aspiration. Evidence indicates 7Fr drains are just as good as 14Fr, and it can always be upsized later. <br /> ** Regularly flush tubes with saline to keep them patent<br /> ** Remember to check that the drain is properly secured - radiologists don't always secure it properly<br /> ** Regularly clean and observe the drain site to avoid necrotizing infections<br /> ** No true evidence around removal - typically when daily output &lt;30mL (subtracting injected saline) which often takes 5-7 days<br /> * Re-imaging - can give some contrast down the tube to further delineate location and size of persisting cavity. Abscesses which do not collapse, tend to recur.<br /> * The source of the abscess must also be dealt with<br /> * Antibiotics are of secondary importance, and may not actually be evidence-based for abdominal abscesses! Perhaps their most sensible usage is to help control sepsis while drainage is pending, then to cover bacteraemia and spillage after drainage, then to be weaned as soon as pus has been evacuated and the patient improves. Don't need to continue antibiotics just because a drain is in place.<br /> <br /> == Open drainage ==<br /> <br /> * Attempt a direct anatomical approach rather than exploratory laparotomy, where possible<br /> **<br /> ** Subphrenic and subhepatic abscesses can be approached extra-peritoneally through a subcostal incision or (if posterior) through the bed of the 12th rib<br /> ** Pericolic, appendicular and retroperitoneal abscesses are usually best approached through a loin incision<br /> * Try to 'fill' the cavity with omentum or adjacent structures<br /> * With adequate surgical drainage and source control, no drains are necessary<br /> <br /> [[Category:Critical care]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Blood_gas_interpretation&diff=975 2026-03-05T10:31:45Z

<p>SurgopaediaAdmin: </p> <hr /> <div>== Measures: ==<br /> <br /> * pH: normally 7.35-7.45<br /> * PaO2: arterial partial pressure of oxygen - a reflection of the amount of oxygen dissolved in the blood. Normal 10-14kPa.<br /> * PaCO2: Normal 4.5-6kPa - reflects the absolute ventilatory state of a patient and possible respiratory compensatory mechanisms<br /> * HCO3-: normal 24-28mmol/L. Bicarbonate is the main plasma buffer. A low value suggests consumption, often due to increased acid load e.g. lactic acid. A high value suggests retention of base to compensate for hypoventilation causing an acidaemia.<br /> * Base deficit/base excess: normal +2 to -2. This describes whether the body's buffers are being consumed (deficit) or retained (excess).<br /> ** A measure of the amount of fixed base added to an aliquot (1L) of blood to bring pH to 7.4<br /> ** Essentially goes lower in anaerobic metabolism and acidosis<br /> ** Might actually be a better predictor of poor outcomes in trauma patients than lactate - in one study a moderate BD on admission meant a mortality of 15%, while severe BD meant 35% mortality<br /> ** Normal 2 to -2<br /> ** Mild -3 to -5<br /> ** Moderate -6 to -9<br /> ** Severe &lt;-9<br /> * Serum lactate - normal &lt;1.2mmol/L. A reflection of the extent of anaerobic metabolism occurring, and secondarily a measure of the liver's ability to metabolise lactate and regenerate bicarbonate ions.<br /> * Anion gap - normal range 10-15mmol/L.<br /> <br /> <br /> Relative hypoxaemia is a more useful measure than absolute PaO2, which is essentially comparing it to FiO2<br /> <br /> * As FiO2 increases towards 1, PaO2 should also increase<br /> * Use PaO2/FiO2 (should be &gt;40kPa, or patient is hypoxic)<br /> <br /> == Metabolic acidosis ==<br /> <br /> * Impaired tissue perfusion - deal with cause<br /> * Renal failure - deal with cause, bicarbonate, RRT<br /> * Hepatic failure - deal with cause<br /> ** Or KULT (ketones urea lactate toxins)<br /> * NAGMA - usually hyperchloraemic acidaemia - most often seen following vigorous resus with 0.9% saline, also bladder surgery and ileal conduit formation.<br /> *<br /> <br /> == Resp acidosis ==<br /> <br /> * Inadequate CO2 elimination by lungs relative to rate of CO2 produced by cellular metabolism<br /> ** Head or spinal injury - ventilation<br /> ** Drug overdose - ventilate, antidote<br /> ** Chest wall injury - ventilate<br /> ** Myopathy/peripheral neuropathy - ventilate<br /> ** Pulmonary disease - treat disease, resp support +/- ventilate<br /> ** Massive PE - re-establish perfusion of ventilated lung<br /> <br /> == Metabolic alkalosis ==<br /> <br /> * Typically occurs when there is both an increase in alkali and impaired excretion of bicarb<br /> * In surgical patients, frequently as a result of H+ loss (vomiting or NGT drainage, especially in gastric outlet obstruction), or from excess bicarb regeneration as a result of diuretic therapy<br /> * Can also occur with mineralocorticoid excess<br /> <br /> == Resp alkalosis ==<br /> <br /> * Occurs when alveolar ventilation exceeds the rate necessary to eliminate CO2 produced by cellular metabolism<br /> <br /> <br /> <br /> <br /> [[Category:Critical care]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Sepsis/SIRS&diff=974 2026-03-05T10:31:21Z

<p>SurgopaediaAdmin: </p> <hr /> <div>== '''Definition''' ==<br /> <br /> * Sepsis is defined as '''life-threatening organ dysfunction''' caused by a dysregulated host response to infection<br /> ** SEPSIS 3 (2016) defines '''organ dysfunction''' as an acute change in total SOFA score of two or more points consequent to infection<br /> ** This was found to have superior predictive value than SIRS score alone (only 0.74 vs 0.64 though, so SIRS score does retain some validity)<br /> * Septic shock - a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality<br /> <br /> == '''Risk factors''' ==<br /> <br /> * Extremes of age<br /> * Indwelling devices/breach of skin integrity<br /> * IVDU<br /> * ICU/HDU<br /> * Immunosuppression<br /> * Surgery in past 6/52<br /> <br /> == '''Pathophysiology:''' ==<br /> <br /> === '''Normal response to infection''' ===<br /> <br /> ** Host response initiated when innate immune cells (especially macrophages) recognise and to microbial components<br /> *** Pattern-recognition receptors (PRRs) on the surface of immune cells recognise and bind to microbial pathogen-associated molecular patterns (PAMPs) or endogenous danger signals<br /> **** PRRs include toll-like receptors (TLRs) and others<br /> *** Neutrophils begin to defend against pathogens - phagocytosis, secretion of antimicrobial peptides, and the release of neutrophil extracellular traps (NETs)<br /> *** Signalling cascade developed via the activation of cytosolic nuclear factor-kb (NF-kb), which leads to activation of genes involved in host inflammatory response such as TNF-a, IL-1, IL-6, chemokines, vascular adhesion molecule-1, and nitric oxide<br /> *** Polymorphonuclear leucocytes become activated and aggregate at site of infection, causing warmth and erythema due to local vasodilation and hyperaemia<br /> *** Pro-coagulant status causes micro-thrombosis<br /> *** Some anti-inflammatory mediators balance this activation<br /> *** If the inflammatory process is balanced, haemostasis is restored, leading to tissue repair and healing<br /> <br /> === '''Transition to sepsis''' ===<br /> <br /> ** Sepsis occurs when the release of pro-inflammatory mediators exceeds the boundaries of the local environment, leading to a more generalised response (can also occur without sepsis, as SIRS). This can also be characterised as malignant intra-vascular inflammation<br /> ** It is unclear why this happens, but likely multifactorial<br /> *** Direct effects of invading micro-organisms and their toxins<br /> *** Release of large quantities of pro-inflammatory mediators - mainly IL-1 and TNF-a<br /> *** Complement activation<br /> *** Possible genetic susceptibility<br /> *** Loss or reduction of Compensatory Anti-inflammatory Response Syndrome (CARS) which includes factors like IL-4 and 10<br /> ** Excessive and prolonged activation of these pathways probably contributes to the development of multiple organ dysfunction<br /> ** Leads to vasodilation, enhanced capillary leak and eventually myocardial depression<br /> <br /> === '''Systemic effects of sepsis''' ===<br /> <br /> ** Organ dysfunction<br /> *** Circulation - hypotension due to diffuse vasodilation - distributive shock, largely mediated by NO and prostacyclin<br /> *** Lung - endothelial injury leads to pulmonary oedema and ARDS<br /> *** GIT - depressed function allowing translocation<br /> *** Liver dysfunction<br /> *** Kidney - pre-renal injury, including ATN<br /> *** CNS - often fails before other organs - encephalopathy<br /> ** Multiple organ dysfunction syndrome (MODS) - see below<br /> ** Tissue ischaemia - due to derangements in metabolic autoregulation, and also endothelial injury<br /> ** Cytopathic injury<br /> ** Cell death pathways activated<br /> ** Immunosuppression<br /> ** Activation of coagulation system and vascular endothelium - DIC<br /> <br /> == '''Diagnosis:''' ==<br /> <br /> === '''New criteria''' ===<br /> <br /> ** '''qSOFA''' (recommended by CCrISP, and was initially thought to be a good way of approximating SOFA score by Sepsis 3, but the data to back up that use has been highly conflicted, and it is probably less useful than first thought) - Breathing, BP, Brain<br /> *** Two or more of:<br /> **** RR &gt;22<br /> **** SBP&lt;100<br /> **** Altered mentation<br /> ** SOFA - Sequential Organ Failure Assessment score - more complicated points calculator, up to 4 points in each category, best for ICU patients<br /> *** Respiratory failure<br /> *** Platelet level<br /> *** Bilirubin<br /> *** BP/vasopressors<br /> *** GCS<br /> *** Creatinine<br /> ** Septic shock - patients who, after adequate fluid resuscitation and antibiotics, meet the following criteria:<br /> *** Persistent lactate &gt;2<br /> *** Vasopressors required to maintain MAP &gt;65<br /> *** ''40% risk of mortality in this group, compared to 10% in those who do not''<br /> <br /> === '''''Old criteria:''''' ===<br /> <br /> ** '''''SIRS''''' ''(no longer recommended for clinical use by sepsis 3 - think of it as an appropriate, regulated non-specific response to infection)''':'''''<br /> *** ''Two or more of:''<br /> **** ''Temp &gt;38 or &lt;36''<br /> **** ''HR &gt;90''<br /> **** ''RR&gt;20''<br /> **** ''WCC &gt;12 or &lt;4''<br /> **** ''Acutely altered mental state''<br /> **** ''BGL &gt; 6.6 in absence of diabetes''<br /> ** '''''Sepsis = SIRS + documented source of infection'''''<br /> *** ''Alternative definition from CCrISP is of 'a life-threatening organ dysfunction caused by a dysregulated host response to infection'''<br /> ** '''''Severe sepsis = SIRS + altered organ perfusion''''' ''(no longer a clinically useful definition according to CCrISP)''<br /> *** ''CVS (lactate &gt; 1.2)''<br /> *** ''Pa02/Fi02 &lt; 30 or Pa02 &lt; 9.3kPa''<br /> *** ''Urine output &lt; 120ml over 4 hours''<br /> *** ''GCS &lt; 15 acutely''<br /> ** '''''Septic shock:''''' ''infection plus''<br /> *** ''Definition 1:''<br /> **** ''Vasopressors to maintain MAP &gt;65, '''and'''''<br /> **** ''Lactate &gt;2''<br /> *** ''Associated with 40% mortality''<br /> <br /> === '''MODS''' ===<br /> <br /> ** Progressive organ dysfunction in an acutely ill patient, such that homeostasis cannot be maintained without intervention.<br /> ** Primary - organ dysfunction is directly attributable to the insult itself<br /> ** Secondary - organ dysfunction is a consequence of the host's response<br /> ** Typically lungs, liver and kidneys affected most<br /> ** Early MODS (&lt;3 days) is usually inadequate fluid resuscitation. Late MODS is usually infection.<br /> ** Treatment is via generalised approach<br /> *** Resuscitate<br /> *** Treat infections<br /> *** Maintain tissue oxygenation<br /> *** Debride devitalised tissue<br /> *** Early enteral nutrition<br /> *** Early mobilisation<br /> <br /> == Approach when seeing a patient with possible sepsis on ward/ED: ==<br /> <br /> * CCrISP ABCD<br /> * Use qSOFA to evaluate for organ dysfunction<br /> * Intervene as below<br /> * Consider ICU if goal-directed resuscitation is required<br /> * Identify likely source of sepsis<br /> ** Chest<br /> ** Abdomen<br /> ** CNS - headache/neck stiffness<br /> ** Lines - &gt;48 hours old or being used for TPN<br /> ** Urinary<br /> <br /> == Intervention ==<br /> <br /> * '''Within one hour - the Sepsis Six: (three in, three out)'''<br /> ** High-flow oxygen<br /> ** IV Abx<br /> ** IVF - be aggressive if patient is hypotensive and there isn't a contraindication - bolus of 20mL/kg, or 30mL/kg if lactate &gt;4<br /> ** BCs<br /> ** Hb, lactate<br /> ** Hourly UO<br /> * '''Within three hours:'''<br /> ** If persistent hypotension or increased lactate, apply goal-directed resuscitation<br /> ** Consider need for escalation of monitoring and level of care<br /> * '''Within six hours:'''<br /> ** Apply vasopressors for hypotension that does not respond to initial fluid, aiming MAP&gt;65<br /> ** Reassess volume status and tissue perfusion and document findings<br /> ** Remeasure lactate if it was initially elevated<br /> * '''Definitive control:'''<br /> ** Septic screen - CXR, urine, stool, sputum, review and culture all lines<br /> <br /> == Follow-up: ==<br /> <br /> * Consider and anticipate risk of multi-organ failure:<br /> ** ARDS - respiratory support almost always needed, usually mechanical ventilation. Vague clinical picture, so suspicion is needed, and escalation for critical care input.<br /> ** Cardiovascular failure <br /> *** Loss of peripheral vascular tone<br /> *** Loss of circulating volume<br /> *** Myocardial depression secondary to cytokines<br /> ** Renal failure<br /> *** Often established early on during hypotension<br /> ** Gut<br /> ** Brain<br /> ** Clotting system<br /> *** Thrombocytopaenia<br /> *** Coagulopathies<br /> ** Liver<br /> <br /> <br /> [[Category:Critical care]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=The_acute_abdomen&diff=973 2026-03-05T10:30:23Z

<p>SurgopaediaAdmin: </p> <hr /> <div><br /> == Pathophysiology of intra-abdominal inflammation ==<br /> <br /> * Irritation of peritoneal membrane (chemical or bacteria) causes increased blood flow, increased permeability and formation of local fibrinous exudate<br /> * Bowel will develop a localised ileus<br /> * Adherence forms between local structures due to fibrin<br /> * Peritonitis = peritoneal inflammation from any cause<br /> <br /> <br /> == Types of pain: ==<br /> <br /> === Visceral pain: ===<br /> <br /> ** Mechanism<br /> *** Travels along C-fibres - in effect, autonomic afferent fibres<br /> ** Colicky pain occurs with distension<br /> *** Small bowel - every 5 minutes<br /> *** Large bowel - every 10 minutes<br /> *** Pain should disappear almost completely between attacks<br /> ** Radiates to midline - vague and poorly localised, but often epigastrium/umbilical/hypogastrium<br /> ** Occurs with '''stretching/distension''' of viscus<br /> ** Mediated by splanchnic sympathetic nerves<br /> ** Can occur from liver capsule<br /> <br /> === Peritoneal/parietal pain ===<br /> <br /> ** Pain fibres which pass to spinal cord along segmental nerves<br /> ** Mediates guarding/peritonism - reflex contraction of abdominal wall muscles in response to noxious stimulus of the pain fibres of the same dermatome<br /> ** Often inflammatory - syndrome depends on the type of fluid<br /> *** Gastric contents highly irritating - severe sudden pain<br /> *** Small bowel contents produces less pain<br /> *** Bile is also extremely irritant<br /> *** Blood is irritant but not to the same degree as bile or gastric juice<br /> <br /> === Referred pain ===<br /> <br /> ** Right shoulder<br /> *** Liver<br /> *** GB<br /> *** Right hemidiaphragm<br /> ** Left shoulder<br /> *** Heart<br /> *** Tail of pancreas<br /> *** Spleen<br /> *** Left hemidiaphragm<br /> ** Scrotum and testicles<br /> *** Ureter<br /> ** Pancreatitis to the back<br /> ** Renal colic to groin<br /> ** Pneumonia to abdomen<br /> ** Testicles to hypogastrium<br /> ** Spinal pathology causing abdominal pain<br /> <br /> === Specific syndromes ===<br /> <br /> ** Ischaemic bowel - almost all visceral, until transmural ischaemia is present<br /> ** Splenic infarct - almost all peritoneal<br /> ** Acute salpingitis - all peritoneal<br /> ** Acute appendicitis - visceral then peritoneal<br /> ** Perforation - chemical peritonitis causes severe peritonitis, whereas gas does not cause as much peritonitis<br /> *** Sigmoid diverticulitis - generally not much peritonism<br /> *** Perf gastric ulcer - rapid pain and peritonism<br /> ** Acute pancreatitis - both visceral and peritoneal<br /> ** Capsule stretching - visceral (ovary, liver)<br /> ** Biliary obstruction - epigastric discomfort<br /> ** LBO - hypogastric discomfort<br /> ** Ureteric colic - peristalsis is less prominent, so pain is somewhat constant, with exacerbations. Can radiate to groin or even lower, to the testicle or labia, but does not radiate to the back of the leg. <br /> ** Kidney pain - constant gnawing pain in loin/renal angle.<br /> <br /> * Patients experiencing paroxysms colic should be unable to lie still. This pain relates to distension and would be experienced in areas of visceral pain referral. Once the actual somatic nerves in parietal peritoneum are affected, pain localises.<br /> * Beware patients taking steroids, who may have a smaller inflammatory response and therefore less tenderness and systemic infective features.<br /> <br /> == '''Evaluating the acute abdomen''' ==<br /> <br /> === History ===<br /> <br /> * Age/demographics<br /> ** Think about which conditions are likely<br /> * Exact time and mode of onset<br /> ** Sudden onset - think perforated ulcer, acute pancreatitis, ruptured AAA/ectopic, ovarian torsion<br /> * Pain<br /> ** Character<br /> ** Radiation<br /> ** Shifting<br /> *** Irritation of somatic nerves<br /> *** Either direct inflammation of an organ, or fluid (e.g. gastric contents moving to RIF in perforated ulcer)<br /> ** Postural <br /> *** Retroperitoneal pain is worse when lying back<br /> ** Worse with eating - SBO, biliary colic, pancreatitis, diverticulitis, bowel perforation<br /> ** Better with eating - non-perforated PUD or gastritis<br /> * Vomiting<br /> *# Severe irritation of peritoneal/mesenteric nerves<br /> *#* Vomiting will be early<br /> *# Obstruction of an involuntary muscular tube<br /> *#* Vomiting can be later<br /> *#* Early vomiting in SBO indicates high obstruction<br /> *#* Pain almost always prior to vomiting in appendicitis<br /> ** Acute gastritis - non-bilious<br /> ** Obstructions - bilious<br /> *** First gastric contents, then bilious, then yellow-green, then yellow, then orange/brown faeculent <br /> ** In surgical conditions, vomiting will come after pain. The vomiting is secondary to stimulation of medullary afferent fibres triggered by visceral afferent pain fibres. In medical causes of vomiting, the vomiting often precedes abdominal pain.<br /> * Bowels<br /> * Menstruation<br /> <br /> === Examination ===<br /> General inspection<br /> <br /> * Observe facial expression<br /> * Check for shock<br /> * Anaemia - conjunctivae, hands<br /> * Posture<br /> ** Colic - restlessness. This is seen in diseases that cause pain without peritoneal irritation, as patients try to get comfortable.<br /> ** Peritonitic - still<br /> ** Hip flexion on one side - psoas irritation<br /> ** Both hips flexed - peritonitis<br /> ** Pancreatic/retroperitoneal - sitting up<br /> <br /> Vitals<br /> <br /> * Pulse<br /> * RR<br /> ** Tachypnoea is a late sign in abdo disease - metabolic acidosis<br /> * Temperature<br /> ** Fluctuates during day. &gt;37.2 at 0600 and &gt;37.7 at 1600 signify fever<br /> ** Oral temperature is generally 0.6 deg lower than rectal would be<br /> ** TM temp is close to central<br /> ** However, for best real temperature, get bladder/rectal/oesophageal/pulmonary artery catheter<br /> ** We lose the ability to develop a fever with old age, so temperature increases may be modest even with severe sepsis<br /> ** Temperature is known to rise by about 0.6 deg with ovulation and remain at that level until menstruation<br /> ** Hyperpyrexia &gt; 41.5 - probably CNS haemorrhage<br /> <br /> Abdomen<br /> <br /> * Watch movement with respiration - should move freely<br /> ** Contrast with chest - thorax will move less in pneumonia but abdomen will move more<br /> * Gentle palpation<br /> ** Remember to palpate for bladder<br /> * Percussion/rebound<br /> ** Check for tympanism - if heard all over, suspect free gas. If all but RUQ, could be distended bowel. If any focal dullness other than RUQ, suspect a mass.<br /> * Rigidity<br /> ** If you suspect the patient to be avoiding abdominal breathing by choice rather than because of severe pain, try resting left hand on the sternum with a fair amount of pressure while you examine with the right. This prevents costal breathing<br /> * Hyperaesthesia - can give clues as to which nerve is affected by inflammation - probably more useful in chronic cases<br /> ** Suggests nerve root compression if present<br /> * Psoas sign<br /> * Obturator sign (obturator internus)<br /> * Liver dullness<br /> ** Normal: midclavicular line fifth rib to costal margin; midaxillary line ribs 7-11<br /> ** Resonant note over liver in midaxillary line - consider atrophic liver, abdominal distension, free air. Not a useful test when the abdomen is very distended.<br /> * Shifting dullness - so non-specific as to be not that useful<br /> <br /> <br /> == Specific locations ==<br /> <br /> * Central<br /> ** Acute apendicitis, SBO, pancreatitis, MI<br /> * Central + shock<br /> ** Pancreatitis<br /> ** Mesenteric thrombosis<br /> ** Internal haemorrhage<br /> ** Ruptured AAA<br /> ** Dissecting aneurysm<br /> ** Ectopic<br /> * Pain + vomiting and distension, without rigidity<br /> ** SBO<br /> ** Consider gastritis<br /> * Pain + distension + constipation, but minimal vomiting<br /> ** Likely LBO<br /> * Severe abdo pain with collapse and general rigidity<br /> ** Perforation<br /> <br /> == Non-surgical causes of acute abdomen ==<br /> <br /> * Endocrine/metabolic<br /> ** Uraemia<br /> ** Diabetic crisis<br /> ** Addisonian crisis<br /> ** Acute intermittent porphyria<br /> ** Hereditary mediterranean fever<br /> * Haematologic<br /> ** Sickle cell crisis<br /> ** Acute leukaemia<br /> ** Other blood dyscrasias<br /> * Toxins and drugs<br /> ** Lead poisoning<br /> ** Other heavy metal poisoning<br /> ** Narcotic withdrawal<br /> ** Black widow spider poisoning<br /> <br /> == Imaging ==<br /> <br /> * AXR<br /> ** Will detect as little as 1ml of air in peritoneal cavity<br /> * Lateral decubitus xray<br /> ** Useful in detecting pneumoperitoneum in those that cannot stand but needs 5-10ml of air<br /> <br /> [[Category:Critical care]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Respiratory_complications&diff=972 2026-03-05T10:29:50Z

<p>SurgopaediaAdmin: </p> <hr /> <div><br /> == Atelectasis ==<br /> <br /> * Basal collapse secondary to anaesthetic, abdo incision, post-op narcotics, etc<br /> * If not reopened, alveoli remain full o fsecretions, and pneumonia will occur<br /> * Risk factors:<br /> ** Smokers<br /> ** Obese<br /> ** Copious pulmonary secretions<br /> * Controversial as to whether this actually results in fever<br /> * Treatment is chest physio<br /> ** Incentive spirometry, deep breathing, coughing<br /> <br /> == Pneumonia ==<br /> <br /> == Aspiration pneumonitis ==<br /> <br /> * Prevention: <br /> ** Fasting<br /> ** PPI/H2 not shown to be helpful<br /> ** Awake fibreoptic intubation in high-risk individuals<br /> * CXR - infiltrate in posterior segments of upper lobes, apical segments of lower lobes<br /> * If aspiration is witnessed, abx are not indicated immediately unless SBO, or no improvement within 48 hours (treat gram-negatives)<br /> <br /> == Pleural effusion ==<br /> <br /> * See topic under thoracics<br /> <br /> [[Category:Respiratory]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Acute_renal_failure&diff=971 2026-03-05T10:28:59Z

<p>SurgopaediaAdmin: </p> <hr /> <div><br /> '''Sudden reduction in renal function resulting in the accumulation of nitrogenous wastes.'''<br /> <br /> == '''Principles of renal failure in surgical patient:''' ==<br /> <br /> * The kidneys cannot function without adequate perfusion<br /> * Renal perfusion is dependent on adequate blood pressure<br /> * A surgical patient with poor urine output usually requires more fluid<br /> * Absolute anuria is usually due to urinary tract obstruction<br /> * Poor urine output in a surgical patient is not initially treated with diuretics<br /> <br /> == '''Aetiology''' ==<br /> <br /> * '''Pre-renal (75%) - can lead to ATN in hours.''' The kidney is structurally and functionally intact, but blood flow and GFR are reduced.<br /> ** Sepsis<br /> ** Hypovolaemia<br /> ** Low cardiac output<br /> * '''Renal (20%) - involves parenchymal damage'''<br /> ** Acute tubular necrosis - commonest<br /> ** Renal ischaemia - hypoxia, hypo-perfusion<br /> ** Medications<br /> *** Nsaids, ACE inhibitors<br /> *** Note trimethoprim can cause a 30% rise in creatinine, without necessarily reflecting kidney injury, due to competitive inhibition of creatinine metabolism<br /> ** Iodinated contrast media<br /> *** Can occur within 48 hours of administration<br /> *** Pre-hydration<br /> *** ?NAC<br /> *** Systematic reviews now saying this may not really exist<br /> ** Interstitial nephritis<br /> ** Hepatorenal syndrome<br /> ** Abdominal compartment syndrome<br /> * '''Post-renal (5%) - obstruction and back-pressure'''<br /> ** Bilateral ureteric obstruction<br /> ** Bladder outlet obstruction<br /> <br /> == Pathophysiology: ==<br /> <br /> * GFR can be estimated from serum creatinine, BMI and gender<br /> **<br /> * Pre-renal injuries:<br /> ** Systemic hypoperfusion leads to increased sympathetic neural tone and release of renin and ADH<br /> ** Leads to arteriolar vasoconstriction primarily in the renal, splanchnic and musculocutaneous circulations to preserve blood flow to the heart and brain<br /> ** Renal vasoconstriction leads to reduced blood flow and GFR<br /> * Acute tubular necrosis<br /> ** Occurs in the setting of prolonged or severe ischaemia<br /> ** Renal tubular cells are more vulnerable than the cortex due to their position deep in the medulla<br /> ** May lead to necrosis, with denuding of the epithelium and occlusion of the tubular lumen by casts and cell debris<br /> * Urine output<br /> ** Normal urine output is 0.5-2mL/kg/hr<br /> ** Oliguria is &lt;0.5mL/kg/hr<br /> ** Anuria is &lt;100mL/day (approx 0.1mL/kg/hr)<br /> <br /> == Diagnosis and classification: ==<br /> <br /> * Oliguric (&lt;400mL/ day or &lt;17mL/hr)<br /> * Non-oliguric (&gt;2L/day)<br /> * '''After you have excluded post-renal causes, and undertaken adequate fluid resuscitation, you can diagnose and classify as AKI based on:'''<br /> ** 'Acute Kidney Injury Network' classification is most useful according to CCrISP - one of:<br /> <br /> * Three stages of AKI:<br /> <br /> == Approach to workup/investigation: ==<br /> <br /> * Sudden onset post-op complete anuria is post-renal UNTIL PROVEN OTHERWISE<br /> ** Catheter kinks<br /> ** Surgical damage to urinary tract<br /> ** Probably needs an USS straight away if nothing obvious found<br /> * Initial investigations:<br /> ** Dipstick/MCS/osmolarity<br /> *** Marked proteinuria or microscopic haematuria with casts suggests a primary renal insult<br /> *** Casts<br /> **** ATN: pigmented coarse granular casts and renal tubular epithelial cells<br /> **** Glomerulonephritis: proteinuria, haematuria, red cell casts<br /> **** Pyelonephritis: White and red cell casts<br /> ** USS<br /> *** As above - mandatory in anuric patient<br /> *** The acutely injured kidney will be echo bright due to oedema, but normal size<br /> *** CKD likely shows a small (&lt;9cm) kidney with echo-bright parenchyma<br /> ** Bloods to consider<br /> *** FBE/UEC/CMP<br /> *** LFT (hepatorenal)<br /> *** CK (rhabdomyolysis - dark brown urine that tests positive for myoglobin)<br /> *** CRP<br /> *** VBG/ABG (for lactate and overall physiology)<br /> <br /> * Establish aetiology:<br /> ** Is it pre-renal? And do we need to restore volume?<br /> ** Differentiating prerenal from renal<br /> *** Prerenal will be a/w dehydration - consider whether large losses are occurring elsewhere<br /> *** BUN &gt; 20<br /> *** Brown urine? Myoglobinuria?<br /> *** In ATN, expect low osmolar urine with high sodium and low urea/creatinine, because the concentrating ability is impaired. In pre-renal AKI, the concentrating ability is retained, so you tend to get high osmolarity and high urea/creatinine. See full table below.<br /> ** If prerenal - is it hypovolaemia or heart failure?<br /> *** If hypovolaemic - give fluids<br /> *** If heart failure - give diuretics<br /> * Management:<br /> ** IDC?<br /> ** Avoid nephrotoxics - aminoglycosides, NSAIDs, ACE inhibitors, opioids, beta blockers<br /> ** Alter dose of renally excreted meds<br /> ** Careful fluid balance - restore perfusion as much as possible by first restoring euvolaemia, then an accurate maintenance fluid rate<br /> ** Check electrolytes - essentially check indications for dialysis<br /> ** Check for complications below<br /> ** Maintain sats &gt;94%<br /> <br /> == '''Complications''' ==<br /> <br /> * '''Hyperkalaemia'''<br /> ** See separate topic<br /> **<br /> * '''Pulmonary oedema'''<br /> ** Sit patient upright<br /> ** Stop all infusions<br /> ** High flow oxygen<br /> ** Monitor saturations<br /> ** ?IV diamorphone 2.5 mg<br /> ** ?IV GTN infusion if SBP &gt; 100<br /> ** ?IV frusemide<br /> ** ?ICU<br /> * '''Indications for dialysis:'''<br /> ** Absolute:<br /> *** Refractory hyperkalaemia (&gt;6mmol/L)<br /> *** Refractory pulmonary oedema and fluid overload<br /> *** Uraemic encephalopathy<br /> ** Relative:<br /> *** Acidosis (pH &lt; 7.2)<br /> *** Uraemia<br /> **** Threshold relates to the rapidity of rise as well as the absolute urea level and presence of symptoms<br /> **** Rise above 35mmol/L unresponsive to other therapies is usually an absolute indication<br /> *** Pericarditis<br /> *** Toxin removal<br /> <br /> [[Category:Renal]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=IV_fluids&diff=970 2026-03-05T10:28:14Z

<p>SurgopaediaAdmin: </p> <hr /> <div><br /> == Crystalloids ==<br /> <br /> * Electrolyte solutions with small molecules that can diffuse freely from intravascular to interstitial fluid compartments<br /> * 25% will stay intravascularly, and 75% will be in the interstitial compartment<br /> * 0.9% saline<br /> ** Differs from plasma - higher sodium and chloride concentrations, higher osmolality, lower pH<br /> ** Cause interstitial oedema more than CSL due to higher sodium load<br /> ** Produces a hyperchloraemic metabolic acidosis in large volumes<br /> * Ringer's lactate (CSL/Hartmann's)<br /> ** Essentially 0.9% NaCL with sodium lactate, potassium and ionised calcium added<br /> ** Doesn't change pH<br /> ** Doesn't change serum lactate in healthy patients, and the impact on unwell patients is unknown, but is thought to be negligible, unless the bloods are taken from downstream<br /> * 5% dextrose<br /> ** Does provide some calories - 3L = 510kcal/day, although this is less important now that we have TPN and enteral feeding<br /> ** Causes a disproportionate cellular swelling due to uptake of dextrose; conversely, causes cellular dehydration in patients with impaired cellular glucose uptake<br /> ** Encourages anaerobic metabolism in critically unwell patients - causes a significant rise in serum lactate<br /> ** Causes hyperglycaemia<br /> ** Therefore, don't use it for critically ill patients<br /> <br /> == Colloid fluids ==<br /> <br /> * A particulate solution with particles that do not dissolve completely. In clinical terms, this is a fluid with solutes that cannot pass into the interstitium, and hence create a colloid osmotic pressure/oncotic pressure to hold water in the vascular compartment.<br /> * Albumin solutions<br /> ** Usually given as 250mL of 5%, or 50-100mL of 25%<br /> ** Volume effect begins to dissipate at 6 hours, and can be lost after 12 hours<br /> ** 5% is safe to use as a resuscitation fluid, and may outperform crystalloids where hypovolaemia is secondary to blood loss (although, should just give blood)<br /> ** The 25% solution draws fluid intravascularly from interstitial space, and therefore shouldn't be used for volume resuscitation, but may be useful in situations where hypovolaemia is the result of hypoalbuminaemia<br /> <br /> <br /> [[Category:Peri-op medicine]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Suturing&diff=969 2026-03-05T10:26:40Z

<p>SurgopaediaAdmin: </p> <hr /> <div>== Shape: ==<br /> <br /> * 1/4 circle: ophthalmic and microsurgery<br /> * 3/8 circle: general - skin<br /> * 1/2 circle: general - fascia, vessels, GIT<br /> * 5/8 circle ('J'): vascular and 'cavities'<br /> * Straight: wound closure - now discouraged<br /> * J: deep cavities<br /> <br /> == Size: ==<br /> <br /> * Chord length - the linear distance from the point of the curved needle to the swage<br /> * Needle length - distance measured along the needle from the point to the swage (this is what you normally get on the packaging)<br /> <br /> == Tip: ==<br /> <br /> * Cutting/reverse cutting: cut through tissue to make an entrance point, so should be used on tougher tissues - periosteum, skin, tendons, sclera<br /> ** Conventional cutting cuts '''upwards''', along the inside of the curve. There is a risk of tear-out, so should be avoided for delicate tissues.<br /> ** Reverse cutting has the cutting edge on the outside. Better for tendon sheath and skin.<br /> * Taperpoint: viscera/most fascia/blood vessels<br /> ** CT1: 36mm<br /> ** CT2: 26mm<br /> * Tapercut - like taperpoint but for denser tissue<br /> * Blunt - for fascia<br /> * Round-bodied - delicate tissue - sharp point with smooth shaft<br /> * Mostly, the needle is joined or 'swaged' to the thread - referred to as 'atraumatic' needle because the hole is as small as possible<br /> <br /> <br /> == Materials ==<br /> <br /> * Monofilament - less tissue reaction, less infection, less scarring<br /> * Braided - can harbour infection, more likely to catch or cut out<br /> <br /> * Nylon (Ethilon/polyamide) - usually monofilament. Poor handling/knotting. Ensure knots are tied square to avoid slippage. Remove memory prior to use. Breaks down very slowly. 6 throws. Handles better when wet.<br /> * Silk - easy handling, secure knots, rare slippage. Low tensile strength. Rougher on tissues, so hurts on removal. Nidus for infection. Do produce an inflammatory reaction. 3 throws only required. Loses tensile strength at 1 year and disappears after 2 years.<br /> * Polypropylene - '''prolene''' - non-absorbable, non-reactive. 6 throws. Can be used for bowel anastomosis. Biologically inert.  Expensive. <br /> * Polydioxanone - '''PDS'''. Synthetic, monofilament, absorbable. Minimal tissue reaction. Hydrolysis starts at 90 days, complete at 6 months. Needs four throws to knot securely. Maintains strength in the presence of infection or exposure to harsh substances such as urine, bile and pancreatic juice. <br /> * Polyglactin 910 ('''vicryl'''). Synthetic, multifilament, absorbable. Braided. Absorption commences 20-30 days, complete by 60-90 days, loses 50% of tensile strength within 3 weeks. Minor inflammatory reaction. <br /> ** Standard Vicryl - coated with polyglactin 370 and calcium stearate, to reduce bacterial adherence, improve handling and decrease resistance<br /> ** Vicryl Plus - also coated with the antiseptic triclosan - has been shown to reduce surgical site infections<br /> ** '''Vicryl rapide''' - coated polyglactin 910 (lower molecular weight coating than standard Vicryl) - strength retention for 7-10 days, complete absorption 40-60 days, but lower tensile strength than normal Vicryl. Mucosa and skin (falls out on its own after a week or so).<br /> * Poligecaptone 25 ('''Monocryl''', kaprosyn). Synthetic, monofilament, absorbable. Little tissue reaction, great handling. Fully absorbed 90-120 days. All tensile strength lost by 21 days.<br /> ** Monocryl - poligecaptone 25 with a lubricant coating. Comes undyed or purple. Available as a Plus version, coated with triclosan. <br /> * Ethibond (braided polyester coated with polybutylate). Non-absorbable. Expensive. Strong. <br /> * TiCron (braided polyethylene coated with silicone)<br /> <br /> == Suture sizes ==<br /> <br /> * 1<br /> * 0 (1/0)<br /> * 2/0<br /> * 3/0<br /> * 4/0<br /> * 5/0<br /> <br /> == Knots: ==<br /> <br /> * Surgeon's knot is useful as a first throw with synthetic monofilaments<br /> **<br /> * 3-1-2 technique can be helpful in preventing slipping for heavy monofilament sutures such as 0 or 1 prolene<br /> **<br /> * Two-handed technique is suggested for deep or poorly-accessible locations<br /> ** Advantage is that the two threads are in control the whole time - makes it easier to maintain tension<br /> ** Can do a double-throw to start with<br /> * One-handed technique is the simpler technique I first learnt (called one-handed since the right hand only acts as an anchor)<br /> <br /> <br /> Simple everting skin suture<br /> <br /> * To evert the skin more, make the deeper portion of the bite wider than the superficial portion<br /> <br /> Vertical mattress (Stewart) suture<br /> <br /> * Guarantees eversion<br /> * Don't need to tie with excessive tension<br /> <br /> Connell, Cushing, Lembert, Halsted, seromuscular sutures - see 'anastomosis' topic<br /> <br /> <br /> Continuous locked stitch<br /> <br /> <br /> Whip stitch<br /> <br /> * Out to in, out to in, out to in, etc<br /> * Quick and easy<br /> <br /> <br /> Staples<br /> <br /> * 5-10mm apart, depending on thickness of skin and underlying structures<br /> <br /> <br /> Pulley suture (good for tensioning difficult wounds)<br /> <br /> # In 3mm from wound on side A<br /> # Out 10mm from wound on side B<br /> # In 10mm from wound on side A<br /> # Out 3mm from wound on side B<br /> # Hence tie between the two 3mm points<br /> <br /> <br /> Cross-stitch (good for closing circular wounds e.g. punch biopsy)<br /> <br /> <br /> Three-point corner suture (for closing triangles)<br /> <br /> [[Category:Operating theatre]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Iron_deficiency&diff=968 2026-03-05T10:24:23Z

<p>SurgopaediaAdmin: </p> <hr /> <div>Blood loss until proven otherwise.<br /> <br /> == '''Aetiology''' ==<br /> <br /> * '''Blood loss (most common)'''<br /> ** Overt<br /> *** Traumatic haemorrhage<br /> *** UGIB<br /> *** Haemoptysis<br /> *** Menorrhagia (normally 1mg per day)<br /> *** Pregnancy and delivery<br /> *** Haematuria<br /> ** Occult<br /> *** Frequent blood donation<br /> *** Haemodialysis (2g per year)<br /> *** Excessive diagnostic blood testing<br /> *** Occult GIT<br /> *** Haemolysis with urinary losses<br /> *** GIT parasites<br /> * '''Reduced iron absorption''' (uncommon)<br /> ** Diet<br /> ** Coeliac<br /> ** Atrophic gastritis<br /> ** Helicobacter pylori<br /> ** Bariatric surgery (especially RYGB and biliopancreatic diversion with duodenal switch)<br /> * '''Medications'''<br /> ** PPIs (may be correlation rather than causation)<br /> ** Medications that increase risk of GIB (NSAIDs, anticoagulants)<br /> * '''Redistribution after EPO'''<br /> * '''Urinary/pulmonary haemosiderosis'''<br /> * '''Inherited disorders'''<br /> * '''High-intensity athletics'''<br /> <br /> == '''Pathophysiology''' ==<br /> <br /> * Normal body iron content is 3-4g, with 2g in RBCs<br /> * Normally absorbed in duodenum and jejunum<br /> * Mild to moderate iron deficiency causes mainly blunted marrow proliferation and hypoproliferative anaemia<br /> * Severe iron deficiency causes a hyperplastic marrow, despite the inadequate iron supply, and cytoplasmic maturation defect results<br /> <br /> == '''Interpretation of tests''' ==<br /> <br /> * '''Serum iron''' can be low in anaemia of chronic disease, post-op, malignancy, low protein stores, or inflammatory processes. It is therefore not specific for iron deficiency. It also fluctuates a lot from day to day.<br /> * '''Ferritin''' reflects body iron stores, except in systemic inflammation. Low ferritin is therefore specific for iron deficiency - false low values are very uncommon. False normal levels can be seen in concurrent acute or chronic inflammation, hepatocellular damage, or some malignancies.<br /> * '''Transferrin''' should be elevated or high normal in true iron deficiency - if both transferrin and serum iron are low, this likely reflects acute inflammation/anaemia of chronic disease.<br /> * '''Transferrin saturation''' &lt;20% can also indicate iron deficiency, but this picture can also be seen in anaemia of chronic disease as serum iron levels drop.<br /> * If the true picture is still hard to interpret and clinically significant - either perform a bone marrow aspirate, or trial iron supplementation and see if anaemia improves within 4-6 weeks.<br /> <br /> <br /> {| class=&quot;wikitable&quot;<br /> | <br /> |'''Normal'''<br /> |'''Iron deficiency without anemia'''<br /> |'''Iron deficiency with mild anemia'''<br /> |'''Iron deficiency with severe anemia'''<br /> |-<br /> |'''Hemoglobin'''<br /> |Normal range*<br /> |Normal range*<br /> |'''9 to 12 g/dL (90 to 120 g/L)'''<br /> |'''6 to 7 g/dL (60 to 70 g/L)'''<br /> |-<br /> |'''Red blood cell size and appearance'''<br /> |Normal<br /> |Normal<br /> |'''Normal or slight hypochromia (slight decrease in MCHC)'''<br /> |'''Microcytosis (decrease in MCV) and hypochromia (decrease in MCHC)'''<br /> |-<br /> |'''Serum ferritin'''<br /> |40 to 200 ng/mL (40 to 200 mcg/L; 89.9 to 449 picoM/L)<br /> |'''&lt;40 ng/mL'''¶ '''(&lt;40 mcg/L; &lt;89.9 picoM/L)'''<br /> |'''&lt;20 ng/mL (&lt;20 mcg/L; &lt;45 picoM/L)'''<br /> |'''&lt;10 ng/mL (&lt;10 mcg/L; &lt;22.5 picoM/L)'''<br /> |-<br /> |'''Serum iron'''<br /> |60 to 150 mcg/dL (10.7 to 26.7 microM/L)<br /> |60 to 150 mcg/dL (10.7 to 26.7 microM/L)<br /> |'''&lt;60 mcg/dL (&lt;10.7 microM/L)'''<br /> |'''&lt;40 mcg/dL (&lt;7.1 microM/L)'''<br /> |-<br /> |'''Total iron-binding capacity (TIBC; transferrin)'''<br /> |300 to 360 mcg/dL (53.7 to 64.4 microM/L)<br /> |300 to 390 mcg/dL (53.7 to 69.8 microM/L)<br /> |'''350 to 400 mcg/dL (62.6 to 71.6 microM/L)'''<br /> |'''&gt;410 mcg/dL (&gt;73.4 microM/L)'''<br /> |-<br /> |'''Transferrin saturation (serum iron/TIBC)'''<br /> |20 to 50%<br /> |20%<br /> |'''&lt;15%'''<br /> |'''&lt;10%'''<br /> |-<br /> |'''Reticulocyte hemoglobin[1]'''<br /> |30.6 to 35.4 pg<br /> |22.3 to 34.7 pg<br /> |14.8 to 34.0 pg<br /> |Data not available<br /> |-<br /> |'''Bone marrow iron stain'''<br /> |Adequate iron present<br /> |'''Iron absent'''<br /> |'''Iron absent'''<br /> |'''Iron absent'''<br /> |-<br /> |'''Erythrocyte zinc protoporphyrin, ng/mL RBC'''<br /> |30 to 70<br /> |30 to 70<br /> |'''100 to 200'''<br /> |'''100 to 200'''<br /> |}<br /> <br /> == '''Iron supplementation''' ==<br /> <br /> * After infusion, Hb will start to rise 1-2 weeks later, and normally rising about 20 points over the three weeks.<br /> * Hb should return to normal by 8 weeks, along with iron studies returning to normal<br /> * Recheck iron studies 4-8 weeks afterwards<br /> * Keep giving iron until Hb normalises (of course, fix the blood loss too)<br /> * Each unit of RBCs contains about 250mg of iron <br /> * Usually wait until acute infection resolves before giving IV iron (although UTD says not much evidence for or against)<br /> <br /> <br /> All IV iron formulations have a similar efficacy and safety profile; base choice on formulary advice. Generally give about 1000mg - more has not been proven to be helpful. There is a dose calculator on UTD.<br /> <br /> <br /> Austin has Ferinject and Monofer available. The main difference is that you can give 1.5g of Monofer but only 1g of Ferinject at a time.<br /> <br /> <br /> {| class=&quot;wikitable&quot;<br /> |'''Drug'''<br /> |'''Trade (brand) name'''<br /> |'''Concentration of elemental iron'''<br /> |'''Dosing'''<br /> <br /> '''(adults)'''<br /> |'''Test dose'''<br /> |'''Premedication'''<br /> |-<br /> |Ferric carboxymaltose (FCM)<br /> |Injectafer (United States), Ferinject(United Kingdom and other countries)<br /> |50 mg/mL<br /> |<br /> ** Weight ≥50 kg: 1 or 2 doses of 750 mg, given 7 or more days apart<br /> <br /> '''-OR-'''<br /> <br /> ** Weight &lt;50 kg: 1 or 2 doses of 15 mg/kg, given 7 or more days apart<br /> |Not required<br /> |<br /> ** We do not routinely premedicate for any of the IV iron products.<br /> ** For patients with asthma, multiple drug allergies, or inflammatory arthritis, we often give methylprednisolone alone prior to the iron infusion. We do not give diphenhydramine.<br /> |-<br /> |Ferric derisomaltose (previously called iron isomaltoside)<br /> |Monoferric (United States, Canada), Monofer (United Kingdom, other countries)<br /> |100 mg/mL<br /> |<br /> ** Weight ≥50 kg: Single dose of 1000 mg<br /> <br /> '''-OR-'''<br /> <br /> ** Weight ≥50 kg: Up to 3 doses of 500 mg given over 7 days<br /> <br /> '''-OR-'''<br /> <br /> ** Weight &lt;50 kg: Single dose of 20 mg/kg<br /> |Not required<br /> |<br /> |-<br /> |Ferric gluconate (FG)<br /> |Ferrlecit<br /> |12.5 mg/mL<br /> |<br /> ** Multiple doses of 125 to 250 mg<br /> |Not required, but recommended if the patient has a history of multiple drug allergies<br /> |<br /> |-<br /> |Ferumoxytol*<br /> |Feraheme (United States), Rienso (United Kingdom and other countries)<br /> |30 mg/mL<br /> |<br /> ** Single dose of 1020 mg<br /> <br /> '''-OR-'''<br /> <br /> ** 2 doses of 510 mg, given 3 to 8 days apart<br /> |Not required<br /> |<br /> |-<br /> |Iron dextran, low molecular weight (LMW ID)¶<br /> |INFeD (United States), Dexiron (Canada), CosmoFer (United Kingdom and other countries)<br /> |50 mg/mL<br /> |<br /> ** Single dose of 1000 mg (diluted in 250 mL normal saline) given over 1 hour<br /> <br /> '''-OR-'''<br /> <br /> ** Multiple doses of 100 mg<br /> |Yes, 25 mg (0.5 mL) prior to the first dose<br /> |<br /> |-<br /> |Iron sucrose (IS)<br /> |Venofer<br /> |20 mg/mL<br /> |<br /> ** Multiple doses of 100 to 300 mg<br /> |Not required, but recommended if the patient has a history of multiple drug allergies<br /> |<br /> |}<br /> <br /> *<br /> <br /> [[Category:Haematology]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=RBC_transfusion&diff=967 2026-03-05T10:24:05Z

<p>SurgopaediaAdmin: </p> <hr /> <div>== '''Thresholds for transfusion:''' ==<br /> <br /> * Acutely symptomatic patient (MI, haemodynamic instability, orthostatic hypotension, tachycardia, marked dyspnoea at rest): 100<br /> * Pre-existing CAD: 80<br /> * ACS, including acute MI: 80-100<br /> * Orthopaedic surgery: 80<br /> * Most other situations, including septic shock, UGIB and stable ICU patient: 70<br /> <br /> == Estimating transfusion requirement: ==<br /> <br /> * One unit and reassess (expected rise in a 70kg adult is 10g/L per unit) <br /> * OR<br /> * 0.4 x weight in kg x desired Hb rise (g/L)<br /> * Neonates/paeds: 0.5 x weight in kg x desired Hb rise (g/L)<br /> <br /> <br /> Default administration time over 2 hours, but up to 4 hours if at risk of CCF<br /> <br /> <br /> == Estimating need for MTP: ==<br /> One each for:<br /> <br /> * Positive FAST<br /> * Penetrating mechanism<br /> * SBP &lt; 90<br /> * HR &gt; 120<br /> <br /> If two or more points, strongly consider activating MTP<br /> <br /> <br /> '''MTP'''<br /> <br /> * 1:1:1 FFP/pooled platelets/RBC ratio is probably best<br /> <br /> == '''Transfusion reactions''' ==<br /> <br /> * Fever +/- chills/rigors<br /> ** Stop transfusion, screen for haemolytic transfusion reaction<br /> ** If hypotension, tachycardia or temp &gt;39 is present, could be acute haemolytic reaction or bacterial contamination. Check patient ID with label. Culture patient and product. Reaction form, G+H, DAT, FBE, LDH, bilirubin, haptoglobin, coags, UEC, urinalysis. IV antibiotics if sepsis is suspected. Notify lab/haematologist. <br /> * Allergic reactions<br /> ** Minor (&lt;2/3 of body): stop transfusion, give antihistamine, recommence if reaction subsides.<br /> ** Major: stop transfusion, give antihistamine and corticosteroid, reaction form.<br /> ** With dyspnoea, airway obstruction, angio-oedema, hypotension: stop transfusion, prepare adrenaline, initiate BLS, also screen for haemolysis, check IgA level and antibody (could be IgA deficiency).<br /> * Dyspnoea or hypoxia<br /> ** TACO - diuretics, sit upright<br /> ** TRALI - CXR to check for infiltrates, HLA and HNA Ab and typing<br /> ** Bacterial contamination or acute haemolytic transfusion reaction<br /> <br /> <br /> <br /> <br /> <br /> <br /> &lt;nowiki&gt;https://transfusion.com.au/adverse_events/management_steps&lt;/nowiki&gt;<br /> <br /> * Good basic guidance on managing ?transfusion reactions<br /> <br /> [[Category:Haematology]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Anaemia&diff=966 2026-03-05T10:23:37Z

<p>SurgopaediaAdmin: </p> <hr /> <div><br /> A reduction in haemoglobin concentration, haematocrit, or RBC count.<br /> <br /> == '''Aetiology''' ==<br /> <br /> * '''Decreased RBC production''' (low reticulocytes, little or no change in RBC morphology)<br /> ** Iron deficiency<br /> ** Acute and chronic inflammation<br /> ** Renal disease<br /> ** Hypometabolic states - protein malnutrition and endocrine deficiencies<br /> ** Marrow damage<br /> * '''Maturation disorders''' (slightly to moderately elevated reticulocytes, with microcytosis or macrocytosis)<br /> * '''Decreased survival'''<br /> ** Increased RBC destruction - high reticulocytes &gt;3x normal<br /> ** Acute blood loss - reticulocytes up to 2.5x normal<br /> <br /> == '''Definition''' ==<br /> <br /> * Female - Hb &lt; 119 or haematocrit &lt;35%<br /> * Male - Hb &lt;136 or haematocrit &lt;40%<br /> * Use same cut-offs for all ethnicities and ages<br /> * Lower normal cut-offs in pregnancy - 110 in first trimester, 105 in second and third trimester<br /> <br /> == '''Diagnostic approach based on MCV''' ==<br /> <br /> == '''Diagnostic approach based on reticulocyte count''' ==<br /> <br /> * Decreased (or inappropriately low)<br /> ** Deficiency of iron, B12, folate or copper<br /> ** Medications that suppress the bone marrow<br /> ** Primary bone marrow disorders (MDS, myelofibrosis, leukaemia)<br /> ** Very recent bleeding within 5-7 days, pre-compensation<br /> * Increased<br /> ** Haemolysis<br /> ** Repletion of deficient iron, B12, folate or copper<br /> ** Recovery from bleeding<br /> <br /> {| class=&quot;wikitable&quot;<br /> |'''RBC size/'''<br /> <br /> '''MCV'''<br /> |'''Reticulocyte count'''<br /> |<br /> |-<br /> |<br /> |'''Low or normal*'''<br /> |'''Increased'''<br /> |-<br /> |'''Microcytic'''<br /> <br /> MCV &lt;80 fL<br /> |<br /> ** Iron deficiency (late)<br /> ** Anemia of chronic disease/inflammation<br /> ** Sideroblastic anemias<br /> |<br /> ** Thalassemia<br /> ** Hemolysis¶<br /> |-<br /> |'''Normocytic'''<br /> <br /> MCV 80 to 100 fL<br /> |<br /> ** Bleeding (acute)<br /> ** Iron deficiency (early)<br /> ** Anemia of chronic disease/inflammation<br /> ** Bone marrow suppression (cancer, aplastic anemia, infection)<br /> ** Chronic renal insufficiency<br /> ** Hypothyroidism<br /> ** Hypopituitarism<br /> ** Excess alcohol<br /> ** Copper deficiency/zinc poisoning<br /> |<br /> ** Bleeding (with bone marrow recovery)<br /> ** Hemolysis¶<br /> ** Bone marrow recovery (eg, after infection, vitamin B12 or folate replacement, and/or iron replacement)<br /> |-<br /> |'''Macrocytic'''<br /> <br /> MCV &gt;100 fL<br /> |<br /> ** Vitamin B12 or folate deficiency<br /> ** Excess alcohol<br /> ** Myelodysplastic syndrome<br /> ** Liver disease<br /> ** Hypothyroidism<br /> ** HIV infection<br /> ** Medications that interfere with nuclear maturation (hydroxyurea, methotrexate, some chemotherapy agents)<br /> |<br /> ** Hemolysis¶<br /> ** Bone marrow recovery (eg, after infection, vitamin B12 or folate replacement, and/or iron replacement)<br /> |}<br /> <br /> <br /> <br /> == Clinical scenarios ==<br /> <br /> * Pancytopaenia or bicytopaenia<br /> ** See separate topic<br /> <br /> == Treatment ==<br /> <br /> * Each pRBC contains:<br /> **<br /> * Iron replacement<br /> ** See separate topic<br /> <br /> [[Category:Haematology]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=LFTs_and_liver_function_assessment&diff=965 2026-03-05T10:23:17Z

<p>SurgopaediaAdmin: </p> <hr /> <div><br /> == General approach to abnormal LFTs: ==<br /> <br /> * Primary liver disorder vs secondary liver derangement?<br /> * Intrahepatic vs non-hepatic cause?<br /> * Is this a clinically significant derangement?<br /> * Acute vs chronic? If chronic, is it compensated or decompensated?<br /> <br /> <br /> === Bilirubin ===<br /> <br /> * Cause<br /> ** Pre-hepatic<br /> *** Haemolysis<br /> **** Rarely produces bili levels &gt; 50-90micromol/L<br /> ** Hepatic<br /> ** Post-hepatic<br /> * Conjugated/unconjugated has limited value in clinical practice. Conjugated levels are highest in cholestatic disease and fulminant liver failure. Unconjugated hyperbilirubinaemia may reflect haemolysis, physiological neonatal jaundice or genetic defects (including Gilbert's). <br /> * Renal failure will reduce renal clearance of conjugated bili, which can have a significant effect on serum levels.<br /> <br /> === Albumin ===<br /> <br /> * Factors impacting levels: nutrition, hepatic synthesis, losses (nephrotic syndrome, protein-losing enteropathy)<br /> * Half-life of 17-26 days - usually chronic rather than acute dysfunction<br /> <br /> === INR ===<br /> <br /> * Vitamin K-dependent clotting factors are synthesised by the liver. Factors VII, IX and X often fall with significant disease.<br /> * Derangements can develop quickly, due to short half-life. Can even occur within hours (fatty liver of pregnancy).<br /> * Cholestasis can lead to vitamin K malabsorption and raise INR that way. If the INR fails to come down with vitamin K, that suggests hepatocellular dysfunction.<br /> <br /> === Transaminases ===<br /> <br /> * Best conceptualised as reflecting hepatocyte damage or injury - do not reflect functional capacity. Enter the circulation following hepatocellular lysis, or sometimes sublethal hepatocyte injury.<br /> * Aetiology<br /> ** NAFLD <br /> *** Most common cause of transaminase derangements in Australia. <br /> ** Viral hepatitis<br /> *** ALT levels usually higher than AST<br /> ** Alcoholic liver disease<br /> *** AST usually more than double ALT (in the presence of cirrhosis, the diagnostic value of AST:ALT ratios is lost)<br /> ** Marked elevations (&gt;1000 U/L) often reflect viral hepatitis, drug reactions, or acute exacerbations of chronic autoimmune hepatitis. Can also be seen with cholestasis, shock and cardiac failure.<br /> ** Hepatic mets<br /> * '''ALT (alanine aminotransferase)'''<br /> ** Liver-specific: elevation here is highly suggestive of liver disease<br /> * '''AST (aspartate aminotransferase)'''<br /> ** Enzyme found in liver, skeletal muscle, myocardium, kidney, pancreas, erythrocytes. Damage to any of these cell lines will result in derangements.<br /> * Persistent elevation requires investigation to exclude significant chronic liver disease. <br /> <br /> === '''ALP (alkaline phosphatase)''' ===<br /> <br /> * Enzyme localised to the biliary membrane of hepatocytes. Marker of biliary disease or a hepatic infiltrative disorder.<br /> * Also found in '''bone''' (Paget's disease, tumours involving bone, acromegaly, fractures), '''intestine, kidney, placenta''', and can be elevated with damage to these organs. Also will be high during '''pregnancy''' and during periods of rapid growth ('''neonatal''' and '''adolescent''' periods). Can see a mild rise during infarction of heart, lung, GIT and kidneys.<br /> * 75% of patients with cholestasis have ALP &gt; 3x ULN <br /> ** It CAN be normal in cholestasis.<br /> * Mild elevations of ALP are often seen in hepatocellular injury.<br /> <br /> === '''GGT (gamma glutamyl transpeptidase)''' ===<br /> <br /> * Membrane-bound enzyme present in liver, pancreas, kidney, intestine and prostate<br /> * Levels increase with any liver disease. NO increase in a normal pregnancy or with bone disease.<br /> * Associated with ALP in cholestatic disease - an elevated GGT supports hepatic origin of an elevated ALP.<br /> * Heavy drinkers will often have an elevated GGT. Should normalise over 2-5 weeks of abstinence. <br /> * Also consider:<br /> ** Biliary disease<br /> ** Pancreatitis<br /> ** Obesity<br /> ** Hyperlipidaemia<br /> ** Anorexia nervosa<br /> ** Diabetes mellitus<br /> ** Hyperthyroidism<br /> ** Porphyria<br /> ** MI<br /> ** Drugs - barbiturates, tricyclic antidepressants, anticonvulsants<br /> <br /> === LDH (lactate dehydrogenase) ===<br /> <br /> * Glycolytic enzyme present in all cells<br /> * Will be elevated out of proportion to transaminases in ischaemic liver injury and secondary malignancy<br /> <br /> === AFP ===<br /> <br /> * Elevation &gt; 1000 U/L is most often due to HCC<br /> <br /> == '''Jaundice''' ==<br /> <br /> === '''Pre-hepatic''' ===<br /> <br /> ** Gilbert's disease<br /> *** Most common cause of unconjugated hyperbilirubinaemia<br /> *** Mild hereditary deficiency of glucuronyl transferase - 5-7% of population<br /> *** Disease exacerbated by fasting and febrile illness<br /> *** If serum ALP and transaminases are normal, haemolysis is excluded, and hyperbilirubinaemia is unconjugated, requires no further investigation<br /> ** Bilirubin overproduction<br /> *** Aetiology<br /> **** Chronic haemolysis e.g. prosthetic heart valves<br /> **** Hereditary spherocytosis<br /> **** Acute intravascular haemolysis<br /> ***** Sickle cell crisis<br /> ***** Transfusion reaction<br /> **** Acute extravascular haemolysis<br /> ***** Reabsorption of haematoma<br /> **** Ineffective erythropoiesis (leads to destruction of RBCs in bone marrow)<br /> ***** Aetiology<br /> ****** Pernicious anaemia<br /> ****** Severe IDA<br /> ****** Sideroblastic anaemia<br /> ****** Folate deficiency<br /> ****** Lead poisoning<br /> *** Diagnosis<br /> **** Blood film<br /> **** Haptoglobin (will be low)<br /> **** LDH (will be high)<br /> ** Impaired delivery to liver<br /> *** Usually the result of portosystemic shunting (cirrhosis and CCF)<br /> <br /> === '''Hepatic''' ===<br /> <br /> === '''Post-hepatic''' ===<br /> <br /> ** '''Intra-hepatic cholestasis'''<br /> *** Idiosyncratic drug reaction (augmentin, flucloxacillin, etc - see table below)<br /> *** Viral hepatitis, especially hepatitis A, can occasionally do it<br /> ** '''Extra-hepatic obstructive jaundice'''<br /> *** Usually stones or jaundice<br /> <br /> '''Differentiating hepatocellular and obstructive:'''<br /> <br /> == '''Post-surgical/ICU jaundice''' ==<br /> <br /> * Increased bilirubin production<br /> ** Destruction of transfused cells<br /> ** RBCs damaged by cell saver<br /> ** Reabsorption of haematomas<br /> ** Other causes of haemolysis - see above<br /> * Liver ischaemia<br /> ** Check for presence of hypotension in perioperative period<br /> ** Transaminases rise rapidly to 1,000-10,000 with hyperbilirubinaemia and fall within 24-48 hours if normal perfusion is restored<br /> * Systemic infections causing cholestasis<br /> * Drug toxicity - often antibiotics, consider anaesthetic agents<br /> * TPN<br /> ** TPN can cause:<br /> *** Fatty liver<br /> *** Cholestasis<br /> *** Portal inflammation<br /> *** Gallstone formation<br /> *** Occasionally steatohepatitis and cirrhosis<br /> ** Usually arises 1-4 weeks after initiation and resolves on discontinuation<br /> *** Especially transaminase levels go up within 1 week, with ALP and GGT rising later. Increases in bilirubin can occur but are unusual<br /> ** Usually, it's multifactorial. Transaminase rise due to glucose intolerance. Cholestasis due to abnormal lipid metabolism.<br /> ** Small adjustments to TPN composition can fix this.<br /> <br /> <br /> <br /> <br /> '''Further screening'''<br /> <br /> * Standard screen:<br /> <br /> hepatitis A, B and C serology<br /> <br /> EBV<br /> <br /> CMV<br /> <br /> HIV<br /> <br /> antinuclear antibody (ANA)<br /> <br /> smooth muscle antibody<br /> <br /> antimitochondrial antibody<br /> <br /> iron studies<br /> <br /> TSH<br /> <br /> cholesterol<br /> <br /> * Viral hepatitis<br /> **<br /> <br /> *<br /> * Paracetamol level<br /> * Liver biopsy - only if patient is not getting better or getting worse, and significant illness<br /> <br /> <br /> '''The well patient with abnormal LFTs'''<br /> <br /> * Most commonly NAFLD, alcohol or drugs<br /> * First consider causes based on clinical context<br /> * History<br /> ** Hepatitis<br /> *** Overseas travel/migration - Southeast Asia<br /> *** Exposure to blood products/injection/tattooing<br /> *** Sexual history<br /> *** Exposure to others with liver disease<br /> ** Cholestatic factors<br /> * Examination<br /> ** Signs of chronic liver disease as above<br /> **<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> '''Immunocompromised patient with jaundice'''<br /> <br /> * HIV<br /> ** Biliary pain and fever - AIDS cholangiopathy<br /> * Mycobacterium avium-intracellulare<br /> * Drugs<br /> * CMV<br /> * Bacillary peliosis hepatis<br /> * Lymphoma<br /> * Mycobacterium tuberculosis<br /> * Kaposi's sarcoma<br /> * Hepatitis B or C<br /> * Cryptococcal infection<br /> <br /> <br /> '''Jaundice in patients with transplanted organs'''<br /> <br /> * Hepatic graft versus host disease<br /> * Veno-occlusive disease - common in first few weeks after BM transplant<br /> * Viral hepatitis<br /> * Drug-induced liver disease - cyclosporin<br /> <br /> <br /> References:<br /> <br /> * 'Abnormal liver function tests results' chapter in Clinical Gastroenterology 3e (Talley). <br /> <br /> <br /> <br /> '''Assessment of liver function'''<br /> <br /> * Routine screening tests<br /> ** LFTs<br /> *** Useful starting point<br /> ** Albumin<br /> *** Synthesised exclusively in the liver - good general measure of hepatic synthetic function<br /> *** Decreased synthesis in chronic malnutrition, acute injury/infection/inflammation<br /> ** PT/INR<br /> *** Prolonged PT is a sign of advanced chronic liver disease<br /> ** Thrombocytopaenia<br /> *** Provides insight into severity of portal HTN in patients with liver disease<br /> * Specific diagnostic tests<br /> ** Liver screen - see above<br /> ** Tumour markers (AFP/CEA)<br /> ** Tests based on liver's ability to clear exogenously administered substances are not very useful because they don't detect subclinical disease<br /> *** Aminopyrine breath test (based on cytochrome P450 clearance of radiolabelled aminopyrine)<br /> *** Antipyrene test<br /> ** Technetium-99m-galactosyl human serum albumin scintigraphy and Tc-99m-mebrofenin hepatobiliary scintigraphy are potentially useful to identify patients at risk for post-resectional liver failure who might benefit from liver-augmenting techniques<br /> * Quantitative tests<br /> ** Child-Pugh reflects peri-operative mortality after partial hepatectomy<br /> **<br /> <br /> [[Category:Gastroenterology]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Hypoglycaemia&diff=964 2026-03-05T10:20:41Z

<p>SurgopaediaAdmin: </p> <hr /> <div><br /> '''Hypoglycaemia'''<br /> * Aetiology:<br /> ** Accelerated insulin absorption<br /> *** Exercise<br /> *** Hot environmental conditions<br /> ** Unfavourable factors relating to insulin administration<br /> *** Too early<br /> *** Too much<br /> *** Inadequate food intake<br /> ** Alcohol consumption (inhibits hepatic gluconeogenesis)<br /> ** Loss of counter-regulatory hormones<br /> *** Addison's disease<br /> *** Hypothyroidism<br /> *** Hypopituitarism<br /> *** Blunted glucagon secretion (as in long-standing T1DM)<br /> *** Intestinal malabsorption<br /> *** Renal failure (impaired insulin clearance)<br /> * Natural history:<br /> ** ~3.8 - adrenaline and glucagon secretion increases<br /> ** ~3 - onset of hypoglycaemic symptoms<br /> ** ~2.8 - neuroglycopaenia and cognitive impairment<br /> ** &lt;1 - coma<br /> <br /> [[Category:Endocrinology]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Peri-op_diabetes&diff=963 2026-03-05T10:20:17Z

<p>SurgopaediaAdmin: </p> <hr /> <div>== '''Elective peri-op management of diabetes:''' ==<br /> <br /> * Simple things:<br /> ** First on list<br /> ** Don't drive themselves to hospital (hypoglycaemia)<br /> ** Clear apple juice if hypo pre-op<br /> ** Consider pre and post op admission<br /> * Referral to endocrinology:<br /> ** All type 1 diabetics<br /> ** All patients on subcut pump<br /> * T1DM:<br /> ** Do not withhold basal insulin<br /> ** BSL hourly<br /> ** Check ketones if BSL &gt; 15<br /> ** Use insulin infusion with 5% dextrose at q18h<br /> ** Do not stop insulin infusion unless already given insulin 2 hours previously<br /> * SGLT2 (flozins):<br /> ** Cease 3/7 pre-op and only restart when patient is eating and drinking normally<br /> ** Day cases - withhold on day of procedure only<br /> * Aim 6.1-10 mmol/L<br /> * '''T2DM Oral'''<br /> ** Continue orals and non-insulin injectables until morning of surgery, then withhold day of surgery<br /> ** Restart when eating, except metformin, which should be withhold until renal function back to normal<br /> * '''T1DM/T2DM insulin-controlled'''<br /> ** Short procedures (2 hours) can continue subcut insulin<br /> *** If breakfast is likely to be only delayed, not missed, then can continue usual basal regime.<br /> *** Morning procedures causing missed meals, or afternoon procedures:<br /> **** Withhold short-acting while fasting<br /> **** Give half usual morning dose of long-acting<br /> **** Insulin pumps can continue at their usual basal rate<br /> **** Run slow IV dextrose while fasting<br /> **** T1DM - can reduce previous night's dose of long-acting by 20%. Not necessary in T2DM.<br /> ** Longer/complex procedures<br /> *** Should be on insulin infusion started with enough time to bring sugars under control<br /> <br /> == '''Acute management of T2DM in emergency patients''' ==<br /> <br /> * Avoid sliding scale alone - usually inadequate<br /> * Ideally should have a basal-bolus regime which is frequently adjusted<br /> <br /> == '''SGLT-2 inhibitors in emergency cases - euDKA''' ==<br /> <br /> * Epidemiology<br /> ** The overall risk of this happening is doubled compared to placebo but still really low - about 0.5% of patients per year<br /> * Risk factors<br /> ** Lean patients<br /> ** Low-carbohydrate diet<br /> ** Hypovolaemic<br /> ** Low reserve of insulin-secreting cells (long-term insulin use, T1DM)<br /> ** Sudden reduction in insulin dose<br /> ** Increased requirement for insulin (acutely unwell, surgery, alcohol abuse)<br /> ** Hidden diagnosis of latent autoimmune diabetes of adulthood (LADA)<br /> * Pathophysiology<br /> ** Urinary glucose excretion is independent of circulating insulin level<br /> ** Inhibition of SGLT2 may lead to increased glucagon and consequently liver production of glucose and ketones<br /> ** There is also a linked renal cotransporter, normally responsible for excreting lactate and ketones, that may be inhibited by SGLT-2 inhibitors<br /> ** Euglycaemic (meaning BSL&lt;13.9) DKA can occur during illness or when ongoing glucosuria masks stress-induced requirements for insulin. DKA might be present due to lack of/resistance to insulin, but the BSL is not elevated due to ongoing urinary losses.<br /> ** Often a hyper-chloraemic metabolic acidosis complicates recovery from DKA<br /> * Prevention<br /> ** Withhold SGLT-2 inhibitors three days prior<br /> ** Prevent hypovolaemia<br /> * Diagnosis<br /> ** Check serum ketones in any patient fasting or with nausea/vomiting/anorexia who has had SGLT-2 inhibitors within past 3 days<br /> ** My plan: BD BSL and ketone checks, and daily VBG, until either the patient is eating again, or it's been 3/7 since SGLT-2 inhibitor<br /> * Management<br /> ** Stop the SGLT-2 inhibitor<br /> ** Generally, both insulin and glucose are required to correct the problem<br /> *** First, ensure K+ &gt; 3.3 and volume resuscitate with 0.9% normal saline<br /> *** Start insulin infusion as per protocol (generally 0.1IU/kg bolus followed by continuous infusion, although can just start with continuous infusion; replace 0.9% saline with 5% Dextrose with BSL&lt;11.1)<br /> **** Some say just start directly on Dextrose 5% infusion<br /> *** Give bicarbonate if pH &lt; 6.9, which may require additional administration of calcium<br /> *** Once acid-base balance is restored, switch to subcutaneous insulin in an intensive regimen, such as 0.5-0.8IU/kg short-acting with meals and a long-acting insulin at night<br /> ** Talk to endocrinology before reinstating the SGLT-2 inhibitor<br /> ** See 'DKA' page<br /> <br /> <br /> <br /> <br /> &lt;&lt;Peri-Op Guidelines for Patients with Type1 and Type2 Diabetes.pdf&gt;&gt;<br /> <br /> [[Category:Endocrinology]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Post-op_AF&diff=962 2026-03-05T10:19:55Z

<p>SurgopaediaAdmin: </p> <hr /> <div><br /> Note that post-op atrial fibrillation and atrial flutter can be managed the same, according to UTD<br /> <br /> == '''Epidemiology''' ==<br /> <br /> * Incidence 0.4-3% after non-cardiac surgery<br /> * Incidence peaks post-op day 2<br /> <br /> == '''Secondary precipitant''' ==<br /> <br /> * Always consider missed medication<br /> * Infection/systemic inflammation<br /> * Sympathetic activation in general<br /> * Pain<br /> * Low serum magnesium/other electrolytes<br /> * Anaemia<br /> * Hypothermia<br /> * Hypoxia<br /> * Hypervolaemia<br /> * Acidosis<br /> * Acute MI<br /> * Acute alcohol consumption<br /> * Thyrotoxicosis<br /> * Acute pericardial disease<br /> * Acute PE<br /> * Other acute pulmonary pathology<br /> * Caffeine is not proven to increase risk<br /> <br /> == '''Classification''' ==<br /> <br /> * Unstable<br /> ** Hypotension (for which AF is suspected to be causal or contributory, and standard therapy to treat other underlying causes has failed)<br /> ** Altered mental status<br /> ** Ischaemia<br /> ** Heart failure<br /> ** Cardiogenic shock<br /> ** Very rapid ventricular rates (accessory pathway)<br /> <br /> == '''Investigation/initial management''' ==<br /> <br /> * ECG<br /> * Bloods including electrolytes, free T4, TSH<br /> * Troponin if clinical suspicion for ACS or ECG evidence of cardiac ischaemia, or uncertainty thereof<br /> * Septic screen including CXR<br /> * Fix reversible causes above<br /> <br /> == '''Drug options''' ==<br /> <br /> * Amiodarone<br /> ** Rate control and rhythm control (can be a problem if not anticoagulated)<br /> ** Contraindications<br /> *** Sino-atrial block<br /> *** Severe hypotension<br /> *** Thyroid disease<br /> *** CCF<br /> *** Pregnancy and breastfeeding<br /> * Flecainide<br /> ** Contraindications<br /> *** Atrial flutter<br /> *** CCF<br /> *** Structural heart disease<br /> *** Recent MI<br /> * Beta-blockers<br /> ** Indications<br /> *** Preferred agents when AF is associated hyper-adrenergic states<br /> ** Contraindications<br /> *** Asthma/COPD<br /> *** Uncontrolled heart failure<br /> *** Sick sinus syndrome<br /> *** Heart block<br /> *** Hypotension (approx &lt;100)<br /> *** Severe peripheral vascular disease<br /> *** Pregnancy and breastfeeding<br /> * Calcium channel blockers<br /> ** Contraindications<br /> *** Heart failure<br /> *** Hypotension<br /> *** Sick sinus syndrome<br /> *** Heart block<br /> *** AF with WPW<br /> *** VT<br /> *** Pregnancy and breastfeeding<br /> *** Already on beta-blocker<br /> * Digoxin<br /> ** Popular for long-term rate control, but slow response in acute setting (peak response at least 6 hours)<br /> ** Mostly has a role in AF with heart failure<br /> ** Often used in combination with beta blockers or CCBs - works synergistically<br /> ** Doesn't tend to drop BP<br /> <br /> <br /> == '''Initial management''' ==<br /> <br /> * '''Approach'''<br /> ** Rate-control strategy first, unless unstable and successful ventricular rate control cannot be achieved<br /> ** Avoid RVR and the possibility of ensuing cardiac ischaemia<br /> ** HR target of &lt;120 is reasonable post-op<br /> ** Indications for rhythm control:<br /> *** Symptomatic AF despite good rate control<br /> *** Rate control difficult to achieve<br /> *** Patients unlikely to have a recurrence of AF (younger, less comorbidities, small left atrium)<br /> *** Consider when good reason to avoid anticoagulation<br /> ** &gt;50% with new post-op AF will convert to sinus rhythm within 24 hours<br /> *** If this occurs, no need for further management, but should have outpatient Holter and TTE<br /> * '''For rate control'''<br /> ** Metoprolol 25mg PO BD (75mg max; can start with 12.5mg BD in a stable patient sometimes, particularly if there might be chronicity to AF and you’d like to start slowly) or 5mg IV (in increments up to 15mg - not good on ward) OR<br /> ** Amiodarone 300mg IV (up to 5mg/kg) OR<br /> ** Digoxin 0.25mg IV every two hours, to a total dose of 1.5mg, then 0.125-0.375mg IV daily<br /> ** Calcium channel blocker or a second agent at discretion of cardiology<br /> * '''For rhythm control (unstable patient, or other indication for rhythm control)'''<br /> ** IV amiodarone 300mg (up to 5mg/kg) or diltiazem/flecainide)<br /> ** Synchronised DCR (requires peri-procedural anticoagulation and then for 4/52 afterwards)<br /> * '''Specific situations'''<br /> ** Able to give PO, stable - PO metoprolol, with consideration of digoxin in CCF, or PO amiodarone if second agent is required<br /> *** Generally worth trying PO metoprolol first, even if absorption is considered to be borderline or questionable, as long as the patient is stable<br /> ** Unable to give PO, stable on ward - IV digoxin<br /> ** Able to give PO, unstable - IV amiodarone and ICU<br /> ** Unable to give PO, unstable - IV amiodarone and ICU<br /> <br /> == '''Subsequent management''' ==<br /> <br /> * Approach<br /> ** Re-evaluate rate control vs rhythm control<br /> *** Rhythm - amiodarone 200mg BD for one month, then 200mg daily<br /> *** Rate - metoprolol 25mg BD, or amiodarone same dose as above<br /> * Anticoagulation<br /> ** If already on it, restart when safe<br /> ** Single episode AF lasting &lt;48 hours: no anticoagulation unless other high-risk features<br /> ** Multiple episodes of AF or a single episode lasting &gt;48 hours: anticoagulation for four weeks if CHA2DS2-VASc = 2 or more<br /> ** Reassess after four weeks and continue anticoagulation if there are recurrences after four weeks<br /> * Telemetry<br /> ** Definitely needed<br /> *** Significant bradycardia &lt;40bpm or pauses<br /> *** Use of a second agent<br /> ** Ideal but not mandatory<br /> *** Syncope<br /> *** Unexplained collapse<br /> *** Non-sustained ventricular arrhythmias<br /> ** Other patients do not need telemetry, according to Austin protocol<br /> * CCU<br /> ** Ischaemic chest pain<br /> ** Significant elevation in troponin<br /> * TTE<br /> * Cardiology F/U<br /> <br /> [[Category:Cardiology]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Dressings&diff=961 2026-03-05T10:19:06Z

<p>SurgopaediaAdmin: </p> <hr /> <div>'''Benefits of dressings:'''<br /> <br /> -        Occlusion. Moist, warm environment is better for healing than open wounds.<br /> <br /> -        Maintaining correct fluid balance – either dealing with exudates, or adding hydration to wound.<br /> <br /> -        Debriding unwanted slough or necrotic tissue.<br /> <br /> -        Protection – from water or other contamination.<br /> <br /> -        Haemostasis – either compression or direct contact.<br /> <br /> -        Antimicrobial activity.<br /> {| class=&quot;wikitable&quot;<br /> |'''Dressing type'''<br /> |'''Advantages'''<br /> |'''Disadvantages'''<br /> |'''Examples'''<br /> |'''Typical usage'''<br /> |-<br /> |Gauze<br /> |Mechanical debridement<br /> <br /> Good for filling dead space<br /> <br /> Cheap<br /> <br /> Absorptive<br /> |Sometimes painful to remove<br /> <br /> Can peel off granulation tissue on removal<br /> <br /> Requires daily dressing changes<br /> <br /> Permeable to fluid and bacteria<br /> |Gauze<br /> <br /> Saline-soaked gauze (absorbs blood, gently debrides)<br /> <br /> Betadine-soaked gauze (for grossly infected wounds)<br /> |Early post-op open wounds<br /> <br /> Infected wounds<br /> |-<br /> |Films<br /> |Semipermeable<br /> <br /> Retains moisture<br /> <br /> Waterproof<br /> <br /> Allows wound visualisation<br /> |Can tear skin<br /> <br /> Reactions common with repeated usage<br /> <br /> Not good for infected wounds<br /> |Tegaderm<br /> <br /> Opsite<br /> |Closed clean wounds<br /> |-<br /> |Hydrocolloid<br /> |Protects – impermeable to bacteria<br /> <br /> Waterproof/resistant<br /> <br /> |Not very absorptive – not good with exudates<br /> <br /> Not good on infected wounds<br /> <br /> Gets ratty after a week or so<br /> |Duoderm<br /> <br /> Comfeel<br /> |Laparotomy wounds post-op<br /> <br /> Low-exudative pressure ulcers<br /> |-<br /> |Foam<br /> |Highly absorptive<br /> <br /> Non-adherent<br /> <br /> Conformable<br /> <br /> Good under a compression dressing<br /> |Will macerate wound edges if it stays on long enough to become soaked<br /> |Allevyn<br /> <br /> Mepilex foam<br /> <br /> Mepilex border – minimally adherent and absorbent<br /> <br /> |Under pressure dressings<br /> <br /> Dead space<br /> <br /> Highly exudative wounds<br /> |-<br /> |Alginate<br /> |Highly absorptive<br /> <br /> Some haemostatic properties<br /> <br /> Fills dead space<br /> |Falls apart in the wound – annoying fibres, hard to remove later, sometimes unclear if whole dressing has been removed<br /> <br /> Useless in dry wounds<br /> <br /> Can dehydrate wound bed<br /> <br /> Dries rock hard in 48 hours.<br /> |Kaltostat<br /> <br /> Algisite<br /> <br /> Aquacel (similar use, but not really alginate)<br /> |Initial dressing in slowly oozing operative open wounds<br /> <br /> Chronic highly exudative wounds<br /> |-<br /> |VAC (vacuum assisted closure)<br /> |Reduces number of dressing changes required<br /> <br /> Easier to tailor to wound<br /> <br /> Controls exudate well<br /> <br /> Moist and warm environment, ideal for healing<br /> |Have to carry pump<br /> <br /> Expensive (although mostly compensated by less dressing changes)<br /> |VAC<br /> <br /> SNAP<br /> <br /> PREVENA<br /> <br /> PICO<br /> |Acute or chronic open wounds with good arterial supply and no infection.<br /> <br /> |-<br /> |Hydrogels<br /> |Rehydrate wound<br /> <br /> Can fill dead space<br /> |Can cause periwound maceration<br /> <br /> Minimal absorption<br /> |Solosite<br /> <br /> Prontosan (removes slough and biofilm – chemical debridement)<br /> <br /> Sorbact gel<br /> |<br /> |-<br /> |Antimicrobial dressings<br /> |Some antibacterial activity<br /> |Doesn’t make much difference<br /> <br /> '''Expensive'''<br /> |Aquacel Ag<br /> <br /> Mepilex Ag<br /> <br /> Acticoat (very expensive!!!)<br /> <br /> Allevyn Ag<br /> <br /> Sorbact<br /> |Can be useful in wounds with suspected chronic low-grade infection<br /> <br /> Generally over-used, apart from Sorbact, which is fairly cheap and good for diabetic ulcers.<br /> |-<br /> |Non-adherent<br /> |Less pain to remove and won’t peel off grafts/granulation tissue<br /> |Usually doesn’t do much else to the wound other than not stick to it<br /> |Mepitel – can be left on for 1+ weeks<br /> <br /> Adaptic<br /> <br /> Jelonet (paraffin gauze) – non-adherent for 2-3 days at most<br /> |Burns<br /> <br /> Large areas of early granulation tissue<br /> <br /> Desquamation<br /> <br /> After skin grafts<br /> |}<br /> [[Category:Skin, soft tissue and wounds]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Wound_healing&diff=960 2026-03-05T10:18:57Z

<p>SurgopaediaAdmin: </p> <hr /> <div>== Stages ==<br /> <br /> # Inflammation<br /> ## Haemostasis (damage limitation) - erythrocyte and platelet plug<br /> ## Inflammation - increased permeability, migration, and activation<br /> ### Initial neutrophils<br /> ### But healing is largely mediated by macrophages - arrive as monocytes within 24-48 hours of injury, release a lot of chemokines/cytokines<br /> ### Lymphocytes appear day 5-7 - seem to be related to downregulating healing as wound closes. Can be affected by drugs that suppress T-lymphocyte function (steroids, cyclosporine, tacrolimus)<br /> ### Can continue up to two weeks<br /> # Proliferation<br /> ## Acute response is over - scaffolding laid for repair of wound - formation of granulation tissue (capillary bed, fibroblasts, macrophages, and collagen etc scaffolding)<br /> ## Growth factors secreted, primarily by macrophages, which recruit the fibroblasts<br /> ##<br /> # Maturation/remodelling/epithelialisation<br /> ## Centripetal movement of the whole thickness of surrounding skin<br /> ## Complex interaction of ECM and fibroblasts (which have changed to become myofibroblasts)<br /> ## Remodelling occurs as type III collagen is largely replaced by mature type I collagen<br /> <br /> == Wound classification ==<br /> {| class=&quot;wikitable&quot;<br /> |Type 1 - clean<br /> |<br /> ** Uninfected operative wound with no inflammation and no entering of special tracts<br /> ** Heal with negligible risk of infection<br /> ** Primary closure is best<br /> |-<br /> |Type 2 - clean contaminated<br /> |<br /> ** Operative wounds where the respiratory, alimentary, genital, or urinary tracts were entered under controlled conditions<br /> ** Only minor spillage <br /> ** Close primarily after wound toilet<br /> |-<br /> |3 - contaminated<br /> |<br /> ** Open, fresh, accidental wounds<br /> ** Operative where non-purulent inflammation is present<br /> ** Operative with major break in sterile technique or spillage from GIT<br /> ** Need copious irrigation before delayed primary or sometimes primary closure<br /> |-<br /> |4 - dirty<br /> <br /> |<br /> ** Infected, contaminated, or devitalised wounds (the organisms causing post-op infection were present prior to the operation)<br /> ** Includes perforated viscera<br /> ** Open wounds &gt;12 hours<br /> ** Need to be converted to type 1 or 2 prior to closure<br /> |}<br /> <br /> == Primary intention ==<br /> <br /> * Fibrinous adhesions between surfaces by 24 hours<br /> * Granulation tissue grows in<br /> * Collagen is laid down<br /> * Wound contracts, scar forms<br /> * 10% strength at day 5, 50% at day 21<br /> <br /> == Secondary intention ==<br /> <br /> * Clot on surface allows moist environment at base of wound<br /> * Debrided by phagocytic WBCs<br /> * Collagen produced by fibroblasts in a matrix of mucopolysaccharides - granulation tissue<br /> * Myofibroblasts cause wound contraction<br /> * Epithelium migrates to cover wound<br /> <br /> == Management of clean surgical wounds ==<br /> <br /> * Fibrin layer forms within the first few days, especially if subcuticular suture is used (takes a bit longer with staples)<br /> * Dry gauze on top is only necessary for about three days; after that, can be uncovered, or dry gauze at most (opsite)<br /> * Can bathe/shower (in clean water) after five days<br /> * A red area of a surgical wound does not mean cellulitis - it means pus that needs to be drained. Drain it locally by removing a few sutures or staples and then continue to observe it. If the cavity probes elsewhere, may need to open further.<br /> * Only give antibiotics if there is severe cellulitis or fascia is involved<br /> * Wound swabs are generally unnecessary, unless the wound is becoming problematic and MRSA may be involved<br /> <br /> == Chronic/non-healing wounds ==<br /> <br /> * Occurs when the normal healing process is disrupted, most often because an underlying disorder causes a prolonged, unchecked pro-inflammatory state<br /> * There often seems to be inhibition of growth factors and other negative implications on a cellular level<br /> <br /> <br /> == Factors influencing wound healing ==<br /> (&gt;90% of ulcers are associated with either chronic venous insufficiency, arterial occlusive disease, or diabetic neuropathy)<br /> <br /> === '''Local''' ===<br /> <br /> ** Ischaemia<br /> *** '''Inadequate inflow''' - vessel ligation, '''PVD,''' systemic hypotension<br /> **** See separate topics<br /> **** Use WIfI classification to determine severity and guide intervention<br /> **** Toe pressure can be useful in guiding chance of wound healing<br /> **** In general same principles apply as for other wounds - pressure offloading, debridement of non-viable tissue, infection control, moist wound healing<br /> **** Leave adherent eschar or dry gangrene in place until revascularisation has occurred<br /> **** After revascularisation, be aware of limb oedema<br /> ***** For grafts ending at popliteal level, below-knee IPC is useful<br /> ***** For grafts ending distally, a pedal compression boot is useful<br /> **** Common for infection to develop as areas of eschar/dry gangrene heal - need to be followed closely. Some surgeons prefer to amputate necrotic digits or perform wide debridements of eschar a few days after revascularisation.<br /> *** Dead tissue at wound edge<br /> *** Overly tight or closely spaced sutures<br /> *** Tension on wound edge<br /> *** Smoking - 30% reduction in wound blood flow<br /> ** Tension<br /> ** Dead space<br /> ** Foreign bodies/contamination<br /> ** Infection<br /> *** Collagenolysis increases, tissue pressure elevates<br /> *** Mechanical and antibiotic therapy can decrease bacterial count, reduce inflammation, and allow wound closure<br /> *** See separate topic: 'wound infection'<br /> ** Haematoma<br /> *** Predisposes to infection and wound complications<br /> ** Local trauma<br /> ** Chronic tissue factors<br /> *** '''Chronic venous insufficiency'''<br /> **** Venous disease in any combination of anatomic sites may result in limb ulceration, including superficial venous insufficiency alone, however most of the time a venous ulcer is present, there is involvement of the deep venous system (see below)<br /> ****<br /> **** Chronic upregulation of pro-inflammatory cytokines appears to mediate the development of tissue fibrosis and the clinical appearance of lipodermatosclerosis (which is believed to be a pre-ulcerative condition). Ulceration eventually occurs secondary to minor trauma.<br /> **** Should have an USS to assess for this (saphenous reflux, perforator incompetence, and iliac outflow stenosis, etc)<br /> **** Sustained high-strength compression of the limb is the basis for treatment of venous leg ulcers, and must be maintained throughout treatment. Results in healing in 60-70% of patients after 4-6 months.<br /> **** Venous intervention is recommended whenever superficial venous reflux is a prominent component of the abnormal venous function. Limited evidence supporting the removal of varicose channels extending into the ulcer bed.<br /> **** Other therapies have been studied including skin grafting, but this is only useful in select cases<br /> *** Lymphoedema, ischaemia, scarring<br /> ** Sutures<br /> *** Silk - nidus for infection<br /> *** Too tight?<br /> ** Irradiation<br /> <br /> === '''General health''' ===<br /> <br /> ** '''Diabetes'''<br /> *** Macrovascular disease and microangiopathy<br /> *** Sensory neuropathy - repeated trauma<br /> *** Immunosuppression<br /> ** Advanced age<br /> ** Malnutrition<br /> *** Vitamin C<br /> *** Vitamin A<br /> ** Mineral deficiencies<br /> *** Zinc<br /> *** Iron<br /> ** Immunosuppression<br /> ** Medications<br /> *** Corticosteroids<br /> *** Chemotherapy<br /> ** Smoking <br /> ** Systemic illness<br /> <br /> == Approach to a chronic/non-healing wound: ==<br /> <br /> * Review all potential contributing factors from above<br /> * Check for granulation tissue - most negative factors above will stagnate the wound in the inflammatory phase<br /> * Remember that many rare causes of non-healing wounds can only be diagnosed with biopsy!<br /> * Wagner classification system:<br /> **<br /> * Wound bed preparation:<br /> ** Debridement of non-viable tissue<br /> *** Remove callus, eschar, fibrinous material, and slough. None of these have regenerative capacity, and they harbour bacteria, and prevent migration of healthy epithelium.<br /> *** Chemical debridement is possible, mostly using collagenase, and this is most effective at removing a moderate amount of fibrinous slough from the wound base, but is ineffective against thick tissue or eschar<br /> *** There are many methods of debridement, but none have ever been found to be superior to standard surgical debridement<br /> ** Identification and correction of bacterial involvement<br /> *** Controversial as to whether wounds that are colonised but not clinically infected should be treated<br /> *** Rutherford's says wounds with poor progress or any evidence of enlargement or infection should have quantitative cultures, and anything growing to &gt;10^5 bacterial counts per cubic mm should be treated with systemic therapy, guided by sensitivities<br /> *** It is advantageous to remove biofilms where possible<br /> ** Control of chronic inflammation<br /> ** Elimination of limb oedema<br /> ** Control of wound exudate<br /> <br /> == Hypertrophic scars/keloids ==<br /> <br /> * Excessive net collagen deposition<br /> * Keloids '''grow beyond borders of original wounds'''<br /> ** Rarely regress<br /> ** Aetiology<br /> *** Much more prevalent in dark skin<br /> *** Genetics<br /> ** Pathogenesis<br /> *** Disorganised type I and III collagen<br /> ** Clinical features<br /> *** Often form at previous minor trauma/scars e.g. earlobes from piercings<br /> *** Generally get bigger over time, do not regress<br /> *** Often a/w pain and pruritis<br /> ** Treatment<br /> *** Medical<br /> **** Topical/intralesional corticosteroids<br /> **** Radiotherapy (often in conjunction with surgery, however one big study didn't show any difference to recurrence rates if it was included)<br /> *** Surgical<br /> **** Consider if refractory to medical treatment for 12 months<br /> **** Leads to recurrence of 45-100%<br /> * Hypertrophic scars are raised scars '''within confines of original wound'''<br /> ** Occur with prolonged inflammation and tension<br /> ** Frequently regress spontaneously<br /> ** Well-organised type III collagen<br /> ** Prevent by avoiding wound tension, hydration/occlusion, and use of taping/pressure garments<br /> *** Indicated in severe burns, mechanical trauma, necrotising infections, or grafting<br /> ** Treatment:<br /> *** 6-12 weeks: pressure therapy<br /> *** &gt;6mo: silicone therapy, intralesional corticosteroids (triamcinolone acetonide, 10-40mh/mL injected into papillary dermis every 2-4 weeks until flat. Works &gt;50% of patients<br /> * Approach to hypertrophic scars/keloids:<br /> ** History - including other scars, family history<br /> ** Examination - can use Vancouver scar scale to give objective measure of scar<br /> ** Counsel patient about difficult nature of problem and define goals of therapy:<br /> *** Relief of symptoms<br /> *** Reduction of scar volume<br /> *** Functional or cosmetic improvement<br /> ** Initial trial of intra-lesional triamcinolone acetonide at a concentration of 10 to 40mg/mL<br /> *** Reduces volume<br /> *** Improves pain and pruritis<br /> *** Repeat treatment several times at 4-6 week intervals<br /> *** Injections are painful. Can cause dermal atrophy, skin ulceration, hyperpigmentation, telangiectasia.<br /> ** Can try combination fluouracil and triamcinolone - 50-96% had a good response in one meta-analysis - but these studies are of low quality. Can cause pain and hyperpigmentation.<br /> ** Can trial pressure - there are special devices for earlobes. Limited evidence. May be beneficial in combination with surgery.<br /> ** Surgery - recurrence approaches 100% - however is probably lower if combined with peri-operative triamcinolone or fluorouracil<br /> ** Post-op radiation therapy. Evidence from retrospective observational trials.<br /> <br /> [[Category:Skin, soft tissue and wounds]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Negative_pressure_wound_therapy&diff=959 2026-03-05T10:18:47Z

<p>SurgopaediaAdmin: </p> <hr /> <div><br /> Continuous/intermittent application of subatmospheric pressure to system<br /> <br /> Exact mechanism is somewhat unclear<br /> <br /> == Advantages ==<br /> <br /> * Significantly reduce the number of dressing changes required for complex or dirty wounds - decreasing pain<br /> * Easier to tailor and manage in position<br /> * Particularly pronounced effect in diabetic patients<br /> <br /> == Disadvantages ==<br /> <br /> * Have to carry pump<br /> * ?Cost - however consider that amount of wound care is actually drastically reduced<br /> <br /> == '''Contraindications''' ==<br /> <br /> * Exposed vital structures (organs, blood vessels, vascular grafts) - leads to tissue erosion<br /> ** Need to wait for granulation layer to form, or tissue graft/flap is done<br /> ** Can MAYBE use barrier dressings sometimes but experienced hands only<br /> * Presence of malignancy<br /> <br /> == '''Relative contraindications''' ==<br /> <br /> * Ischaemic wounds - no benefit demonstrated, may worsen ischaemia<br /> * Ongoing infection or devilatised tissue - debride and treat infection first<br /> * Fragile skin (age, corticosteroid use, etc)<br /> * Adhesive allergy<br /> <br /> == '''Indications''' ==<br /> <br /> * Elective and emergency laparotomy wounds for high-risk patients<br /> * Acute surgical wounds eg debridement - can be applied immediately post op<br /> * After grafting - associated with significant reduction in loss of graft area<br /> * Acute open wounds - faster wound closure<br /> * Burns - maybe<br /> * Traumatic wounds - primary advantage is ease of application/dressing changes<br /> * Chronic wounds - provided wound is well-vascularised - '''check pulses, and if not present, should evaluate arteries prior to placement'''<br /> ** DFU<br /> ** Pressure ulcer<br /> ** Open abdomen<br /> ** Venous stasis ulcers - particularly useful in preparing wound bed for graft and managing exudate<br /> * Prophylactic use on large surgical wounds to prevent SSI and dehiscence - more RCTs needed<br /> ** PREVENA and PICO ''probably'' prevent SSI and dehiscence for emergency wounds - however more research needed<br /> ** Moderate certainty that these also reduce SSI in elective setting. The effect is likely more pronounced where other risk factors are present, such as diabetes, smoking, obesity and prolonged operating time.<br /> <br /> == Placement: ==<br /> <br /> # Trim foam to fit - don't extend beyond edges of wound<br /> # Secure beneath adhesive sheet<br /> # Cut hole in adhesive<br /> # Suction port placed and connected to pump<br /> # Pressure between -50 and -175 (commonly -125)<br /> <br /> == Direct effects ==<br /> <br /> * Moist and warm environment, ideal for wound healing<br /> * Fluid removed - first from wound, then from interstitial space<br /> * Positive pressure to wound surface<br /> * Foam contracts, drawing edges together or bolstering grafts/flaps down<br /> <br /> == Indirect effects ==<br /> <br /> * Reduced perfusion due to positive pressure. Ischaemia leads to increased granulation - more prominent with intermittent or variable pressure<br /> * Diminished inflammatory response<br /> * Altered bacterial burden<br /> * Changes in biochemistry<br /> <br /> == Complications ==<br /> <br /> * Wounds often become malodourous however infection is actually rare<br /> ** Try adding Aquacel silver interposition layer, or hydrotherapy at time of dressing change, or withholding VAC for a day or two, or using some topical metronidazole<br /> * Pain with dressing change - dry saline soak off or soaking in LA without adrenaline<br /> * Bleeding - severe haemorrhage can occur during removal of foam adherent to granulation tissue<br /> * Infection - often due to pre-existing inadequately treated infection<br /> ** Stop NPWT, irrigate and debride, wound cultures, empiric Abx<br /> <br /> == Specific systems ==<br /> <br /> === PREVENA ===<br /> <br /> * 125mmHg pressure, captures effluent into separate canister<br /> <br /> === PICO ===<br /> <br /> * 80mmHg, absorbent pad instead of canister (capacity 200ml)<br /> <br /> [[Category:Skin, soft tissue and wounds]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Necrotising_fasciitis&diff=958 2026-03-05T10:18:37Z

<p>SurgopaediaAdmin: </p> <hr /> <div>''An infection of the deep soft tissues, that results in progressive destruction of the muscle fascia and overlying subcutaneous fat''<br /> <br /> == '''Predisposing factors''' (20% of cases occur in patients with none of these factors) ==<br /> <br /> ** Older age<br /> ** Obesity<br /> ** Advanced diabetes<br /> ** Alcoholism<br /> ** Cirrhosis<br /> ** Chronic debilitation<br /> ** Vasculopathy<br /> ** IVDU<br /> ** Immunosuppression<br /> ** Malignancy<br /> ** Chemotherapy<br /> ** HTN<br /> ** COPD<br /> ** ESKD<br /> ** CCF<br /> ** Perianal abscess<br /> ** Perforated viscus<br /> ** Recent surgery<br /> <br /> <br /> == '''Pathophysiology''' ==<br /> <br /> ** Rapidly progressive inflammatory infection of deep fascia<br /> ** Bacterial exotoxins such as haemolysin, streptolysis and leucocidin <br /> ** Infection typically spreads along the muscle fascia due to its relatively poor blood supply, but muscle tissue itself is frequently spared<br /> ** There is associated thrombosis of dermal vessels leading to secondary necrosis of overlying subcutaneous tissues<br /> ** Skin ischaemia, anaesthesia and necrosis eventually appears, but the skin can appear normal even with quite severe underlying infection<br /> ** Results in liquefactive necrosis<br /> ** Sepsis from combination of exotoxins, toxic shock syndrome and massive cytokine response<br /> <br /> **<br /> <br /> **<br /> <br /> == '''Classification''' ==<br /> <br /> ** Type I (polymicrobial - both aerobic and anaerobic bacteria - Fournier's)<br /> *** Usually seen in elderly or those with underlying illness (diabetes, vascular disease, pressure ulcer, episiotomy, haemorrhoid/fissure)<br /> *** Usually presents with gas in tissue<br /> *** Typically seen with an anaerobic species (Bacteroides, Clostridium, or Peptostreptococcus) in combination with ''Enterobacteriacaeae'' (E coli, Enterobacter, Klebsiella, Proteus) and one or more facultative anaerobic streptococci (although not commonly group A strep)<br /> *** The facultative anaerobes lower the local oxygen tension, allowing anaerobic proliferation<br /> *** The anaerobes produce toxins and inhibit host phagocytosis<br /> *** Marked leukaemoid reactions with Clostridial infection<br /> ** Type II (monomicrobial)<br /> *** Usually Group A strep (GAS) or Staph aureus<br /> *** Can occur in any age group and without underlying comorbidities<br /> *** Half have a clear portal of entry and half do not (theorised to be haematogenous translocation from the throat to a site of blunt trauma or muscle strain)<br /> *** 'M protein' is an important virulence determinant of GAS - M versions 1 and 3 are associated with streptococcal toxic shock syndrome, where pyrogenic exotoxins are produced, increasing cytokine production and contributing to shock<br /> *** Usually seen with CRP &gt;200, modestly increased WCC with marked left shift, and AKI in the absence of hypotension<br /> ** Type III (water-borne bacteria)<br /> *** Vibrio, Aeromonas<br /> *** Cirrhosis and eating contaminated oysters are risk factors<br /> ** Type IV (Candida and other fungi)<br /> <br /> <br /> == '''Differential diagnosis''' ==<br /> <br /> ** Necrotizing cellulitis<br /> *** Typically caused by anaerobes<br /> *** Clostridial vs non-clostridial<br /> **** Crepitus observed in both types<br /> **** Sparing of fascia and muscles<br /> *** Relatively mild systemically<br /> ** Cellulitis<br /> *** Normal CK/AST<br /> *** Not usually septic, apart from low-grade<br /> ** Pyoderma gangrenosum<br /> *** IBD patients<br /> *** No cellulitis<br /> *** Violaceous ulcer edge<br /> *** Less sepsis<br /> *** Worsens with surgery<br /> *** Normal fascial planes<br /> *** Responds to steroids, does not respond to antibiotics<br /> ** Pyomyositis (abscesses) or necrotizing myositis (gangrene)<br /> *** An infection of skeletal muscle typically caused by GAS and other beta-haemolytic streptococci<br /> *** Preceded by skin abrasions, blunt trauma, or heavy exercise<br /> *** Separate to clostridial myonecrosis<br /> ** DVT<br /> <br /> == '''Diagnosis''' ==<br /> <br /> ** &quot;'''Necrotising fasciitis is a surgical diagnosis characterised by friability of the superficial fascia, dishwater-grey exudate, and a notable absence of pus'''.&quot;<br /> ** Classically:<br /> *** Oedema (75%)<br /> *** Erythema (72%)<br /> *** Severe pain (72%)<br /> *** Tenderness (68%)<br /> *** Fever (60%)<br /> *** Skin bullae or necrosis (38%)<br /> ** Differentiating from cellulitis:<br /> *** Recent surgery<br /> *** Pain out of proportion to clinical signs<br /> *** Hypotension<br /> *** Skin necrosis<br /> *** Haemorrhagic bullae<br /> *** Elevated CK and AST suggest injury to deeper tissue<br /> ** '''Scoring systems'''<br /> *** '''LRINEC'''<br /> **** LRINEC: high specificity for severe disease, but PPV is 57-92% with a score of 5.8 or higher<br /> ****<br /> ** '''Bedside exploration'''<br /> *** LA<br /> *** Area of greatest oedema/necrosis<br /> *** Thin dishwasher-fluid like exudate, not frank pus<br /> *** Non-contractile muscles<br /> *** Send for urgent MCS and histo<br /> <br /> <br /> == '''Clinical approach''' ==<br /> <br /> ** '''Indications for immediate exploration in theatre:'''<br /> *** Crepitus or gas in tissue on imaging<br /> *** Skin discolouration or necrosis<br /> *** Thin, foul-smelling wound discharge<br /> *** Rapid progression clinically<br /> *** Severe pain out of proportion to skin findings<br /> ** '''Suspicious for NF with systemic signs, but not convincing:''' bedside cut-down, then LRINEC score, imaging and observation/medical management<br /> ** '''Possible diagnosis, but systemically well:''' LRINEC score, imaging and observation/medical management<br /> <br /> <br /> == '''Resuscitation''' ==<br /> <br /> ** Blood cultures first<br /> ** Bacterial haemolysis often occurs, meaning haematocrit drops before Hb. Base transfusion on haematocrit rather than Hb.<br /> ** Need to give a lot of IVF, and albumin along with it<br /> ** Antibiotics: <br /> *** First-line: meropenem 1g TDS/tazocin 4.5g TDS + vancomycin 25-30mg/kg loading dose + clindamycin 600mg TDS/lincomycin 600mg TDS<br /> *** Add ciprofloxacin 400mg TDS if there is a risk of water-borne infection<br /> *** Severe penicillin allergy: generally still give meropenem, but 1% risk of cross-reactivity, seek ID advice. They may advise a regime of gentamicin or ciprofloxacin and metronidazole instead. <br /> ** IVIg has been shown to reduce 30-day mortality from 33% to 15% in a 2018 meta-analysis, but only in the setting of setreptococcal infection<br /> ** Droplet and contact precautions for first 24 hours, if suspicious for GAS<br /> <br /> == '''Surgery''' ==<br /> <br /> ** Peri-op factors<br /> *** Faecal diversion?<br /> *** Amputation?<br /> *** Second-look within 48 hours<br /> *** Early consideration of reconstruction - SSG?<br /> *** Remember to ensure they have cross match/G+H<br /> *** Should have second pair of eyes<br /> ** Operative debridement<br /> *** Prep and drape widely<br /> *** Debride widely - be brutal - need clear margins<br /> *** Fat that glistens, muscle that twitches, skin that bleeds<br /> *** Send tissue for Gram stain, culture and histopathology<br /> <br /> == '''Post-op''' ==<br /> <br /> ** Hyperbaric oxygen treatment MIGHT be useful but jury definitely still out<br /> ** If the Gram stain returns as Gram-positive rods, be concerned for Clostridial myonecrosis (gas gangrene) and have a lower threshold for subsequent amputation<br /> <br /> == '''Outcome''' ==<br /> <br /> ** Mortality<br /> *** Polymicrobial infection 21%<br /> **** Fournier's 22-40%<br /> **** Cervical necrotizing fasciitis 22%<br /> **** Neonatal NF - 59%<br /> *** Monomicrobial NF 14-34%<br /> ** Worse prognostic factors:<br /> *** WCC &gt;30<br /> *** Serum creatinine &gt;177<br /> *** Age &gt;60<br /> *** Streptococcal TSS<br /> *** Clostridial infection<br /> *** Delay in surgery &gt;24 hours<br /> *** Infections involving the head, neck, thorax, or abdomen<br /> <br /> [[Category:Skin, soft tissue and wounds]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Suspicious_breast_lesion&diff=957 2026-03-05T10:18:28Z

<p>SurgopaediaAdmin: </p> <hr /> <div><br /> == Principles ==<br /> <br /> * Any suspicious palpable breast mass requires additional imaging and diagnostic biopsy<br /> * '''Triple test''' - the combination of clinical, radiological and pathological evaluation of a breast lump<br /> ** Should be used for all solid breast lumps or asymmetric localised nodularity<br /> ** Clinical history and examination, mammogram (if &gt;40yo) and USS, non-excisional biopsy (usually core)<br /> ** Sensitivity of 99.6% for cancer<br /> ** Companion recommends scoring all components of the assessment 1-5 to allow easy perception of discordance<br /> **<br /> ** So you end up with E1-E5, R1-R5, U1-U5, B1-B5<br /> * See BI-RADS definitions under 'screening/imaging'<br /> <br /> <br /> == History/examination ==<br /> <br /> * See separate topic<br /> <br /> == Differential diagnosis for breast lump ==<br /> <br /> * Benign breast lesion (separate topic)<br /> * Malignant breast lesion<br /> * Most likely diagnosis<br /> ** &lt;30yo - fibroadenoma<br /> ** 40-50yo - cyst<br /> ** &gt;50yo - cancer<br /> <br /> == Differential diagnosis for axillary lump ==<br /> <br /> * Lymph nodes - explore recent local or systemic infections<br /> * Skin lesions<br /> * Accessory breast tissue<br /> <br /> == Non-palpable: ==<br /> <br /> * Imaging findings triggering workup:<br /> ** Use BI-RADS<br /> ** See separate 'imaging' topic<br /> * Choice of biopsy approach<br /> ** See separate 'biopsy technique' topic<br /> ** Imaging-guided CNB generally best first option<br /> ** Then consider excisional biopsy based on indications on 'biopsy technique' topic<br /> * Prognosis<br /> ** 75-80% of patients with indicated biopsy for non-palpable breast lesion ultimately have benign findings<br /> <br /> == Palpable ==<br /> <br /> * Choice of biopsy approach<br /> ** As above<br /> <br /> [[Category:Breast]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Skin_infections&diff=956 2026-03-05T10:18:18Z

<p>SurgopaediaAdmin: </p> <hr /> <div>== '''Definitions:''' ==<br /> <br /> * '''Cellulitis''' involves deeper dermis and subcutaneous tissue. Can get petechiae, ecchymosis, bullae. Indistinct borders. Beta-haemolytic strep and stap aureus - see below for a table of other organisms based on inoculating mechanism.<br /> * '''Erysipelas''' involves upper dermis and epidermis - clear demarcation on skin, often raised edges, more rapid onset, brighter red appearance. Involvement of the ear is a distinguishing feature of erysipelas - no deeper dermal tissue. Mostly caused by beta-haemolytic strep.<br /> * '''Skin abscess''' is a collection of pus within dermis or subcutaneous tissue<br /> * '''Furuncle''' (boil) is a deep infection of a hair follicle<br /> * '''Carbuncle''' is a collection of multiple coalesced furuncles. Commonly seen on back, axila, buttocks<br /> <br /> == '''Differential diagnosis''' ==<br /> <br /> * Necrotizing fasciitis - rapidly-progressive erythema or pain out of proportion to exam findings<br /> * Toxic shock syndrome<br /> * Clostridial myonecrosis<br /> <br /> == '''Complications''' ==<br /> <br /> * Bacteraemia<br /> * Endocarditis<br /> * Metastatic infection <br /> * Sepsis<br /> * Toxic shock syndrome<br /> * Septic arthritis or OM<br /> <br /> == '''Principles of management:''' ==<br /> <br /> * Antibiotics<br /> ** Treat for cellulitis whenever you are uncertain whether it is cellulitis or erysipelas<br /> ** Indications for MRSA coverage<br /> *** Systemic toxicity<br /> *** Cellulitis with purulent wound drainage<br /> *** Known MRSA colonisation or infection<br /> *** Injection drug use<br /> *** High-risk neutropaenia<br /> ** Regimens: <br /> *** No MRSA factors: cefazolin/cefalexin<br /> *** MRSA factors: Bactrim OR Augmentin DF + doxycycline 100mg BD. Generally avoid clindamycin due to C diff risk and MRSA resistance.<br /> *** MRSA and needs IV: vancomycin<br /> *** Erysipelas can generally be managed as an outpatient: Augmentin DF, cefalexin, or as above if risk of MRSA<br /> * Symptomatic improvement usually within 24-48 hours, but skin manifestations can take longer. Look for reductions in pain, fever, brightness of erythema, and WCC. Skin can begin to weep, blister, or crack as cellulitis evolves - not generally a marker of worsening infection<br /> * Consider decolonisation for MRSA carriers<br /> * Surgery<br /> ** Excision of boil/carbuncle and primary closure - be careful not to spill pus into the wound - incise an ellipse to the extent of the skin changes, then tunnel the subcutaneous resection slightly outwards to ensure you don't go into the cavity<br /> <br /> <br /> == Bacteriology ==<br /> {| class=&quot;wikitable&quot;<br /> |'''Exposure'''<br /> |'''Pathogen'''<br /> |-<br /> |Most common pathogens (regardless of exposure)<br /> |<br /> ** Group A ''Streptococcus'' (ie, ''Streptococcus pyogenes'')<br /> ** Non-group A, beta-hemolytic streptococci (groups B, C, G, and F)<br /> ** ''Staphylococcus aureus'' (''S. aureus'')<br /> |-<br /> |Cirrhosis<br /> |<br /> ** Gram-negative bacilli:<br /> ** ''Klebsiella'' spp<br /> ** ''Escherichia coli''<br /> ** ''Vibrio vulnificus'' and ''Vibrio parahaemolyticus''*<br /> ** ''Aeromonas'' spp*<br /> |-<br /> |Splenic or humoral immune dysfunction<br /> |<br /> ** Encapsulated bacteria:<br /> ** ''Streptococcus pneumoniae''<br /> ** ''Haemophilus influenzae''<br /> |-<br /> |Neutropenia<br /> |<br /> ** ''Pseudomonas aeruginosa'' and other Gram-negative bacilli<br /> ** ''Clostridium'' spp<br /> ** Invasive fungal infections<br /> |-<br /> |Fresh water (lakes, rivers)<br /> |<br /> ** ''Aeromonas hydrophila''<br /> ** ''Plesiomonas shigelloides''<br /> ** ''Edwardsiella tarda''<br /> ** ''Pseudomonas aeruginosa''<br /> ** ''Shewanella'' spp<br /> |-<br /> |Salt water<br /> |<br /> ** ''Vibrio vulnificus'' and ''Vibrio parahaemolyticus''<br /> ** ''Erysipelothrix rhusiopathiae''<br /> |-<br /> |Shellfish ingestion, especially oysters<br /> |<br /> ** ''Vibrio vulnificus'' and ''Vibrio parahaemolyticus''<br /> |-<br /> |Animal bite<br /> |<br /> ** ''See separate topic 'bites'''<br /> |-<br /> |Human bite<br /> |<br /> ** ''See separate topic 'bites'''<br /> |-<br /> |Traumatic wound contaminated by soil<br /> |<br /> ** ''Clostridium'' spp<br /> ** ''Pseudomonas aeruginosa'' and other Gram-negative bacilli<br /> ** Fungi (eg, mucormycosis)<br /> |-<br /> |Nail puncture through sneakers<br /> |<br /> ** ''Pseudomonas aeruginosa''<br /> |-<br /> |Recent travel<br /> |<br /> ** Depends on the location of travel<br /> |}<br /> [[Category:Skin, soft tissue and wounds]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Breast_abscess&diff=955 2026-03-05T10:18:04Z

<p>SurgopaediaAdmin: </p> <hr /> <div>Localised collection of inflammatory exudate in the breast tissue.<br /> <br /> == '''Risk factors''' ==<br /> <br /> * Obese<br /> * Smokers<br /> * Maternal age &gt;30 years<br /> * First pregnancy<br /> * Problems with breastfeeding<br /> <br /> == '''Pathophysiology''' ==<br /> <br /> * Complication of mastitis (cellulitis with breast parenchymal inflammation and swelling)<br /> * Mastitis can develop in two ways<br /> ** Lactational infections<br /> *** Something inhibits milk drainage (nipple trauma and oedema, dehydration and inspissation, oversupply, feeding difficulties, rapid weaning, maternal malnutrition)<br /> *** Collections of stagnant milk<br /> *** Organisms infiltrate through nipple and grow in the stagnant milk<br /> ** Chronic subareolar infections associated with duct ectasia (also called periductal mastitis/non-lactational infections)<br /> *** Risk factors<br /> **** Smoking (majority of patients - 89% in one study)<br /> **** Diabetes<br /> *** Pathophysiology<br /> **** An inflammatory condition of the subareolar ducts<br /> **** Likely caused by toxins, microvascular damage by lipid peroxidases, and altered bacterial flora<br /> **** Duct ectasia and squamous metaplasia ensue, causing stasis of ductal secretions<br /> **** Secondary infections and abscess formation<br /> ***** Most often mixed infections with anaerobes and skin flora<br /> ***** Infections frequently recur, because the underlying duct is diseased<br /> **** Inflammatory changes can eventually lead to retraction or inversion of the nipple, subareolar masses, and chronic fistula to peri-areolar skin<br /> <br /> == '''Classification''' ==<br /> <br /> *<br /> * Central usually due to periductal mastitis<br /> * Peripheral less common, sometimes associated with underlying disease states or trauma<br /> <br /> == '''Microbiology''' ==<br /> <br /> * Mostly Staph aureus<br /> * Patients with recurrent abscesses have an increased incidence of mixed flora and anaerobic infection<br /> * Culture of breast milk can guide antibiotics if aspirate is not available<br /> * Blood cultures only helpful if there is evidence of systemic sepsis<br /> <br /> == '''Differential diagnosis''' ==<br /> <br /> * Lactating women:<br /> ** Plugged duct<br /> ** Galactocoele - soft cystic mass that won't be tender. Can diagnose based on aspiration of milk.<br /> * All women:<br /> ** Inflammatory breast cancer. Consider this if the infection does not resolve with appropriate treatment (one week antibiotics), or in non-lactating post-menopausal women without any precipitating factors or systemic signs of infection. Skin thickening due to oedema, erythema, peau d'orange appearance.<br /> *** Investigate with imaging and a punch biopsy of affected skin and possibly core biopsy from deeper masses - if this is negative, doesn't exclude the diagnosis though. May need MRI.<br /> ** Idiopathic granulomatous mastitis (IGM)<br /> *** Rare chronic inflammatory breast disease with unclear cause<br /> **** Possibly related to corynebacterium infection<br /> *** Non-caseating granulomas and microabscesses confined to a lobule<br /> *** Painful mass associated with fistulas, abscesses, inflammatory changes<br /> *** No association with smoking<br /> *** Clinical presentation and radiological findings similar to breast cancer<br /> *** Don't excise it - often followed by persistent wound discharge and failure to heal<br /> *** Steroids and immunomodulators have been used, but variable efficacy<br /> *** The condition tends to resolve spontaneously over 6-18 months, so best to treat supportively, especially treating the episodes of infection and abscess formation, through as minimal an intervention as possible<br /> <br /> == '''Management''' ==<br /> <br /> * Approach<br /> ** Antibiotics and frequent emptying of the breast (step up approach)<br /> * Simple advice:<br /> ** Continued milk draining is important - essentially drains the abscess, resulting in reduced duration of symptoms and improved outcome<br /> ** Not a contraindication to breastfeeding on that side<br /> ** Warm soaks are helpful for mastitis<br /> * Antibiotics<br /> ** Flucloxacillin <br /> ** Consider anaerobic organisms if subareolar location, hidradenitis suppuritiva, recurrent abscess - Augmentin DF would be a good option for a non-lactational infection<br /> ** MRSA is possible but uncommon<br /> * Percutaneous drainage<br /> ** Appropriate first-line when skin is viable<br /> ** Repeat every 2-3 days until no collection remains or the fluid aspirated is serous<br /> ** Few abscesses require more than 2-3 drainages<br /> ** Pigtail catheters can be placed if desired, but not normally necessary<br /> ** Technique<br /> *** Can be USS-guided if desired<br /> *** First try with a 21 gauge needle and inject LA + adrenaline<br /> *** If pus is too thick, use a 19 or 17 gauge needle<br /> *** Wash out cavity until clear<br /> *** Irrigate with LA solution<br /> ** Risk factors for failure of aspiration:<br /> *** Abscess &gt;5cm in diameter<br /> *** Unusually large volume of aspirated pus<br /> *** Delay to treatment<br /> * Surgical drainage<br /> ** Indications<br /> *** Compromised overlying skin (ischaemia/pressure necrosis) - see bottom for examples of compromise<br /> *** Skin overlying abscess is very thin and shiny, or if it appears like the abscess is about to burst through the skin<br /> *** Not responsive to percutaneous aspiration<br /> *** Repeated infections requiring excision of subareolar duct complex, and sometimes the entire NAC<br /> ** Technique<br /> *** See separate topic<br /> * Follow-up<br /> ** MMG and USS six weeks post-presentation for all women to exclude IBC<br /> <br /> == '''Complications''' ==<br /> <br /> * Recurrence<br /> * Mammary duct fistula<br /> ** Communication between major subareolar duct and the skin, usually in the periareolar region<br /> ** Can occur after I+D of a central abscess or after spontaneous drainage<br /> ** Seen in smokers, recurrent abscesses<br /> ** Fistulotomy or fistulectomy can be done. Fistulectomy gives a better result - see topic under 'breast operations'.<br /> * Milk fistula<br /> ** Tract between skin and lactiferous duct after surgical intervention<br /> ** Milk drains through skin<br /> ** Mainly occurs with big incisions or large drains<br /> ** Usually resolves spontaneously<br /> ** If persistent, usually resolves with cessation of lactation - wean from that breast and only nurse from other side<br /> * Antibioma<br /> ** When treated with antibiotics but not drained, it can become a sterile collection - firm, painless, smooth swelling<br /> ** Aspirate it, don't excise it<br /> <br /> <br /> <br /> ^ischaemic skin<br /> <br /> ^pressure necrosis<br /> <br /> ^thinned skin<br /> [[Category:Breast]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Hernia&diff=954 2026-03-05T10:17:53Z

<p>SurgopaediaAdmin: </p> <hr /> <div>An abnormal protrusion of an organ or tissue through a defect in its surrounding walls.<br /> <br /> == Anatomy ==<br /> <br /> * Most commonly involves the abdominal wall<br /> * Occurs only at sites where the aponeurosis and fascia are not covered by striated muscle.<br /> * Neck/orifice is located at the innermost musculo-aponeurotic layer<br /> * Sac protrudes from the neck, and is lined by peritoneum<br /> * No consistent relationship between the area of a hernia defect and size of sac<br /> <br /> == Presentation ==<br /> <br /> * Reducible - when the contents can be replaced within the surrounding musculature<br /> * Strangulated - compromised blood supply to contents<br /> ** Occurs more often in large hernias with small orifices<br /> ** Can be either obstructed arterial flow or venous drainage or both<br /> * Obstructed - occurs due to adhesions between the contents of the sac and peritoneal lining<br /> * Richter hernia - a small portion of the antimesenteric wall of the intestine is trapped within the hernia, and strangulation can occur without obstruction<br /> <br /> <br /> <br /> == '''Loss of domain''' ==<br /> <br /> * Not well-defined - 'a hernia sac of great size that forms a secondary abdominal cavity'; 'large enough that primary fascial closure either cannot be achieved without additional reconstructive techniques or significant risk of complications due to raised abdominal pressure'<br /> ** &gt;20-50% of abdominal contents residing outside the abdomen<br /> ** One definition from Tanaka et al: '''when hernia volume greater than &gt;25% of abdominal compartment volume (excluding hernia)'''<br /> * Pathophysiology<br /> ** Abdominal contents no longer reside in the abdominal cavity, and therefore cannot simply be placed back inside<br /> ** Natural rigidity of abdominal wall becomes compromised and musculature retracts<br /> ** Complications:<br /> *** MSK problems<br /> *** Ventilatory dysfunction - cause paradoxical respiratory abdominal movement - compromised respiratory function<br /> *** GIT dysfunction - can result in bowel oedema, stasis of the splanchnic venous system, urinary retention, and constipation<br /> *** Psychosocial issues<br /> * Management<br /> ** Patient needs to understand how big of an undertaking this is going to be<br /> ** Optimise everything medically - see separate topic under 'ventral incisional hernia'<br /> ** May need additional techniques for closure - see 'ventral incisional hernia'<br /> *** Usually benefits from Botox and component separation<br /> ** Watch post-op for intra-abdominal hypertension<br /> <br /> == '''Classification of hernias''' ==<br /> <br /> * '''Anatomical - European Hernia Working Group'''<br /> <br /> * Complex vs simple<br /> ** Patient factors<br /> ** Anatomical factors<br /> <br /> <br /> == '''Management principles''' ==<br /> <br /> * Goals<br /> ** Fix the problem/restoration of function in line with patient expectations<br /> ** Minimise complications, pain, disability<br /> ** Cosmesis<br /> ** Durable repair with low recurrence rate<br /> ** Functional/dynamic abdominal wall<br /> * Principles<br /> ** Optimise patient pre-op<br /> ** Restore anatomy and recreate linea alba<br /> ** Reinforce the repair when possible with wide mesh overlap<br /> ** Tension-free repair<br /> * Contraindications to operation<br /> ** Medically/surgically unfit<br /> ** Absence of available tissue<br /> ** No benefit or improvement in QoL<br /> ** Risks outweigh benefits<br /> <br /> <br /> == '''Hernia emergencies''' ==<br /> <br /> === '''Strangulation or bowel obstruction = urgent repair''' ===<br /> <br /> ** Ideally within 4-6 hours from onset of symptoms<br /> <br /> === '''Acutely incarcerated, but no signs of strangulation''' ===<br /> <br /> ** Offer urgent repair<br /> ** Can also attempt reduction, and if reducible, can follow up with surgeon in a few days to exclude reincarceration and arrange elective repair<br /> ** If fails reduction, can proceed to urgent surgery<br /> ** 'Taxis' - the rearrangement of tissues, that is, reduction of hernia, to avoid surgery<br /> *** Contraindications: presence of strangulated bowel within the hernia (tachycardia, hypotension, peritonitis; erythema, hot and painful local skin; blood tests including WCC are unreliable)<br /> **** Note that it's generally very unlikely that the hernia contains strangulated bowel if it's been reduced successfully<br /> **** Obstruction but not strangulation is not necessarily a contraindication to reduction<br /> *** &gt;24 hours since onset of symptoms seems to be associated with higher likelihood of strangulation<br /> **** If within 24 hours and no sign of strangulation, attempt reduction; if later, surgery and examination of sac should be preferenced<br /> *** GPS (gentle, prepared, safe)<br /> **** Gentle manipulation through external ring - avoid 'reduction en masse' where the herniated bowel and constricting ring are reduced together, providing a false sense of achievement<br /> **** Prepared - consider procedural sedation/'''IV morphine + midaz /min bolus morphine until desired level of analgaesia achieved)'''<br /> **** Safe - avoid attempting if concern for strangulation<br /> *** Procedure<br /> **** As much trendelenburg position as tolerated<br /> **** Direct herniae will be easier to re-insert<br /> **** Gentle pulling on edge of sac - will realign sac in direction of canal<br /> **** Gently massage back into canal<br /> **** Can take 5-10 min<br /> **** If bowel is present, a satisfying gurgling sound is often heard on reduction<br /> **** Need period of observation post-reduction to ensure pain resolved<br /> <br /> *<br /> <br /> [[Category:Abdo wall and retroperitoneum]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Fascial_dehiscence&diff=953 2026-03-05T10:17:30Z

<p>SurgopaediaAdmin: </p> <hr /> <div><br /> When abdominal wall tension is greater than tissue or suture strength or knot security.<br /> <br /> * Complete dehiscence: full partition of fascia and skin, possibly involving evisceration<br /> * Partial dehiscence: separation of fascial edges of the wound, without evisceration, but often with exposure of the underlying omentum or viscera<br /> <br /> == '''Epidemiology''' ==<br /> <br /> * Incidence is 3-3.5% after laparotomy<br /> * Complete fascial dehiscence is associated with a mortality of 10% - this should not be interpreted as 'causative' though<br /> <br /> == '''Risk factors:''' ==<br /> <br /> * Patient:<br /> ** Age &gt;70<br /> ** Obesity<br /> ** Smoking<br /> ** COPD<br /> ** Steroid use<br /> ** DM<br /> ** Malnutrition<br /> ** Ascites<br /> ** Previous laparotomies<br /> * Disease:<br /> ** Abdominal trauma<br /> ** Ruptured AAA<br /> ** Retroperitoneal haematoma<br /> ** Pancreatitis<br /> ** Peritonitis/sepsis<br /> ** Bowel occlusion surgery with resection or suture<br /> ** Wound infection - more likely with fascial infection rather than superficial<br /> ** Wound class III or IV<br /> ** Presence of enterocutaneous fistula<br /> ** Synthetic mesh infection<br /> ** Necrotising fasciitis<br /> ** Abdominal wall defect &gt;10cm width<br /> ** Incision length &gt;18cm<br /> * Can use Veterans Affairs Medical Center score or Rotterdam score to predict risk of suture complications<br /> <br /> == '''Causes:''' ==<br /> <br /> * Technical:<br /> ** Knot failure or inadequate strength of suture<br /> ** Fascial damage - tension, ischaemia, suture material failure<br /> ** Poor closure technique - in the majority of cases, sutures have pulled through rather than broken - either placed too close to fascial edge or under too much tension<br /> *** Poor quality of tissue<br /> *** Increased intra-abdominal pressure<br /> *** Bites too big or small<br /> * SSI/intra-abdominal abscess<br /> * Increased intra-abdominal pressure<br /> <br /> == '''Presentation''' ==<br /> <br /> * Increased serosanguinous drainage from wound - 'moderate to large'<br /> * Mostly 4-14 days post-op (mean 8 days)<br /> * 'Popping' sensation<br /> * Incisional bulge exacerbated by Valsalva manoeuvres<br /> * Absence of a healing ridge by day 5<br /> <br /> == '''Management''' ==<br /> <br /> * Partial dehiscence<br /> ** Consider conservative management for small dehiscences if bowel is covered<br /> ** Carefully consider why it happened<br /> *** Should get a CT to rule out an intra-abdominal cause of dehiscence<br /> ** Otherwise, to theatre for re-closure<br /> * Complete dehiscence<br /> ** Initial:<br /> *** Moist dressing over wound, taped securely to skin<br /> *** Assess for factors that may have led to this including infection/IAH<br /> ** If superficial infection is present:<br /> *** Drainage, antibiotics and local wound management then either<br /> *** Option 1 - vac, then fix the incisional hernia later<br /> *** Option 2 - debridement and delayed primary closure once the infection is resolved<br /> ** If deep infection is present, and the abdomen is inaccessible:<br /> *** Treat the intra-abdominal infection<br /> *** Planned ventral incisional hernia once the infection is resolved<br /> *** Consider biologic mesh to breach the defect<br /> ** Early dehiscence with no infection:<br /> *** Primary abdominal wall closure<br /> <br /> == '''Operation''' ==<br /> <br /> * Debride wound edges<br /> * Look for signs of infection or other reasons for dehiscence<br /> * Close wound again, if no infection, and wound can be safely closed<br /> * Retention sutures not recommended by Sabiston/UTD<br /> * Common option seems to be to add some interrupted 0 PDS or Nylon every 5cm<br /> <br /> [[Category:Abdo wall and retroperitoneum]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin https://surgopaedia.org/w/index.php?title=Ulcerative_colitis&diff=952 2026-03-05T10:14:04Z

<p>SurgopaediaAdmin: </p> <hr /> <div>A chronic inflammatory condition characterised by relapsing and remitting episodes of inflammation, limited to the mucosal layers of the colon.<br /> <br /> == '''Epidemiology''' ==<br /> <br /> * Disease of Western world<br /> * Increasing prevalence over time<br /> * Bimodal onset<br /> ** 15-30yo<br /> ** 50-80yo<br /> <br /> == '''Risk factors''' ==<br /> <br /> * Genetic<br /> * Sleep deprivation<br /> * Possibly infection<br /> <br /> == '''Protective factors''' ==<br /> <br /> * Smoking - tends to suppress symptoms and lower risk<br /> * Appendicectomy<br /> <br /> == '''Pathophysiology''' ==<br /> <br /> * Almost invariably involves the rectum, beginning at the dentate line<br /> * Tends to involve more proximal parts of the colon in a continuous fashion<br /> ** Ulcerative proctitis - disease confined to the rectum<br /> ** Ulcerative proctosigmoiditis - disease limited to the rectum and sigmoid colon<br /> ** Left-sided colitis - disease that extends as far proximally as the splenic flexure<br /> ** Extensive colitis - disease extending proximal to the splenic flexure<br /> * Natural history<br /> ** Typically, intermittent exacerbations alternating with long periods of complete symptomatic remission<br /> ** Those who present with just proctitis have a more benign long-term course<br /> ** 15% proceed to surgery<br /> <br /> == '''Presentation''' ==<br /> <br /> * Usually present with diarrhoea, which may be bloody or not<br /> ** Bowel movements are frequent and small in volume due to proctitis<br /> ** Bloody diarrhoea suggests UC as opposed to CD<br /> * Colicky abdominal pain, urgency, tenesmus, incontinence<br /> * Usually gradual onset of symptoms over several weeks or months<br /> * Systemic symptoms - fever, fatigue, weight loss, anaemia<br /> * Most have a mild index attack, but 27% have a moderate and 1% severe (see severity below)<br /> * Extra-intestinal manifestations: see 'Crohn disease' - same<br /> <br /> == '''Investigations''' ==<br /> <br /> * Check for inflammatory and nutritional markers<br /> ** Albumin, Hb, iron<br /> * Serologic markers<br /> ** Antibodies against Saccharomyces cerevisiae (ASCA) - positive in 35-50% of Crohn's, and &lt;1% of UC<br /> <br /> ** Perinuclear antineutrophilic cytoplasmic antibodies (p-ANCA)<br /> *** (Helpful in differentiating Crohn's and UC - ASCA positive, p-ANCA negative suggests CD, whereas p-ANCA is more likely to be elevated in UC)<br /> <br /> * Stool MCS + CDT<br /> * ALP may be elevated in PSC<br /> * AXR:<br /> ** Patients with severe disease may show proximal constipation, mucosal thickening/'thumbprinting', colonic dilatation<br /> * Barium enema<br /> ** Avoid in unwell patients - may precipitate ileus with toxic megacolon<br /> * CT and MRI<br /> ** May demonstrate marked thickening of the bowel wall - non-specific<br /> ** Lower sensitivity than barium enema for the detection of subtle early mucosal disease<br /> * Endoscopy<br /> ** Use Mayo Clinic Scoring System to grade<br /> ** Inflammation involving rectum and extending proximally in a continuous and circumferential pattern with a sharp cut-off between involve and uninvolved mucosa<br /> ** Can also have a 'caecal patch' of inflammation around the appendiceal orifice which is non-continuous with other areas of inflammation<br /> ** Backwash ileitis may be seen in patients with UC with active right-sided colitis - typically diffuse, rather than the patchy inflammation seen in CD ileum<br /> ** Loss of vascular markings due to engorgement of the mucosa<br /> ** Petechiae<br /> ** Exudates<br /> ** Oedema<br /> ** Erosions<br /> ** Touch friability/spontaneous bleeding<br /> ** Non-neoplastic pseudo-polyps<br /> <br /> ***<br /> <br /> ** Severe: macro-ulcerations, profuse bleeding, copious exudates<br /> **<br /> <br /> * Biopsies of bowel<br /> ** Nothing fully specific for UC, but presence of two or more features is suggestive<br /> *** '''Crypt abscesses'''; crypt branching, shortening and disarray; and crypt atrophy<br /> *** Epithelial cell abnormalities - '''goblet cell/mucin depletion''' and Paneth cell metaplasia<br /> *** '''Increased lamina propria cellularity''' (polymorphonuclear leucocytes), basal plasmacytosis, basal lymphoid aggregates, and lamina propria eosinophils<br /> ** Absence of mural sinus tracts, deep fissural ulcers, and granulomas, as well as by the absence of transmural lymphoid aggregates in an area not deeply ulcerated<br /> <br /> == '''Diagnostic criteria''' ==<br /> <br /> * Chronic diarrhoea for &gt;4 weeks<br /> * Evidence of active inflammation on endoscopy<br /> * Chronic inflammation on biopsy<br /> * Exclusion of other causes of colitis/proctitis<br /> <br /> == '''Differential diagnosis''' ==<br /> <br /> * Infectious colitis<br /> ** C diff<br /> ** CMV<br /> ** Salmonella, Giardia<br /> ** Parasites and other infectious agents<br /> * Proctitis<br /> ** Gonorrhoea, chlamydia, syphilis<br /> ** HSV<br /> * Medication colitis<br /> ** NSAIDs<br /> ** Retinoic acid<br /> ** Checkpoint inhibitors<br /> ** Mycophenolate<br /> ** Gold<br /> * Ischaemic colitis<br /> * Radiation proctitis/colitis<br /> * Crohn disease<br /> ** More likely than UC if no gross bleeding, perianal disease present, and fistulas<br /> ** Granulomas on biopsy<br /> * IBD undetermined/indeterminate colitis<br /> ** See discussion under 'Crohn disease'<br /> * Diversion colitis<br /> * Solitary rectal ulcer syndrome<br /> * Graft versus host disease<br /> ** History of bone marrow transplantation<br /> ** Differentiate on histology - GVHD has crypt wall necrosis with the accumulation of degenerative material in the dead crypt cells<br /> <br /> == '''Severity''' ==<br /> <br /> === Montreal classification: ===<br /> <br /> **<br /> <br /> {| class=&quot;wikitable&quot;<br /> |<br /> |Mild<br /> |Moderate<br /> |Severe<br /> |-<br /> |Diarrhoea frequency<br /> |&lt;5<br /> |5, with blood<br /> |&gt;5, with blood<br /> |-<br /> |Systemic features<br /> |None<br /> |Low-grade fever<br /> |Fever, tachycardia<br /> |-<br /> |Symptoms<br /> |Mild<br /> |Moderate<br /> |Severe<br /> |-<br /> |ESR<br /> |Normal<br /> |Mildly elevated<br /> |&gt;30mm/hour<br /> |-<br /> |Weight loss<br /> |None<br /> |None<br /> |Yes<br /> |-<br /> |Anaemia<br /> |None<br /> |Mild<br /> |Hb &lt;105<br /> |}<br /> <br /> === Mayo Clinic Scoring System ===<br /> <br /> **<br /> <br /> === Truelove and Witts ===<br /> <br /> ** See separate topic 'toxic megacolon'<br /> ** Severe: severe diarrhoea (6 or more motions per day) with macroscopic blood, fever &gt;=37.8, HR &gt; 90, Hb &lt;105, elevated CRP or ESR<br /> ** Fulminant: Bloody stools &gt;=10/day, accompanied by abdominal pain and distension, in addition to the above criteria.<br /> <br /> == '''Medical management''' ==<br /> <br /> === '''Principles:''' ===<br /> <br /> ** See 'Crohn disease' topic for background on goals and medications available<br /> ** Leave the ins and outs to gastro, but need to have a broad awareness of classes and strategies used<br /> <br /> === '''Medication classes (see Crohn's topic for details):''' ===<br /> <br /> ** Induction of remission<br /> *** Mainstay has been steroids, enemas, oral or IV<br /> *** If that fails or for severe disease, sometimes need immunomodulators<br /> ** Maintenance therapy<br /> *** Aminosalicylates (a.k.a. 5-ASA/5-aminosalicylic acid)<br /> *** Can include steroids, but preferably not<br /> *** Immunomodulators<br /> *** Biologics<br /> *** Calcineurin inhibitors - cyclosporin/tacrolimus, sometimes used as rescue therapy for ASUC<br /> *** Antibiotics - low-quality data to support use as induction agents<br /> * '''Initial therapy for active proctitis or distal colitis (distal to splenic flexure):'''<br /> ** Mesalazine orally and rectally. Rectal topical therapy is probably the easiest way to target treatment to the affected area, but may not be effective for many reasons. Rectal preparation best given before bed, tolerated better at night.<br /> *** Isolated ulcerative proctitis: suppositories<br /> *** Extends &gt;20cm from anal verge: foam or enema<br /> *** Proximal to sigmoid: enema<br /> ** If 5-aminosalicylates are ineffective, add rectal steroids (e.g. 'Predsol' prednisolone enemas 20mg/100mL, can start off with a 1-2 week course).<br /> ** Continue until symptoms have resolved, then taper over several weeks.<br /> ** If symptoms recur, restart induction therapy.<br /> * '''For induction therapy for colitis proximal to splenic flexure'''<br /> ** For mild-mod disease, PO prednisolone/5-aminosalicylate<br /> ** For severe, probably need an immunomodulator<br /> * '''For unresponsive active colitis'''<br /> ** Oral prednisolone 40-50mg PO daily, then taper over 6-8 weeks<br /> * '''For acute severe ulcerative colitis (Truelove and Witts criteria)'''<br /> ** Hydrocortisone 100mg IV q6h 3-5 days<br /> ** If they fail to respond to that, 'salvage therapy' is infliximab (possibly cyclosporin), and possibly upadacitinib<br /> * '''Standard maintenance regime:'''<br /> ** Mesalazine 1-3g orally per day and a mesalazine rectal preparation 2-3 times per week<br /> ** If more severe, or frequent relapses, add an immunomodulator or biologic (usually infliximab)<br /> <br /> <br /> <br /> <br /> <br /> <br /> == '''Elective surgical management''' ==<br /> <br /> === '''Indications for surgery''' ===<br /> <br /> ** Failure to respond to maximal medical therapy (severe disease)<br /> ** Patient preference<br /> ** Dysplasia/malignancy<br /> *** Colectomy indicated if multiple areas of low-grade dysplasia or areas of high-grade dysplasia are found<br /> *** Especially difficult to identify suspicious areas with active colitis<br /> *** If high-grade dysplasia is found on random biopsy, 42% chance of finding cancer after proctocolectomy<br /> *** Cancer can develop in areas of low-grade dysplasia without necessarily <br /> *** Close surveillance an alternative if patient willing<br /> ** Failure to grow/thrive (children)<br /> ** Severe extra-intestinal disease which may respond to surgery<br /> <br /> === '''Surgical options:''' ===<br /> <br /> ** Total proctocolectomy with either end ileostomy or IPAA<br /> *** No difference in overall quality of life<br /> ** End ileostomy<br /> *** Be wary of patients with PSC - risk factor for both chronic pouchitis and peristomal varices - preference for IPAA given life-threatening nature of varices<br /> ** IPAA (ileal pouch-anal anastomosis)<br /> *** Patient selection<br /> **** UC not responding to medical therapy<br /> **** Dysplasia/malignancy<br /> *** Construction process:<br /> **** Three-stage:  (preferred for patients who are hospitalised with refractory disease, or are on biologics/steroids, obese, young women wishing to preserve fertility)<br /> <br /> ****# Subtotal colectomy with end ileostomy and rectal stump<br /> ****# Proctectomy with IPAA and loop ileostomy<br /> ****# Ileostomy takedown<br /> <br /> **** Two-stage: (favoured in well patients with malignancy)<br /> <br /> ****# Total proctocolectomy with IPAA and loop ileostomy<br /> ****# Ileostomy takedown<br /> <br /> **** One-stage:<br /> <br /> ****# Total proctocolectomy with IPAA and no diversion<br /> <br /> ***** Appropriate if no immunosuppression, good nutritional state, and no tension on IPAA<br /> <br /> *** Often difficult to get enough length for a tension-free ileal anastomosis<br /> **** Check whether you have enough length before you form a pouch! Can leave as end ileostomy. If the apex of the pouch can reach 6cm below the inferior margin of symphysis pubis, then a tension-free anastomosis can usually be constructed.<br /> **** Completely mobilise small bowel to root of mesentery, but preserve ileocolic vessels<br /> **** Transverse incisions on visceral peritoneum of the mesentery - 'mesenteric releases'<br /> **** Careful division of select vascular arcades in small bowel mesentery - can divide terminal branches of SMA, because they are likely to be the thing creating most tension. Jamieson's says ileocolic itself can be divided if necessary for an S pouch, and the major continuation of SMA for a J pouch. Put a bulldog clamp on before division to test if it leads to ischaemia.<br /> *** Pouch configuration<br /> **** Stapled anastomosis requires a short cuff of rectum, which is a potential source of symptoms - 'cuffitis' and cancer.<br /> **** Hand-sewn anastomosis can be done with a mucusectomy - remove all rectal mucosa down to anorectal junction, so might have a lower rate of cancers. Maybe worse continence. Usually done from outside with an anal retractor (lone star). Note that this might make it harder for the pouch to reach down.<br /> **** Preference for stapled J-pouch - simplest and easiest, least complications<br /> **** Or, 'double-stapled' if you are also talking about the staple for the pouch-anal anastomosis (using the circular staple for that one)<br /> **** W-pouch below - uncommonly done<br /> **** S-pouch - can provide a bit more reach and larger reservoir<br /> ****<br /> <br /> *<br /> *<br /> <br /> * Outcomes:<br /> ** Expect to have up to 6 loose bowel motions per day - need good anal sphincter control<br /> ** Function often improves over the first 6 months<br /> * Ileostomy closure<br /> ** Anastomosis should be thoroughly investigated prior to closure<br /> ** DRE, endoscopy, gastrografin<br /> * Complications<br /> ** SBO (20%)<br /> ** Sexual dysfunction<br /> ** Ileostomy complications<br /> ** Leak<br /> *** Sepsis<br /> *** Fistula<br /> ** Anastomotic stricture<br /> *** Often a reflection of tension<br /> ** Pouchitis<br /> *** Medical management - abx, probiotics, budesonide enemas. Consider immunosuppressive therapy<br /> *** Surgical therapy if refractive - diversion or pouch excision<br /> <br /> * Uncommon procedures<br /> ** Total proctocolectomy with continent ileostomy ('Kock's Pouch')<br /> *** Continence maintained by an intussuscepted segment of ileum positioned between the ileal reservoir and the end ileostomy<br /> *** Very prone to dessusception, which requires revision<br /> *** Not done much any more<br /> *** Works best in thin patients<br /> ** Subtotal colectomy with ileorectal anastomosis<br /> *** Avoids complications of pelvic dissection - sexual function for both men and women<br /> *** Still need rectal surveillance<br /> *** Suitable for patients with limited rectal involvement, but that is rare with UC<br /> <br /> <br /> == '''Emergency surgical management''' ==<br /> <br /> * Indications<br /> ** Acute fulminant colitis, including toxic megacolon (see separate topic)<br /> ** Significant GIT haemorrhage (uncommon in modern era)<br /> * Choice of surgery<br /> ** Subtotal colectomy with end ileostomy or Hartmann's procedure are least morbid options<br /> *** Indicated for sick patients<br /> ** Shouldn't do IPAA initially<br /> <br /> == '''Peri-op management:''' ==<br /> <br /> * '''Pre-op'''<br /> ** Anti-TNF agents (infliximab, adalimumab, certolizumab) - associated with increased operative complications - controversial<br /> *** Ideally last dose &gt;4/52 pre-op<br /> *** UC - possible a/w pelvic sepsis after IPAA - 3-stage approach favoured in patients on anti-TNF drugs<br /> *** CD - possible increase in complications, but controversial and not clear<br /> <br /> *** Vedolizumab<br /> **** Ideally last dose 4-8/52 pre-op<br /> **** UC - no increased risk of infection<br /> **** CD - similar rates of infection to anti-TNF drugs<br /> *** Ustekinumab<br /> **** Similar complication rates to anti-TNFs<br /> **** Ideally last dose 4/52 pre-op<br /> *** Restart 4/52 post-op where necessary<br /> <br /> ** Corticosteroids<br /> <br /> *** Well-established detrimental effect on anastomotic healing<br /> *** UC: should do delayed IPAA formation in patients who cannot be weaned to &lt;20mg/day for 6/52 pre-op<br /> *** CD - high risk of infection is generally ameliorated by stoma instead of primary anastomosis<br /> **** Should still be reduced if possible<br /> <br /> ** Nutrition<br /> <br /> *** UC - no pre-op TPN<br /> *** CD - poorly studied in biologic era, but no clear role for pre-op TPN<br /> **** Still need to optimise nutrition<br /> <br /> ** Planning<br /> <br /> *** Pre-op imaging is crucial +/- capsule endoscopy<br /> *** Looking for important disease in other areas of GIT<br /> *** Planning extent of resection<br /> <br /> * '''Post-op'''<br /> ** A well-functioning stoma allows a much better quality of life than a poorly-functioning anorectum<br /> <br /> *** Leakage<br /> *** Skin irritation<br /> *** Difficulty maintaining a seal<br /> *** Retraction<br /> *** Ischaemia<br /> *** Mucocutaneous separation<br /> *** Pyoderma gangrenosum can develop around stoma sites (2-5% of those who have stomas for IBD)<br /> **** Early recognition and corticosteroid treatment<br /> **** Good stoma care<br /> <br /> ** Ileostomy creation high-risk for readmission<br /> <br /> *** AKI + dehydration common<br /> <br /> ** Infection - high-risk overall, particularly with immunosuppression<br /> <br /> *** Intra-abdominal sepsis reportedly 8%, median nine days post-op<br /> *** High-risk: previous intestinal resection + triple therapy immunosuppressed (22% overall risk)<br /> *** Anastomotic leaks: particularly those with multiple previous resections<br /> **** Stapled side-to-side anastomosis have lower leak rates<br /> <br /> ** Stump blow-out<br /> <br /> *** Oversewing staple line and decompressing rectal tube are purported to decrease blowout rate, but limited evidence<br /> *** Can also bring above fascia to secure either below skin or as mucus fistula<br /> <br /> ** Pouch complications:<br /> ** VTE - more common than would be expected - consider 4 weeks prophylactic enoxaparin<br /> ** ERAS is vital<br /> <br /> == '''Cancer risk/endoscopic surveillance''' ==<br /> <br /> * 20% malignancy after 30 years of colitis - tends to arise in a field of dysplasia, which appears abnormal<br /> * Start 8-10 years post-diagnosis - main goal is to detect dysplasia<br /> * Limited evidence that screening actually reduces mortality<br /> * Divide patients into three groups<br /> ** Low risk - every 5 years<br /> ** Moderate risk - every three years<br /> ** High risk (extensive or active disease, or any previous dysplasia, or other high-risk features including first-degree relatives) - every year<br /> * Four-quadrant random biopsies every 10cm, for a total of at least 32 biopsies, in addition to suspicious lesions<br /> * Conservative advice would be, any high-grade dysplasia on random biopsy should have total proctocolectomy<br /> * Areas of dysplasia should have EMR. If unresectable endoscopically, should have proctocolectomy.<br /> <br /> <br /> [[Category:Colorectal]]<br /> [[Category:Intern education]]</div>

SurgopaediaAdmin