GENERAL SURGERYGENERAL SURGERY FOR FOR

DENTAL STUDENTSDENTAL STUDENTSBYBY

Dr. AHMAD K. SHAHWAN Dr. AHMAD K. SHAHWAN

PH.D. GENERAL SURGERYPH.D. GENERAL SURGERY

Approach to the Surgical Patient: Approach to the Surgical Patient: The management of surgical disorders The management of surgical disorders

requires not only the application of requires not only the application of technical skills and training in the basic technical skills and training in the basic sciences to the problems of diagnosis and sciences to the problems of diagnosis and treatment but also a sympathy and indeed treatment but also a sympathy and indeed love for the patient. The surgeon must be a love for the patient. The surgeon must be a doctor, an applied scientist, an engineer, an doctor, an applied scientist, an engineer, an artist. Because life or death often depends artist. Because life or death often depends upon the validity of surgical decisions, the upon the validity of surgical decisions, the surgeon's judgment must be matched by surgeon's judgment must be matched by courage in action and by a high degree of courage in action and by a high degree of technical proficiency technical proficiency

Approach to the Surgical Patient:Approach to the Surgical Patient:

1)1) History-History-

2)2) physical Examination -physical Examination -

3)3) Investigations-Investigations-

4)4) Pre-operative preparation -Pre-operative preparation -

5)5) operation -operation -

6)6) post-operative treatment-post-operative treatment-

7)7) management of complications.management of complications.

Approach to the Surgical Patient:Approach to the Surgical Patient: The History :The History :At their first contact, the surgeon must gain At their first contact, the surgeon must gain

the patient's confidence and convey the the patient's confidence and convey the assurance that help is available and will be assurance that help is available and will be provided. The surgeon must demonstrate provided. The surgeon must demonstrate concern for the patient as a person who concern for the patient as a person who needs help and not just as a "case" to be needs help and not just as a "case" to be processed. This is not always easy to do, processed. This is not always easy to do, and there are no rules of conduct except to and there are no rules of conduct except to be gentle and considerate. be gentle and considerate.

The HistoryThe HistoryI- The chief complaintI- The chief complaint :i.e. what the problem that :i.e. what the problem that

bring the patient to the doctor& its duration .bring the patient to the doctor& its duration .

II- The present historyII- The present history: in full detail:: in full detail:

1-when the complaint start exactly ? (day , hour).1-when the complaint start exactly ? (day , hour).2-how it starts? (slowly ,abruptly )2-how it starts? (slowly ,abruptly )3-its course ? (increasing , the same or decreasing ).3-its course ? (increasing , the same or decreasing ).4- any associated symptoms? (pain 4- any associated symptoms? (pain

vomiting ,fever ,drowsiness ,change in vision ,………..) vomiting ,fever ,drowsiness ,change in vision ,………..) ..

5- the provoking factors: what increase the complaint?5- the provoking factors: what increase the complaint?6- the releasing factors;what decrease the complaint ?6- the releasing factors;what decrease the complaint ?7- relieved by medication or not ?7- relieved by medication or not ?8- constant or intermittent ,its duration & for how long ?8- constant or intermittent ,its duration & for how long ?

The HistoryThe History e.g. e.g. The pain:The pain:1)1) The site :The site :2)2) The onset :gradual ,sudden or explosive The onset :gradual ,sudden or explosive 3)3) The character: burning ,colicky, vague ,heaviness,The character: burning ,colicky, vague ,heaviness,

…..…..4)4) The severity: mild ,moderate or sever .The severity: mild ,moderate or sever .5)5) constant or intermittent .constant or intermittent .6)6) relieved by medication or not & what medication ?relieved by medication or not & what medication ?7)7) Factors increase it :movement ,eating, standing ,….Factors increase it :movement ,eating, standing ,….8)8) Factors decrease it :movement ,eating, standing ,…Factors decrease it :movement ,eating, standing ,…9)9) Radiation to other site ?Radiation to other site ?10)10) Associated symptoms: vomiting ,fever …..Associated symptoms: vomiting ,fever …..

The HistoryThe HistoryE.g.: E.g.: vomitingvomiting : : What did the patient vomit? Food ,fluid ,What did the patient vomit? Food ,fluid ,

………… How much? How much? How often?How often? What did the color of the vomitus ? What did the color of the vomitus ?

yellow ,green, brown,….yellow ,green, brown,…. Was vomiting projectile? Was vomiting projectile? The taste of the vomitus ?acidic , bitter ,The taste of the vomitus ?acidic , bitter ,

…..…..

The HistoryThe HistoryIII- III- The past history;The past history;

1)1) Any same complain before ? How it started & Any same complain before ? How it started & how ended?how ended?

2)2) Any other complain before? Related to the Any other complain before? Related to the complaint or not related ?complaint or not related ?

3)3) Any other diseases? hypertension. ,diabetes Any other diseases? hypertension. ,diabetes mellitus , cardiac problem,…mellitus , cardiac problem,…

IV –The drug IV –The drug historyhistory :aspirin ,anticoagulant ,contraceptive :aspirin ,anticoagulant ,contraceptive pills ,chemotherapy .pills ,chemotherapy .

V- The surgical historyV- The surgical history :any operation before, :any operation before, type of anesthesia ,any complication?type of anesthesia ,any complication?

The HistoryThe HistoryVI- Nutritional historyVI- Nutritional history :dehydration . Loss :dehydration . Loss

of electrolyte ,protein deficiency.of electrolyte ,protein deficiency.VII- Menstrual historyVII- Menstrual history :regularity ,duration , :regularity ,duration ,

amount,..amount,..VIII-Family historyVIII-Family history: known disease in the : known disease in the

family ,same disease in the family ,same disease in the family ,hereditary diseases? .family ,hereditary diseases? .

IX- Environmental historyIX- Environmental history..X- Habbit historyX- Habbit history :smoking, alcohol ,drug :smoking, alcohol ,drug

abuse .abuse .XI- Hypersensitivity history .XI- Hypersensitivity history .

The physical examination:The physical examination: All patients are sensitive and somewhat All patients are sensitive and somewhat

embarrassed at being examined .embarrassed at being examined . The examining room and table should be The examining room and table should be

comfortable ,worm, closed, and drapes comfortable ,worm, closed, and drapes should be used if the patient is required to should be used if the patient is required to strip for the examination. strip for the examination. A female nurse A female nurse should be present if the patient is femaleshould be present if the patient is female. . Most patients will relax if they are allowed to Most patients will relax if they are allowed to talk a bit during the examination, which is talk a bit during the examination, which is another reason for taking the past history another reason for taking the past history while the examination is being done. while the examination is being done.

The physical examination:The physical examination:I.I. Inspection Inspection :any scar, pulsation, :any scar, pulsation,

swelling, redness, discharge, swelling, redness, discharge, asymmetry, hair distribution, ulcers, asymmetry, hair distribution, ulcers, wound ,….wound ,….

II.II. Palpation Palpation :(superficial palpation for :(superficial palpation for masses, tenderness,….&deep palpation masses, tenderness,….&deep palpation for deep masses )for deep masses )

III.III. PercationPercation :to differentiate between air & :to differentiate between air & solid surfaces.solid surfaces.

IV.IV. AuscultationAuscultation :by use stethoscope to :by use stethoscope to hear normal & abnormal sounds.hear normal & abnormal sounds.

E.g. if we find a E.g. if we find a lump (mass),lump (mass), we should know: we should know:1)1) The site .The site .2)2) The size .The size .3)3) The shape .The shape .4)4) The edge (cut or rounded).The edge (cut or rounded).5)5) Tenderness .Tenderness .6)6) Pulsation .Pulsation .7)7) Flactuality .Flactuality .8)8) Consistency .Consistency .9)9) Mobility .Mobility .10)10) The surface.The surface.11)11) Reducibility .Reducibility .12)12) Regional draining lymph node .Regional draining lymph node .

E.g. if we find E.g. if we find an ulceran ulcer we should know: we should know:1)1) The site .The site .2)2) The size .The size .3)3) The shape .The shape .4)4) The edge .The edge .5)5) The base (what you can feel) .The base (what you can feel) .6)6) The floor (what you can see) .The floor (what you can see) .7)7) The color .The color .8)8) The secretion .The secretion .9)9) The vascularity .The vascularity .10)10) Regional draining lymph node .Regional draining lymph node .

InvestigationsInvestigationsI- I- Simple Simple bloodblood investigations: investigations:1)1) C.B.C. (complete blood count) which C.B.C. (complete blood count) which

reveals hemoglobin, white blood cells, red reveals hemoglobin, white blood cells, red blood cells, platelets count,blood cells, platelets count,

2)2) Blood group & Rh-factor.Blood group & Rh-factor.3)3) Blood sugar (fasting or random or post Blood sugar (fasting or random or post

brandial) .brandial) .4)4) The kidney function tests (Blood The kidney function tests (Blood

urea ,serum creatinine) .urea ,serum creatinine) .5)5) Electrolyte: Na+ ,K+, Ca++,…..Electrolyte: Na+ ,K+, Ca++,…..6)6) The liver function test (ALT, AST ,Serum The liver function test (ALT, AST ,Serum

bilirubin ,Serum protein & albumin ) .bilirubin ,Serum protein & albumin ) .7)7) P.T. & P.T.T.P.T. & P.T.T.

InvestigationsInvestigationsII- II- urineurine exam (general & culture). exam (general & culture).

III- III- StoolStool exam (general & culture). exam (general & culture).

IV- IV- ultrasonographyultrasonography..

V- V- X-rayX-ray::

1- simple X-ray (without dye) e.g. chest X-1- simple X-ray (without dye) e.g. chest X-ray ,abdominal X-ray ,K.U.B. ,skull X-ray ,abdominal X-ray ,K.U.B. ,skull X-ray ,panorama X-ray, ….ray ,panorama X-ray, ….

2- X-ray with dye :e.g. barium meal ,barium 2- X-ray with dye :e.g. barium meal ,barium enema, I.V.P……enema, I.V.P……

3- C.T. ( computerized tomography ) scan .3- C.T. ( computerized tomography ) scan .

4- M.R.I. (magnetic resonance imaging) .4- M.R.I. (magnetic resonance imaging) .

VI- VI- E.C.G E.C.G . (electro cardio graphy ). (electro cardio graphy )

InvestigationsInvestigations Special Examinations:Special Examinations:

such as cystoscopy, gastroscopy, such as cystoscopy, gastroscopy, esophagoscopy, colonoscopy, esophagoscopy, colonoscopy, angiography, and bronchoscopy are angiography, and bronchoscopy are often required in the diagnosis of certain often required in the diagnosis of certain surgical disorders. surgical disorders. The surgeon must be The surgeon must be familiar with the indications and familiar with the indications and limitations of these procedureslimitations of these procedures and be and be prepared to consult with colleagues in prepared to consult with colleagues in medicine and other surgical specialties medicine and other surgical specialties as required. as required.

Pre-operative preparationPre-operative preparation According to the type of operation, we should According to the type of operation, we should

do:do:1)1) All the required investigationsAll the required investigations2)2) Prepare blood .Prepare blood .3)3) Shaving the operation site.Shaving the operation site.4)4) The patient take a bath.The patient take a bath.5)5) Examined by the anesthetist.Examined by the anesthetist.6)6) Prepare I.C.U. if the patient need.Prepare I.C.U. if the patient need.7)7) Give him premedications like diazepam a night Give him premedications like diazepam a night

before the operationbefore the operation..8)8) Fasting 8 hours before the operationFasting 8 hours before the operation . .The patient should enter the operation The patient should enter the operation

room in the room in the optimumoptimum conditioncondition

Approach to the Surgical Patient:Approach to the Surgical Patient:

--operation ---operation -

--post-operative treatment---post-operative treatment-

--management of complications--management of complications..

(according to the type of the (according to the type of the operation.)operation.)

Postoperative Care: Postoperative Care: The recovery from surgery can be divided into The recovery from surgery can be divided into

three phases: three phases: (1) an immediate, or post-anesthetic phase; (1) an immediate, or post-anesthetic phase; (2) an intermediate phase, ( the hospitalization (2) an intermediate phase, ( the hospitalization

period); period);

(3) a convalescent phase. (3) a convalescent phase. During the first two phases, care is principally During the first two phases, care is principally

directed at maintenance of homeostasis, treatment directed at maintenance of homeostasis, treatment of pain, and prevention and early detection of of pain, and prevention and early detection of complications. The convalescent phase is a complications. The convalescent phase is a transition period from the time of hospital transition period from the time of hospital discharge to full recovery.discharge to full recovery.

The trend toward earlier postoperative discharge The trend toward earlier postoperative discharge after major surgery make the 3after major surgery make the 3rdrd phase more phase more important.important.

1-The Immediate Postoperative Period1-The Immediate Postoperative Period

The major causes of early complications The major causes of early complications and death following major surgery are and death following major surgery are acute pulmonary, cardiovascular, and fluid acute pulmonary, cardiovascular, and fluid derangements.derangements. The post-anesthesia care The post-anesthesia care unit (PACU) is staffed by specially trained unit (PACU) is staffed by specially trained personnel and provided with equipment for personnel and provided with equipment for early detection and treatment of these early detection and treatment of these problems. All patients should be problems. All patients should be monitored in this specialized unit initially monitored in this specialized unit initially following major procedures .following major procedures .

1-The Immediate Postoperative Period1-The Immediate Postoperative PeriodThe patient can be discharged from the recovery The patient can be discharged from the recovery

room when cardiovascular, pulmonary, and room when cardiovascular, pulmonary, and neurologic function have returned to baseline, neurologic function have returned to baseline, which usually occurs 1–3 hours following which usually occurs 1–3 hours following operation.operation.

Patients who require continuing ventilatory or Patients who require continuing ventilatory or circulatory support or who have other conditions circulatory support or who have other conditions that require frequent monitoring are transferred to that require frequent monitoring are transferred to an an intensive care unit (I.C.U.) intensive care unit (I.C.U.) . In this setting, . In this setting, nursing personnel specially trained in the nursing personnel specially trained in the management of respiratory and cardiovascular management of respiratory and cardiovascular emergencies are available.emergencies are available.

Monitoring equipment is available to enable early Monitoring equipment is available to enable early detection of cardio-respiratory derangements. detection of cardio-respiratory derangements.

Postoperative Orders in The Immediate Postoperative Orders in The Immediate Postoperative PeriodPostoperative Period

The nursing team must be advised of the nature of The nursing team must be advised of the nature of the operation and the patient's condition.the operation and the patient's condition.

Postoperative orders should cover the followingPostoperative orders should cover the following: : 1- Monitoring the following:1- Monitoring the following:A- Vital SignsA- Vital Signs : Blood pressure, pulse, and : Blood pressure, pulse, and

respiration should be recorded frequently until respiration should be recorded frequently until stable and then regularly until the patient is stable and then regularly until the patient is discharged from the recovery room. The discharged from the recovery room. The frequency of vital sign measurements thereafter frequency of vital sign measurements thereafter depends upon the nature of the operation and depends upon the nature of the operation and the course in the PACU. Continuous the course in the PACU. Continuous electrocardiographic monitoring is indicated for electrocardiographic monitoring is indicated for most patients in the PACU. Any major changes most patients in the PACU. Any major changes in vital signs should be communicated to the in vital signs should be communicated to the anesthesiologist and surgeon immediately.anesthesiologist and surgeon immediately.

B-Central Venous PressureB-Central Venous Pressure

Central venous pressure should be Central venous pressure should be recorded periodically in the early recorded periodically in the early postoperative period if the operation postoperative period if the operation has entailed large blood losses or fluid has entailed large blood losses or fluid shifts, and invasive monitoring is shifts, and invasive monitoring is available. A available. A Swan-Ganz catheterSwan-Ganz catheter for for measurement of pulmonary artery measurement of pulmonary artery wedge pressure is indicated under wedge pressure is indicated under these conditions if the patient has these conditions if the patient has borderline cardiac or respiratory borderline cardiac or respiratory function.function.

C- Fluid BalanceC- Fluid BalanceThe anesthetic record includes all fluid The anesthetic record includes all fluid

administered as well as blood loss and urine administered as well as blood loss and urine output during the operation. This record output during the operation. This record should be continued in the postoperative should be continued in the postoperative period and should also include fluid losses period and should also include fluid losses from drains and stomas. This aids in from drains and stomas. This aids in assessing hydration and helps to guide assessing hydration and helps to guide intravenous fluid replacement. A bladder intravenous fluid replacement. A bladder catheter can be placed for frequent catheter can be placed for frequent measurement of urine output. In the absence measurement of urine output. In the absence of a bladder catheter, the surgeon should be of a bladder catheter, the surgeon should be notified if the patient is unable to void within notified if the patient is unable to void within 6–8 hours after operation.6–8 hours after operation.

D- Other Types of MonitoringD- Other Types of Monitoring

Depending on the nature of the operation Depending on the nature of the operation and the patient's pre-existing and the patient's pre-existing conditions, other types of monitoring conditions, other types of monitoring may be necessary. Examples include may be necessary. Examples include measurement of intracranial pressure measurement of intracranial pressure and level of consciousness following and level of consciousness following cranial surgery and monitoring of distal cranial surgery and monitoring of distal pulses following vascular surgery or in pulses following vascular surgery or in patients with casts.patients with casts.

2- Respiratory Care2- Respiratory Care

In the early postoperative period, the In the early postoperative period, the patient may remain mechanically patient may remain mechanically ventilated or treated with supplemental ventilated or treated with supplemental oxygen by mask or nasal prongs. These oxygen by mask or nasal prongs. These orders should be specified. For orders should be specified. For intubated patients, tracheal suctioning or intubated patients, tracheal suctioning or other forms of respiratory therapy must other forms of respiratory therapy must be specified as required. Patients who be specified as required. Patients who are not intubated should do deep are not intubated should do deep breathing exercises frequently to prevent breathing exercises frequently to prevent atelectasis.atelectasis.

3- Position in Bed and Mobilization3- Position in Bed and Mobilization

The postoperative orders should describe any The postoperative orders should describe any required special positioning of the patient. required special positioning of the patient. Unless doing so is contraindicated, the patient Unless doing so is contraindicated, the patient should be turned from side to side every 30 should be turned from side to side every 30 minutes until conscious and then hourly for minutes until conscious and then hourly for the first 8–12 hours to minimize atelectasis.the first 8–12 hours to minimize atelectasis.

Early ambulation is encouraged to reduce Early ambulation is encouraged to reduce venous stasis; the upright position helps to venous stasis; the upright position helps to increase diaphragmatic function.increase diaphragmatic function.

Venous stasis may also be minimized by Venous stasis may also be minimized by intermittent compression of the calf by intermittent compression of the calf by pneumatic stockings.pneumatic stockings.

4- Diet4- Diet

Patients at risk for emesis and pulmonary Patients at risk for emesis and pulmonary aspiration should have nothing by mouth aspiration should have nothing by mouth until some gastrointestinal function has until some gastrointestinal function has returned (usually within 4 days). Most returned (usually within 4 days). Most patients can tolerate liquids by mouth shortly patients can tolerate liquids by mouth shortly after return to full consciousness.after return to full consciousness.

5- Administration of Fluid and Electrolytes5- Administration of Fluid and Electrolytes

Orders for postoperative intravenous fluids Orders for postoperative intravenous fluids should be based on maintenance needs and should be based on maintenance needs and the replacement of gastrointestinal losses the replacement of gastrointestinal losses from drains, fistulas, or stomas.from drains, fistulas, or stomas.

6- Drainage Tubes6- Drainage TubesDrain care should be included in the postoperative orders. Drain care should be included in the postoperative orders.

Details such as type and pressure of suction, irrigation Details such as type and pressure of suction, irrigation fluid and frequency, and skin exit site care should be fluid and frequency, and skin exit site care should be specified. The surgeon should examine drains specified. The surgeon should examine drains frequently, since the character or quantity of drain frequently, since the character or quantity of drain output may herald the development of postoperative output may herald the development of postoperative complications such as bleeding or fistulas.complications such as bleeding or fistulas.

7- Medications7- MedicationsOrders should be written for antibiotics, analgesics, Orders should be written for antibiotics, analgesics,

gastric acid suppression, deep vein thrombosis gastric acid suppression, deep vein thrombosis prophylaxis, and sedatives. If appropriate, preoperative prophylaxis, and sedatives. If appropriate, preoperative medications should be reinstituted. Careful attention medications should be reinstituted. Careful attention should be paid to replacement of corticosteroids in should be paid to replacement of corticosteroids in patients at risk, since postoperative adrenal patients at risk, since postoperative adrenal insufficiency may be life-threatening. Other medications insufficiency may be life-threatening. Other medications such as antipyretics, laxatives, and stool softeners such as antipyretics, laxatives, and stool softeners should be used selectively as indicatedshould be used selectively as indicated..

8- Laboratory Examinations and 8- Laboratory Examinations and ImagingImaging

The use of postoperative laboratory and The use of postoperative laboratory and radiographic examinations should be to radiographic examinations should be to detect specific abnormalities in high-detect specific abnormalities in high-risk groups. The routine use of daily risk groups. The routine use of daily chest radiographs, blood counts, chest radiographs, blood counts, electrolytes, and renal or liver function electrolytes, and renal or liver function panels is not useful.panels is not useful.

The Intermediate Postoperative Period The Intermediate Postoperative Period

The intermediate phase starts with The intermediate phase starts with complete recovery from anesthesia and complete recovery from anesthesia and lasts for the rest of the hospital stay. lasts for the rest of the hospital stay. During this time, the patient recovers During this time, the patient recovers most basic functions and becomes most basic functions and becomes self-sufficient and able to continue self-sufficient and able to continue convalescence at home.convalescence at home.

1- Care of the Wound :1- Care of the Wound :Within hours after a wound is closed, the wound Within hours after a wound is closed, the wound

space fills with an inflammatory exudate. space fills with an inflammatory exudate. Epidermal cells at the edges of the wound Epidermal cells at the edges of the wound begin to divide and migrate across the wound begin to divide and migrate across the wound surface. By 48 hours after closure, deeper surface. By 48 hours after closure, deeper structures are completely sealed off from the structures are completely sealed off from the external environment. Sterile dressings external environment. Sterile dressings applied in the operating room provide applied in the operating room provide protection during this period. Dressings over protection during this period. Dressings over closed wounds should be removed on the third closed wounds should be removed on the third or fourth postoperative day. If the wound is or fourth postoperative day. If the wound is dry, dressings need not be reapplied; this dry, dressings need not be reapplied; this simplifies periodic inspection. Dressings simplifies periodic inspection. Dressings should be removed earlier if they are wet, should be removed earlier if they are wet, because soaked dressings increase bacterial because soaked dressings increase bacterial contamination of the wound. contamination of the wound.

1- Care of the Wound:1- Care of the Wound:Dressings should also be removed if the patient Dressings should also be removed if the patient

has manifestations of infection (such as fever has manifestations of infection (such as fever or increasing wound pain). The wound should or increasing wound pain). The wound should then be inspected and the adjacent area gently then be inspected and the adjacent area gently compressed. compressed. Any drainage from the wound Any drainage from the wound should be examined by culture and Gram-should be examined by culture and Gram-stained smear.stained smear. Removal of the dressing and Removal of the dressing and handling of the wound during the first 24 hours handling of the wound during the first 24 hours should be done with should be done with aseptic techniqueaseptic technique. . Medical personnel should wash their hands Medical personnel should wash their hands before and after caring for any surgical wound. before and after caring for any surgical wound. Gloves should always be used when there is Gloves should always be used when there is contact with open wounds or fresh wounds.contact with open wounds or fresh wounds.

1- Care of the Wound :1- Care of the Wound :Generally, skin sutures or skin staples may be Generally, skin sutures or skin staples may be

removed by the fifth postoperative day and removed by the fifth postoperative day and replaced by tapes. Sutures should be left in replaced by tapes. Sutures should be left in longer (eg, for 2 weeks) in incisions thatlonger (eg, for 2 weeks) in incisions that

1- cross creases (eg, groin, popliteal area);1- cross creases (eg, groin, popliteal area); 2-for incisions closed under tension;2-for incisions closed under tension; 3-for some incisions in the extremities (eg, the 3-for some incisions in the extremities (eg, the

hand);hand); 4-with incisions of any kind in debilitated 4-with incisions of any kind in debilitated

patients.patients. Sutures should be removed if suture tracts Sutures should be removed if suture tracts

show signs of infection. If the incision is show signs of infection. If the incision is healing normally, the patient may be allowed to healing normally, the patient may be allowed to shower or bathe by the seventh postoperative shower or bathe by the seventh postoperative day. day.

1- Care of the Wound :1- Care of the Wound :Fibroblasts proliferate in the wound space quickly, and Fibroblasts proliferate in the wound space quickly, and

by the end of the first postoperative week, new by the end of the first postoperative week, new collagen is abundant in the wound. On palpation of collagen is abundant in the wound. On palpation of the wound, connective tissue can be felt as a the wound, connective tissue can be felt as a prominence (the healing ridge) and is evidence that prominence (the healing ridge) and is evidence that healing is normal. Tensile strength is minimal for the healing is normal. Tensile strength is minimal for the first 5 days. It increases rapidly between the fifth and first 5 days. It increases rapidly between the fifth and twentieth postoperative days and more slowly twentieth postoperative days and more slowly thereafter. Wounds continue to gain tensile strength thereafter. Wounds continue to gain tensile strength slowly for about 2 years. In otherwise healthy slowly for about 2 years. In otherwise healthy patients, the wound should be subjected to only patients, the wound should be subjected to only minor stress for 6–8 weeks. When wound healing is minor stress for 6–8 weeks. When wound healing is expected to be slower than normal (e.g., in elderly or expected to be slower than normal (e.g., in elderly or debilitated patients or those taking corticosteroids), debilitated patients or those taking corticosteroids), activity should be delayed even further activity should be delayed even further

1- Care of the Wound :1- Care of the Wound :When a wound has been contaminated with bacteria When a wound has been contaminated with bacteria

during surgery, it is often best to leave the skin and during surgery, it is often best to leave the skin and subcutaneous tissues open and either to perform subcutaneous tissues open and either to perform delayed primary closure or allow secondary closure to delayed primary closure or allow secondary closure to occur.occur. The wound is loosely packed with fine-mesh The wound is loosely packed with fine-mesh gauze in the operating room and is left undisturbed for gauze in the operating room and is left undisturbed for 4–5 days; the packing is then removed. If at this time 4–5 days; the packing is then removed. If at this time the wound contains only serous fluid or a small the wound contains only serous fluid or a small amount of exudate, the skin edges can be amount of exudate, the skin edges can be approximated with tapes. If drainage is considerable approximated with tapes. If drainage is considerable or infection is present, the wound should be allowed or infection is present, the wound should be allowed to close by secondary intention. In this case, the to close by secondary intention. In this case, the wound should be packed with moist-to-dry dressings, wound should be packed with moist-to-dry dressings, which are changed once or twice daily. The patient which are changed once or twice daily. The patient can usually learn how to care for the wound and can usually learn how to care for the wound and should be discharged as soon as his or her general should be discharged as soon as his or her general condition permits. Most patients do not require condition permits. Most patients do not require visiting nurses to assist with wound care at home. visiting nurses to assist with wound care at home.

1- Care of the Wound :1- Care of the Wound :Wound healing is faster if the state of nutrition is normal

and there are no specific nutritional deficits. For example, vitamin C deficiency interferes with collagen synthesis and vitamin A deficiency decreases the rate of epithelialization. Deficiencies of copper, magnesium, and other trace metals decrease the rate of scar formation. Supplemental vitamins and minerals should be given postoperatively when deficiencies are suspected, but wound healing cannot be accelerated beyond the normal rate by nutritional supplements.

Wound problems should be anticipated in patients taking corticosteroids, which inhibit the inflammatory response, fibroblast proliferation, and protein synthesis in the wound. Maturation of the scar and gain of tensile strength occur more slowly. Extra precautions include using non-absorbable suture materials for fascial closure, delaying removal of skin stitches, and avoiding stress in the wound for 3–6 months.

2-Management of Drains :2-Management of Drains :Drains are used either to prevent or to treat an unwanted Drains are used either to prevent or to treat an unwanted

accumulation of fluid such as pus, blood, or serum. accumulation of fluid such as pus, blood, or serum. Drains are also used to evacuate air from the pleural Drains are also used to evacuate air from the pleural cavity so that the lungs can reexpand. When used cavity so that the lungs can reexpand. When used prophylactically, drains are usually placed in a sterile prophylactically, drains are usually placed in a sterile location. Strict precautions must be taken to prevent location. Strict precautions must be taken to prevent bacteria from entering the body through the drainage bacteria from entering the body through the drainage tract in these situations. The external portion of the tract in these situations. The external portion of the drain must be handled with aseptic technique, and the drain must be handled with aseptic technique, and the drain must be removed as soon as it is no longer drain must be removed as soon as it is no longer useful. When drains have been placed in an infected useful. When drains have been placed in an infected area, there is a smaller risk of retrograde infection of area, there is a smaller risk of retrograde infection of the peritoneal cavity, since the infected area is usually the peritoneal cavity, since the infected area is usually walled off. Drains should usually be brought out walled off. Drains should usually be brought out through a separate incision, because drains through the through a separate incision, because drains through the operative wound increase the risk of wound infection. operative wound increase the risk of wound infection.

2-Management of Drains :2-Management of Drains : Closed drains connected to suction devices Closed drains connected to suction devices

are preferable to open drains (such as are preferable to open drains (such as Penrose) that predispose to wound Penrose) that predispose to wound contamination. The quantity and quality of contamination. The quantity and quality of drainage should be recorded, and drainage should be recorded, and contamination minimized. When drains are contamination minimized. When drains are no longer needed, they may be withdrawn no longer needed, they may be withdrawn entirely at one time if there has been little or entirely at one time if there has been little or no drainage or may be progressively no drainage or may be progressively withdrawn over a period of a few days.withdrawn over a period of a few days.

2-Management of Drains :2-Management of Drains : Sump drains (such as Davol drains) have an Sump drains (such as Davol drains) have an

airflow system that keeps the lumen of the drain airflow system that keeps the lumen of the drain open when fluid is not passing through it, and they open when fluid is not passing through it, and they must be attached to a suction device. Sump drains must be attached to a suction device. Sump drains are especially useful when the amount of drainage are especially useful when the amount of drainage is large or when drainage is likely to plug other is large or when drainage is likely to plug other kinds of drains. Some sump drains have an extra kinds of drains. Some sump drains have an extra lumen through which saline solution can be lumen through which saline solution can be infused to aid in keeping the tube clear. After infused to aid in keeping the tube clear. After infection has been controlled and the discharge is infection has been controlled and the discharge is no longer purulent, the large-bore catheter is no longer purulent, the large-bore catheter is progressively replaced with smaller catheters, and progressively replaced with smaller catheters, and the cavity eventually closes.the cavity eventually closes.

3-Postoperative Pulmonary Care 3-Postoperative Pulmonary Care The changes in pulmonary function observed The changes in pulmonary function observed

following anesthesia and surgery are principally following anesthesia and surgery are principally the result of decreased vital capacity, functional the result of decreased vital capacity, functional residual capacity (FRC), and pulmonary edema. residual capacity (FRC), and pulmonary edema. These changes are accentuated in patients who These changes are accentuated in patients who are : are :

obese,obese, who smoke heavily, or who smoke heavily, or who have preexisting lung disease.who have preexisting lung disease. Elderly patients are particularly vulnerable Elderly patients are particularly vulnerable

because they have decreased compliance, because they have decreased compliance, increased closing volume, increased residual increased closing volume, increased residual volume, and increased dead space, all of which volume, and increased dead space, all of which enhance the risk of postoperative atelectasis. enhance the risk of postoperative atelectasis.

3-Postoperative Pulmonary Care3-Postoperative Pulmonary Care

Pain is thought to be one of the main Pain is thought to be one of the main causes of shallow breathing causes of shallow breathing postoperatively. Complete abolition of pain, postoperatively. Complete abolition of pain, however, does not completely restore however, does not completely restore pulmonary function . The principal means of pulmonary function . The principal means of minimizing atelectasis is deep inspiration. minimizing atelectasis is deep inspiration. Early mobilization, encouragement to take Early mobilization, encouragement to take deep breaths (especially when standing), deep breaths (especially when standing), and good coaching by the nursing staff and good coaching by the nursing staff suffice for most patientssuffice for most patients. .

4-Postoperative Fluid & Electrolyte Management 4-Postoperative Fluid & Electrolyte Management

Postoperative fluid replacement should be based on the Postoperative fluid replacement should be based on the following considerations: following considerations:

(1) maintenance requirements,(1) maintenance requirements, (2) extra needs resulting from systemic factors (e.g., fever, (2) extra needs resulting from systemic factors (e.g., fever,

burns),burns), (3) losses from drains, and(3) losses from drains, and (4) requirements resulting from tissue edema and ileus (third (4) requirements resulting from tissue edema and ileus (third

space losses).space losses). Daily maintenance requirements for sensible and insensible Daily maintenance requirements for sensible and insensible

loss in the adult are about 1500–2500 mL depending on the loss in the adult are about 1500–2500 mL depending on the patient's age, gender, weight, and body surface area. A patient's age, gender, weight, and body surface area. A rough estimate can be obtained by multiplying the patient's rough estimate can be obtained by multiplying the patient's weight in kilograms times 30 (e.g., 1800 mL/24 h in a 60-kg weight in kilograms times 30 (e.g., 1800 mL/24 h in a 60-kg patient). Maintenance requirements are increased by fever, patient). Maintenance requirements are increased by fever, hyperventilation, and conditions that increase the catabolic hyperventilation, and conditions that increase the catabolic rate.rate.

4-Postoperative Fluid & Electrolyte Management4-Postoperative Fluid & Electrolyte Management For patients requiring intravenous fluid replacement For patients requiring intravenous fluid replacement

for a short period (most postoperative patients), it is for a short period (most postoperative patients), it is not necessary to measure serum electrolytes at any not necessary to measure serum electrolytes at any time during the postoperative period, but time during the postoperative period, but measurement is indicated in more complicated measurement is indicated in more complicated patients (those with extra fluid losses, sepsis, patients (those with extra fluid losses, sepsis, preexisting electrolyte abnormalities, or other factors). preexisting electrolyte abnormalities, or other factors). Assessment of the status of fluid balance requires Assessment of the status of fluid balance requires accurate records of fluid intake and output and is accurate records of fluid intake and output and is aided by weighing the patient daily.aided by weighing the patient daily.

As a rule, 2000–2500 mL of 5% dextrose &/or normal As a rule, 2000–2500 mL of 5% dextrose &/or normal saline & / or lactated Ringer's solution is given daily. saline & / or lactated Ringer's solution is given daily. Potassium should usually Potassium should usually notnot be added during the first be added during the first 24 hours after surgery, because increased amounts of 24 hours after surgery, because increased amounts of potassium enter the circulation during this time as a potassium enter the circulation during this time as a result of operative trauma and increased aldosterone result of operative trauma and increased aldosterone activity.activity.

SolutionSolution GlucosGlucose (g/l)e (g/l)

NaNa

(meq/(meq/l)l)

ClCl

(meq/(meq/l)l)

Hco3Hco3

(meq(meq/l)/l)

KK

(meq/l)(meq/l)

5%5%

glucoseglucose5050 -------- -------- -------- --------

0.9%0.9%

salinesaline-------- 154154 154154 -------- --------

dextrose dextrose 4.3 % with 4.3 % with saline 0.18 saline 0.18 %%

4343 3131 3131 -------- --------

Ringer’s Ringer’s lactate lactate solutionsolution

-------- 130130 109109 2828 44

5% 5% dextrose in dextrose in 0.9%saline0.9%saline

5050 154154 154154 -------- --------

OsmOsmolariolarity/lty/l

Iso=Iso=300300

Iso=Iso=300300

Iso=Iso=300300

Iso=Iso=300300

HyperHyper=600=600

4-Postoperative Fluid & Electrolyte Management4-Postoperative Fluid & Electrolyte Management

In most patients, fluid loss through a nasogastric In most patients, fluid loss through a nasogastric tube is less than 500 mL/d and can be replaced tube is less than 500 mL/d and can be replaced by increasing the infusion used for maintenance by increasing the infusion used for maintenance by a similar amount. About 20 meq of potassium by a similar amount. About 20 meq of potassium should be added to every liter of fluid used to should be added to every liter of fluid used to replace these losses. However, with the replace these losses. However, with the exception of urine, body fluids are isosmolar and exception of urine, body fluids are isosmolar and if large volumes of gastric or intestinal juice are if large volumes of gastric or intestinal juice are replaced with normal saline solution, electrolyte replaced with normal saline solution, electrolyte imbalance will eventually result. Whenever imbalance will eventually result. Whenever external losses from any site amount to 1500 external losses from any site amount to 1500 mL/d or more, electrolyte concentrations in the mL/d or more, electrolyte concentrations in the fluid should be measured periodically, and the fluid should be measured periodically, and the amount of replacement fluids should be adjusted amount of replacement fluids should be adjusted to equal the amount lost. to equal the amount lost.

5-Postoperative Care of the 5-Postoperative Care of the Gastrointestinal Tract Gastrointestinal Tract

In the immediate postoperative period, the stomach In the immediate postoperative period, the stomach may be decompressed with a nasogastric tube. may be decompressed with a nasogastric tube. Nasogastric intubation was once used in almost Nasogastric intubation was once used in almost all patients undergoing laparotomy to avoid all patients undergoing laparotomy to avoid gastric distention and vomiting, The nasogastric gastric distention and vomiting, The nasogastric tube should be connected to low intermittent tube should be connected to low intermittent suction and irrigated frequently to ensure patency. suction and irrigated frequently to ensure patency. The tube should be left in place for 2–3 days or The tube should be left in place for 2–3 days or until there is evidence that normal peristalsis has until there is evidence that normal peristalsis has returned (e.g., return of appetite, audible returned (e.g., return of appetite, audible peristalsis, or passage of flatus).peristalsis, or passage of flatus).

5-Postoperative Care of the 5-Postoperative Care of the Gastrointestinal TractGastrointestinal Tract

Once the nasogastric tube has been Once the nasogastric tube has been withdrawn, fasting is usually continued for withdrawn, fasting is usually continued for another 24 hours, and the patient is then another 24 hours, and the patient is then started on a liquid diet. Opioids may started on a liquid diet. Opioids may interfere with gastric motility and should be interfere with gastric motility and should be stopped in patients who have evidence of stopped in patients who have evidence of gastro-paresis beyond the first gastro-paresis beyond the first postoperative week. After most operations postoperative week. After most operations in areas other than the peritoneal cavity, the in areas other than the peritoneal cavity, the patient may be allowed to resume a regular patient may be allowed to resume a regular diet as soon as the effects of anesthesia diet as soon as the effects of anesthesia have completely worn off.have completely worn off.

6-Postoperative Pain 6-Postoperative Pain Severe pain is a common sequela of Severe pain is a common sequela of

intrathoracic, intra-abdominal, and major bone intrathoracic, intra-abdominal, and major bone or joint procedures. About 60% of such or joint procedures. About 60% of such patients perceive their pain to be severe, 25% patients perceive their pain to be severe, 25% moderate, and 15% mild. In contrast, following moderate, and 15% mild. In contrast, following superficial operations on the head and neck, superficial operations on the head and neck, limbs, or abdominal wall, less than 15% of limbs, or abdominal wall, less than 15% of patients characterize their pain as severe. The patients characterize their pain as severe. The factors responsible for these differences factors responsible for these differences include include duration of surgery, degree of duration of surgery, degree of operative trauma, type of incision, and operative trauma, type of incision, and magnitude of intraoperative retractionmagnitude of intraoperative retraction. Gentle . Gentle handling of tissues, expedient operations, and handling of tissues, expedient operations, and good muscle relaxation help lessen the good muscle relaxation help lessen the severity of postoperative pain.severity of postoperative pain.

6-Postoperative Pain6-Postoperative Pain While factors related to the nature of the While factors related to the nature of the

operation influence postoperative pain, it operation influence postoperative pain, it is also true that the same operation is also true that the same operation produces different amounts of pain in produces different amounts of pain in different patients. This varies according different patients. This varies according to individual physical, emotional, and to individual physical, emotional, and cultural characteristics. Much of the cultural characteristics. Much of the emotional aspect of pain can be traced to emotional aspect of pain can be traced to anxiety. Feelings such as helplessness, anxiety. Feelings such as helplessness, fear, and uncertainty contribute to anxiety fear, and uncertainty contribute to anxiety and may heighten the patient's perception and may heighten the patient's perception of pain.of pain.

7-Physician-Patient Communication7-Physician-Patient Communication

Close attention to the patient's Close attention to the patient's needs, frequent reassurance, and needs, frequent reassurance, and genuine concern help minimize genuine concern help minimize postoperative pain. Spending a few postoperative pain. Spending a few minutes with the patient every day minutes with the patient every day in frank discussions of progress and in frank discussions of progress and any complications does more to any complications does more to relieve pain than many physicians relieve pain than many physicians realize. realize.

8-Parenteral Opioids8-Parenteral Opioids

Opioids are the mainstay of therapy for Opioids are the mainstay of therapy for postoperative pain. Their analgesic effect is postoperative pain. Their analgesic effect is via two mechanisms:via two mechanisms:

(1) a direct effect on opioid receptors and (1) a direct effect on opioid receptors and (2) stimulation of a descending brain stem (2) stimulation of a descending brain stem

system that contributes to pain inhibition. system that contributes to pain inhibition. Morphine ,pethidine & tramalMorphine ,pethidine & tramal are the most are the most widely used opioid for treatment of widely used opioid for treatment of postoperative pain. Morphine may be postoperative pain. Morphine may be administered intravenously, either administered intravenously, either intermittently or continuously intermittently or continuously

Nonopioid Parenteral AnalgesicsNonopioid Parenteral Analgesics

They are non-steroidal anti-inflammatory They are non-steroidal anti-inflammatory drugs (NSAID) with potent analgesic and drugs (NSAID) with potent analgesic and moderate anti-inflammatory activities. It is moderate anti-inflammatory activities. It is available in injectable form suitable for available in injectable form suitable for postoperative use .postoperative use .

E.g. aspirin (acetyl salicylic acid ),diclofen E.g. aspirin (acetyl salicylic acid ),diclofen sodium ,piroxicam,….sodium ,piroxicam,….

Oral AnalgesicsOral Analgesics Within several days following most surgical Within several days following most surgical

procedures, the severity of pain decreases to a procedures, the severity of pain decreases to a point where oral analgesics suffice. Aspirin should point where oral analgesics suffice. Aspirin should be avoided as an analgesic postoperatively, since be avoided as an analgesic postoperatively, since it interferes with platelet function, prolongs it interferes with platelet function, prolongs bleeding time, and interferes with the effects of bleeding time, and interferes with the effects of anticoagulants. For most patients, a combination anticoagulants. For most patients, a combination of acetaminophen with codeine (e.g., Tylenol) or of acetaminophen with codeine (e.g., Tylenol) or with propoxyphene (analgan) suffices. with propoxyphene (analgan) suffices.

As with all opioids, tolerance develops with long-As with all opioids, tolerance develops with long-term use. term use.

Continuous Epidural AnalgesiaContinuous Epidural Analgesia Intercostal BlockIntercostal Block

Postoperative Complications: Postoperative Complications:

Postoperative complications may result from Postoperative complications may result from 1- 1- the primary disease,the primary disease,

2- the operation, or2- the operation, or 3-unrelated factors.3-unrelated factors. Occasionally, one complication results from Occasionally, one complication results from

another previous one (eg, myocardial another previous one (eg, myocardial infarction following massive postoperative infarction following massive postoperative bleeding). The clinical signs of disease are bleeding). The clinical signs of disease are often blurred in the postoperative period. often blurred in the postoperative period. Early detection of postoperative Early detection of postoperative complications requires repeated evaluation complications requires repeated evaluation of the patient by the operating surgeon and of the patient by the operating surgeon and other team members . other team members .

Postoperative Complications:Postoperative Complications: Prevention of complications starts in the preoperative Prevention of complications starts in the preoperative

period with evaluation of the patient's disease and risk period with evaluation of the patient's disease and risk factors.factors. Improving the health of the patient before surgery Improving the health of the patient before surgery is one goal of the preoperative evaluation. For example, is one goal of the preoperative evaluation. For example, cessation of smoking for 6 weeks before surgery cessation of smoking for 6 weeks before surgery decreases the incidence of postoperative pulmonary decreases the incidence of postoperative pulmonary complications from 50% to 10%. Correction of gross complications from 50% to 10%. Correction of gross obesity decreases intra-abdominal pressure and the risk of obesity decreases intra-abdominal pressure and the risk of wound and respiratory complications and improves wound and respiratory complications and improves ventilation postoperatively.ventilation postoperatively.

The surgeon should explain the operation and the The surgeon should explain the operation and the expected postoperative course to the patient and family. expected postoperative course to the patient and family. The preoperative hospital stay, if one is necessary, should The preoperative hospital stay, if one is necessary, should be as short as possible both to reduce costs and to be as short as possible both to reduce costs and to minimize exposure to antibiotic-resistant microorganisms. minimize exposure to antibiotic-resistant microorganisms. Adequate training in respiratory exercises planned for the Adequate training in respiratory exercises planned for the postoperative period substantially decreases the incidence postoperative period substantially decreases the incidence of postoperative pulmonary complications.of postoperative pulmonary complications.

Postoperative Complications:Postoperative Complications:Early mobilization, proper respiratory care, and Early mobilization, proper respiratory care, and

careful attention to fluid and electrolyte needs are careful attention to fluid and electrolyte needs are important. On the evening after surgery the patient important. On the evening after surgery the patient should be encouraged to sit up, cough, breathe should be encouraged to sit up, cough, breathe deeply, and walk, if possible. The upright position deeply, and walk, if possible. The upright position permits expansion of basilar lung segments, and permits expansion of basilar lung segments, and walking increases the circulation of the lower walking increases the circulation of the lower extremities and lessens the danger of venous extremities and lessens the danger of venous thromboembolism.thromboembolism.

In severely ill patients, continuous monitoring of In severely ill patients, continuous monitoring of systemic blood pressure and cardiac performance systemic blood pressure and cardiac performance enables identification and correction of mild enables identification and correction of mild derangements before they become severe. derangements before they become severe.

I- Wound ComplicationsI- Wound Complications2- Seroma :2- Seroma :A seroma is a fluid collection in the wound other than pus or A seroma is a fluid collection in the wound other than pus or

blood. Seromas often follow operations that involve blood. Seromas often follow operations that involve elevation of skin flaps and transection of numerous elevation of skin flaps and transection of numerous lymphatic channels (eg, mastectomy, operations in the lymphatic channels (eg, mastectomy, operations in the groin). Seromas delay healing and increase the risk of groin). Seromas delay healing and increase the risk of wound infection. Those located under skin flaps can wound infection. Those located under skin flaps can usually be evacuated by needle aspiration. Compression usually be evacuated by needle aspiration. Compression dressings should then be applied to seal lymphatic leaks dressings should then be applied to seal lymphatic leaks and prevent reaccumulation. Small seromas that recur may and prevent reaccumulation. Small seromas that recur may be treated by repeated evacuation. Seromas of the groin, be treated by repeated evacuation. Seromas of the groin, which are common after vascular operations, are best left which are common after vascular operations, are best left to resorb without aspiration, since the risks of introducing to resorb without aspiration, since the risks of introducing a needle (infection, disruption of vascular structures, etc) a needle (infection, disruption of vascular structures, etc) are greater than the risk associated with the seroma itself. are greater than the risk associated with the seroma itself. If seromas persist—or if they start leaking through the If seromas persist—or if they start leaking through the wound—the wound should be explored in the operating wound—the wound should be explored in the operating room and the lymphatics ligated.room and the lymphatics ligated.

I- Wound ComplicationsI- Wound Complications1- Hematoma :1- Hematoma :Wound hematoma, a collection of blood and clot in the wound, is Wound hematoma, a collection of blood and clot in the wound, is

one of the most common wound complications and is almost one of the most common wound complications and is almost always caused by imperfect hemostasis. Patients receiving always caused by imperfect hemostasis. Patients receiving aspirin or low-dose heparin have a slightly higher risk of aspirin or low-dose heparin have a slightly higher risk of developing this complication. The risk is much higher in patients developing this complication. The risk is much higher in patients who have been given systemically effective doses of who have been given systemically effective doses of anticoagulants and those with preexisting coagulopathies. anticoagulants and those with preexisting coagulopathies. Vigorous coughing or marked arterial hypertension immediately Vigorous coughing or marked arterial hypertension immediately after surgery may contribute to the formation of a wound after surgery may contribute to the formation of a wound hematoma.hematoma.

Hematomas produce elevation and discoloration of the wound Hematomas produce elevation and discoloration of the wound edges, discomfort, and swelling. Blood sometimes leaks edges, discomfort, and swelling. Blood sometimes leaks through skin sutures. Neck hematomas following operations on through skin sutures. Neck hematomas following operations on the thyroid, parathyroid, or carotid artery are particularly the thyroid, parathyroid, or carotid artery are particularly dangerous, because they may expand rapidly and compromise dangerous, because they may expand rapidly and compromise the airway. Small hematomas may resorb, but they increase the the airway. Small hematomas may resorb, but they increase the incidence of wound infection. Treatment in most cases consists incidence of wound infection. Treatment in most cases consists of evacuation of the clot under sterile conditions, ligation of of evacuation of the clot under sterile conditions, ligation of bleeding vessels, and reclosure of the wound.bleeding vessels, and reclosure of the wound.

I- Wound ComplicationsI- Wound Complications3- Wound Dehiscence:3- Wound Dehiscence:Wound dehiscence is partial or total disruption of any or Wound dehiscence is partial or total disruption of any or

all layers of the operative wound. Rupture of all layers all layers of the operative wound. Rupture of all layers of the abdominal wall and extrusion of abdominal of the abdominal wall and extrusion of abdominal viscera is evisceration. Wound dehiscence occurs in viscera is evisceration. Wound dehiscence occurs in 1–3% of abdominal surgical procedures. Systemic and 1–3% of abdominal surgical procedures. Systemic and local factors contribute to the development of this local factors contribute to the development of this complication.complication.

3-1-- Systemic Risk Factors :3-1-- Systemic Risk Factors :Dehiscence is rare in patients under age 30 but affects Dehiscence is rare in patients under age 30 but affects

about 5% of patients over age 60 having laparotomy. It about 5% of patients over age 60 having laparotomy. It is more common in patients with diabetes mellitus, is more common in patients with diabetes mellitus, uremia, immunosuppression, jaundice, sepsis, uremia, immunosuppression, jaundice, sepsis, hypoalbuminemia, and cancer; in obese patients; and hypoalbuminemia, and cancer; in obese patients; and in those receiving corticosteroidsin those receiving corticosteroids..

3-2- Local Risk Factors:3-2- Local Risk Factors:The three most important local factors predisposing to wound The three most important local factors predisposing to wound

dehiscence are dehiscence are inadequate closure, increased intra-abdominal inadequate closure, increased intra-abdominal pressure, and deficient wound healing.pressure, and deficient wound healing. Dehiscence often results Dehiscence often results from a combination of these factors rather than from a single from a combination of these factors rather than from a single one. The type of incision (transverse, midline, etc) does not one. The type of incision (transverse, midline, etc) does not influence the incidence of dehiscence.influence the incidence of dehiscence.

E.g. E.g. Adequacy of Closure:Adequacy of Closure:This is the single most important factor. The fascial layers give This is the single most important factor. The fascial layers give

strength to a closure, and when fascia disrupts, the wound strength to a closure, and when fascia disrupts, the wound separates. Accurate approximation of anatomic layers is separates. Accurate approximation of anatomic layers is essential for adequate wound closure. Most wounds that essential for adequate wound closure. Most wounds that dehisce do so because the sutures tear through the fascia. dehisce do so because the sutures tear through the fascia. Prevention of this problem includes performing a neat incision, Prevention of this problem includes performing a neat incision, avoiding devitalization of the fascial edges by careful handling avoiding devitalization of the fascial edges by careful handling of tissues during the operation, placing and tying sutures of tissues during the operation, placing and tying sutures correctly, and selecting the proper suture material. Sutures must correctly, and selecting the proper suture material. Sutures must be placed 2–3 cm from the wound edge and about 1 cm apart. be placed 2–3 cm from the wound edge and about 1 cm apart. Dehiscence is often the result of using too few stitches and Dehiscence is often the result of using too few stitches and placing them too close to the edge of the fascia. Ostomies and placing them too close to the edge of the fascia. Ostomies and drains should be brought out through separate incisions to drains should be brought out through separate incisions to reduce the rate of wound infection and disruption.reduce the rate of wound infection and disruption.

II- Respiratory Complications II- Respiratory Complications Respiratory complications are the most common single Respiratory complications are the most common single

cause of morbidity after major surgical procedures and the cause of morbidity after major surgical procedures and the second most common cause of postoperative deaths in second most common cause of postoperative deaths in patients older than 60 years.patients older than 60 years.

Patients undergoing chest and upper abdominal operations Patients undergoing chest and upper abdominal operations are particularly prone to pulmonary complications. The are particularly prone to pulmonary complications. The incidence is lower after pelvic surgery and even lower after incidence is lower after pelvic surgery and even lower after extremity or head and neck procedures.extremity or head and neck procedures.

Pulmonary complications are more common after emergency Pulmonary complications are more common after emergency operations. operations.

Special hazards are posed by preexisting chronic obstructive Special hazards are posed by preexisting chronic obstructive pulmonary disease (chronic bronchitis, emphysema, pulmonary disease (chronic bronchitis, emphysema, asthma, pulmonary fibrosis). Elderly patients are at much asthma, pulmonary fibrosis). Elderly patients are at much higher risk because they have decreased compliance, higher risk because they have decreased compliance, increased residual volumes, and increased dead space, all increased residual volumes, and increased dead space, all of which predispose to atelectasis.of which predispose to atelectasis.

II- Respiratory ComplicationsII- Respiratory Complications1- Atelectasis1- AtelectasisAtelectasis, the most common pulmonary Atelectasis, the most common pulmonary

complication, affects 25% of patients who complication, affects 25% of patients who have abdominal surgery. It is more common have abdominal surgery. It is more common in patients who are elderly or overweight in patients who are elderly or overweight and in those who smoke or have symptoms and in those who smoke or have symptoms of respiratory disease. It appears most of respiratory disease. It appears most frequently in the first 48 hours after frequently in the first 48 hours after operation and is responsible for over 90% of operation and is responsible for over 90% of febrile episodes during that period. In most febrile episodes during that period. In most cases, the course is self-limited and cases, the course is self-limited and recovery uneventful.recovery uneventful.

Atelectasis is usually manifested by fever (pathogenesis Atelectasis is usually manifested by fever (pathogenesis unknown), tachypnea, and tachycardia. Physical unknown), tachypnea, and tachycardia. Physical examination may show elevation of the diaphragm and examination may show elevation of the diaphragm and decreased breath sounds.decreased breath sounds.

Postoperative atelectasis can be largely prevented by early Postoperative atelectasis can be largely prevented by early mobilization, frequent changes in position, encouragement mobilization, frequent changes in position, encouragement to cough, and physiotherapy. Preoperative teaching of to cough, and physiotherapy. Preoperative teaching of respiratory exercises and postoperative execution of these respiratory exercises and postoperative execution of these exercises prevents atelectasis in patients without exercises prevents atelectasis in patients without preexisting lung disease. preexisting lung disease.

Treatment consists of clearing the airway by chest Treatment consists of clearing the airway by chest percussion, coughing, or nasotracheal suction. percussion, coughing, or nasotracheal suction. Bronchodilators and mucolytic agents given by nebulizer Bronchodilators and mucolytic agents given by nebulizer may help in patients with severe chronic obstructive may help in patients with severe chronic obstructive pulmonary disease. Atelectasis from obstruction of a major pulmonary disease. Atelectasis from obstruction of a major airway may require intrabronchial suction through an airway may require intrabronchial suction through an endoscope, a procedure that can usually be performed at endoscope, a procedure that can usually be performed at the bedside with mild sedationthe bedside with mild sedation

2- Pulmonary Aspiration2- Pulmonary AspirationAspiration of oropharyngeal and gastric contents is Aspiration of oropharyngeal and gastric contents is

normally prevented by the gastroesophageal and normally prevented by the gastroesophageal and pharyngoesophageal sphincters. Insertion of pharyngoesophageal sphincters. Insertion of nasogastric and endotracheal tubes and depression of nasogastric and endotracheal tubes and depression of the central nervous system by drugs interfere with the central nervous system by drugs interfere with these defenses and predispose to aspiration. Other these defenses and predispose to aspiration. Other factors, such as gastroesophageal reflux, food in the factors, such as gastroesophageal reflux, food in the stomach, or position of the patient, may play a role. stomach, or position of the patient, may play a role. Trauma victimsTrauma victims are particularly likely to aspirate are particularly likely to aspirate regurgitated gastric contents when consciousness is regurgitated gastric contents when consciousness is depressed. Patients with intestinal obstruction and depressed. Patients with intestinal obstruction and pregnant women—who have increased intra-abdominal pregnant women—who have increased intra-abdominal pressure and decreased gastric motility—are also at pressure and decreased gastric motility—are also at high risk of aspiration. Two-thirds of cases of aspiration high risk of aspiration. Two-thirds of cases of aspiration follow thoracic or abdominal surgery, and of these, one-follow thoracic or abdominal surgery, and of these, one-half result in pneumonia. The death rate for grossly half result in pneumonia. The death rate for grossly evident aspiration and subsequent pneumonia is about evident aspiration and subsequent pneumonia is about 50%.50%.

The magnitude of pulmonary injury produced by The magnitude of pulmonary injury produced by aspiration of fluid, usually from gastric contents, is aspiration of fluid, usually from gastric contents, is determined by determined by the volume aspirated, its pH, and the the volume aspirated, its pH, and the frequency of the event.frequency of the event. If the aspirate has a pH of 2.5 If the aspirate has a pH of 2.5 or less, it causes immediate or less, it causes immediate chemical pneumonitischemical pneumonitis, , which results in local edema and inflammation, which results in local edema and inflammation, changes that increase the risk of secondary infection.changes that increase the risk of secondary infection.

Aspiration of solid matter can produce airway Aspiration of solid matter can produce airway obstruction. Obstruction of distal bronchi, though well obstruction. Obstruction of distal bronchi, though well tolerated initially, can lead to atelectasis and tolerated initially, can lead to atelectasis and pulmonary abscess formation. The basal segments pulmonary abscess formation. The basal segments are affected most often. Tachypnea, fever, and are affected most often. Tachypnea, fever, and hypoxia are usually present within hours; less hypoxia are usually present within hours; less frequently, cyanosis, wheezing, and apnea may frequently, cyanosis, wheezing, and apnea may appear. In patients with massive aspiration, appear. In patients with massive aspiration, hypovolemia caused by excessive fluid and colloid hypovolemia caused by excessive fluid and colloid loss into the injured lung may lead to hypotension and loss into the injured lung may lead to hypotension and shock.shock.

AspirationAspiration can be can be prevented byprevented by preoperative preoperative fasting, proper positioning of the patient, and fasting, proper positioning of the patient, and careful intubation.careful intubation. A single dose of cimetidine A single dose of cimetidine before induction of anesthesia may be of value before induction of anesthesia may be of value in situations where the risk of aspiration is high. in situations where the risk of aspiration is high.

Treatment of aspirationTreatment of aspiration involves reestablishing involves reestablishing patency of the airway and preventing further patency of the airway and preventing further damage to the lung. Endotracheal suction damage to the lung. Endotracheal suction should be performed immediately, as this should be performed immediately, as this procedure confirms the diagnosis and procedure confirms the diagnosis and stimulates coughing, which helps to clear the stimulates coughing, which helps to clear the airway. Bronchoscopy may be required to airway. Bronchoscopy may be required to remove solid matter. Fluid resuscitation should remove solid matter. Fluid resuscitation should be undertaken concomitantly. Antibiotics are be undertaken concomitantly. Antibiotics are used initially when the aspirate is heavily used initially when the aspirate is heavily contaminated; they are used later to treat contaminated; they are used later to treat pneumonia. pneumonia.

3- Postoperative Pneumonia 3- Postoperative Pneumonia Pneumonia is the most common pulmonary Pneumonia is the most common pulmonary

complication among patients who die after complication among patients who die after surgery. It is directly responsible for death in surgery. It is directly responsible for death in more than half of these patients. Patients who’s more than half of these patients. Patients who’s requiring prolonged ventilatory support are at requiring prolonged ventilatory support are at highest risk for developing postoperative highest risk for developing postoperative pneumonia.pneumonia.

Atelectasis, aspiration, and copious secretions Atelectasis, aspiration, and copious secretions are important predisposing factors. are important predisposing factors.

The clinical manifestations of postoperative The clinical manifestations of postoperative pneumonia are fever, tachypnea, increased pneumonia are fever, tachypnea, increased secretions, and physical changes suggestive of secretions, and physical changes suggestive of pulmonary consolidation. A chest x-ray usually pulmonary consolidation. A chest x-ray usually shows localized parenchymal consolidation. shows localized parenchymal consolidation.

3- Postoperative Pneumonia3- Postoperative Pneumonia

Maintaining the airway clear of secretions Maintaining the airway clear of secretions is of paramount concern in the prevention is of paramount concern in the prevention of postoperative pneumonia. Respiratory of postoperative pneumonia. Respiratory exercises, deep breathing, and coughing exercises, deep breathing, and coughing help prevent atelectasis, which is a help prevent atelectasis, which is a precursor of pneumonia. precursor of pneumonia.

Treatment consists of measures to aid the Treatment consists of measures to aid the clearing of secretions and administration clearing of secretions and administration of antibiotics. Sputum obtained directly of antibiotics. Sputum obtained directly from the trachea, usually by endotracheal from the trachea, usually by endotracheal suctioning, is required for specific suctioning, is required for specific identification of the infecting organism. identification of the infecting organism.

III-Fat Embolism III-Fat Embolism Fat embolism is relatively common but only Fat embolism is relatively common but only

rarely causes symptoms. Fat particles can be rarely causes symptoms. Fat particles can be found in the pulmonary vascular bed in 90% of found in the pulmonary vascular bed in 90% of patients who have had fractures of long bones or patients who have had fractures of long bones or joint replacements. Fat embolism can also be joint replacements. Fat embolism can also be caused by exogenous sources of fat, such as caused by exogenous sources of fat, such as blood transfusions, intravenous fat emulsion, or blood transfusions, intravenous fat emulsion, or bone marrow transplantation. Fat embolism bone marrow transplantation. Fat embolism symptoms consist of neurologic dysfunction, symptoms consist of neurologic dysfunction, respiratory insufficiency, and petechiae of the respiratory insufficiency, and petechiae of the axillae, chest, and proximal arms. axillae, chest, and proximal arms.

Fat embolism characteristically begins 12–72 Fat embolism characteristically begins 12–72 hours after injury but may be delayed for several hours after injury but may be delayed for several days. The diagnosis is clinical. The finding of fat days. The diagnosis is clinical. The finding of fat droplets in sputum and urine is common after droplets in sputum and urine is common after trauma. trauma.

IV- Cardiac ComplicationsIV- Cardiac Complications Cardiac complications following surgery may be Cardiac complications following surgery may be

life-threatening. Their incidence is reduced by life-threatening. Their incidence is reduced by appropriate preoperative preparation.appropriate preoperative preparation.

Dysrhythmias, unstable angina, heart failure, or Dysrhythmias, unstable angina, heart failure, or severe hypertension should be corrected before severe hypertension should be corrected before surgery whenever possible. Valvular disease—surgery whenever possible. Valvular disease—especially aortic stenosis—limits the ability of the especially aortic stenosis—limits the ability of the heart to respond to increased demand during heart to respond to increased demand during operation or in the immediate postoperative operation or in the immediate postoperative period. When aortic stenosis is recognized period. When aortic stenosis is recognized preoperatively , the incidence of major preoperatively , the incidence of major perioperative complications is small. perioperative complications is small. Thus, Thus, patients with preexisting heart disease should be patients with preexisting heart disease should be evaluated by a cardiologist preoperatively.evaluated by a cardiologist preoperatively.

IV- Cardiac ComplicationsIV- Cardiac Complications General anesthesia depresses the myocardium, and General anesthesia depresses the myocardium, and

some anesthetic agents predispose to dysrhythmias. some anesthetic agents predispose to dysrhythmias. Monitoring of cardiac activity and blood pressure Monitoring of cardiac activity and blood pressure

during the operation detects dysrhythmias and during the operation detects dysrhythmias and hypotension early.hypotension early.

In patients with a high cardiac risk, In patients with a high cardiac risk, regional regional anesthesiaanesthesia may be safer than general anesthesia for may be safer than general anesthesia for procedures below the umbilicus.procedures below the umbilicus.

Non-cardiac complications may affect the Non-cardiac complications may affect the development of cardiac complications by increasing development of cardiac complications by increasing cardiac demands in patients with a limited reserve. cardiac demands in patients with a limited reserve. E.g. Postoperative sepsis and hypoxemia. Fluid E.g. Postoperative sepsis and hypoxemia. Fluid overload can produce acute left ventricular failure. overload can produce acute left ventricular failure.

Patients with coronary artery disease, dysrhythmias, Patients with coronary artery disease, dysrhythmias, or low cardiac output should be monitored or low cardiac output should be monitored postoperatively in an intensive care unit.postoperatively in an intensive care unit.

V- Complications of Intravenous V- Complications of Intravenous Therapy & Hemodynamic Monitoring Therapy & Hemodynamic Monitoring 1- Air Embolism1- Air EmbolismAir embolism may occur during or after insertion of a venous Air embolism may occur during or after insertion of a venous

catheter or as a result of accidental introduction of air into catheter or as a result of accidental introduction of air into the line. Intravenous air lodges in the right atrium, the line. Intravenous air lodges in the right atrium, preventing adequate filling of the right heart. This is preventing adequate filling of the right heart. This is manifested by hypotension, jugular venous distention, and manifested by hypotension, jugular venous distention, and tachycardia. tachycardia.

This complication can be avoided by placing the patient in This complication can be avoided by placing the patient in the Trendelenburg position when a central venous line is the Trendelenburg position when a central venous line is inserted.inserted.

Emergency treatment consists of aspiration of the air with a Emergency treatment consists of aspiration of the air with a syringe. If this is unsuccessful, the patient should be syringe. If this is unsuccessful, the patient should be positioned right side up and head down, which will help positioned right side up and head down, which will help dislodge the air from the right atrium and return circulatory dislodge the air from the right atrium and return circulatory dynamics to normal.dynamics to normal.

V- Complications of Intravenous V- Complications of Intravenous Therapy & Hemodynamic MonitoringTherapy & Hemodynamic Monitoring2- Phlebitis2- PhlebitisA needle or a catheter inserted into a vein and left in A needle or a catheter inserted into a vein and left in

place will in time cause inflammation at the entry place will in time cause inflammation at the entry site. When this process involves the vein, it is site. When this process involves the vein, it is called called phlebitisphlebitis. Factors determining the degree of . Factors determining the degree of inflammation are the nature of the cannula, the inflammation are the nature of the cannula, the solution infused, bacterial infection, and venous solution infused, bacterial infection, and venous thrombosis. thrombosis. Phlebitis is one of the most common Phlebitis is one of the most common causes of fever after the third postoperative day.causes of fever after the third postoperative day. The symptomatic triad of induration, edema, and The symptomatic triad of induration, edema, and tenderness is characteristic. Prevention of phlebitis tenderness is characteristic. Prevention of phlebitis is best accomplished by observance of aseptic is best accomplished by observance of aseptic techniques during insertion of venous catheters, techniques during insertion of venous catheters, frequent change of tubing (ie, every 48–72 hours),frequent change of tubing (ie, every 48–72 hours),

VI-Postoperative FeverVI-Postoperative FeverFever occurs in about 40% of patients after major Fever occurs in about 40% of patients after major

surgery. In most patients the temperature elevation surgery. In most patients the temperature elevation resolves without specific treatment. However, resolves without specific treatment. However, postoperative fever may herald a serious infection, postoperative fever may herald a serious infection, and it is therefore important to evaluate the patient and it is therefore important to evaluate the patient clinically. clinically.

Normal body tempreture is 36.7—37.3’cNormal body tempreture is 36.7—37.3’c

Fever within 48 hoursFever within 48 hours after surgery is usually caused by after surgery is usually caused by

1- atelectasis: Re-expansion of the lung causes body 1- atelectasis: Re-expansion of the lung causes body temperature to return to normal.temperature to return to normal.

2- reactions to drugs ,anesthesia ,blood transfusion , 2- reactions to drugs ,anesthesia ,blood transfusion , absorption of haematoma , absorption of haematoma ,

VI-Postoperative FeverVI-Postoperative Fever fever appears in the third postoperative day,fever appears in the third postoperative day,

atelectasis is a less likely explanation. The atelectasis is a less likely explanation. The differential diagnosis of fever at this time includes differential diagnosis of fever at this time includes catheter-related phlebitis, pneumonia, and urinary catheter-related phlebitis, pneumonia, and urinary tract infection. A directed history and physical tract infection. A directed history and physical examination complemented by focused laboratory examination complemented by focused laboratory and radiologic studies usually determine the and radiologic studies usually determine the cause.cause.

Patients without infection are rarely febrile after Patients without infection are rarely febrile after the fifth postoperative day. the fifth postoperative day.

Fever in the fifth postoperative dayFever in the fifth postoperative day suggests suggests wound infection or, less often, anastomotic wound infection or, less often, anastomotic breakdown and intra-abdominal abscesses. breakdown and intra-abdominal abscesses.

VI-Postoperative FeverVI-Postoperative Fever

Fever after the 7Fever after the 7thth postoperative day (in postoperative day (in the 2the 2ndnd week ) week ) suggests deep venous suggests deep venous thrombosis in the calf muscles .thrombosis in the calf muscles .

Special Medical Problems in Surgical Special Medical Problems in Surgical Patients Patients 

Diabetes Mellitus :Diabetes Mellitus : Diabetic patients undergo more surgical procedures Diabetic patients undergo more surgical procedures

than do non-diabetics, and management of the than do non-diabetics, and management of the diabetic patient before, during, and after surgery is diabetic patient before, during, and after surgery is an important responsibility of the surgeon. an important responsibility of the surgeon. Fortunately, because close control of fluids, Fortunately, because close control of fluids, electrolytes, glucose, and insulin is now possible electrolytes, glucose, and insulin is now possible in the operating room, control of blood glucose in the operating room, control of blood glucose levels during the peri-operative period is usually levels during the peri-operative period is usually relatively simple. Marked hyperglycemia should be relatively simple. Marked hyperglycemia should be avoided during surgery; the greater danger, avoided during surgery; the greater danger, however, is from severe unrecognized however, is from severe unrecognized hypoglycemia.hypoglycemia.

Diabetes Mellitus :Diabetes Mellitus : Preoperative Workup :Preoperative Workup : Blood glucose concentrations may Blood glucose concentrations may

be elevated in diabetic patients be elevated in diabetic patients during the preoperative period. during the preoperative period. Physical trauma, if present, Physical trauma, if present, combined with the emotional and combined with the emotional and physiologic stress of the illness may physiologic stress of the illness may cause epinephrine and cortisol levels cause epinephrine and cortisol levels to rise, in each case resulting in to rise, in each case resulting in increased blood glucose levels. increased blood glucose levels.

Diabetes Mellitus :Diabetes Mellitus : The preoperative workupThe preoperative workup of patients with diabetes of patients with diabetes

mellitus includes mellitus includes 1.1. A thorough physical examination, with special care to A thorough physical examination, with special care to

discover occult infections;discover occult infections;2.2. An ECG to rule out myocardial infarction;An ECG to rule out myocardial infarction;3.3. A chest x-ray to identify hidden pneumonia or A chest x-ray to identify hidden pneumonia or

pulmonary edema. pulmonary edema. 4.4. A complete urinalysis can rule out urinary tract A complete urinalysis can rule out urinary tract

infection and proteinuria, the earliest signs of infection and proteinuria, the earliest signs of diabetic renal disease.diabetic renal disease.

5.5. Serum potassium levels are measured to check for Serum potassium levels are measured to check for hypokalemia or hyperkalemia .hypokalemia or hyperkalemia .

6.6. Serum creatinine levels are used to assess renal Serum creatinine levels are used to assess renal function.function.

The serum glucose concentration should ideally be The serum glucose concentration should ideally be between 100 and 200 mg/dL,between 100 and 200 mg/dL,

Preoperative & Intraoperative Preoperative & Intraoperative Management of Diabetic PatientsManagement of Diabetic Patients

Type 2 (Non-Insulin-Dependent) Diabetes Type 2 (Non-Insulin-Dependent) Diabetes MellitusMellitus

Approximately 85% of diabetics over age 50 years have only Approximately 85% of diabetics over age 50 years have only a moderately decreased ability to produce and secrete a moderately decreased ability to produce and secrete insulin, and when at home they can usually be controlled insulin, and when at home they can usually be controlled by diet or by oral hypoglycemic drugs. If the serum by diet or by oral hypoglycemic drugs. If the serum glucose level is below 200 mg/dL on the morning of glucose level is below 200 mg/dL on the morning of surgery, oral hypoglycemic drugs should be withheld; and surgery, oral hypoglycemic drugs should be withheld; and 5% glucose solution should be administered intravenously 5% glucose solution should be administered intravenously at a rate of about 100 mL/h. This means that over a 10-hour at a rate of about 100 mL/h. This means that over a 10-hour period, only 50 g of glucose would be given; by contrast, period, only 50 g of glucose would be given; by contrast, during an average day, a diabetic on a normal diet would during an average day, a diabetic on a normal diet would consume four to five times as much carbohydrate (ie, 200–consume four to five times as much carbohydrate (ie, 200–250 g). 250 g).

If the operation is lengthy, blood glucose levels should be If the operation is lengthy, blood glucose levels should be measured every 3–4 hours during surgery to ensure measured every 3–4 hours during surgery to ensure adequate glucose control. adequate glucose control. The goal is to maintain The goal is to maintain glucose levels between 100 and 200 mg/dLglucose levels between 100 and 200 mg/dL,,

Type 1 (Insulin-Dependent) Diabetes Type 1 (Insulin-Dependent) Diabetes

MellitusMellitusType 1 patients require insulin during surgery. It can be Type 1 patients require insulin during surgery. It can be

administered by any of the following methods:administered by any of the following methods: (1) subcutaneous administration of short-acting insulin;(1) subcutaneous administration of short-acting insulin; (2) constant infusion of a mixture of glucose and insulin; or(2) constant infusion of a mixture of glucose and insulin; or (3) separate infusions of glucose and insulin. (3) separate infusions of glucose and insulin. blood glucose levels should be monitored at least every 2 blood glucose levels should be monitored at least every 2

hours during the procedure to avoid hypoglycemia below hours during the procedure to avoid hypoglycemia below 60 mg/dL and hyperglycemia above 200 mg/dL. 60 mg/dL and hyperglycemia above 200 mg/dL.

Blood glucose levels can be measured rapidly during surgery Blood glucose levels can be measured rapidly during surgery with a portable electronic glucose analyzer.with a portable electronic glucose analyzer.

Postoperative CarePostoperative Care Hypoglycemia, the most common postoperative Hypoglycemia, the most common postoperative

complication, most often follows the use of long-complication, most often follows the use of long-acting insulin given subcutaneously before surgery. acting insulin given subcutaneously before surgery. Although hypoglycemia may also occur if the Although hypoglycemia may also occur if the intravenous insulin infusion is excessive in relation to intravenous insulin infusion is excessive in relation to that of the glucose, an infusion of 1.5 units or less of that of the glucose, an infusion of 1.5 units or less of insulin per hour, when given with 5% glucose, rarely insulin per hour, when given with 5% glucose, rarely results in hypoglycemia. Blood glucose levels should results in hypoglycemia. Blood glucose levels should be measured every 2–4 hours and the patient be measured every 2–4 hours and the patient monitored for signs and symptoms of hypoglycemia monitored for signs and symptoms of hypoglycemia (eg, anxiety, tremulousness, profuse sweating without (eg, anxiety, tremulousness, profuse sweating without fever). When hypoglycemia is detected, the amount of fever). When hypoglycemia is detected, the amount of glucose infused should be promptly increased and the glucose infused should be promptly increased and the insulin decreased. insulin decreased.

Postoperative CarePostoperative Care

In the intermediate In the intermediate phase ;we do blood phase ;we do blood sugar every 6 hours sugar every 6 hours & give soluble & give soluble insulin insulin subcutaneously subcutaneously according to the according to the following table :following table :

Less than Less than 200 mg/dl200 mg/dl

NothingNothing

200-250200-250 5 units5 units

250-300250-300 10 units10 units

300-350300-350 15 units15 units

Above 350Above 350 20 units20 units

This is continue till the patient can drink &/0r eat This is continue till the patient can drink &/0r eat then the patient return to his old medical treatment then the patient return to his old medical treatment & do blood sugar twice daily to be sure that its & do blood sugar twice daily to be sure that its level below 180 mg/dl.level below 180 mg/dl.

A marked increase in glucose and insulin A marked increase in glucose and insulin requirements postoperatively suggests the requirements postoperatively suggests the presence of occult infection (eg, wound infection, presence of occult infection (eg, wound infection, cellulitis at the intravenous site, urinary tract cellulitis at the intravenous site, urinary tract infection, or unrecognized aspiration pneumonia).infection, or unrecognized aspiration pneumonia).

Adjustments in the rate of glucose or insulin Adjustments in the rate of glucose or insulin administration must be based on administration must be based on bloodblood glucose glucose levels.levels.

HypertensionHypertension Patients with uncomplicated and Patients with uncomplicated and

controlled hypertension usually tolerate controlled hypertension usually tolerate surgery well. The patient advised to took surgery well. The patient advised to took his medication till the day of surgery & at his medication till the day of surgery & at the morning of surgery & continue after the morning of surgery & continue after the surgery if possible or replace it with the surgery if possible or replace it with parentral drugs.parentral drugs.

The patient should stop aspirin a week The patient should stop aspirin a week before surgery & an internist should before surgery & an internist should consulted before the operation.consulted before the operation.

Respiratory Disease Respiratory Disease Acute Upper Respiratory Tract Infections :Acute Upper Respiratory Tract Infections :Both anesthesia and surgery provide opportunities for the spread Both anesthesia and surgery provide opportunities for the spread

of infection because respiratory defense mechanisms are of infection because respiratory defense mechanisms are compromised and instrumentation of the airway may be compromised and instrumentation of the airway may be required. Therefore, the presence of a cold, pharyngitis, or required. Therefore, the presence of a cold, pharyngitis, or tonsillitis is tonsillitis is a relative contraindication to elective surgery,a relative contraindication to elective surgery, since viral infections decrease defense mechanisms against since viral infections decrease defense mechanisms against bacterial infections.bacterial infections.

If surgery is necessary, the appropriate antibiotic should be If surgery is necessary, the appropriate antibiotic should be administered and manipulation of the infected area avoided administered and manipulation of the infected area avoided when possible.when possible.

Acute Lower Respiratory Tract Infections Acute Lower Respiratory Tract Infections (Tracheitis, Bronchitis, Pneumonia) :(Tracheitis, Bronchitis, Pneumonia) :

These infections are These infections are absolute contraindications to absolute contraindications to elective surgery.elective surgery. For emergency surgery, therapy For emergency surgery, therapy includes humidification of inhaled gases, removal of includes humidification of inhaled gases, removal of lung secretions, and continued administration of lung secretions, and continued administration of bronchodilators and antibiotics.bronchodilators and antibiotics.

Bronchial Asthma :Bronchial Asthma :patients with bronchial asthma who are undergoing patients with bronchial asthma who are undergoing

surgery are at increased risk of pulmonary surgery are at increased risk of pulmonary complications. complications. Preoperative managementPreoperative management includes includes adjustment of bronchodilator medication, cessation adjustment of bronchodilator medication, cessation of smoking, and treatment of infection. of smoking, and treatment of infection.

IntraoperativeIntraoperative bronchoconstriction from mechanical bronchoconstriction from mechanical stimulation of the airway must be prevented so that stimulation of the airway must be prevented so that appropriate anesthetics can be given in adequate appropriate anesthetics can be given in adequate concentrations. Since intraoperative use of concentrations. Since intraoperative use of bronchodilators may be necessary, adverse bronchodilators may be necessary, adverse interactions between anesthetic agents and interactions between anesthetic agents and bronchodilators must be avoided. Many patients with bronchodilators must be avoided. Many patients with bronchial asthma have been treated with bronchial asthma have been treated with corticosteroids and require corticosteroid therapy in corticosteroids and require corticosteroid therapy in the perioperative periodthe perioperative period

aneamiaaneamia Surgical patients with anemia should undergo a thorough Surgical patients with anemia should undergo a thorough

workup to identify and treat the underlying cause before workup to identify and treat the underlying cause before elective procedures are undertaken. A detailed history elective procedures are undertaken. A detailed history should be obtained to identify any symptoms of blood loss should be obtained to identify any symptoms of blood loss from the genitourinary and gastrointestinal tracts. A from the genitourinary and gastrointestinal tracts. A history of renal, hepatic, hematologic, or endocrinologic history of renal, hepatic, hematologic, or endocrinologic disorders and a medication history should be elicited. A disorders and a medication history should be elicited. A history suggestive of hemolytic episodes or a family history suggestive of hemolytic episodes or a family history of anemia may offer clues to the diagnosis. Signs history of anemia may offer clues to the diagnosis. Signs of pallor, jaundice, lymphadenopathy, and organomegaly of pallor, jaundice, lymphadenopathy, and organomegaly should be sought on physical examination.should be sought on physical examination.

A complete laboratory evaluation including CBC, A complete laboratory evaluation including CBC, reticulocyte count, peripheral smear, and stool test for reticulocyte count, peripheral smear, and stool test for occult blood should be done.occult blood should be done.

Correctable causes of anemia, like deficiencies of iron, Correctable causes of anemia, like deficiencies of iron, folate, and vitamin B12 , should be treated.folate, and vitamin B12 , should be treated.

Preoperative red blood cell (RBC) transfusions are not Preoperative red blood cell (RBC) transfusions are not routinely recommended, and the decision to transfuse routinely recommended, and the decision to transfuse should be based on the need to improve tissue should be based on the need to improve tissue oxygenation.oxygenation.

pregnancypregnancyThe Pregnancy may alter or mask the signs and symptoms of The Pregnancy may alter or mask the signs and symptoms of

the particular presentation or course of disease, so that the particular presentation or course of disease, so that diagnosis is made more difficult. Furthermore, the fetus diagnosis is made more difficult. Furthermore, the fetus and changes in maternal physiology and anatomy must be and changes in maternal physiology and anatomy must be considered in the use of diagnostic tests, medical therapy, considered in the use of diagnostic tests, medical therapy, and the planning of surgical procedures.and the planning of surgical procedures.

Any major operation represents a risk not only to the mother Any major operation represents a risk not only to the mother but to the fetus as well. An increase in both preterm but to the fetus as well. An increase in both preterm delivery and growth restriction in infants that resulted from delivery and growth restriction in infants that resulted from pregnancies that involved a surgical procedure.pregnancies that involved a surgical procedure.

Although there is no evidence that congenital anomalies are Although there is no evidence that congenital anomalies are induced in the developing fetus by anesthesia, induced in the developing fetus by anesthesia, semielective procedures should be deferred until the semielective procedures should be deferred until the second trimester of pregnancy, exercising the greatest second trimester of pregnancy, exercising the greatest precautions to prevent hypoxia and hypotension.precautions to prevent hypoxia and hypotension.

Emergent surgical procedures should proceed as necessary; Emergent surgical procedures should proceed as necessary; however, changes in maternal physiology—particularly in however, changes in maternal physiology—particularly in cardiac output and maternal blood volume—as well as of cardiac output and maternal blood volume—as well as of the size of the gravid uterus must be considered.the size of the gravid uterus must be considered.

Normal valuesNormal values : :Blood ureaBlood urea 25-40mg/dl25-40mg/dl

Serum creatinineSerum creatinine 0.7-1.2 mg/dl0.7-1.2 mg/dl

Fasting blood sugarFasting blood sugar 80 -120 mg/dl80 -120 mg/dl

Post brandial B.S.Post brandial B.S. 120-180 mg/dl120-180 mg/dl

Random B.S.Random B.S. 120 -140 mg/dl120 -140 mg/dl

Serum sodiumSerum sodium 135 -145 meq /l135 -145 meq /l

Serum potassiumSerum potassium 3.5 – 4.5 meq /l3.5 – 4.5 meq /l

Serum calciumSerum calcium 9 -11 mg/dl9 -11 mg/dl

WBCWBC 4000-10000 cell/dl4000-10000 cell/dl

RBCRBC 4 -10 *10^6 cell/dl4 -10 *10^6 cell/dl

Heamoglobin Heamoglobin 12-16 gm /dl12-16 gm /dl

Fluid & Electrolyte Management Fluid & Electrolyte Management

Fluid intakeFluid intake (input ) is derived from two sources: (input ) is derived from two sources: (1) exogenous; and (1) exogenous; and (2) endogenous.(2) endogenous.Exogenous water:Exogenous water: is either drunk or ingested in solid food. is either drunk or ingested in solid food.

The quantities vary within wide limits, but average 2—3 The quantities vary within wide limits, but average 2—3 litres per 24 hours, of which nearly half is contained in litres per 24 hours, of which nearly half is contained in solid food.solid food.

The water requirements of infants and children are relatively The water requirements of infants and children are relatively greater than those of adults because of:greater than those of adults because of:

(1) the larger surface area per unit of body weight;(1) the larger surface area per unit of body weight; (2) the greater metabolic activity due to growth; (3) the (2) the greater metabolic activity due to growth; (3) the

comparatively poor concentrating ability of the immature comparatively poor concentrating ability of the immature kidney.kidney.

Endogenous water:Endogenous water: is released during the oxidation of is released during the oxidation of ingested food; the amount is normally less than 500 ml / ingested food; the amount is normally less than 500 ml / 24 hours. However, during starvation, this amount is 24 hours. However, during starvation, this amount is supplemented by water released from the breakdown of supplemented by water released from the breakdown of body tissues.body tissues.

Fluid outputFluid outputWater is lost from the body by four routes.Water is lost from the body by four routes.1 • By the lungs1 • By the lungs. About 400 ml of water is lost in expired air each 24 . About 400 ml of water is lost in expired air each 24

hours. In a dry atmosphere, and when the respiratory rate is hours. In a dry atmosphere, and when the respiratory rate is increased, the loss is correspondingly greater .increased, the loss is correspondingly greater .

2•By the skin.2•By the skin. When the body becomes overheated, there is visible When the body becomes overheated, there is visible perspiration, but throughout life invisible perspiration is always perspiration, but throughout life invisible perspiration is always occurring. The cutaneous fluid loss varies with the atmospheric occurring. The cutaneous fluid loss varies with the atmospheric temperature and humidity, muscular activity and body temperature. temperature and humidity, muscular activity and body temperature. In a temperate climate the average loss is between 600 and 1000 ml In a temperate climate the average loss is between 600 and 1000 ml / 24 hours./ 24 hours.

3• Faeces.3• Faeces. Between 60 and 150 ml of water are lost by this route daily. Between 60 and 150 ml of water are lost by this route daily. In diarrhoea this amount is greatly multiplied.In diarrhoea this amount is greatly multiplied.

4• Urine.4• Urine. The output of urine is under the control of multiple The output of urine is under the control of multiple influences, such as blood volume, hormonal and nervous influences, such as blood volume, hormonal and nervous influences, among which the influences, among which the antidiuretic hormoneantidiuretic hormone acts by acts by stimulating the reabsorption of water from the renal tubules. The stimulating the reabsorption of water from the renal tubules. The normal urinary output is approximately 1500 ml / 24 hours, and normal urinary output is approximately 1500 ml / 24 hours, and provided that the kidneys are healthy, the specific gravity of the provided that the kidneys are healthy, the specific gravity of the urine bears a direct relationship to the volume. A minimum urinary urine bears a direct relationship to the volume. A minimum urinary output of approximately 400 ml / 24 hours is required to excrete the output of approximately 400 ml / 24 hours is required to excrete the end products of protein metabolism.end products of protein metabolism.

Water depletion :Water depletion :Pure water depletion is usually due to diminished Pure water depletion is usually due to diminished

intake. This may be due to lack of availability, intake. This may be due to lack of availability, difficulty or inability to swallow because of painful difficulty or inability to swallow because of painful conditions of the mouth and pharynx, or conditions of the mouth and pharynx, or obstruction in the oesophagus. Pure water obstruction in the oesophagus. Pure water depletion may also follow the increased loss from depletion may also follow the increased loss from the lungs after tracheostomy. This loss may be as the lungs after tracheostomy. This loss may be as much as 500 ml in excess of the normal insensible much as 500 ml in excess of the normal insensible loss. After tracheostomy, humidification of the loss. After tracheostomy, humidification of the inspired air is an important preventive measure.inspired air is an important preventive measure.

Clinical features :Clinical features :The main symptoms are weakness and intense The main symptoms are weakness and intense

thirst. The urinary output is diminished and its thirst. The urinary output is diminished and its specific gravity increased.specific gravity increased.

TreatmentTreatment by drinking water &/or give 5%glucose by drinking water &/or give 5%glucose water solution. water solution.

Water intoxicationWater intoxication This can occur when excessive amounts This can occur when excessive amounts

of water, low sodium or hypotonic of water, low sodium or hypotonic solutions are taken or given by any route. solutions are taken or given by any route. The commonest cause on surgical wards The commonest cause on surgical wards is the over-prescribing of intravenous 5% is the over-prescribing of intravenous 5% glucose solutions to postoperative glucose solutions to postoperative patients. patients.

Similarly, water intoxication can occur if Similarly, water intoxication can occur if the body retains water in excess to the body retains water in excess to plasma solutes. This can be seen in the plasma solutes. This can be seen in the syndrome of inappropriate antidiuretic syndrome of inappropriate antidiuretic hormone (SIADH) secretion which is most hormone (SIADH) secretion which is most commonly associated with lung commonly associated with lung conditions such as lobar pneumonia, conditions such as lobar pneumonia, empyema and oat-cell carcinoma of empyema and oat-cell carcinoma of bronchus, as well as head injury.bronchus, as well as head injury.

Clinical features:Clinical features:These include drowsiness, weakness, sometimes These include drowsiness, weakness, sometimes

convulsions and coma. Nausea and vomiting of clear fluid convulsions and coma. Nausea and vomiting of clear fluid are common, and, with the exception of the SIADH, usually are common, and, with the exception of the SIADH, usually the patient passes a considerable amount of dilute urine. the patient passes a considerable amount of dilute urine. Laboratory investigations may show a falling haematocrit, Laboratory investigations may show a falling haematocrit, serum sodium and other electrolyte concentrations.serum sodium and other electrolyte concentrations.

Treatment :Treatment :The intake of water having been stopped, the best course is The intake of water having been stopped, the best course is

water restriction. If the patient fails to improve, transfer to water restriction. If the patient fails to improve, transfer to an intensive care unit will be necessary for more invasive an intensive care unit will be necessary for more invasive monitoring and controlled manipulation of fluids and monitoring and controlled manipulation of fluids and electrolytes. The administration of diuretics or hypertonic electrolytes. The administration of diuretics or hypertonic saline should not be undertaken lightly as rapid changes in saline should not be undertaken lightly as rapid changes in serum sodium concentration may result in neuronal serum sodium concentration may result in neuronal demyelination and a fatal outcome. demyelination and a fatal outcome.

HaemorrhageHaemorrhageThe types of haemorrhage :The types of haemorrhage :1- Arterial haemorrhage :1- Arterial haemorrhage :Arterial haemorrhage is recognised as bright red blood, Arterial haemorrhage is recognised as bright red blood,

spurting as a jet which rises and falls in time with the spurting as a jet which rises and falls in time with the pulse. pulse.

2- Venous haemorrhage :2- Venous haemorrhage :Venous haemorrhage is a darker red, a steady and copious Venous haemorrhage is a darker red, a steady and copious

flow. The colour darkens still further from excessive flow. The colour darkens still further from excessive oxygen desaturation when blood loss is severe. Blood loss oxygen desaturation when blood loss is severe. Blood loss is particularly rapid when large veins are opened, e.g. is particularly rapid when large veins are opened, e.g. common femoral or jugular.common femoral or jugular.

Venous bleeding can be under increased pressure as in Venous bleeding can be under increased pressure as in asphyxia, or from ruptured varicose veins. Pulmonary asphyxia, or from ruptured varicose veins. Pulmonary artery haemorrhage is dark red (venous blood) , whereas artery haemorrhage is dark red (venous blood) , whereas bleeding from the pulmonary veins is bright red bleeding from the pulmonary veins is bright red (oxygenated).(oxygenated).

3- Capillary haemorrhage :3- Capillary haemorrhage : It is a bright red, often rapid, ooze. If continuing for It is a bright red, often rapid, ooze. If continuing for

many hours, blood loss can become serious, as in many hours, blood loss can become serious, as in haemophilia.haemophilia.

4- Primary haemorrhage : 4- Primary haemorrhage : It occurs at the time of injury or operation.It occurs at the time of injury or operation.

5- Reactionary haemorrhage :5- Reactionary haemorrhage : It may follow primary haemorrhage within 24 hours It may follow primary haemorrhage within 24 hours

(usually 4—6 hours) and is mainly due to rolling (usually 4—6 hours) and is mainly due to rolling (‘slipping’) of a ligature, dislodgement of a clot or (‘slipping’) of a ligature, dislodgement of a clot or cessation of reflex vasospasm. The precipitating cessation of reflex vasospasm. The precipitating circumstances are: circumstances are:

(1)(1) The rise in blood pressure and the refilling of the The rise in blood pressure and the refilling of the venous system on recovery from shock; venous system on recovery from shock;

(2)(2) Restlessness, coughing and vomiting which raise the Restlessness, coughing and vomiting which raise the venous pressure (e.g. reactionary venous venous pressure (e.g. reactionary venous haemorrhage within a few hours of thyroidectomy).haemorrhage within a few hours of thyroidectomy).

6- Secondary haemorrhage :6- Secondary haemorrhage :Secondary haemorrhage occurs after 7—14 days, Secondary haemorrhage occurs after 7—14 days,

and is due to infection and sloughing of part of the and is due to infection and sloughing of part of the wall of an artery. Predisposing factors are wall of an artery. Predisposing factors are pressure of a drainage tube, a fragment of bone, a pressure of a drainage tube, a fragment of bone, a ligature in an infected area or cancer. It is also a ligature in an infected area or cancer. It is also a complication of arterial surgery and amputations. complication of arterial surgery and amputations. It is heralded by ‘warning’ haemorrhages, which It is heralded by ‘warning’ haemorrhages, which are bright red stains on the dressing, followed by a are bright red stains on the dressing, followed by a sudden severe haemorrhage which may be fatal. sudden severe haemorrhage which may be fatal.

In advanced cancer, the erosion of a main vessel In advanced cancer, the erosion of a main vessel (e.g. carotid or uterine) by a locally ulcerating (e.g. carotid or uterine) by a locally ulcerating growth becomes the way of merciful termination to growth becomes the way of merciful termination to the patient’s suffering. Secondary haemorrhage is the patient’s suffering. Secondary haemorrhage is prone to occur with anorectal wounds, for example prone to occur with anorectal wounds, for example after haemorrhoidectomy.after haemorrhoidectomy.

7- External haemorrhage :7- External haemorrhage :External haemorrhage is visible, revealed External haemorrhage is visible, revealed

haemorrhage.haemorrhage.8- Internal haemorrhage :8- Internal haemorrhage :Internal haemorrhage is invisible, concealed Internal haemorrhage is invisible, concealed

haemorrhage. Internal bleeding may be haemorrhage. Internal bleeding may be concealed as in ruptured spleen or liver, concealed as in ruptured spleen or liver, fractured femur, ruptured ectopic gestation or in fractured femur, ruptured ectopic gestation or in cerebral haemorrhage. cerebral haemorrhage.

Concealed haemorrhage may become revealed as Concealed haemorrhage may become revealed as in haematemesis or melaena from a bleeding in haematemesis or melaena from a bleeding peptic ulcer, as in haematuria from a ruptured peptic ulcer, as in haematuria from a ruptured kidney, or via the vagina in accidental uterine kidney, or via the vagina in accidental uterine haemorrhage of pregnancy.haemorrhage of pregnancy.

Measurement of acute blood loss:Measurement of acute blood loss:Assessment and management of blood loss must Assessment and management of blood loss must

be related to the pre-existing circulating blood be related to the pre-existing circulating blood volume, which can be derived from the patient’s volume, which can be derived from the patient’s weight:weight:

• • infant 80—85 ml/kg;infant 80—85 ml/kg;• • adult 65—75 ml/kg.adult 65—75 ml/kg. Measuring blood loss :Measuring blood loss :1-  1-  Blood clotBlood clot : T : The size of a clenched fist is he size of a clenched fist is

roughly equal to 500 ml.roughly equal to 500 ml.2- 2- Swelling in closed fracturesSwelling in closed fractures : : Moderate swelling Moderate swelling

in closed fracture of the tibia equals 500—1500 in closed fracture of the tibia equals 500—1500 ml blood loss. Moderate swelling in a fractured ml blood loss. Moderate swelling in a fractured shaft of femur equals 500—2000 ml blood loss.shaft of femur equals 500—2000 ml blood loss.

3- 3- Swab weighingSwab weighing : : In the operating theatre, blood In the operating theatre, blood loss can be measured by weighing the swabs loss can be measured by weighing the swabs after use and subtracting the dry weight. The after use and subtracting the dry weight. The resulting total obtained (1 g = 1 ml) is added to resulting total obtained (1 g = 1 ml) is added to the volume of blood collected in the suction or the volume of blood collected in the suction or drainage bottles. Blood, plasma and water are drainage bottles. Blood, plasma and water are also lost from the vascular system because of also lost from the vascular system because of evaporation from open wounds, sweating and evaporation from open wounds, sweating and expired water via the lungs. expired water via the lungs.

4- 4- Haemoglobin levelHaemoglobin level : : This is estimated in g/100 This is estimated in g/100 ml (g/dl), normal values being 12—16 g/100 ml ml (g/dl), normal values being 12—16 g/100 ml (12—16 g/dl). There is no immediate change in (12—16 g/dl). There is no immediate change in haemorrhage, but after some hours the level haemorrhage, but after some hours the level falls by influx of interstitial fluid into the falls by influx of interstitial fluid into the vascular compartment in order to restore the vascular compartment in order to restore the blood volume.blood volume.

5- 5- Measurement of central venous pressureMeasurement of central venous pressure . .

The treatment of haemorrhageThe treatment of haemorrhage1-1-   Pressure and packingPressure and packingThe first-aid treatment of haemorrhage from a wound is a The first-aid treatment of haemorrhage from a wound is a

pressure dressing made from anything handy which is pressure dressing made from anything handy which is soft and clean. The dressing or pack should be bound on soft and clean. The dressing or pack should be bound on tightly.tightly.

Other examples of pressure used to control haemorrhage Other examples of pressure used to control haemorrhage include digital pressure, for example the use of forefinger include digital pressure, for example the use of forefinger and thumb for epistaxis. and thumb for epistaxis.

Packing by means of rolls of wide gauze is an important Packing by means of rolls of wide gauze is an important standby in operative surgery. If several rolls are used, the standby in operative surgery. If several rolls are used, the ends must be tied together to ensure complete removal ends must be tied together to ensure complete removal later.later.

N.B. If on removal of pressure or packing, bleeding appears N.B. If on removal of pressure or packing, bleeding appears to have ceased completely, one should not assume that to have ceased completely, one should not assume that all is well, especially when dealing with deep wounds all is well, especially when dealing with deep wounds involving large veins. Continued close observation is involving large veins. Continued close observation is required and rapid operative action may be called for .required and rapid operative action may be called for .

2- 2- Position and restPosition and restElevation of limbs (e.g. in ruptured varicose veins) employs Elevation of limbs (e.g. in ruptured varicose veins) employs

gravity to reduce bleeding. Elevation also causes helpful gravity to reduce bleeding. Elevation also causes helpful vasoconstriction. A bed elevator is often used to raise the vasoconstriction. A bed elevator is often used to raise the foot of the bed, and thus increasing venous return to the foot of the bed, and thus increasing venous return to the heart also augmenting cardiac output. heart also augmenting cardiac output. GravityGravity is also is also used in certain operations, as in thyroidectomy when the used in certain operations, as in thyroidectomy when the patient is tilted feet downwards (reverse Trendelenburg patient is tilted feet downwards (reverse Trendelenburg position) or as in stripping of varicose veins when a head-position) or as in stripping of varicose veins when a head-down tilt is used (Trendelenburg position ).down tilt is used (Trendelenburg position ).

3- 3- operative techniquesoperative techniquesArtery forceps (haemostats) and clips are mechanical Artery forceps (haemostats) and clips are mechanical

means of controlling bleeding by pressure. The clamped means of controlling bleeding by pressure. The clamped vessel can be ligated or it can be coagulated with vessel can be ligated or it can be coagulated with diathermy. diathermy.

Suturing may be employed. The vessel can be underrun or Suturing may be employed. The vessel can be underrun or transfixed by needle and suture, and then ligated, while if transfixed by needle and suture, and then ligated, while if the continuity of a main vessel is to be restored ;very thin the continuity of a main vessel is to be restored ;very thin thread is used on atraumatic needle.thread is used on atraumatic needle.

4-4- Other topical applicationsOther topical applications for for oozing include gauze or sponge, which is oozing include gauze or sponge, which is absorbed by the body. ‘Oxycel’ or absorbed by the body. ‘Oxycel’ or gelatingelatin spongesponge provides a network upon which provides a network upon which fibrin and platelets can be deposited. fibrin and platelets can be deposited. Gauze soaked in adrenalin (1:1000) can be Gauze soaked in adrenalin (1:1000) can be applied. applied. Bone waxBone wax is used for oozing is used for oozing bone.bone.

The whole or part of a bleeding viscus may The whole or part of a bleeding viscus may have to be excised (e.g. splenectomy ) . A have to be excised (e.g. splenectomy ) . A ruptured kidney is treated conservatively ruptured kidney is treated conservatively if possible . if possible .

Natural blood volume and red cell Natural blood volume and red cell recovery :recovery :

The recovery of blood volume begins The recovery of blood volume begins immediately by the withdrawal of fluid immediately by the withdrawal of fluid from the tissues into the circulation. from the tissues into the circulation. There is haemodilution. Plasma There is haemodilution. Plasma proteins are replaced by the liver. Red proteins are replaced by the liver. Red cell recovery takes some 5—6 weeks. cell recovery takes some 5—6 weeks. The iron content will be less than The iron content will be less than normal if stores are depleted or normal if stores are depleted or absorption is impaired, for example absorption is impaired, for example after gastrectomy.after gastrectomy.

Transfusion of blood and blood productsTransfusion of blood and blood productsThe indications for transfusion in surgical practice are as The indications for transfusion in surgical practice are as

follows :follows :1• Following traumatic incidents where there has been severe 1• Following traumatic incidents where there has been severe

blood loss, or haemorrhage from pathological lesions, for blood loss, or haemorrhage from pathological lesions, for example from the gastrointestinal tract.example from the gastrointestinal tract.

2• During major operative procedures where a certain amount 2• During major operative procedures where a certain amount of blood loss is inevitable, for example above knee of blood loss is inevitable, for example above knee amputation or cardiovascular surgery.amputation or cardiovascular surgery.

3• Following severe burns where, despite initial fluid and 3• Following severe burns where, despite initial fluid and protein replacement, there may be associated haemolysis.protein replacement, there may be associated haemolysis.

4•  Postoperatively in a patient who has become severely 4•  Postoperatively in a patient who has become severely anaemic.anaemic.

5•  Preoperatively, usually in the form of packed cells given 5•  Preoperatively, usually in the form of packed cells given slowly in cases of chronic anaemia where surgery is slowly in cases of chronic anaemia where surgery is indicated urgently, i.e. where there is inadequate time for indicated urgently, i.e. where there is inadequate time for effective iron or other replacement therapy, or where the effective iron or other replacement therapy, or where the anaemia is unresponsive to therapy, for example aplastic anaemia is unresponsive to therapy, for example aplastic anaemia.anaemia.

Preparation of blood products for transfusionPreparation of blood products for transfusion It is important that blood donors should be fit and with no It is important that blood donors should be fit and with no

evidence of infection, in particular hepatitis and human evidence of infection, in particular hepatitis and human immunodeficiency virus (HIV) infection{ acquired immuno-immunodeficiency virus (HIV) infection{ acquired immuno-deficiency syndrome (AIDS)}, which are transmitted in donor deficiency syndrome (AIDS)}, which are transmitted in donor blood.blood.

Blood is collected into a sterile commercially prepared plastic Blood is collected into a sterile commercially prepared plastic bag with needle and plastic tube attached in a complete, closed bag with needle and plastic tube attached in a complete, closed sterile unit.sterile unit.

With the donor lying on a couch, a sphygmomanometer cuff is With the donor lying on a couch, a sphygmomanometer cuff is applied to the upper arm and inflated to a pressure of 70 mmHg . applied to the upper arm and inflated to a pressure of 70 mmHg . After introducing 0.5 ml of local anaesthetic, a big needle is After introducing 0.5 ml of local anaesthetic, a big needle is introduced into the median cubital vein and introduced into the median cubital vein and 410410 ml of blood ml of blood allowed to run into the bag containing allowed to run into the bag containing 7575 ml of anticoagulant ml of anticoagulant solution (solution (CPDCPD — citrate potassium dextrose). — citrate potassium dextrose).

During collection, the blood is constantly mixed with the During collection, the blood is constantly mixed with the anticoagulant to prevent clotting, and at the end of the anticoagulant to prevent clotting, and at the end of the procedure the tube is clamped and the needle removed. procedure the tube is clamped and the needle removed. Specimens for use in blood grouping and cross-matching Specimens for use in blood grouping and cross-matching procedures may be obtained by clamping off small sections of procedures may be obtained by clamping off small sections of the plastic tubing containing the donor blood.the plastic tubing containing the donor blood.

Blood storage :Blood storage :All blood for transfusion must be stored in special blood bank All blood for transfusion must be stored in special blood bank

refrigerators controlled at refrigerators controlled at 4’C ± 2’C4’C ± 2’C. Blood allowed to stand . Blood allowed to stand at higher temperatures for more than 2 hours is in danger of at higher temperatures for more than 2 hours is in danger of transmitting infection.transmitting infection.

CPD blood has a shelf-life of 3 weeks (CPDA of 5 weeks).CPD blood has a shelf-life of 3 weeks (CPDA of 5 weeks).

The red blood cells :The red blood cells : or erythrocytes, suffer a temporary or erythrocytes, suffer a temporary reduction (24—72 hours) in their ability to release oxygen to reduction (24—72 hours) in their ability to release oxygen to the tissues of the recipient, so if a patient requires an urgent the tissues of the recipient, so if a patient requires an urgent and massive transfusion it is wise to give 1 or 2 units of and massive transfusion it is wise to give 1 or 2 units of blood which are less than 7 days old.blood which are less than 7 days old.

White blood cells : White blood cells : White blood cells are rapidly destroyed in White blood cells are rapidly destroyed in stored blood.stored blood.

Platelets: Platelets: At 4 ‘C the survival of platelets is considerably At 4 ‘C the survival of platelets is considerably reduced, and few are functionally useful after 24 hours. reduced, and few are functionally useful after 24 hours. Platelets which are separated show good survival even after Platelets which are separated show good survival even after 72 hours.72 hours.

Clotting factors : Clotting factors : Like platelets, clotting factors VIII and V are Like platelets, clotting factors VIII and V are labile and their levels fall quicklylabile and their levels fall quickly

Blood fractions :Blood fractions :Whole blood may be divided into various fractions. This is Whole blood may be divided into various fractions. This is

not only more economical of blood donors, but certain not only more economical of blood donors, but certain fractions are more appropriate than whole blood fractions are more appropriate than whole blood transfusion for certain clinical conditions. Fractionation transfusion for certain clinical conditions. Fractionation procedures are relatively safe and simple, using sealed procedures are relatively safe and simple, using sealed sterile plastic bag units.sterile plastic bag units.

Packed red cells :Packed red cells :Packed red cells are especially advisable in patients with Packed red cells are especially advisable in patients with

chronic anaemia, in the elderly, in small children and in chronic anaemia, in the elderly, in small children and in patients in whom introduction of large volumes of fluid patients in whom introduction of large volumes of fluid may cause cardiac failure. Packed red cells are suitable may cause cardiac failure. Packed red cells are suitable for most forms of transfusion therapy, including major for most forms of transfusion therapy, including major surgery. Good packing can be obtained by letting the surgery. Good packing can be obtained by letting the blood sediment and removing the plasma, or by blood sediment and removing the plasma, or by centrifugation of whole blood at 2000—2300g for 15—20 centrifugation of whole blood at 2000—2300g for 15—20 minutes.minutes.

Platelet-rich plasma :Platelet-rich plasma :Platelet-rich plasma is suitable for transfusions to patients Platelet-rich plasma is suitable for transfusions to patients

with thrombocytopenia who are either bleeding or require with thrombocytopenia who are either bleeding or require surgery. It is prepared by centrifugation of freshly donated surgery. It is prepared by centrifugation of freshly donated blood at 150—200 g for 15—20 minutes.blood at 150—200 g for 15—20 minutes.

Platelet concentrate :Platelet concentrate :Platelet concentrate for transfusion to patients with Platelet concentrate for transfusion to patients with

thrombocytopenia is prepared by centrifugation of platelet thrombocytopenia is prepared by centrifugation of platelet rich plasma at 1200—1500 g for 15—20 minutes.rich plasma at 1200—1500 g for 15—20 minutes.

Plasma :Plasma :This is removed after centrifugation of whole blood at 2000—This is removed after centrifugation of whole blood at 2000—

2300 g for 15—20 minutes and it may be further processed 2300 g for 15—20 minutes and it may be further processed or fractionated in various ways.or fractionated in various ways.

Human albumin 4.5 % :Human albumin 4.5 % : Repeated fractionation of plasma by Repeated fractionation of plasma by organic liquids followed by heat treatment results in this organic liquids followed by heat treatment results in this plasma fraction, which is rich in protein but free from the plasma fraction, which is rich in protein but free from the danger of transmission of serum hepatitis. This may be danger of transmission of serum hepatitis. This may be stored for several months in liquid form at 4’C and is stored for several months in liquid form at 4’C and is suitable for replacement of protein, for example following suitable for replacement of protein, for example following severe burns.severe burns.

Fresh frozen plasma:Fresh frozen plasma: Plasma removed from fresh blood Plasma removed from fresh blood obtained within 4 hours is rapidly frozen by immersing in a obtained within 4 hours is rapidly frozen by immersing in a solid carbon dioxide and ethyl alcohol mixture. This is solid carbon dioxide and ethyl alcohol mixture. This is stored at - 40’C and is a good source of all the coagulation stored at - 40’C and is a good source of all the coagulation factors. It is the treatment of choice when considering factors. It is the treatment of choice when considering surgery in patients with abnormal coagulation due to surgery in patients with abnormal coagulation due to severe liver failure. It may also be given in any of the severe liver failure. It may also be given in any of the congenital clotting factor deficiency diseases in their congenital clotting factor deficiency diseases in their milder forms, especially Christmas disease (Factor IX milder forms, especially Christmas disease (Factor IX deficiency) or haemophilia (Factor VIII deficiency).deficiency) or haemophilia (Factor VIII deficiency).

Cryoprecipitate:Cryoprecipitate: When fresh frozen plasma is allowed to When fresh frozen plasma is allowed to thaw at 4’C a white glutinous precipitate remains and, if the thaw at 4’C a white glutinous precipitate remains and, if the supernatant plasma is removed, this cryoprecipitate is a supernatant plasma is removed, this cryoprecipitate is a very rich source of Factor VIII. It is stored at - 40’C and is very rich source of Factor VIII. It is stored at - 40’C and is immediately available for treatment of patients with immediately available for treatment of patients with haemophilia (Factor VIII deficiency). The advantage of haemophilia (Factor VIII deficiency). The advantage of cryoprecipitate treatment in haemophilia is the simplicity cryoprecipitate treatment in haemophilia is the simplicity of administering large quantities of Factor VIII in relatively of administering large quantities of Factor VIII in relatively small volumes by intravenous injection. It is also a rich small volumes by intravenous injection. It is also a rich source of fibrinogen, of value in hypofibrinogenaemic source of fibrinogen, of value in hypofibrinogenaemic states.states.

Blood grouping and cross-matching Blood grouping and cross-matching

There are two groups of antigens There are two groups of antigens on the cell surface of human red on the cell surface of human red cells :cells :

1- antigens of the ABO blood 1- antigens of the ABO blood groups groups

2- antigens of the rhesus (Rh) 2- antigens of the rhesus (Rh) blood groups.blood groups.

Antigens of the ABO blood Antigens of the ABO blood groups :groups :

These are strongly antigenic found These are strongly antigenic found on the RBC cell membrane and on the RBC cell membrane and are associated with naturally are associated with naturally occurring antibodies in the occurring antibodies in the serum. Individuals show four serum. Individuals show four different ABO cell groups : A , different ABO cell groups : A , B , AB & OB , AB & O

AntigenAntigen AntibodyAntibody

AA Anti BAnti B

BB Anti AAnti A

ABAB NothingNothing

OO Anti A & Anti A & anti Banti B

Antigens of the rhesus blood Antigens of the rhesus blood groups :groups :

The antigen of major The antigen of major importance in this group is importance in this group is Rh(D), which is strongly Rh(D), which is strongly antigenic . Antibodies to the antigenic . Antibodies to the D antigen are D antigen are notnot naturally naturally present , but their formation present , but their formation may be stimulated by the may be stimulated by the transfusion of Rh-positive transfusion of Rh-positive red cells to Rh.negative red cells to Rh.negative patient . Such acquired patient . Such acquired antibodies are capable, antibodies are capable, during pregnancy, of during pregnancy, of crossing the placenta and, if crossing the placenta and, if present in a Rh-negative present in a Rh-negative mother, may cause severe mother, may cause severe haemolytic anaemia and haemolytic anaemia and even death (hydrops fetalis) even death (hydrops fetalis) in a Rh-positive fetus in in a Rh-positive fetus in utero.utero.

Blood Blood group Rh group Rh positivepositive

Blood Blood group Rh group Rh negativenegative

A+,B+A+,B+

AB+,AB+,

O+O+

A-,B-,A-,B-,

AB-AB-

O-O-

Blood groupBlood group Give toGive to : : Take from :Take from :

A +A + A+,AB+A+,AB+ A+,A-,O+,O-A+,A-,O+,O-

A-A- A+,A-,AB+,AB-A+,A-,AB+,AB- A-,O-A-,O-

B+B+ B+,AB+B+,AB+ B+,B-,O+,O-B+,B-,O+,O-

B-B- B+,B-,AB+,AB-B+,B-,AB+,AB- B- ,O-B- ,O-

AB+AB+ AB+AB+ A+,A-,B+,B-,AA+,A-,B+,B-,AB+,AB-,O+,O-B+,AB-,O+,O-(all blood (all blood groups)groups)

AB-AB- AB+, AB-AB+, AB- A-,B-,AB-,O-A-,B-,AB-,O-

O+O+ A+,B+,AB+,O+A+,B+,AB+,O+ O+,O-O+,O-

O-O- All blood All blood groupsgroups

O-O-

IncompatibilityIncompatibility::If antibodies present in the recipient’s serum are incompatible with If antibodies present in the recipient’s serum are incompatible with

the donor’s cells, a transfusion reaction will result. This is the the donor’s cells, a transfusion reaction will result. This is the result of agglutination and haemolysis of the donated cells result of agglutination and haemolysis of the donated cells leading in severe cases to acute renal tubular necrosis and renal leading in severe cases to acute renal tubular necrosis and renal failure. For this reason, therefore, it is essential that all failure. For this reason, therefore, it is essential that all transfusion should be preceded by:transfusion should be preceded by:

1•  ABO and rhesus grouping of the recipient’s and donor’s cells 1•  ABO and rhesus grouping of the recipient’s and donor’s cells so that only ABO and Rh(D) compatible blood is given;so that only ABO and Rh(D) compatible blood is given;

2•direct matching of the recipient’s serum with the donor’s cells to 2•direct matching of the recipient’s serum with the donor’s cells to confirm ABO compatibility and to test for rhesus and any other confirm ABO compatibility and to test for rhesus and any other blood group antibody present in the serum of the recipient.blood group antibody present in the serum of the recipient.

Blood grouping and cross-matching require full laboratory Blood grouping and cross-matching require full laboratory procedures and take 1 hour. In emergencies it may be necessary procedures and take 1 hour. In emergencies it may be necessary to reduce this time. In such emergencies, it may be advisable to to reduce this time. In such emergencies, it may be advisable to restore the patient’s blood volume by saline, gelatin (e.g. restore the patient’s blood volume by saline, gelatin (e.g. Haemaccel), dextran or human albumin 4.5 % until blood has Haemaccel), dextran or human albumin 4.5 % until blood has been made available. Alternatively, donor blood, been made available. Alternatively, donor blood, group group 0-0-negativenegative, which is compatible with the majority of individuals, , which is compatible with the majority of individuals, should be given and this should always be available in acute should be given and this should always be available in acute emergency situations.emergency situations.

Giving blood :Giving blood :Blood transfusion is commenced by:Blood transfusion is commenced by:1 • selection and preparation of the site;1 • selection and preparation of the site;2 • careful checking of the donor blood: this should bear a 2 • careful checking of the donor blood: this should bear a

compatibility label stating the patient’s name, hospital reference compatibility label stating the patient’s name, hospital reference number, ward and blood group;number, ward and blood group;

3 • insertion of the needle or cannula — the latter may be valuable if 3 • insertion of the needle or cannula — the latter may be valuable if intravenous therapy is required for any length of time;intravenous therapy is required for any length of time;

4 • giving detailed written instructions as to the rate of flow, for 4 • giving detailed written instructions as to the rate of flow, for example 40 drops/m allows one 540 ml unit of blood to be example 40 drops/m allows one 540 ml unit of blood to be transfused in 4 hours.transfused in 4 hours.

In acute emergencies, it may be necessary to increase the rate of flow In acute emergencies, it may be necessary to increase the rate of flow and it is possible to give 1—2 units in 30 minutes using a pressure and it is possible to give 1—2 units in 30 minutes using a pressure cuff around a plastic bag of blood.cuff around a plastic bag of blood.

Warming bloodWarming blood : : the blood must be warmed before reaching the the blood must be warmed before reaching the patient by passing it through a carefully temperature-regulated patient by passing it through a carefully temperature-regulated blood warming unit, thus reducing the risk of cardiac arrest from blood warming unit, thus reducing the risk of cardiac arrest from large volumes of cold blood direct from the refrigerator.large volumes of cold blood direct from the refrigerator.

Filtering blood :Filtering blood : A filter with an absolute filtration rating of 40 A filter with an absolute filtration rating of 40 micron will filter off platelet aggregates and leucocytes micron will filter off platelet aggregates and leucocytes membranes in stored blood.membranes in stored blood.

Auto-transfusionAuto-transfusionThis is an old, well-tried method of immediately This is an old, well-tried method of immediately

restoring a patient’s blood volume, by transfusion restoring a patient’s blood volume, by transfusion with his or her own blood. with his or her own blood. In an emergencyIn an emergency, for , for example, in a case of ruptured ectopic gestation, the example, in a case of ruptured ectopic gestation, the blood is collected from the peritoneal cavity and put blood is collected from the peritoneal cavity and put into a sterile container suitable for connecting to into a sterile container suitable for connecting to transfusion tubing. The classical method of filtration transfusion tubing. The classical method of filtration of this blood to prevent the transfusion of any small of this blood to prevent the transfusion of any small clots is to place a piece of sterile gauze within the clots is to place a piece of sterile gauze within the container. Nowadays, special autotransfusion container. Nowadays, special autotransfusion apparatus is being marketed.apparatus is being marketed.

For major elective procedures,For major elective procedures, the patient may the patient may ‘donate’ his or her own blood, withdrawal and ‘donate’ his or her own blood, withdrawal and storage taking place up to 3 weeks before it is storage taking place up to 3 weeks before it is required. Natural blood volume and most of the red required. Natural blood volume and most of the red cell recovery will have taken place in that time.cell recovery will have taken place in that time.

Complications of blood transfusion :Complications of blood transfusion :

1-Congestive cardiac failure1-Congestive cardiac failure

This is especially liable to occur in the This is especially liable to occur in the elderly or where there is cardiovascular elderly or where there is cardiovascular insufficiency, and may result from too insufficiency, and may result from too rapid infusion of large volumes of blood. It rapid infusion of large volumes of blood. It is advisable in the individual with chronic is advisable in the individual with chronic anaemia to give packed red cells and, at anaemia to give packed red cells and, at the same time, give diuretic drugs. The the same time, give diuretic drugs. The transfusion should be given slowly, i.e. I transfusion should be given slowly, i.e. I unit over 4—6 hours and, if necessary, on unit over 4—6 hours and, if necessary, on two separate occasions.two separate occasions.

2- Transfusion reactions :2- Transfusion reactions : These may be the result of the following problems:These may be the result of the following problems:2-1 •  2-1 •  IncompatibilityIncompatibility. This should be avoided if the correct . This should be avoided if the correct

procedures of grouping and cross-matching have been procedures of grouping and cross-matching have been adopted but, in fact, it is nearly always due to human error adopted but, in fact, it is nearly always due to human error in the collection, labelling or checking of the specimens and in the collection, labelling or checking of the specimens and donor bags. The patient develops a rigor, temperature and donor bags. The patient develops a rigor, temperature and pain in the loins, and may become extremely alarmed. The pain in the loins, and may become extremely alarmed. The transfusion should be stopped immediately, and a fresh transfusion should be stopped immediately, and a fresh specimen of venous blood and urine from the patient sent specimen of venous blood and urine from the patient sent together with the residue of all the used units of donor blood together with the residue of all the used units of donor blood to the laboratory for checking.to the laboratory for checking.

A close watch should be kept on the patient’s pulse, blood A close watch should be kept on the patient’s pulse, blood pressure and urinary output. Frusemide 80—120 mg i.v. pressure and urinary output. Frusemide 80—120 mg i.v. should be given to provoke a diuresis, and repeated if the should be given to provoke a diuresis, and repeated if the urine output falls below 30 ml/hour. Dialysis may be urine output falls below 30 ml/hour. Dialysis may be necessary.necessary.

2-2 • 2-2 • Simple pyrexial reactionsSimple pyrexial reactions in which the patient develops in which the patient develops pyrexia, rigor and some increase in pulse rate. These are the pyrexia, rigor and some increase in pulse rate. These are the result of ‘pyrogens’ in the donor apparatus and are largely result of ‘pyrogens’ in the donor apparatus and are largely avoided by the use of plastic disposable giving sets.avoided by the use of plastic disposable giving sets.

2-3 • 2-3 • Allergic reactionsAllergic reactions in which the patient develops mild in which the patient develops mild tachycardia and an urticarial rash; This is the result of tachycardia and an urticarial rash; This is the result of allergic reaction to plasma products in the donor blood. The allergic reaction to plasma products in the donor blood. The reaction is treated by stopping the transfusion and giving an reaction is treated by stopping the transfusion and giving an antihistamine drug (chlorpheniramine 10 mg or antihistamine drug (chlorpheniramine 10 mg or diphenhydrazine 25 mg).diphenhydrazine 25 mg).

2-4 •   2-4 •   Sensitisation to leucocytes and plateletsSensitisation to leucocytes and platelets. This is not . This is not uncommon in those patients who have received many uncommon in those patients who have received many transfusions in the past, for example for thalassaemia, transfusions in the past, for example for thalassaemia, refractory anaemia or aplastic anaemia. The individual refractory anaemia or aplastic anaemia. The individual develops antibodies to donated white cells or platelets, develops antibodies to donated white cells or platelets, which cause reactions with each transfusion. They may be which cause reactions with each transfusion. They may be minimised by giving packed red cells from which plasma is minimised by giving packed red cells from which plasma is removed . Aspirin, antihistamines or steroids may also be removed . Aspirin, antihistamines or steroids may also be given to the recipient if necessary.given to the recipient if necessary.

2-5 •  2-5 •  Immunological sensitisationImmunological sensitisation. Only the same ABO and . Only the same ABO and Rh(D) groups are considered for blood transfusion. Immune Rh(D) groups are considered for blood transfusion. Immune antibodies may be stimulated by transfusion, and may give antibodies may be stimulated by transfusion, and may give rise to difficulties with compatibility tests or to haemolytic rise to difficulties with compatibility tests or to haemolytic transfusion reactions.transfusion reactions.

3-Infections3-InfectionsThere are four main reasons for blood transfusion causing infection in There are four main reasons for blood transfusion causing infection in

the recipient.the recipient.3-1 • 3-1 • Serum hepatitis virusSerum hepatitis virus may be transmitted from the donor and is may be transmitted from the donor and is

usually a severe hepatitis arising approximately 3 months after the usually a severe hepatitis arising approximately 3 months after the transfusion. It should be avoided by adequate good screening of the transfusion. It should be avoided by adequate good screening of the blood donor and by testing for the presence of the hepatitis blood donor and by testing for the presence of the hepatitis associated antigen in the blood prior to transfusion.associated antigen in the blood prior to transfusion.

3-2 •  3-2 •  HIV infectionHIV infection can be transmitted by blood and blood products. All can be transmitted by blood and blood products. All donors must be screened . Haemophiliacs are at special risk because donors must be screened . Haemophiliacs are at special risk because of their more frequent requirements for blood products.of their more frequent requirements for blood products.

3-3 • 3-3 • Bacterial infectionBacterial infection may result faulty storage. This arises most may result faulty storage. This arises most commonly from the donor blood being left in a warm room for some commonly from the donor blood being left in a warm room for some hours before the transfusion is commenced. This allows proliferation hours before the transfusion is commenced. This allows proliferation of any bacteria, and transfusion of such infected blood may result in of any bacteria, and transfusion of such infected blood may result in severe septicaemia in the recipient and rapid death.severe septicaemia in the recipient and rapid death.

3-4 • 3-4 • MalariaMalaria can be transmitted by blood transfusion in areas where the can be transmitted by blood transfusion in areas where the disease is endemic. Whenever possible, donors should be screened disease is endemic. Whenever possible, donors should be screened and the disease eradicated (by treatment of the donors who are and the disease eradicated (by treatment of the donors who are positive) before blood is obtained or given. If the need for transfused positive) before blood is obtained or given. If the need for transfused blood is so urgent that precautions are impossible before blood is so urgent that precautions are impossible before transfusion, then the patient should be given prophylactic transfusion, then the patient should be given prophylactic antimalarial drugs.antimalarial drugs.

4- Thrombo phlebitis4- Thrombo phlebitis5- Air embolism5- Air embolism6- Coagulation failure6- Coagulation failureCoagulation failure is due to:Coagulation failure is due to:6-1 • Dilution of clotting factors/platelets due to 6-1 • Dilution of clotting factors/platelets due to

large volumes of stored blood being used to large volumes of stored blood being used to replace losses as stored blood is low in platelets, replace losses as stored blood is low in platelets, Factor VIII and Factor V;Factor VIII and Factor V;

6-2 • Disseminated intravascular coagulation (DIC) 6-2 • Disseminated intravascular coagulation (DIC) following an incompatible blood transfusion, following an incompatible blood transfusion, particularly ABO incompatibility. The further particularly ABO incompatibility. The further haemorrhage may be treated by replacement of haemorrhage may be treated by replacement of the deficient factors (usually fibrinogen, Factors the deficient factors (usually fibrinogen, Factors VIII, V and II, and platelets), with fresh frozen VIII, V and II, and platelets), with fresh frozen plasma, cryoprecipitate and platelet plasma, cryoprecipitate and platelet concentrates. Paradoxically, heparin may be used concentrates. Paradoxically, heparin may be used sometimes for the treatment of DIC.sometimes for the treatment of DIC.

E.g. of haemorrhagic diseasesE.g. of haemorrhagic diseases : :1- Haemophilia :1- Haemophilia :Haemophilia (haemophilia A) is a haemorrhagic diathesis Haemophilia (haemophilia A) is a haemorrhagic diathesis

caused by the congenital deficiency in the blood of caused by the congenital deficiency in the blood of Factor VIII [ Factor VIII [ antihaemophilic globulin (AHG) antihaemophilic globulin (AHG) ]. It is a sex-]. It is a sex-linked characteristic, transmitted by the asymptomatic linked characteristic, transmitted by the asymptomatic female carriers, and manifest only in males.female carriers, and manifest only in males.

The levels of Factor VIII in the blood of severe The levels of Factor VIII in the blood of severe haemophiliacs may be less than 1 % of the average haemophiliacs may be less than 1 % of the average normal level. In the case of spontaneous haemorrhage normal level. In the case of spontaneous haemorrhage (e.g. into joints) treatment should aim at raising the level (e.g. into joints) treatment should aim at raising the level to at least 20 %. Should surgery be anticipated in the to at least 20 %. Should surgery be anticipated in the haemophiliac, the level should be raised to 50-100 %.haemophiliac, the level should be raised to 50-100 %.

2- Christmas disease :2- Christmas disease :Christmas disease (haemophilia B) is a congenital disease Christmas disease (haemophilia B) is a congenital disease

resulting from the deficiency of Factor IX (Christmas resulting from the deficiency of Factor IX (Christmas factor). Clinically, the manifestations of the disease are factor). Clinically, the manifestations of the disease are similar to haemophilia. Factor IX is replaced by the similar to haemophilia. Factor IX is replaced by the transfusion of fresh frozen plasma, transfusion of fresh frozen plasma,

3- Von Willebrand’s disease: 3- Von Willebrand’s disease: is a type of haemorrhagic disease, with low is a type of haemorrhagic disease, with low

plasma levels of both Factor VIII plasma levels of both Factor VIII complement and Factor VIII related complement and Factor VIII related antigen, and platelet abnormalities. antigen, and platelet abnormalities.

Blood substitutes — albumin, dextran, (colloid solution)Blood substitutes — albumin, dextran, (colloid solution)One of the most urgent requirements in a patient One of the most urgent requirements in a patient

suffering from acute blood loss is the re-establishment suffering from acute blood loss is the re-establishment of a normal blood volume. This may be achieved of a normal blood volume. This may be achieved satisfactorily with a number of plasma substitutes.satisfactorily with a number of plasma substitutes.

1- Human albumin 4.5 %1- Human albumin 4.5 % was used whilst cross-matching was used whilst cross-matching is being performed. Two to three units (1.2 litres) are is being performed. Two to three units (1.2 litres) are given intravenously over 30 minutes. It is valuable in given intravenously over 30 minutes. It is valuable in patients with burns where there has been severe loss patients with burns where there has been severe loss of protein. There is no risk of transmitting hepatitis.of protein. There is no risk of transmitting hepatitis.

2- Dextrans2- Dextrans are polysaccharide polymers of varying are polysaccharide polymers of varying molecular weight producing an osmotic pressure molecular weight producing an osmotic pressure similar to that of plasma. They have the disadvantage similar to that of plasma. They have the disadvantage of inducing of inducing rouleauxrouleaux of the red cells and this interferes of the red cells and this interferes with blood-grouping and cross-matching procedures, with blood-grouping and cross-matching procedures, hence the need for a blood sample beforehand. hence the need for a blood sample beforehand. Dextrans interfere with platelet function and may be Dextrans interfere with platelet function and may be associated with abnormal bleeding, and for this reason associated with abnormal bleeding, and for this reason it is recommended that the total volume of dextran it is recommended that the total volume of dextran should not exceed 1000 ml.should not exceed 1000 ml.

Parenteral fluid therapy (crystelloid solution )Parenteral fluid therapy (crystelloid solution )1• 1• dextrose 5 % dextrose 5 % is an isotonic solution that supplies calories without is an isotonic solution that supplies calories without

electrolytes. It is useful in the postoperative period when sodium electrolytes. It is useful in the postoperative period when sodium excretion is reduced. It is also valuable when the salt requirements excretion is reduced. It is also valuable when the salt requirements of a patient needing much fluid have been satisfied on a particular of a patient needing much fluid have been satisfied on a particular day. Prolonged administration of 5 % dextrose solution alone is day. Prolonged administration of 5 % dextrose solution alone is liable to result in hyponatraemia, and may cause thrombosis of the liable to result in hyponatraemia, and may cause thrombosis of the vein used;vein used;

2• 2• isotonic (0.9 % ) saline solutionisotonic (0.9 % ) saline solution is required to replace the normal is required to replace the normal sodium requirement (500 ml isotonic saline/day) and additional sodium requirement (500 ml isotonic saline/day) and additional volume is required when a large amount of sodium has been lost by volume is required when a large amount of sodium has been lost by vomiting, or by gastric, duodenal or intestinal aspiration, or vomiting, or by gastric, duodenal or intestinal aspiration, or excessive sweating.excessive sweating.

3• 3• dextrose 4.3 % with saline 0.18 % (one-fifth isotonic saline)dextrose 4.3 % with saline 0.18 % (one-fifth isotonic saline) — this — this solution is isotonic. Usually it is referred to as dextrose—saline. It solution is isotonic. Usually it is referred to as dextrose—saline. It must not be confused with 5% dextrose in saline, which is must not be confused with 5% dextrose in saline, which is hypertonic;hypertonic;

4• 4• Ringer’s lactate solutionRinger’s lactate solution contains sodium, potassium and chloride contains sodium, potassium and chloride in almost the same concentrations as they are in the plasma. It also in almost the same concentrations as they are in the plasma. It also contains some calcium and some lactate. This solution can be used contains some calcium and some lactate. This solution can be used in hypovolaemic shock while awaiting blood. It is also suitable for in hypovolaemic shock while awaiting blood. It is also suitable for replacing lost intestinal secretions.replacing lost intestinal secretions.

SolutionSolution GlucosGlucose (g/l)e (g/l)

NaNa

(meq/(meq/l)l)

ClCl

(meq/(meq/l)l)

Hco3Hco3

(meq(meq/l)/l)

KK

(meq/l)(meq/l)

5%5%

glucoseglucose5050 -------- -------- -------- --------

0.9%0.9%

salinesaline-------- 150150 150150 -------- --------

dextrose dextrose 4.3 % with 4.3 % with saline 0.18 saline 0.18 %%

4343 3131 3131 -------- --------

Ringer’s Ringer’s lactate lactate solutionsolution

-------- 130130 109109 2828 4 + Ca 4 + Ca ++lactatlactatee

5% 5% dextrose in dextrose in 0.9%saline0.9%saline

5050 150150 150150 -------- --------

OsmolOsmolarity arity meq/lmeq/l

Iso=Iso=300300

Iso=Iso=300300

Iso=Iso=300300

Iso=Iso=300300

HyperHyper=600=600

ShockShockShock is a life-threatening situation. It is due to poor tissue Shock is a life-threatening situation. It is due to poor tissue

perfusion with impaired cellular metabolism, manifested in turn perfusion with impaired cellular metabolism, manifested in turn by serious pathophysiological abnormalities.by serious pathophysiological abnormalities.

Types of shock :Types of shock :1- Vasovagal shock :1- Vasovagal shock :Vasovagal shock is brought about by pooling of blood in larger vascular Vasovagal shock is brought about by pooling of blood in larger vascular

reservoirs (limb muscles), and by dilatation of the splanchnic arteriolar reservoirs (limb muscles), and by dilatation of the splanchnic arteriolar bed, causing reduced venous return to the heart, low cardiac output bed, causing reduced venous return to the heart, low cardiac output and reflex bradycardia and reflex bradycardia due to over stimulation of vagus N.due to over stimulation of vagus N. Consequently, the reduced cerebral perfusion causes cerebral hypoxia Consequently, the reduced cerebral perfusion causes cerebral hypoxia and unconsciousness, but this leads to reflex vasoconstriction & then and unconsciousness, but this leads to reflex vasoconstriction & then increases the venous return and cardiac output as to restore cerebral increases the venous return and cardiac output as to restore cerebral perfusion and consciousness. It must be remembered that if the perfusion and consciousness. It must be remembered that if the patient is maintained in an upright or a sitting position (e.g. in a dental patient is maintained in an upright or a sitting position (e.g. in a dental chair) permanent cerebral damage will occur.chair) permanent cerebral damage will occur.

2- Psychogenic shock :2- Psychogenic shock :Psychogenic shock immediately follows a sudden fright (e.g. Psychogenic shock immediately follows a sudden fright (e.g.

bad news) or accompanies severe pain (e.g. a blow to the bad news) or accompanies severe pain (e.g. a blow to the testes) ,also testes) ,also due to over stimulation of vagus N.due to over stimulation of vagus N.

3- Neurogenic shock :3- Neurogenic shock :Neurogenic shock is caused by traumatic or Neurogenic shock is caused by traumatic or

pharmacological blockade of the sympathetic nervous pharmacological blockade of the sympathetic nervous system, producing dilatation of resistance arterioles and system, producing dilatation of resistance arterioles and capacitance veins leading to capacitance veins leading to relativerelative hypovolaemia and hypovolaemia and hypotension. There is a low blood pressure, a normal or hypotension. There is a low blood pressure, a normal or decreased cardiac output, a normal pulse rate and a warm decreased cardiac output, a normal pulse rate and a warm dry skin. This may be corrected by putting the patient in dry skin. This may be corrected by putting the patient in the Trendelenburg position, the rapid administration of the Trendelenburg position, the rapid administration of fluids and or a vasopressor drug.fluids and or a vasopressor drug.

4- Hypovolaemic shock :4- Hypovolaemic shock :Hypovolaemic shock is due to loss of intravascular volume Hypovolaemic shock is due to loss of intravascular volume

by haemorrhage, dehydration, vomiting and diarrhoea by haemorrhage, dehydration, vomiting and diarrhoea (e.g. cholera, acute enterocolitis). Until 10—15 % blood (e.g. cholera, acute enterocolitis). Until 10—15 % blood volume is lost, the blood pressure is maintained by volume is lost, the blood pressure is maintained by tachycardia and vasoconstriction. Fluid moves into the tachycardia and vasoconstriction. Fluid moves into the intra vascular space from the interstitial space . In intra vascular space from the interstitial space . In addition, the venous capacitance vessels constrict, addition, the venous capacitance vessels constrict, pushing blood into the arterial system and therefore pushing blood into the arterial system and therefore compensating for the volume deficit.compensating for the volume deficit.

E.g. of E.g. of Hypovolaemic shock :Hypovolaemic shock :4-1- 4-1- Traumatic shock:Traumatic shock:Traumatic shock is due primarily to hypovolaemia from Traumatic shock is due primarily to hypovolaemia from

bleeding externally (open wounds), from bleeding bleeding externally (open wounds), from bleeding internally (torn vessels in the mediastinal or peritoneal internally (torn vessels in the mediastinal or peritoneal cavities, ruptured organs such as liver and spleen or cavities, ruptured organs such as liver and spleen or fractured bones) or by fluid loss into contused tissue or fractured bones) or by fluid loss into contused tissue or into distended bowel. Traumatic contusion to the heart into distended bowel. Traumatic contusion to the heart itself may cause pump failure and shock, while damage to itself may cause pump failure and shock, while damage to the nervous system or to the respiratory system results in the nervous system or to the respiratory system results in hypoxia.hypoxia.

4-2-Burns shock :4-2-Burns shock :Burns shock occurs as a result of rapid plasma loss from Burns shock occurs as a result of rapid plasma loss from

the damaged tissues, causing hypovolaemia. When 25 % the damaged tissues, causing hypovolaemia. When 25 % or more of the body surface area is burnt, a generalised or more of the body surface area is burnt, a generalised capillary leakage may result in gross hypovolaemia in the capillary leakage may result in gross hypovolaemia in the first 24 hours. Endotoxaemia due to infection makes first 24 hours. Endotoxaemia due to infection makes matters worse and large volumes of fluids are required for matters worse and large volumes of fluids are required for resuscitation.resuscitation.

5- Cardiogenic shock :5- Cardiogenic shock :Cardiogenic shock occurs when more than 50 % of the Cardiogenic shock occurs when more than 50 % of the

wall of the left ventricle is damaged by infarction. Fluid wall of the left ventricle is damaged by infarction. Fluid over load, particularly when using colloids, can lead to over load, particularly when using colloids, can lead to over-distension of the left ventricle, with pump failure. over-distension of the left ventricle, with pump failure. The resultant high filling pressures exerted by the right The resultant high filling pressures exerted by the right ventricle make fluid leak out of the pulmonary ventricle make fluid leak out of the pulmonary capillaries, thereby causing pulmonary oedema and capillaries, thereby causing pulmonary oedema and hypoxia. If an arrhythmia occurs this will reduce the hypoxia. If an arrhythmia occurs this will reduce the pumping efficiency of the heart, while hypovolaemia pumping efficiency of the heart, while hypovolaemia from excess sweating, vomiting and diarrhoea will from excess sweating, vomiting and diarrhoea will further diminish cardiac output.further diminish cardiac output.

Acute massive pulmonary embolism from a thrombus Acute massive pulmonary embolism from a thrombus originating in a deep vein or an air embolus (more than originating in a deep vein or an air embolus (more than 50 ml), if obstructing more than 50 % of the pulmonary 50 ml), if obstructing more than 50 % of the pulmonary vasculature, will cause acute right ventricular failure. vasculature, will cause acute right ventricular failure. This greatly reduces venous return to the left ventricle, This greatly reduces venous return to the left ventricle, and cardiac output falls catastrophically causing and cardiac output falls catastrophically causing sudden death or severe shock.sudden death or severe shock.

6- Septic (endotoxic) shock :6- Septic (endotoxic) shock :6-1- Hyperdynamic (warm) septic shock:6-1- Hyperdynamic (warm) septic shock: This occurs in This occurs in

serious Gram-negative infections , for example from strangulated serious Gram-negative infections , for example from strangulated intestine, peritonitis, leaking oesophageal or intestinal intestine, peritonitis, leaking oesophageal or intestinal anastomoses, or suppurative biliary conditions. At first, the patient anastomoses, or suppurative biliary conditions. At first, the patient has abnormal or increased cardiac output with tachycardia and a has abnormal or increased cardiac output with tachycardia and a warm, dry skin, but the blood is shunted past the tissue cells, warm, dry skin, but the blood is shunted past the tissue cells, which become damaged by anaerobic metabolism (lactic acidosis). which become damaged by anaerobic metabolism (lactic acidosis). The capillary membranes start to leak and endotoxin is absorbed The capillary membranes start to leak and endotoxin is absorbed into the blood stream, leading to a generalised systemic into the blood stream, leading to a generalised systemic inflammatory state. The immediate and ready treatment of the inflammatory state. The immediate and ready treatment of the cause, including the drainage of pus, is vital to the recovery of the cause, including the drainage of pus, is vital to the recovery of the patient at this stage (in strangulated hernia patient at this stage (in strangulated hernia ‘the danger is in the ‘the danger is in the delay, not in the operation’delay, not in the operation’ ). ).

6-2- Hypovolaemic hypodynamic (cold) septic shock : 6-2- Hypovolaemic hypodynamic (cold) septic shock : This This follows if severe sepsis or endotoxaemia is allowed to persist. follows if severe sepsis or endotoxaemia is allowed to persist. Generalised capillary leakage and other fluid losses lead to severe Generalised capillary leakage and other fluid losses lead to severe hypovolaemia with reduced cardiac output, tachycardia and hypovolaemia with reduced cardiac output, tachycardia and vasoconstriction. The systemic infection induces cardiac vasoconstriction. The systemic infection induces cardiac depression, pulmonary hypertension, pulmonary oedema and depression, pulmonary hypertension, pulmonary oedema and hypoxia which, in turn, reduce cardiac output still further. The hypoxia which, in turn, reduce cardiac output still further. The patient becomes cold, clammy, drowsy and tachypnoeic, but still patient becomes cold, clammy, drowsy and tachypnoeic, but still can be converted to hyperdynamic (warm) shock by the can be converted to hyperdynamic (warm) shock by the administration of several litres of plasma or other colloidal administration of several litres of plasma or other colloidal solution. solution.

7- Anaphylactic shock :7- Anaphylactic shock :Penicillin administration is amongst the common Penicillin administration is amongst the common

causes of anaphylaxis. Other causes include causes of anaphylaxis. Other causes include anaesthetics, dextrans, serum injections, stings anaesthetics, dextrans, serum injections, stings and the consumption of shellfish. The antigen and the consumption of shellfish. The antigen combines with immunoglobin E combines with immunoglobin E (IgE)(IgE) on the on the mast cells and basophils, releasing large mast cells and basophils, releasing large amounts of histamine and SRS-A (slow-release amounts of histamine and SRS-A (slow-release substance-anaphylaxis). These compounds substance-anaphylaxis). These compounds cause bronchospasm, laryngeal oedema and cause bronchospasm, laryngeal oedema and respiratory distress with hypoxia, massive respiratory distress with hypoxia, massive vasodilatation, hypotension and shock. The vasodilatation, hypotension and shock. The mortality is around 10 %.mortality is around 10 %.

Clinical monitoringClinical monitoringIn summary, patient monitoring in shock should include:In summary, patient monitoring in shock should include:

1• pulse;1• pulse;2• blood pressure (recording systolic and diastolic 2• blood pressure (recording systolic and diastolic

pressure, the pulse pressure, using an intra-pressure, the pulse pressure, using an intra-arterial line if necessary);arterial line if necessary);

3• heart rate and rhythm (cardioscope);3• heart rate and rhythm (cardioscope);4• respiratory rate and depth;4• respiratory rate and depth;5• CVP;5• CVP;6• PCWP (pulmonary capillary wedge pressure ) in 6• PCWP (pulmonary capillary wedge pressure ) in

severe shock when the diagnosis is in doubt;severe shock when the diagnosis is in doubt;7• urine output;7• urine output;8• serial blood gases and serum electrolyte 8• serial blood gases and serum electrolyte

measurements.measurements.

Treatment of shockTreatment of shockThe management of all types of shock should be vigorous The management of all types of shock should be vigorous

and quick . The objectives are to increase the cardiac and quick . The objectives are to increase the cardiac output and to improve tissue perfusion, especially in output and to improve tissue perfusion, especially in the coronary, cerebral, renal and mesenteric vascular the coronary, cerebral, renal and mesenteric vascular beds. The plan of action should be based on: beds. The plan of action should be based on:

(1) Treat the primary problem —arrest of haemorrhage, (1) Treat the primary problem —arrest of haemorrhage, draining pus, etc.draining pus, etc.

(2) Improving ventricular filling by giving adequate fluid (2) Improving ventricular filling by giving adequate fluid replacement, for example human albumin solution or replacement, for example human albumin solution or fresh frozen plasma, in sepsis and burns;fresh frozen plasma, in sepsis and burns;

(3) Improving myocardial contractility with inotropic (3) Improving myocardial contractility with inotropic agents — dopamine, dobutamine, adrenaline infusions; agents — dopamine, dobutamine, adrenaline infusions;

(4) Correcting acid—base disturbances, using molar (4) Correcting acid—base disturbances, using molar sodium bicarbonate when the pH of arterial blood is sodium bicarbonate when the pH of arterial blood is less than 7.2, and electrolyte abnormalities, especially less than 7.2, and electrolyte abnormalities, especially potassium and calcium levels.potassium and calcium levels.

(5) In endotoxic shock, once the haemodynamic (5) In endotoxic shock, once the haemodynamic status has been improved, full doses of the status has been improved, full doses of the appropriate antibiotics are given to treat the appropriate antibiotics are given to treat the causal infection. Usually we use causal infection. Usually we use tripple tripple antibioticsantibiotics (amoxicillin for gram positive (amoxicillin for gram positive infection , gentamycin for gram negative infection , gentamycin for gram negative infection & metroniadazole for anaerobic infection & metroniadazole for anaerobic infection ).infection ).

Diabetic patients in endotoxic shock are in a Diabetic patients in endotoxic shock are in a precarious position. Careful monitoring and precarious position. Careful monitoring and control of their nutrition and insulin control of their nutrition and insulin requirements are necessary under the requirements are necessary under the instruction of a clinician with a special interest instruction of a clinician with a special interest in diabetes.in diabetes.

(6) (6) VasodilatorsVasodilators(hydralazine, phentolamine, glyceryl (hydralazine, phentolamine, glyceryl trinitrate infusions and chlorpromazine boluses) may be trinitrate infusions and chlorpromazine boluses) may be given provided the blood volume has been corrected and given provided the blood volume has been corrected and cardiac depression treated such that the systolic blood cardiac depression treated such that the systolic blood pressure is 90 mmHg or more. The indication is persistent pressure is 90 mmHg or more. The indication is persistent vasoconstriction with oliguria, high CVP or PCWP and vasoconstriction with oliguria, high CVP or PCWP and pulmonary oedema. Such therapy will improve cardiac pulmonary oedema. Such therapy will improve cardiac output and tissue perfusion, and reduce the work done by output and tissue perfusion, and reduce the work done by the heart.the heart.

It must be emphasised that vasodilators can only It must be emphasised that vasodilators can only be used with extreme caution and full be used with extreme caution and full haemodynamic monitoring, because the sudden haemodynamic monitoring, because the sudden production of vasodilation in a hypovolaemic or production of vasodilation in a hypovolaemic or dehydrated patient can be followed by a dehydrated patient can be followed by a catastrophic fall in arterial blood pressure.catastrophic fall in arterial blood pressure.

These drugs should be given only in small intravenous These drugs should be given only in small intravenous doses or infusions and only until the extremities become doses or infusions and only until the extremities become warm and pink, and the veins are dilated and well filled.warm and pink, and the veins are dilated and well filled.

  

SterilisationSterilisationSterilisation by steam :Sterilisation by steam :Instruments can be sterilised by steam under pressure Instruments can be sterilised by steam under pressure

using using autoclavesautoclaves. Vegetative bacteria, including . Vegetative bacteria, including tuberculosis, and viruses such as hepatitis B, hepatitis C tuberculosis, and viruses such as hepatitis B, hepatitis C and human immunodeficiency virus (HIV) and heat-and human immunodeficiency virus (HIV) and heat-resistant spores, including Clostridium tetani and resistant spores, including Clostridium tetani and Clostridium perfringens, are killed. The combination of Clostridium perfringens, are killed. The combination of pressure, temperature and time with the moist heat is pressure, temperature and time with the moist heat is important:important:

•  •  134’C (30 lb/in.2) for a hold time of 3 minutes;134’C (30 lb/in.2) for a hold time of 3 minutes;•  •  121’C (15 lb/in.2) for a hold time of 15 minutes;121’C (15 lb/in.2) for a hold time of 15 minutes;•  •  prepacked materials and instruments are processed prepacked materials and instruments are processed

through a porous load autoclave which incorporates a through a porous load autoclave which incorporates a pre-vacuum cycle necessary to extract air. If this is not pre-vacuum cycle necessary to extract air. If this is not achieved then the dried saturated steam cannot penetrate achieved then the dried saturated steam cannot penetrate efficiently. Unwrapped instruments can be sterilised in a efficiently. Unwrapped instruments can be sterilised in a small autoclave within the theatre , which is convenient small autoclave within the theatre , which is convenient when instruments are dropped.when instruments are dropped.

Monitoring :Monitoring :All autoclaves must be regularly maintained according to All autoclaves must be regularly maintained according to

the manufacturer’s instructions, and a record should be the manufacturer’s instructions, and a record should be kept of the cycle time, the pre-vacuum phase, the kept of the cycle time, the pre-vacuum phase, the pressure and temperature. In addition, pressure and temperature. In addition, the steam the steam penetration test (Bowie—Dick test) and chemical penetration test (Bowie—Dick test) and chemical indicators,indicators, for example Brownes tubes or impregnated for example Brownes tubes or impregnated tapes, are used to ensure that such errors as poor tapes, are used to ensure that such errors as poor packing do not interfere with the efficiency of the packing do not interfere with the efficiency of the process. Biological indicators are not appropriate.process. Biological indicators are not appropriate.

Sterilisation by ethylene oxide gas :Sterilisation by ethylene oxide gas :Ethylene oxide is a highly penetrative non-corrosive gas Ethylene oxide is a highly penetrative non-corrosive gas

which has a broad-spectrum cidal action. It is utilised for which has a broad-spectrum cidal action. It is utilised for heat-sensitive materials including electrical equipment. It heat-sensitive materials including electrical equipment. It is not recommended for ventilator ,respiratory equipment is not recommended for ventilator ,respiratory equipment or soiled instruments because organic debris, including or soiled instruments because organic debris, including serum, has a marked adverse effectserum, has a marked adverse effect..

Sterilisation by hot air :Sterilisation by hot air :This is inefficient compared with moist steam sterilisation, This is inefficient compared with moist steam sterilisation,

but it has the advantage in the ability to treat solid non-but it has the advantage in the ability to treat solid non-aqueous liquids grease/ointments and to process closed aqueous liquids grease/ointments and to process closed (airtight) containers. Lack of corrosion may be important, (airtight) containers. Lack of corrosion may be important, particularly with instruments with fine cutting edges such particularly with instruments with fine cutting edges such as ophthalmic instruments. It cannot be used for as ophthalmic instruments. It cannot be used for substances such as rubber, plastics and intravenous fluids substances such as rubber, plastics and intravenous fluids which are denatured.which are denatured.

Sterilisation by low-temperature steam and formaldehyde :Sterilisation by low-temperature steam and formaldehyde :This uses a combination of dried saturated steam and This uses a combination of dried saturated steam and

formaldehyde, with the main advantage being that formaldehyde, with the main advantage being that sterilisation is achieved at a low temperature (73’C) and the sterilisation is achieved at a low temperature (73’C) and the method is therefore suitable for heat-sensitive materials method is therefore suitable for heat-sensitive materials and equipment with integral plastic components. It is not and equipment with integral plastic components. It is not recommended for sealed, oily items or those with retained recommended for sealed, oily items or those with retained air. Some plastics and fabrics absorb formaldehyde, air. Some plastics and fabrics absorb formaldehyde, releasing this in a delayed manner which may cause releasing this in a delayed manner which may cause hypersensitivity to the users.hypersensitivity to the users.

Sterilisation by irradiation :Sterilisation by irradiation :

This technique employs gamma rays or accelerated This technique employs gamma rays or accelerated electrons. It is an industrial process and is electrons. It is an industrial process and is particularly appropriate to the sterilisation of particularly appropriate to the sterilisation of large batches of similar products, such as large batches of similar products, such as syringes, catheters and intravenous cannulas. syringes, catheters and intravenous cannulas. The delivery of an irradiation dose in excess of The delivery of an irradiation dose in excess of 25 kGy is accepted as providing adequate 25 kGy is accepted as providing adequate sterility assurance.sterility assurance.

DisinfectionDisinfectionCleaning of items is essential before Cleaning of items is essential before

disinfection is under taken and the disinfection is under taken and the efficiency also depends on:efficiency also depends on:

1. the nature of microorganisms;1. the nature of microorganisms;

2. the load of microorganisms;2. the load of microorganisms;

3. the duration of exposure to the agent;3. the duration of exposure to the agent;

4. the temperature4. the temperature..

Disinfection with low-temperature steam :Disinfection with low-temperature steam :Typical conditions include exposure to dry Typical conditions include exposure to dry

saturated steam at a temperature of 73’C for a saturated steam at a temperature of 73’C for a period of 20 minutes at a pressure below period of 20 minutes at a pressure below atmospheric. This is a useful process for atmospheric. This is a useful process for dealing with dirty returns from the operating dealing with dirty returns from the operating theatre or clinics which may be contaminated theatre or clinics which may be contaminated with protein from bodily secretions and with protein from bodily secretions and microorganisms. Following this method of microorganisms. Following this method of disinfection the instruments must be cleaned.disinfection the instruments must be cleaned.

Disinfection with boiling water :Disinfection with boiling water :This utilises soft water at 100’C at normal This utilises soft water at 100’C at normal

pressure for 5minutes. Instruments must be pressure for 5minutes. Instruments must be thoroughly cleaned before being utilised.thoroughly cleaned before being utilised.

Disinfection with formaldehyde :Disinfection with formaldehyde :Formaldehyde gas is a broad-spectrum Formaldehyde gas is a broad-spectrum

antimicrobial agent. This process utilises a antimicrobial agent. This process utilises a cabinet which is airtight and circulates gaseous cabinet which is airtight and circulates gaseous formaldehyde up to 50’C.formaldehyde up to 50’C.

Disinfection with glutaraldehyde :Disinfection with glutaraldehyde :A 2 per cent solution of glutataldehyde is effective A 2 per cent solution of glutataldehyde is effective

against most bacterial viruses, including hepatitis against most bacterial viruses, including hepatitis B and C and HIV, and is particularly useful for the B and C and HIV, and is particularly useful for the decontamination of flexible endoscopes.decontamination of flexible endoscopes.

•  •  Thorough cleansing is essential.Thorough cleansing is essential.•  •  The degree of decontamination is proportional to The degree of decontamination is proportional to

the time of immersion.the time of immersion.•  •  It is a toxic substance and causes irritant, allergic It is a toxic substance and causes irritant, allergic

reactions to the staff, particularly skin reactions, reactions to the staff, particularly skin reactions, which limits its usewhich limits its use..

  Safeguards for equipment during sterilisation :Safeguards for equipment during sterilisation : Safeguards during sterilisation must include:Safeguards during sterilisation must include:1 •  thorough cleaning;1 •  thorough cleaning;2 •  appropriate packing for the sterilisation of disinfection 2 •  appropriate packing for the sterilisation of disinfection

process in order to avoid reduced penetration of the process in order to avoid reduced penetration of the active agent. This is particularly important in the packing active agent. This is particularly important in the packing in the autoclave;in the autoclave;

3 •  arrangements of articles so that all surfaces are directly 3 •  arrangements of articles so that all surfaces are directly exposed to the agent. This includes opening or unlocking exposed to the agent. This includes opening or unlocking jointed instruments and disassembling instruments;jointed instruments and disassembling instruments;

4 •  the use of chemical indicators routinely;4 •  the use of chemical indicators routinely;5 •  the interval monitoring of sterilisation process with 5 •  the interval monitoring of sterilisation process with

chemical, thermal and, sometimes, biological indicators;chemical, thermal and, sometimes, biological indicators;6 •  the utilisation of flash sterilisation, where a temperature 6 •  the utilisation of flash sterilisation, where a temperature

of 147’C is used at a pressure of 40 lb/in.2, is now rare of 147’C is used at a pressure of 40 lb/in.2, is now rare and should only be considered in an emergency situation;and should only be considered in an emergency situation;

7 •  a careful maintenance plan for all sterilisation 7 •  a careful maintenance plan for all sterilisation processesprocesses..

Conclusion :Conclusion :Antibiotics, both prophylactic and Antibiotics, both prophylactic and

therapeutic, have not reduced the therapeutic, have not reduced the essential role of asepsis and sterile essential role of asepsis and sterile precautions. Protocols with regard to precautions. Protocols with regard to instrument sterilisation, equipment instrument sterilisation, equipment maintenance, air filtration and maintenance, air filtration and ventilation, and staff behavior are ventilation, and staff behavior are essential. Regular staff education is essential. Regular staff education is imperative.imperative.

TumoursTumours : :A tumour is a new growth of tissue (a mass) which can refer to A tumour is a new growth of tissue (a mass) which can refer to

an inflammatory swelling such as inflammatory tumour or an inflammatory swelling such as inflammatory tumour or to a neoplastic growth. A neoplastic tumour is an to a neoplastic growth. A neoplastic tumour is an uncontrolled proliferation of a clone of cells without useful uncontrolled proliferation of a clone of cells without useful function.function.

Causation :Causation :Cancer is a disease of genes. The cell is the basic unit of Cancer is a disease of genes. The cell is the basic unit of

organisation and control. The genetic code is contained organisation and control. The genetic code is contained within the deoxyribonucleic acid (DNA) molecule present within the deoxyribonucleic acid (DNA) molecule present within the cell nucleus. Genes make proteins which govern within the cell nucleus. Genes make proteins which govern the function and structure of a cell. There are around the function and structure of a cell. There are around 100 000 genes (human genome) representing approximately 100 000 genes (human genome) representing approximately 10 % of the DNA; each cell expresses 5—150000 genes. 10 % of the DNA; each cell expresses 5—150000 genes. Since all genes are present in each cell nucleus, any gene Since all genes are present in each cell nucleus, any gene may be expressed if the gene promoter is switched on, as may be expressed if the gene promoter is switched on, as occurs in neoplasia. Cancer is caused by disease of genes occurs in neoplasia. Cancer is caused by disease of genes which control production of daughter cells from stem cells, which control production of daughter cells from stem cells, cell proliferation, terminal differentiation and programmed cell proliferation, terminal differentiation and programmed cell death (apoptosis)= from the Greek — shedding of cell death (apoptosis)= from the Greek — shedding of autumn leaves. There are three important classes of genes autumn leaves. There are three important classes of genes involved in cancer:involved in cancer:

1-1- tumour suppressor genestumour suppressor genes, which control the cell cycle by , which control the cell cycle by slowing down the cycle or triggering apoptosis (TP53, P16, slowing down the cycle or triggering apoptosis (TP53, P16, APC, RB1);APC, RB1);

2- 2- oncogenes oncogenes, which promote cell proliferation by increasing , which promote cell proliferation by increasing signalling activity from the cell surface to the transcription signalling activity from the cell surface to the transcription apparatus on gene promoters (KRAS, ERBB2, C-MYC);apparatus on gene promoters (KRAS, ERBB2, C-MYC);

3- 3- growth factors and their receptorsgrowth factors and their receptors which are switched on which are switched on by oncogenes or switched off by tumour suppressor genes by oncogenes or switched off by tumour suppressor genes (EGF, TGFa, IGF, FGF).(EGF, TGFa, IGF, FGF).

  A benign tumourA benign tumour grows by expansion without invasion of the grows by expansion without invasion of the extra-cellular matrix. extra-cellular matrix. A malignant tumourA malignant tumour (cancer) grows (cancer) grows by invasion into the extracellular matrix; most solid by invasion into the extracellular matrix; most solid tumours also invade the basement membrane of tumours also invade the basement membrane of endothelium and metastasise. The unit of cancer is the endothelium and metastasise. The unit of cancer is the altered malignant cell which proliferates (altered malignant cell which proliferates (cloneclone). Different ). Different clones usually arise with different characteristics, such as clones usually arise with different characteristics, such as the ability to metastasise via blood vessels or lymphatics. the ability to metastasise via blood vessels or lymphatics. Cancer is a disease of genes which may be inherited or Cancer is a disease of genes which may be inherited or acquired .acquired . Inherited cancers are caused by a specific DNA Inherited cancers are caused by a specific DNA mutation of a tumour suppresser gene inherited in all cells. mutation of a tumour suppresser gene inherited in all cells.

In cells of the organ affected, the (second) homologous gene In cells of the organ affected, the (second) homologous gene is lost, initiating a sequence of is lost, initiating a sequence of genetic mutationsgenetic mutations culminating in cancer. culminating in cancer. Chemical carcinogensChemical carcinogens probably probably account for the majority of sporadic (acquired) cancers. account for the majority of sporadic (acquired) cancers. Natives of Kashmir are prone to cancer of the skin of the Natives of Kashmir are prone to cancer of the skin of the thighs and lower abdomen. This is due to their habit of thighs and lower abdomen. This is due to their habit of keeping warm by squatting and hugging earthenware pots keeping warm by squatting and hugging earthenware pots containing glowing charcoal [the pot being termed a containing glowing charcoal [the pot being termed a fangri ], with the result that the adjacent skin is irritated by fangri ], with the result that the adjacent skin is irritated by heat and fumes. ‘Chimney-sweep’s’ cancer’ , heat and fumes. ‘Chimney-sweep’s’ cancer’ , ‘countryman’s lip’, and ‘tar workers’ cancer’ are other ‘countryman’s lip’, and ‘tar workers’ cancer’ are other examples of carcinoma due to chemical carcinogens. DNA examples of carcinoma due to chemical carcinogens. DNA strand breaks are induced by strand breaks are induced by ultraviolet and ionising ultraviolet and ionising radiationradiation which, if not repaired, lead to cancer. which, if not repaired, lead to cancer. Cellular Cellular instabilityinstability from ageing of stem cell-lines (many common from ageing of stem cell-lines (many common cancers) or chronic inflammation leads to increased cell cancers) or chronic inflammation leads to increased cell proliferation and reduced apoptosis. This results in proliferation and reduced apoptosis. This results in malignant transformation. Squamous cell carcinoma malignant transformation. Squamous cell carcinoma occasionally occurs in a chronic ulcer or in a scar occasionally occurs in a chronic ulcer or in a scar ‘Marjolin’s ulcer’). A fibrosarcoma also may arise in a scar. ‘Marjolin’s ulcer’). A fibrosarcoma also may arise in a scar. At least 20 % of cancers world-wide are caused by At least 20 % of cancers world-wide are caused by oncogenic virusesoncogenic viruses..

Environmental cofactorsEnvironmental cofactors are also important. are also important. Helicobacter pylori is linked to the development Helicobacter pylori is linked to the development of gastric cancer by an unknown mechanism. A of gastric cancer by an unknown mechanism. A diet high in calories and rich in saturated fats diet high in calories and rich in saturated fats (from red meat) is implicated in many cancers (from red meat) is implicated in many cancers including those of the colorectum and pancreas. including those of the colorectum and pancreas. In viral carcinogenesis there are specific In viral carcinogenesis there are specific cofactors for different cancers: malaria cofactors for different cancers: malaria (Burkitt’s lymphoma), immunosuppression (Burkitt’s lymphoma), immunosuppression (post-transport lymphomatous proliferative (post-transport lymphomatous proliferative disease — PTLPD), human immunodeficiency disease — PTLPD), human immunodeficiency virus (Kaposi’s sarcoma ), smoking (cervical virus (Kaposi’s sarcoma ), smoking (cervical cancer) and aflatoxins (liver cancer).cancer) and aflatoxins (liver cancer).

Definitions :Definitions :•   •   Hypertrophy :Hypertrophy :is an increase in the size of an organ without an is an increase in the size of an organ without an

increase in cell numbers.increase in cell numbers.•   •   Hyperplasia :Hyperplasia : is an increase in the size of an organ due to an is an increase in the size of an organ due to an

increase in cell numbers.increase in cell numbers.•   •   Metaplasia :Metaplasia : The epithelium from which the tumour grows has The epithelium from which the tumour grows has

already changed its characteristics: bladder transitional already changed its characteristics: bladder transitional epithelium to squamous epithelium, gallbladder columnar to epithelium to squamous epithelium, gallbladder columnar to squamous epithelium, bronchial columnar to squamous squamous epithelium, bronchial columnar to squamous epithelium, gastric columnar epithelial pattern to intestinal epithelium, gastric columnar epithelial pattern to intestinal epithelial pattern and oesophageal squamous to columnar epithelial pattern and oesophageal squamous to columnar epithelium (Barrett’s oesophagus).epithelium (Barrett’s oesophagus).

• • Dysplasia :Dysplasia :This represents the earliest changes of neo plastic This represents the earliest changes of neo plastic transformation than can be detected at the microstructural level transformation than can be detected at the microstructural level (e.g. by light microscopy). In fact, genetic mutations are (e.g. by light microscopy). In fact, genetic mutations are detectable at an earlier stage. Alterations in intracellular detectable at an earlier stage. Alterations in intracellular organisation, the individual size and shape of the nucleus, organisation, the individual size and shape of the nucleus, cellular size and shape and intercellular three-dimensional cellular size and shape and intercellular three-dimensional organisation indicate dysplasia. These changes may be organisation indicate dysplasia. These changes may be classified as mild, moderate or severe dysplasia. Any grade of classified as mild, moderate or severe dysplasia. Any grade of dysplasia may revert to normal due to elimination of the dysplasia may revert to normal due to elimination of the neoplastic clone, but is least likely with severe dysplasia.neoplastic clone, but is least likely with severe dysplasia.

o Carcinoma in situ :Carcinoma in situ : Severe dysplasia may progress to Severe dysplasia may progress to carcinoma in situ: the cellular, nuclear and three-carcinoma in situ: the cellular, nuclear and three-dimensional architecture resemble cancer but without dimensional architecture resemble cancer but without invasion into the extracellular matrix.invasion into the extracellular matrix.

• • Genotype : Genotype : This is the molecular structure of any cell. A This is the molecular structure of any cell. A malignant genotype will have losses and mutations of malignant genotype will have losses and mutations of tumour suppresser genes and the presence of tumour suppresser genes and the presence of oncogenes.oncogenes.

•   •   Phenotype : Phenotype : This is the appearance of a cell at a This is the appearance of a cell at a microstructural level (microscopic phenotype) and its microstructural level (microscopic phenotype) and its functional state (biological phenotype). A changed functional state (biological phenotype). A changed genotype will always precede a particular phenotype: for genotype will always precede a particular phenotype: for a time the cell may appear to be normal even though it a time the cell may appear to be normal even though it has already acquired a malignant genotype.has already acquired a malignant genotype.

• • Differentiation : Differentiation : Depending on the degree to which the Depending on the degree to which the cells and organisation (morphology) of tumours resemble cells and organisation (morphology) of tumours resemble the parent tissue they are divided into well-differentiated, the parent tissue they are divided into well-differentiated, moderately differentiated and poorly differentiated formsmoderately differentiated and poorly differentiated forms..

o Anaplasia : Anaplasia : Tumours are usually composed of Tumours are usually composed of cells which resemble those of the tissue from cells which resemble those of the tissue from which they arise. Complete loss of which they arise. Complete loss of differentiation (anaplasia) is associated with differentiation (anaplasia) is associated with an aggressive cancer.an aggressive cancer.

• • Teratomas :Teratomas : arise from embryonic stem cells arise from embryonic stem cells containing representative cells from all three containing representative cells from all three embryonic layers: ectoderm, endoderm, embryonic layers: ectoderm, endoderm, mesoderrn . Teratomatous dermoids contain mesoderrn . Teratomatous dermoids contain hair and teeth, muscle and gland tissue. An hair and teeth, muscle and gland tissue. An unusual type is the sacrococcygeal unusual type is the sacrococcygeal teratoma ,which can be considered as foetus teratoma ,which can be considered as foetus in foeto (an ‘included’ foetus).in foeto (an ‘included’ foetus).

• • Blastomas : Blastomas : develop from ‘unipotent’ cells, and develop from ‘unipotent’ cells, and arise from any one of the three embryonic arise from any one of the three embryonic layers (e.g. neuro blastoma).layers (e.g. neuro blastoma).

• • Dermoid cysts : Dermoid cysts : ‘Dermoid’ is a loose term given to cysts ‘Dermoid’ is a loose term given to cysts lined by squamous epithelium occurring in various parts lined by squamous epithelium occurring in various parts of the body. Sebaceous cysts are lined by superficial of the body. Sebaceous cysts are lined by superficial squamous cells and should more accurately be called squamous cells and should more accurately be called ‘epidermoid’.‘epidermoid’.

------Teratomatous dermoidsTeratomatous dermoids (see above) are found in the (see above) are found in the ovary, testis retroperitoneum, superior mediastinurn and ovary, testis retroperitoneum, superior mediastinurn and the presacral area. Malignant change (carcinomatous or the presacral area. Malignant change (carcinomatous or sarcomatous) can occur.sarcomatous) can occur.

—    —    Sequestration dermoidsSequestration dermoids are not new growths, but are are not new growths, but are formed by the inclusion of epithelial ‘nests’ beneath the formed by the inclusion of epithelial ‘nests’ beneath the surface at places where lines of developing skin meet surface at places where lines of developing skin meet and join: midline, external angular process, branchial and join: midline, external angular process, branchial cysts .cysts .

—    —    Implantation dermoidsImplantation dermoids may follow puncture wounds, may follow puncture wounds, commonly of the fingers, when living epithelial cells are commonly of the fingers, when living epithelial cells are implanted beneath the surface.implanted beneath the surface.

Benign tumour :Benign tumour : A benign tumour is usually encapsulated, and does not A benign tumour is usually encapsulated, and does not

disseminate or recur after complete removal. Symptoms and disseminate or recur after complete removal. Symptoms and effects, which can be harmful, are due to its size, position, and effects, which can be harmful, are due to its size, position, and pressure. Certain adenomas secrete a  hormone which may pressure. Certain adenomas secrete a  hormone which may affect bodily functions. Benign tumours are often multiple.affect bodily functions. Benign tumours are often multiple.

Malignant tumour :Malignant tumour : The characteristics of malignancy are:The characteristics of malignancy are:—    —    invasion of surrounding tissues;invasion of surrounding tissues;—    —    pleomorphism (variable shapes) of cells and nuclei;pleomorphism (variable shapes) of cells and nuclei;—  —  rapid growth;rapid growth;—  —  the tendency to spread to other parts of the body (metastasis) the tendency to spread to other parts of the body (metastasis)

by the lymphatics, the bloodstream, along nerve sheaths and by the lymphatics, the bloodstream, along nerve sheaths and across body cavities;across body cavities;

—    —    general weight loss (cachexia in advanced disease).general weight loss (cachexia in advanced disease).  At an early stage, evidence of invasion is the most important sign At an early stage, evidence of invasion is the most important sign

of malignancy. Many cells of a malignant tumour have an of malignancy. Many cells of a malignant tumour have an abnormal number of chromosomes which is not a multiple of the abnormal number of chromosomes which is not a multiple of the usual haploid number (= ‘aneuploidy’).usual haploid number (= ‘aneuploidy’).

It has been suggested that the division of It has been suggested that the division of tumours into these two major groups tumours into these two major groups imposes a concept which is too rigid .imposes a concept which is too rigid .

A third group of intermediate tumors A third group of intermediate tumors exists which includes some carcinoid exists which includes some carcinoid tumours, adenoma of the bronchus, tumours, adenoma of the bronchus, ‘mixed’ salivary tumours and basal-cell ‘mixed’ salivary tumours and basal-cell carcinoma. These intermediate types carcinoma. These intermediate types invade locally, but are much less inclined invade locally, but are much less inclined to lymphatic or especially vascular to lymphatic or especially vascular dissemination.dissemination.

Benign tumoursBenign tumours AdenomaAdenomaAdenomas arise in secretory glands, and Adenomas arise in secretory glands, and

resemble the structure from which they resemble the structure from which they arise. They are encapsulated, and arise. They are encapsulated, and sometimes they secrete hormones which sometimes they secrete hormones which profoundly influence metabolism, as in the profoundly influence metabolism, as in the case of the thyroid, parathyroid and case of the thyroid, parathyroid and pancreas. Occasionaliy an adenoma pancreas. Occasionaliy an adenoma contains a large proportion of fibrous contains a large proportion of fibrous tissue, e.g. the hard fibro adenoma in the tissue, e.g. the hard fibro adenoma in the breast, while in other situations, notably breast, while in other situations, notably the pancreas and thyroid gland, cystic the pancreas and thyroid gland, cystic degeneration is common. Those arising degeneration is common. Those arising from superficial glands of mucous from superficial glands of mucous membrane are liable to pedunculation, as membrane are liable to pedunculation, as in the case of a rectal ‘polyp,.in the case of a rectal ‘polyp,.

PapillomaPapillomaA papilloma consists of a central axis of A papilloma consists of a central axis of

connective tissue, blood vessels and lymphatics; connective tissue, blood vessels and lymphatics; the surface is covered by epithelium, either the surface is covered by epithelium, either squamous, transitional, cuboidal or columnar, squamous, transitional, cuboidal or columnar, according to the site of the tumour. The surface according to the site of the tumour. The surface may be merely roughened, or composed of may be merely roughened, or composed of innumerable delicate villous processes, as in the innumerable delicate villous processes, as in the case of those occurring in the kidney, bladder case of those occurring in the kidney, bladder and rectum. In these situations, papillomas and rectum. In these situations, papillomas resemble malignant tumours, as secondary resemble malignant tumours, as secondary growths arise by implantation and, sooner or growths arise by implantation and, sooner or later, the tumour becomes frankly malignant . later, the tumour becomes frankly malignant . Other common sites for papillomas are the skin, Other common sites for papillomas are the skin, the colon, the tongue and lip, vocal cords and the colon, the tongue and lip, vocal cords and the walls of cysts (particularly those the breast the walls of cysts (particularly those the breast and ovary).and ovary).

FibromaFibromaA true fibroma (containing only fibrous connective tissue) is A true fibroma (containing only fibrous connective tissue) is

rare. Most fibromas are combined with other mesoderm rare. Most fibromas are combined with other mesoderm tissues such as muscle (fibromyoma), fat (fibrolipoma) ,a tissues such as muscle (fibromyoma), fat (fibrolipoma) ,a nerve sheaths (neurofibroma). Multiple tumours are not nerve sheaths (neurofibroma). Multiple tumours are not uncommon as, for example, in neurofibrornatosis (von -uncommon as, for example, in neurofibrornatosis (von -Recklinghausen’s disease,Recklinghausen’s disease,

Fibromas are either hard or soft, depending on the Fibromas are either hard or soft, depending on the proportion of fibrous to the other cellular tissue. Soft proportion of fibrous to the other cellular tissue. Soft fibromas a common in the subcutaneous tissue of the fibromas a common in the subcutaneous tissue of the face, and appear soft, brown swellings.face, and appear soft, brown swellings.

  DesmoidDesmoid ; ;This unusual type of flbroma occurs in the This unusual type of flbroma occurs in the abdominal wall . An intraperitoneal form is associated abdominal wall . An intraperitoneal form is associated with familial adenomato polyposis .with familial adenomato polyposis .

  KeloidKeloid :This overgrowth of fibrous tissue commonly occurs :This overgrowth of fibrous tissue commonly occurs in scars, especially black people.in scars, especially black people.

  LipomaLipoma : :A lipoma is a slowly growing tumour composed of fat cells adult type. A lipoma is a slowly growing tumour composed of fat cells adult type.

Lipomas may be encapsulated or diffuse. It occur anywhere in the Lipomas may be encapsulated or diffuse. It occur anywhere in the body where fat is found and earn the titles of the ‘universal tumour’. body where fat is found and earn the titles of the ‘universal tumour’. The head and neck area, abdominal wall and thighs are particularly The head and neck area, abdominal wall and thighs are particularly favoured sites.favoured sites.

Encapsulated lipomas are among the commonest of tumours. The Encapsulated lipomas are among the commonest of tumours. The characteristic features are the presence of a definite edge and characteristic features are the presence of a definite edge and lobulation. A sense of fluctuation may be obtained. As would be lobulation. A sense of fluctuation may be obtained. As would be expected, a lipoma deeply situated is liable to be mistaken for other expected, a lipoma deeply situated is liable to be mistaken for other swellings. Most lipomas are painless, but some give rise to an aching swellings. Most lipomas are painless, but some give rise to an aching sensation which may radiate.sensation which may radiate.

Multiple lipomas are not uncommon. The tumours remain small or Multiple lipomas are not uncommon. The tumours remain small or moderate in size, and are sometimes painful, in which case the moderate in size, and are sometimes painful, in which case the condition is probably one of neurolipomatosis.condition is probably one of neurolipomatosis.

Dercum ‘s diseaseDercum ‘s disease characterised by tender deposits of fat, especially on characterised by tender deposits of fat, especially on the trunk.the trunk.

Should the lipoma contain an excessive amount of fibrous tissue, it is Should the lipoma contain an excessive amount of fibrous tissue, it is termed a fibrolipoma. In other cases, considerable vascularity is termed a fibrolipoma. In other cases, considerable vascularity is present, often with telangiectasis of the overlying skin, in which case present, often with telangiectasis of the overlying skin, in which case the tumour is a naevo-lipoma. Large lipomas of the thigh , the shoulder the tumour is a naevo-lipoma. Large lipomas of the thigh , the shoulder and the retroperitoneum occasionally undergo sarcomatous changes. and the retroperitoneum occasionally undergo sarcomatous changes. Myxomatous degeneration, saponification and calcification sometimes Myxomatous degeneration, saponification and calcification sometimes occur in lipomas of long duration.occur in lipomas of long duration.

Clinically, circumscribed lipomas are classified according to their Clinically, circumscribed lipomas are classified according to their Situation.Situation.

•  •  Subcutaneous lipoma : Subcutaneous lipoma : Commonly found on the shoulders Commonly found on the shoulders or the back, although no part of the body is immune. A or the back, although no part of the body is immune. A lipoma may be present over the site of a spina bifida. lipoma may be present over the site of a spina bifida. Subcutaneous lipomas occasionally become Subcutaneous lipomas occasionally become pedunculated.pedunculated.

•  •  Sub- fascial lipoma :Sub- fascial lipoma : Occurring under the palmar or plantar Occurring under the palmar or plantar fascia, they are liable to be mistaken for tuberculous fascia, they are liable to be mistaken for tuberculous tenosynovitis, as the tough, overlying fascia masks the tenosynovitis, as the tough, overlying fascia masks the definite edge and lobulation of the tumour. Difficulty is definite edge and lobulation of the tumour. Difficulty is encountered in complete removal as pressure encourages encountered in complete removal as pressure encourages the tumour to ramify. Subfascial lipomas also occur in the the tumour to ramify. Subfascial lipomas also occur in the areolar layer under the epicranial aponeurosis and, if of areolar layer under the epicranial aponeurosis and, if of long duration, they erode the underlying bone, so that a long duration, they erode the underlying bone, so that a depression is palpable on pushing the tumour to one side.depression is palpable on pushing the tumour to one side.

•  •  Sub-synovial lipoma :Sub-synovial lipoma : From the fatty padding around joints, From the fatty padding around joints, especially the knee. In the knee, they are mistaken from especially the knee. In the knee, they are mistaken from Baker’s cysts but are easily distinguished as, in distinction Baker’s cysts but are easily distinguished as, in distinction to a cyst or bursa, their consistency is constant whether to a cyst or bursa, their consistency is constant whether the joint is in extension or flexion.the joint is in extension or flexion.

•  •  Intermuscular lipoma :Intermuscular lipoma : Mainly in the thigh or around the shoulder. Mainly in the thigh or around the shoulder. Owing to transmitted pressure, the tumour becomes firmer when the Owing to transmitted pressure, the tumour becomes firmer when the adjacent muscles are contracted. Weakness or aching results, owing adjacent muscles are contracted. Weakness or aching results, owing to mechanical interference with muscular action. The condition is to mechanical interference with muscular action. The condition is often difficult to distinguish from a fibrosarcoma.often difficult to distinguish from a fibrosarcoma.

•  •  Peri-osteal lipoma :Peri-osteal lipoma : occasionally occur under the periosteum of a occasionally occur under the periosteum of a bone.bone.

•  •  SubserousSubserous lipomalipoma : is sometimes found beneath the pleura, where : is sometimes found beneath the pleura, where they constitute one variety of innocent thoracic tumour. they constitute one variety of innocent thoracic tumour.

•  •  Submucous lipomaSubmucous lipoma : occur under the mucous membrane of the : occur under the mucous membrane of the respiratory or alimentary tracts. Rarely a submucous Iipoma in the respiratory or alimentary tracts. Rarely a submucous Iipoma in the larynx causes respiratory obstruction. A submucous lipoma can larynx causes respiratory obstruction. A submucous lipoma can occur in the tongue. One situated in the intestine is likely to cause an occur in the tongue. One situated in the intestine is likely to cause an intussusception, which may be the first indication of its presence.intussusception, which may be the first indication of its presence.

•  •  Central nervous system Lipomas :Central nervous system Lipomas : may occur anywhere within the may occur anywhere within the extradural spaces, the spinal cord and brain; they usually arise from extradural spaces, the spinal cord and brain; they usually arise from the pia mater, within the central subarachnoid spaces; a lipoma of the the pia mater, within the central subarachnoid spaces; a lipoma of the corpus callosum may be accompanied by calcification . •  corpus callosum may be accompanied by calcification . •  Intraglandular LipomasIntraglandular Lipomas : have been found occasionally in the : have been found occasionally in the pancreas, under the renal capsule and in the breast .pancreas, under the renal capsule and in the breast .

•  •  Retropenitoneal lipoma :Retropenitoneal lipoma :. Large lipomas are seen not infrequently in . Large lipomas are seen not infrequently in the retroperitoneal tissues. Some of them turn out to be the retroperitoneal tissues. Some of them turn out to be liposarcomas.liposarcomas.

Treatment of lipoma : If a lipoma is causing trouble on account of its

site, size, appearance or the presence of pain, removal is indicated.

During operation, any finger-like projections of the tumour into the surrounding tissue should also be removed. Although the tumour is relatively avascular, care is needed to obtain complete haemostasis in the resulting cavity otherwise a haematoma is common, which may be followed by infection and delay in wound healing; drainage is often necessary.

Diffuse lipoma occasionally occurs in the subcutaneous tissue of the neck, from which it spreads on to the preauricular region of the face. The tumour is not obviously encapsulated, and gives rise to no trouble, beyond being unsightly.

Neuroma :Neuroma :True neuromas are rare tumours, and occur in connection True neuromas are rare tumours, and occur in connection

with the sympathetic system. They comprise the following with the sympathetic system. They comprise the following types:types:

•  •  Ganglioneuroma :Ganglioneuroma : which consist of ganglion cells and nerve which consist of ganglion cells and nerve fibres. It arises in connection with the sympathetic ganglia, fibres. It arises in connection with the sympathetic ganglia, and therefore is found in the retroperitoneal tissue, or in and therefore is found in the retroperitoneal tissue, or in the neck or thorax.the neck or thorax.

•  •  Neuroblastoma ;Neuroblastoma ; which is less differentiated than the which is less differentiated than the ganglioneuroma, the cells being of an embryonic type. The ganglioneuroma, the cells being of an embryonic type. The tumour somewhat resembles a round-celled sarcoma, and tumour somewhat resembles a round-celled sarcoma, and disseminates by the bloodstream. It occurs in infants and disseminates by the bloodstream. It occurs in infants and young children. It may occasionally undergo spontaneous young children. It may occasionally undergo spontaneous remission.remission.

•  •  Myelinic neuroma :Myelinic neuroma : is very rare, being composed only of is very rare, being composed only of nerve fibres, as the ganglion cells are absent. They arise in nerve fibres, as the ganglion cells are absent. They arise in connection with the spinal cord or pia mater.connection with the spinal cord or pia mater.

  Neurilemmoma (syn. Schwannoma)Neurilemmoma (syn. Schwannoma)  These lobulated and encapsulated tumours arise from the These lobulated and encapsulated tumours arise from the

neurilemmal cells. They are soft and whitish in appearance. neurilemmal cells. They are soft and whitish in appearance. They displace the nerve from which they arise and can be They displace the nerve from which they arise and can be removed .removed .

  

NeurofibromaNeurofibromaNeurofibroma arise from the connective tissue of Neurofibroma arise from the connective tissue of

the nerve sheath. The following varieties are the nerve sheath. The following varieties are described.described.

A single neurofibromaA single neurofibroma is usually found in the is usually found in the subcutaneous tissue = The ‘painful subcutaneous subcutaneous tissue = The ‘painful subcutaneous nodule’ forms a smooth firm swelling which may nodule’ forms a smooth firm swelling which may be moved in a lateral direction, but is otherwise be moved in a lateral direction, but is otherwise fixed by the nerve from which it arises. fixed by the nerve from which it arises. Paraesthesia or pain is likely to occur from the Paraesthesia or pain is likely to occur from the pressure of the tumour on the nerve fibres which pressure of the tumour on the nerve fibres which are spread over its surface. Cystic degeneration are spread over its surface. Cystic degeneration or sarcomatous changes occur occasionally.or sarcomatous changes occur occasionally.

Neurofibromas may also grow from the sheath of a Neurofibromas may also grow from the sheath of a peripheral nerve or a cranial nerve, e.g. the peripheral nerve or a cranial nerve, e.g. the acoustic tumour . As the nerve fibres are ‘part acoustic tumour . As the nerve fibres are ‘part and parcel’ of the tumour they are difficult to and parcel’ of the tumour they are difficult to remove without removal of the nerve itself. In remove without removal of the nerve itself. In major nerves recurrence is a problem, as is major nerves recurrence is a problem, as is malignant (sarcomatous) change.malignant (sarcomatous) change.

Generalised neurofibromatosis =((syn. von Rechlinghausen’s disease of nerves) :syn. von Rechlinghausen’s disease of nerves) :In this inherited (autosomal-dominant) disease, any In this inherited (autosomal-dominant) disease, any

cranial, spinal or peripheral nerve may be diffusely or cranial, spinal or peripheral nerve may be diffusely or modularly thickened . The overgrowth occurs in modularly thickened . The overgrowth occurs in connection with the endoneurium. Associated connection with the endoneurium. Associated pigmentation (cafe au lait) of the skin is common, and pigmentation (cafe au lait) of the skin is common, and sarcomatous changes may occur.sarcomatous changes may occur.

Plexiform neurofibromatosis :Plexiform neurofibromatosis :This rare condition usually occurs in connection with This rare condition usually occurs in connection with

branches of the fifth cranial nerve , although it may branches of the fifth cranial nerve , although it may occur in the extremities . The affected nerves become occur in the extremities . The affected nerves become enormously thickened as a result of myxofibromatous enormously thickened as a result of myxofibromatous degeneration of the endoneurium.degeneration of the endoneurium.

  False neuroma :False neuroma :Arises from the connective tissue of the nerve sheath Arises from the connective tissue of the nerve sheath

after injury to a nerve (lacerations or amputation). after injury to a nerve (lacerations or amputation). These swellings consist of fibrous tissue and coiled These swellings consist of fibrous tissue and coiled nerve fibres.nerve fibres.

  Haemangiomas :Haemangiomas :      They are represented in various forms, capillary, cavernous They are represented in various forms, capillary, cavernous

and plexiform being common.and plexiform being common.Glomangioma (syn. glomus tumour) :Glomangioma (syn. glomus tumour) :These tumours arise from a cutaneous glomus composed of These tumours arise from a cutaneous glomus composed of

a tortuous arteriole which communicates directly with a a tortuous arteriole which communicates directly with a venule, the vessels being surrounded with a network of venule, the vessels being surrounded with a network of small nerves. small nerves. These specialised organs regulate the These specialised organs regulate the temperature of the skin,temperature of the skin, and are found in the limbs, and are found in the limbs, especially the nail beds. The tumour is compressible. The especially the nail beds. The tumour is compressible. The associated pain is out of all proportion to the size of the associated pain is out of all proportion to the size of the tumour, which may be only a few millimetres in diameter. tumour, which may be only a few millimetres in diameter. The pain is burning in nature and radiates peripherally, and The pain is burning in nature and radiates peripherally, and is more often noticeable when the limb is exposed to is more often noticeable when the limb is exposed to sudden changes in temperature.sudden changes in temperature.

Cutaneous glomus tumours grow very slowly, and do not Cutaneous glomus tumours grow very slowly, and do not become malignant. They should be excised.become malignant. They should be excised.

  Hamartoma :Hamartoma :The term hamartoma is roughly translated from The term hamartoma is roughly translated from

the Greek as a ‘fault’, and its original the Greek as a ‘fault’, and its original meaning was ‘missing the mark in spear meaning was ‘missing the mark in spear throwing’. throwing’.

It is a developmental malformation consisting It is a developmental malformation consisting of overgrowth of tissue or tissues proper to of overgrowth of tissue or tissues proper to the part. The possible range therefore is very the part. The possible range therefore is very wide and the lesions are often multiple. wide and the lesions are often multiple. Common lesions that are hamartomas are Common lesions that are hamartomas are benign pigmented moles, and the majority of benign pigmented moles, and the majority of angiomas and neuro fibromas. On rare angiomas and neuro fibromas. On rare occasions a malignant change occurs in a occasions a malignant change occurs in a hamartoma, but for practical purposes the hamartoma, but for practical purposes the lesion is benign .lesion is benign .

Malignant tumoursMalignant tumoursCarcinomas arise from cells which are ectodermal or Carcinomas arise from cells which are ectodermal or

endodermal in origin, and they are classified squamous, endodermal in origin, and they are classified squamous, basal-celled or glandular (adenocarcinomas). basal-celled or glandular (adenocarcinomas).

Sarcomas occur in connection with structures of mesoblastic Sarcomas occur in connection with structures of mesoblastic origin, hence fibrosarcoma, osteosarcoma.origin, hence fibrosarcoma, osteosarcoma.

Germ cell tumours arise from germ cells (teratoma, Germ cell tumours arise from germ cells (teratoma, seminoma, thecoma). Ovarian cancer is an seminoma, thecoma). Ovarian cancer is an adenocarcinoma: it does not arise from oocytes.adenocarcinoma: it does not arise from oocytes.

  CarcinomaCarcinoma  Squamous cancer arises from surfaces covered by Squamous cancer arises from surfaces covered by

squamous epithelium, particularly as a result of ultraviolet squamous epithelium, particularly as a result of ultraviolet or ionising radiation and chronic irritation. Chronic or ionising radiation and chronic irritation. Chronic irritation of transitional cells (e.g. by a stone in the renal irritation of transitional cells (e.g. by a stone in the renal pelvis) or columnar cells (e.g. the gall bladder) will cause a pelvis) or columnar cells (e.g. the gall bladder) will cause a change in these cells to a squamous type (squamous change in these cells to a squamous type (squamous metaplasia), which may lead on to carcinoma. metaplasia), which may lead on to carcinoma. The regional The regional lymphlymph nodesnodes are likely to be invaded, and may also be are likely to be invaded, and may also be infected from the sepsis attendant upon the primary infected from the sepsis attendant upon the primary growth. growth. Blood-borne metastasesBlood-borne metastases occur, but uncommonly occur, but uncommonly from skin squamous cell carcinoma.from skin squamous cell carcinoma.

  Methods of spread :Methods of spread :1- Direct spread (local extension) : 1- Direct spread (local extension) : Invasion takes place readily along Invasion takes place readily along

connective tissue planes, but no structures are resistant. Veins are connective tissue planes, but no structures are resistant. Veins are invaded commonly. Arteries are rarely invaded. Muscle is less invaded commonly. Arteries are rarely invaded. Muscle is less susceptible to invasion or metastatic deposits than other tissues. susceptible to invasion or metastatic deposits than other tissues. Fascia also limits direct extension, Fascia also limits direct extension,

2- Lymphatics : 2- Lymphatics : by invasion and by embolism.by invasion and by embolism. •  • Invasion.Invasion. The malignant cells grow along the lymphatic vessels from The malignant cells grow along the lymphatic vessels from

the primary growth (permeation). This may even occur in a the primary growth (permeation). This may even occur in a retrograde direction. The cancer cells stimulate perilymphatic retrograde direction. The cancer cells stimulate perilymphatic fibrosis, but this does not stop the advance of the disease. In some fibrosis, but this does not stop the advance of the disease. In some instances, groups of cells may so overcome the surrounding instances, groups of cells may so overcome the surrounding fibrosis that they give rise to intermediate deposits between the fibrosis that they give rise to intermediate deposits between the primary growth and the lymph nodes.primary growth and the lymph nodes.

  •   • EmbolismEmbolism. Cancer cells which invade a lymphatic vessel can break . Cancer cells which invade a lymphatic vessel can break away and are carried by the lymph circulation to a regional node, so away and are carried by the lymph circulation to a regional node, so that nodes comparatively distant from the tumour may be involved that nodes comparatively distant from the tumour may be involved in the early stages.in the early stages.

3- Blood stream : 3- Blood stream : Cancer cells may be detected in the venous Cancer cells may be detected in the venous blood draining an organ involved in carcinoma. A carcinoma of the blood draining an organ involved in carcinoma. A carcinoma of the kidney may kidney may invadeinvade the renal vein and grow inside the lumen into the the renal vein and grow inside the lumen into the vena cava. Malignant vena cava. Malignant emboliemboli may be arrested in the lungs, liver and may be arrested in the lungs, liver and bone marrow (secondary deposits — metastases). Thyroid, breast bone marrow (secondary deposits — metastases). Thyroid, breast and bronchial cancers also commonly disseminate via the blood and bronchial cancers also commonly disseminate via the blood stream.stream.

4- Implantation : 4- Implantation : Implantation of carcinoma has been Implantation of carcinoma has been observed in situations where skin or mucous membrane observed in situations where skin or mucous membrane is in close contact with a primary growth. Examples of is in close contact with a primary growth. Examples of this is carcinoma of the lower lip affecting the upper lip . this is carcinoma of the lower lip affecting the upper lip . Recurrence after operation is occasionally due to Recurrence after operation is occasionally due to implantation of malignant cells in the wound. Examples of implantation of malignant cells in the wound. Examples of this is nodules of carcinoma in the scar of the incision this is nodules of carcinoma in the scar of the incision after mastectomy for a carcinoma of the breast. When a after mastectomy for a carcinoma of the breast. When a cavity is involved, free-floating cells from a carcinoma cavity is involved, free-floating cells from a carcinoma may spread like snowflakes all over its serous surface. may spread like snowflakes all over its serous surface. For the abdomen, For the abdomen, transcoelomic transcoelomic spread is specially spread is specially notable when cells from a colloid carcinoma of the notable when cells from a colloid carcinoma of the stomach gravitate on to an active ovary and give rise to stomach gravitate on to an active ovary and give rise to malignant ovarian tumours (Krukenberg’s tumour ) malignant ovarian tumours (Krukenberg’s tumour ) intracavitary dissemination can also take place within the intracavitary dissemination can also take place within the pleura and cerebrospinal spaces.pleura and cerebrospinal spaces.

5- Nerve sheaths ;5- Nerve sheaths ; Adenocarcinomas, especially pancreas, Adenocarcinomas, especially pancreas, may disseminate along nerve sheathsmay disseminate along nerve sheaths..

Grading and staging : Grading and staging :   Grading and staging are used to assess the degree of malignancy Grading and staging are used to assess the degree of malignancy

of the tumour as an indication of the prognosis, and may be of the tumour as an indication of the prognosis, and may be used as a guide to determine the type and the extent of the used as a guide to determine the type and the extent of the treatment which is required. Advanced staging and grading may treatment which is required. Advanced staging and grading may indicate the need for adjuvant methods of treatment, e.g. by indicate the need for adjuvant methods of treatment, e.g. by chemotherapy or irradiation.chemotherapy or irradiation.

Grading : Grading : Grading predicts the aggressiveness of a malignant Grading predicts the aggressiveness of a malignant neoplasm by characterising its microscopic appearance taking neoplasm by characterising its microscopic appearance taking into account the degree of differentiation, nuclear and cellular into account the degree of differentiation, nuclear and cellular appearance, architectural integrity and the proportion of active appearance, architectural integrity and the proportion of active mitoses.mitoses.

• • Grade 1: well differentiated;Grade 1: well differentiated;• • Grade 2: moderately well differentiated;Grade 2: moderately well differentiated;• • Grade 3: poorly differentiated.Grade 3: poorly differentiated.

  Staging : Staging : (i) TNM classification. This has been adopted by the (i) TNM classification. This has been adopted by the International Union against Cancer (UICC) and has been International Union against Cancer (UICC) and has been extended to many sites of cancer. This is a detailed clinical extended to many sites of cancer. This is a detailed clinical staging which is arrived at simply by the clinician ascertaining staging which is arrived at simply by the clinician ascertaining the following points. What is the extent of the primary Tumour? the following points. What is the extent of the primary Tumour? Are any lymph Nodes affected? Are there any Metastases? The Are any lymph Nodes affected? Are there any Metastases? The information so obtained is scored, e.g. ii carcinoma of the information so obtained is scored, e.g. ii carcinoma of the breast, as follows:breast, as follows:

TumourTumour                                                      NodesNodes                                                MetastasisMetastasisT1T1 2 cm or less.             2 cm or less.            N0N0 No nodes                  No nodes                 M0M0 No metastasis No metastasis  No skin fixationNo skin fixation  T2T2 More than 2 cm,         More than 2 cm,         N1N1 Axillary nodes          Axillary nodes          M1M1 Metastases are Metastases are  but less than 5 cm.          movable (a) not          present includingbut less than 5 cm.          movable (a) not          present including    Skin tethered or              significant,                 involvement of skinSkin tethered or              significant,                 involvement of skin    dimpled. No                  (b) significant              beyond breast, anddimpled. No                  (b) significant              beyond breast, and    pectoral fixation                                               contralateral nodespectoral fixation                                               contralateral nodes  T3T3 More than 5 cm,         More than 5 cm,         N2N2 Axillary Axillary  but less than 10 cm.       nodes fixedbut less than 10 cm.       nodes fixed    Skin infiltrated orSkin infiltrated or    ulcerated. Pectoralulcerated. Pectoralfixationfixation  T4T4More than 10 cm.        More than 10 cm.         N3 N3 Supraclavicular SupraclavicularSkin involved but                 nodes. Oedema Skin involved but                 nodes. Oedema not beyond breast,               of armnot beyond breast,               of armChest-wall fixationChest-wall fixation  

(i) Thus, for example, one patient may (i) Thus, for example, one patient may have an early carcinoma which is have an early carcinoma which is T1N0M0, while in another late case the T1N0M0, while in another late case the extent of the disease may be T2N2M1.extent of the disease may be T2N2M1.

(ii) (ii) Manchester stagingManchester staging. This is a method . This is a method of staging clinical spread of carcinoma of staging clinical spread of carcinoma of the breast .of the breast .

(iii)    (iii)    Dukes’ stagingDukes’ staging. This is a method of . This is a method of classifying the spread of carcinoma of classifying the spread of carcinoma of the rectum and colon .the rectum and colon .

Wounds Wounds and their management are Wounds and their management are

fundamental to the practice of surgery. fundamental to the practice of surgery. Any elective surgical intervention will Any elective surgical intervention will result in a wound in order to gain result in a wound in order to gain access to and deal with the underlying access to and deal with the underlying pathology. In the surgery of trauma the pathology. In the surgery of trauma the wound is the primary pathology.In both wound is the primary pathology.In both situations the surgeon’s task is to situations the surgeon’s task is to minimise the adverse effects of the minimise the adverse effects of the wound, remove or repair damaged wound, remove or repair damaged structures and harness the processes structures and harness the processes of wound healing to restore function.of wound healing to restore function.

Wound HealingWound Healing

PHASES OF WOUND HEALING ;PHASES OF WOUND HEALING ;The wound healing process follows a predictable The wound healing process follows a predictable

pattern that can be divided into : pattern that can be divided into : 1- hemostasis and inflammation, 1- hemostasis and inflammation, 2- proliferation2- proliferation3- maturation 3- maturation 4- remodeling. 4- remodeling. This sequence of events is fluid and overlapping.This sequence of events is fluid and overlapping.All wounds need to progress through this series All wounds need to progress through this series

of cellular and biochemical events that of cellular and biochemical events that characterizes the phases of healing to characterizes the phases of healing to successfully re-establish tissue integrity.successfully re-establish tissue integrity.

1- Hemostasis and Inflammation ; 1- Hemostasis and Inflammation ; Hemostasis precedes and initiates inflammation with the Hemostasis precedes and initiates inflammation with the

ensuing release of chemotactic factors from the wound ensuing release of chemotactic factors from the wound site. Wounding disrupts tissue integrity, Leading to site. Wounding disrupts tissue integrity, Leading to division of blood vessels and direct exposure of division of blood vessels and direct exposure of extracellular matrix to platelets. Exposure of extracellular matrix to platelets. Exposure of subendothelial collagen to platelets results in plateletsubendothelial collagen to platelets results in platelet

aggregation, degranulation, and activation of the coagulation aggregation, degranulation, and activation of the coagulation cascade resulting In a fibrin clot. Platelet granules release cascade resulting In a fibrin clot. Platelet granules release a number of wound-active substances such as platelet-a number of wound-active substances such as platelet-derived growth factor (PDGF), platelet-activating factor derived growth factor (PDGF), platelet-activating factor (PAF), fibronectin, and serotonin. In addition to achieving (PAF), fibronectin, and serotonin. In addition to achieving hemostasis, the fibrin clot serves as scaffolding for thehemostasis, the fibrin clot serves as scaffolding for the

migration into the wound of inflammatory cells such as migration into the wound of inflammatory cells such as polymorphonuclear leukocytes (PMNs,neutrophils) and polymorphonuclear leukocytes (PMNs,neutrophils) and monocytes. monocytes.

Cellular infiltration after injury follows a Cellular infiltration after injury follows a characteristic, predetermined sequence.characteristic, predetermined sequence.PMNsPMNs are are the first infiltrating cells to enter the wound site, the first infiltrating cells to enter the wound site, peaking at 24-48h. Increased vascular peaking at 24-48h. Increased vascular permeability, local prostaglandin release, and the permeability, local prostaglandin release, and the Presence of chemotactic substances such as Presence of chemotactic substances such as complement factors, interleukin-1 (IL-1), tumor complement factors, interleukin-1 (IL-1), tumor necrosis factor-? (TNF-?), platelet factor 4, or necrosis factor-? (TNF-?), platelet factor 4, or bacterial products all stimulate neutrophil bacterial products all stimulate neutrophil migration.migration.

The second population of inflammatory cells that The second population of inflammatory cells that invades the wound consists of invades the wound consists of macrophagesmacrophages. . Derived from circulating monocytes, macrophages Derived from circulating monocytes, macrophages achieve significant numbers in the wound by 48–achieve significant numbers in the wound by 48–96 h post-injury and remain present until wound 96 h post-injury and remain present until wound healing is completehealing is complete

Macrophages,like neutrophils ,participate in wound dMacrophages,like neutrophils ,participate in wound d´ebridement via phagocytosis and contribute to microbial ´ebridement via phagocytosis and contribute to microbial stasis via oxygen radical and nitric oxide synthesis. The stasis via oxygen radical and nitric oxide synthesis. The macrophage’s most pivotal function is activation and macrophage’s most pivotal function is activation and recruitment of other cells via mediators such as cytokines recruitment of other cells via mediators such as cytokines and growth factors. By releasing such mediators as TGF?, and growth factors. By releasing such mediators as TGF?, vascular endothelial growth factor (VEGF), insulin-like vascular endothelial growth factor (VEGF), insulin-like growth factor (IGF), epithelial growth factor (EGF), and growth factor (IGF), epithelial growth factor (EGF), and lactate, macrophages regulate cell proliferation, matrix lactate, macrophages regulate cell proliferation, matrix synthesis, and angiogenesis.synthesis, and angiogenesis.

Macrophages also play a significant role in regulating Macrophages also play a significant role in regulating angiogenesis and matrix deposition and remodeling.angiogenesis and matrix deposition and remodeling.

T-lymphocytesT-lymphocytes comprise an other population of inflammatory comprise an other population of inflammatory / immune cells that routinely invades the wound. Less / immune cells that routinely invades the wound. Less numerous than macrophages, T- Lymphocyte numbers numerous than macrophages, T- Lymphocyte numbers peak at about 1 week post-injury and bridge the transition peak at about 1 week post-injury and bridge the transition From the inflammatory to the proliferative phase of From the inflammatory to the proliferative phase of healing. healing.

2- Proliferation :2- Proliferation :The proliferative phase roughly spans days 4 through 12. The proliferative phase roughly spans days 4 through 12.

During this phase, Tissue continuity is re-established. During this phase, Tissue continuity is re-established. FibroblastsFibroblasts and and endothelial cellsendothelial cells are the last Cell are the last Cell populations to infiltrate the healing wound, and the populations to infiltrate the healing wound, and the strongest chemotactic factor for fibroblasts is strongest chemotactic factor for fibroblasts is platelet-platelet-derived growth factor (PDGF),derived growth factor (PDGF), On entering the wound On entering the wound environment, recruited fibroblasts first need to environment, recruited fibroblasts first need to proliferate, and then become activated, to carry out their proliferate, and then become activated, to carry out their primary function of matrix synthesis and remodeling. primary function of matrix synthesis and remodeling.

This activation is mediated mainly by the cytokines and This activation is mediated mainly by the cytokines and growth factors released from wound macrophages.growth factors released from wound macrophages.

Endothelial cells also proliferate extensively during this Endothelial cells also proliferate extensively during this phase of healing.phase of healing.

These cells participate in the formation of new capillaries These cells participate in the formation of new capillaries (angiogenesis). Endothelial cells migrate from intact (angiogenesis). Endothelial cells migrate from intact venules close to the wound. Their migration, replication, venules close to the wound. Their migration, replication, and new capillary tubule formation are under the and new capillary tubule formation are under the influence of such cytokines and growth factors as TNF-a, influence of such cytokines and growth factors as TNF-a, TGF-?, and VEGF.TGF-?, and VEGF.

Matrix Synthesis :Matrix Synthesis :Biochemistry of Collagen :Biochemistry of Collagen :Collagen is the most abundant protein in the body. Collagen is the most abundant protein in the body.

Type I collagenType I collagen is the major component of is the major component of extracellular matrix in skin. extracellular matrix in skin. Type IIIType III, which also , which also normally is present in skin, becomes more normally is present in skin, becomes more prominent and important during the repair process.prominent and important during the repair process.

Biochemically, each chain of collagen is composed of Biochemically, each chain of collagen is composed of a glycine residue in every third position. These a glycine residue in every third position. These changes in the triplet is made up of proline or lysine changes in the triplet is made up of proline or lysine during the translation process. The polypeptide during the translation process. The polypeptide chain that is translated from mRNA is called chain that is translated from mRNA is called protocollagenprotocollagen. Release of protocollagen into the . Release of protocollagen into the endo- plasmic reticulum results in the hydroxylation endo- plasmic reticulum results in the hydroxylation of proline to hydroxyproline and of lysine to of proline to hydroxyproline and of lysine to hydroxylysine by specific hydroxylases. Prolyl hydroxylysine by specific hydroxylases. Prolyl hydroxylase requires oxygen and iron as hydroxylase requires oxygen and iron as cofactors, ?-ketoglutarate as co-substrate, and cofactors, ?-ketoglutarate as co-substrate, and ascorbic acid (vitaminC) as an electron donor. ascorbic acid (vitaminC) as an electron donor.

In the endoplasmic reticulum, The protocollagen In the endoplasmic reticulum, The protocollagen chain assumes an ?- helical configuration after its chain assumes an ?- helical configuration after its glycosy-lated by the linking of galactose and glycosy-lated by the linking of galactose and glucose at specific hydroxy-lysine residues.glucose at specific hydroxy-lysine residues.

Three ?-helical chains entwine to form a right-handed Three ?-helical chains entwine to form a right-handed superhelical structure Calledsuperhelical structure Called procollagen procollagen . . Although initially joined by weak , ionic bonds, the Although initially joined by weak , ionic bonds, the procollagen molecule becomes much stronger by procollagen molecule becomes much stronger by the covalent cross – linking of lysine residues.the covalent cross – linking of lysine residues.

Extracellularly, the procollagen strands by further Extracellularly, the procollagen strands by further polymerization and cross- linking. The resulting polymerization and cross- linking. The resulting collagen monomer is further polymerized andcollagen monomer is further polymerized and

cross-linked by the formation of intra and cross-linked by the formation of intra and intermolecular covalent bondsintermolecular covalent bonds..

Proteoglycan Synthesis :Proteoglycan Synthesis :lycosaminoglycans comprise a large portion of the “ground lycosaminoglycans comprise a large portion of the “ground

substance” that makes up granulation tissue. Rarely found substance” that makes up granulation tissue. Rarely found free, they couple with proteins to form free, they couple with proteins to form proteoglycansproteoglycans. The . The polysaccharide chain is made up of repeating disacaride polysaccharide chain is made up of repeating disacaride units , composed of glucuronic or iduronic acid and units , composed of glucuronic or iduronic acid and ahexosamine, which usually sulfated. The disaccharide ahexosamine, which usually sulfated. The disaccharide composition of proteoglycans varies from out 10 units in composition of proteoglycans varies from out 10 units in the case of heparin sulfate to as much as 2000 units in the the case of heparin sulfate to as much as 2000 units in the case of hyaluronic acid.case of hyaluronic acid.

The major glycosaminoglycans present in wounds are The major glycosaminoglycans present in wounds are dermatandermatan and and chonoitin sulfatechonoitin sulfate. Fibroblasts synthesize . Fibroblasts synthesize these compounds, increasing their concentration greatly these compounds, increasing their concentration greatly during the first 3 weeks of healing. The interaction between during the first 3 weeks of healing. The interaction between collagen and proteoglycans is being actively studied. As collagen and proteoglycans is being actively studied. As scar collagen is de-posited , the proteoglycans are scar collagen is de-posited , the proteoglycans are incorporated into the collagen scaffolding. However, with incorporated into the collagen scaffolding. However, with scar maturation and collagen remodeling ,the content of scar maturation and collagen remodeling ,the content of proteoglycans gradually diminishes.proteoglycans gradually diminishes.

3- Maturation and 4- Remodeling3- Maturation and 4- Remodeling : : The maturation and remodeling of the scar begins The maturation and remodeling of the scar begins

during the fibroplastic phase, and is characterized during the fibroplastic phase, and is characterized by a reorganization of previously synthesized by a reorganization of previously synthesized collagen. Collagen is broken down by matrix collagen. Collagen is broken down by matrix metallo-proteinases (MMPs). The net wound metallo-proteinases (MMPs). The net wound collagen content is the result of a balance between collagen content is the result of a balance between collagenolysis and collagen synthesis. This will collagenolysis and collagen synthesis. This will shift toward collagen synthesis and eventually shift toward collagen synthesis and eventually

establishment of extracellular matrix composed of a establishment of extracellular matrix composed of a relatively a cellular collagen-rich scar.relatively a cellular collagen-rich scar.

Wound strength and mechanical integrity in the fresh Wound strength and mechanical integrity in the fresh wound are determined by both the quantity and wound are determined by both the quantity and quality of the newly deposited collagen. The quality of the newly deposited collagen. The deposition of matrix at the wound site follows a deposition of matrix at the wound site follows a characteristic pattern: characteristic pattern: fibronectin And collagen type fibronectin And collagen type III constitute the early matrix scaffolding; III constitute the early matrix scaffolding; glycosaminoglycans and proteoglycans represent glycosaminoglycans and proteoglycans represent the next significant matrix components; and collagen the next significant matrix components; and collagen type I is the final matrix.type I is the final matrix. By several weeks post-injury By several weeks post-injury the amount of collagen in the wound reaches the amount of collagen in the wound reaches aplateau, but the tensile strength continues to aplateau, but the tensile strength continues to increase for several more months. Fibril formation increase for several more months. Fibril formation and fibril cross-linking result in decreased collagen and fibril cross-linking result in decreased collagen solubility, increased strength, and increased solubility, increased strength, and increased resistance to enzymatic degradation of the collagen resistance to enzymatic degradation of the collagen matrix. Scar remodeling continues for many(6–matrix. Scar remodeling continues for many(6–12)months post-injury, gradually result in a mature, 12)months post-injury, gradually result in a mature, avascular, and acellular scar. avascular, and acellular scar. The mechanical The mechanical strength of the scar never achieves that of the strength of the scar never achieves that of the uninjured tissue.uninjured tissue.

EpithelializationEpithelializationAlthough tissue integrity and strength are being re-Although tissue integrity and strength are being re-

established, the external barrier must also be restored. established, the external barrier must also be restored. This process, beginning within 1 day of the injury, is This process, beginning within 1 day of the injury, is characterized primarily by proliferation and migration characterized primarily by proliferation and migration of epithelial cells adjacent to the wound. Marginal of epithelial cells adjacent to the wound. Marginal basal cells at the edge of the wound lose their firm basal cells at the edge of the wound lose their firm attachment to the underlying dermis, enlarge, and attachment to the underlying dermis, enlarge, and begin to migrate across the surface of the provisional begin to migrate across the surface of the provisional matrix. Fixed basal cells in a zone near the cut edge matrix. Fixed basal cells in a zone near the cut edge undergo a series of rapid mitotic divisions, and these undergo a series of rapid mitotic divisions, and these cells appear to migrate by moving over one another in cells appear to migrate by moving over one another in a leapfrog fashion until the defect is covered. Once the a leapfrog fashion until the defect is covered. Once the defect is bridged, the migrating epithelial cells lose the defect is bridged, the migrating epithelial cells lose the flattened appearance, become more columnar in flattened appearance, become more columnar in shape, and increase their mitotic activity. Layering of shape, and increase their mitotic activity. Layering of the epithelium is re-established, and the surface layer the epithelium is re-established, and the surface layer eventually keratinizes.eventually keratinizes.

Re-epithelializationRe-epithelialization is complete in less than 48 h in the is complete in less than 48 h in the case of approximated Incised wounds, but may take case of approximated Incised wounds, but may take substantially longer in the case of larger wounds in substantially longer in the case of larger wounds in which there is a significant epidermal / dermal defect. which there is a significant epidermal / dermal defect. If only the epithelium and superficial dermis are If only the epithelium and superficial dermis are damaged, such as occurs in split-thickness skin graft damaged, such as occurs in split-thickness skin graft

(STSG) donor sites or in superficial second – degree (STSG) donor sites or in superficial second – degree burns ,then repair consists primarily of re-burns ,then repair consists primarily of re-epithelialization with minimal or no fibroplasia and epithelialization with minimal or no fibroplasia and granulation tissue formation. The stimuli for re-granulation tissue formation. The stimuli for re-epithelialization remain incompletely defined; epithelialization remain incompletely defined; however, it appears that the process is mediated by a however, it appears that the process is mediated by a combination of a loss of contact inhibition; exposure combination of a loss of contact inhibition; exposure to constituents of the extracellular matrix, particularly to constituents of the extracellular matrix, particularly fibronectin; and cytokines produced by immune fibronectin; and cytokines produced by immune mononuclear cells. In particular EGF, TGF-? ,basic mononuclear cells. In particular EGF, TGF-? ,basic fibroblast growth factor (bFGF), PDGF, fibroblast growth factor (bFGF), PDGF,

Wound Contraction :Wound Contraction :All wounds undergo some degree of contraction. For All wounds undergo some degree of contraction. For

wounds that donot have surgically approximated wounds that donot have surgically approximated edges, the area of the wound will be decreased byedges, the area of the wound will be decreased by

this action (healing by secondary intention) .The this action (healing by secondary intention) .The myofibroblast has been postulated as being the myofibroblast has been postulated as being the major cell responsible for contraction, and it differs major cell responsible for contraction, and it differs from the normal fibroblast in that it possesses a from the normal fibroblast in that it possesses a cytoskeletal structurecytoskeletal structure. Typically this cell contains . Typically this cell contains smooth muscle actin in thick bundles called smooth muscle actin in thick bundles called stress stress fibersfibers, giving myofibroblasts contractile capability. , giving myofibroblasts contractile capability. The smooth muscle actin is un-detectable until day The smooth muscle actin is un-detectable until day 6, and then is increasingly expressed for the next 15 6, and then is increasingly expressed for the next 15 days of wound healing. After 4 weeks this days of wound healing. After 4 weeks this expression fades and the cells are believed to expression fades and the cells are believed to undergo apoptosis. the undifferentiated fibroblasts undergo apoptosis. the undifferentiated fibroblasts may also contribute to wound contraction.may also contribute to wound contraction.

CLASSIFICATION OF WOUNDS ;CLASSIFICATION OF WOUNDS ;Wounds are classified as either Wounds are classified as either acute or chronicacute or chronic.. Acute wounds heal in a predictable manner and Acute wounds heal in a predictable manner and

timeframe. The process occurs with few, ifany, timeframe. The process occurs with few, ifany, complications, and the end result is a well-complications, and the end result is a well-healed wound. Surgical wounds can heal in healed wound. Surgical wounds can heal in several ways. An incised wound that is clean several ways. An incised wound that is clean and sutured closed is said to heal by and sutured closed is said to heal by primary primary intentionintention .Often, because of bacterial .Often, because of bacterial contamination or tissue loss, a wound will be contamination or tissue loss, a wound will be left open to heal by granulation tissue left open to heal by granulation tissue formation and contraction; this constitutes formation and contraction; this constitutes healing by healing by secondary intentionsecondary intention. . Delayed Delayed primary closureprimary closure, or healing by , or healing by tertiary tertiary intentionintention, represents a combination of the first , represents a combination of the first two, consisting of the placement of sutures, two, consisting of the placement of sutures, allowing the wound to stay open for a few allowing the wound to stay open for a few days, and the subsequent closure of the days, and the subsequent closure of the sutures.sutures.

..

Classification of woundClassification of woundA wound can be caused by almost any injurious A wound can be caused by almost any injurious

agent and can involve almost any tissue or agent and can involve almost any tissue or structure. The most useful classification of structure. The most useful classification of wounds from a practical point of view is that of wounds from a practical point of view is that of Rank and Wakefield into tidy and untidy wounds.Rank and Wakefield into tidy and untidy wounds.

1- Tidy wounds1- Tidy woundsTidy wounds are inflicted by sharp instruments and Tidy wounds are inflicted by sharp instruments and

contain no devitalised tissue ; such wounds can contain no devitalised tissue ; such wounds can be closed primarily with the expectation of quiet be closed primarily with the expectation of quiet primary healing. Examples are surgical incisions, primary healing. Examples are surgical incisions, cuts from glass and knife wounds. Skin wounds cuts from glass and knife wounds. Skin wounds will usually be single and clean cut. Tendons, will usually be single and clean cut. Tendons, arteries and nerves will commonly be injured in arteries and nerves will commonly be injured in tidy wounds, but repair of these structures is tidy wounds, but repair of these structures is usually possible . Fractures are uncommon in tidy usually possible . Fractures are uncommon in tidy wounds.wounds.

2- Untidy wounds2- Untidy woundsUntidy wounds result from crushing, tearing, avulsion, Untidy wounds result from crushing, tearing, avulsion,

vascular injury or burns, and contain devitalised tissue . vascular injury or burns, and contain devitalised tissue . Skin wounds will often be multiple and irregular. Skin wounds will often be multiple and irregular. Tendons, arteries and nerves may be exposed, and Tendons, arteries and nerves may be exposed, and might be injured in continuity, but will usually not be might be injured in continuity, but will usually not be divided. Fractures are common and may be multi-divided. Fractures are common and may be multi-fragmentary. Such wounds must not be closed fragmentary. Such wounds must not be closed primarily; if they are closed wound healing is unlikely to primarily; if they are closed wound healing is unlikely to occur without complications. At best there may be occur without complications. At best there may be wound dehiscence, infection and delayed healing, at wound dehiscence, infection and delayed healing, at worst gas gangrene and death may result. The correct worst gas gangrene and death may result. The correct management of untidy wounds is wound excision, by management of untidy wounds is wound excision, by this is meant excision of all devitalised tissue to create this is meant excision of all devitalised tissue to create a tidy wound. Once the untidy wound has been a tidy wound. Once the untidy wound has been converted to a tidy wound by the process of wound converted to a tidy wound by the process of wound excision it can be safely closed (or allowed to heal by excision it can be safely closed (or allowed to heal by second intention). second intention).

SuturesSuturesSuture materials are divided to :Suture materials are divided to :

1-absorbable & non-absorbable sutures:1-absorbable & non-absorbable sutures:

1-1- 1-1- absorbable suturesabsorbable sutures : :

A-A- Plain catgut Plain catgut sutures : which are made sutures : which are made from the sub mucosa of the cat from the sub mucosa of the cat intestine ,& usually absorbed in 1-2 intestine ,& usually absorbed in 1-2 weeks .weeks .

B- B- Chromic catgutChromic catgut: It is a plain catgut but : It is a plain catgut but covered with chrome. It is absorbed in covered with chrome. It is absorbed in 3-4 weeks 3-4 weeks

C- C- Vicryl suturesVicryl sutures :which are made of :which are made of polyglactinic acid & absorbed in 2-3 polyglactinic acid & absorbed in 2-3 months.months.

D- D- Dexon suturesDexon sutures which absorbed in7-9 which absorbed in7-9 months.months.

1-2- 1-2- non-absorbable suturesnon-absorbable sutures : :A- A- SilkSilk :made of silky material that not :made of silky material that not

absorbed.absorbed.B-B- Nylon Nylon sutures suturesC- C- Stainless steelStainless steel sutures suturesD- D- Cotton tapeCotton tape sutures sutures

SuturesSutures2- 2- According to the type of needle:According to the type of needle:2-1- cutting needle .2-1- cutting needle .2-2- round needle .2-2- round needle .2-3- taper cut needle.2-3- taper cut needle.All these are curved needles & also there are strait All these are curved needles & also there are strait

needles differ in its length & thicknessneedles differ in its length & thickness2-4- no needle sutures :which are used 2-4- no needle sutures :which are used

for ligation . for ligation .

The suture thread length about 75 cm & its thickness The suture thread length about 75 cm & its thickness measured by numbers (from thick to thin) ,e.g. 2 , measured by numbers (from thick to thin) ,e.g. 2 , 1 , 0 , 2/0 , 3/0 , 4/0 up to 10/0 which is very thin 1 , 0 , 2/0 , 3/0 , 4/0 up to 10/0 which is very thin suture used for eye operations .suture used for eye operations .

Sarcomas :Sarcomas :Sarcomas differ from carcinomas, not only in their derivation, Sarcomas differ from carcinomas, not only in their derivation,

but in their earlier age incidence, as they are most common but in their earlier age incidence, as they are most common during the first and second decades. Sarcomas often grow during the first and second decades. Sarcomas often grow rapidly and dissemination occurs early via the blood stream rapidly and dissemination occurs early via the blood stream (e.g. ‘cannon-ball’ secondary deposits in the lung from an (e.g. ‘cannon-ball’ secondary deposits in the lung from an osteogenic sarcoma).osteogenic sarcoma).

The macroscopic appearance of a sarcoma varies The macroscopic appearance of a sarcoma varies considerably. As the word implies, most tumours appear considerably. As the word implies, most tumours appear as a fleshy mass, but their consistency depends on the as a fleshy mass, but their consistency depends on the relative proportion of fibrous and vascular tissue. relative proportion of fibrous and vascular tissue. Haemorrhage commonly occurs owing to the very thin Haemorrhage commonly occurs owing to the very thin walls of the veins, which in some places are represented walls of the veins, which in some places are represented merely by venous spaces.merely by venous spaces.

Sarcomatous cells may reproduce tissue similar to that from Sarcomatous cells may reproduce tissue similar to that from which the tumour originated, e.g. osteosarcoma or which the tumour originated, e.g. osteosarcoma or chondrosarcoma. Sometimes a sarcoma develops in pre chondrosarcoma. Sometimes a sarcoma develops in pre existing benign tumours, such as fibroma or a uterine existing benign tumours, such as fibroma or a uterine fibroid.fibroid.

Fibrosarcoma :Fibrosarcoma :Fibrosarcoma is composed of spindle cells of varying lengths (the Fibrosarcoma is composed of spindle cells of varying lengths (the

rounder they are the more malignant they are), and occurs in rounder they are the more malignant they are), and occurs in muscle sheaths, scars and as a fibrous epulis. A fibrosarcoma of a muscle sheaths, scars and as a fibrous epulis. A fibrosarcoma of a muscle sheath presents as an elastic or firm and slowly growing muscle sheath presents as an elastic or firm and slowly growing swelling. Dilated veins over the tumour suggest malignancy, and if swelling. Dilated veins over the tumour suggest malignancy, and if not obvious they may be demonstrated by infrared photography. On not obvious they may be demonstrated by infrared photography. On palpation the tumour often feels warm and pulsation may even be palpation the tumour often feels warm and pulsation may even be detected. Fibrosarcomas not uncommonly arise in scar tissue, detected. Fibrosarcomas not uncommonly arise in scar tissue, sometimes many years after the scar developed. Sir James Paget sometimes many years after the scar developed. Sir James Paget described this as a ‘recurrent fibroid’.described this as a ‘recurrent fibroid’.

Treatment of sarcoma :Treatment of sarcoma :The spread of a fibrosarcoma is hastened by incomplete removal. The The spread of a fibrosarcoma is hastened by incomplete removal. The

moral is that wide excision with surrounding healthy tissues should moral is that wide excision with surrounding healthy tissues should be practised in all cases. This may mean amputation in the case of a be practised in all cases. This may mean amputation in the case of a limb. If untreated or if wide local excision is unsuccessful, a limb. If untreated or if wide local excision is unsuccessful, a fibrosarcoma eventually fungates through the skin. Metastases are fibrosarcoma eventually fungates through the skin. Metastases are widely scattered and, unfortunately, radiotherapy has but little widely scattered and, unfortunately, radiotherapy has but little effect on either the primary growth or the secondary deposits. effect on either the primary growth or the secondary deposits. Sarcomas are often susceptible to anticancer drugs, but Sarcomas are often susceptible to anticancer drugs, but fibrosarcomas are more resistant than other types. Sarcoma of fibrosarcomas are more resistant than other types. Sarcoma of bone is sensitive to radiotherapy, which is used in some cases as bone is sensitive to radiotherapy, which is used in some cases as an alternative to amputation .an alternative to amputation .

Lymphomas :Lymphomas :Lymphomas arise in lymph nodes, tonsils, Peyer’s Lymphomas arise in lymph nodes, tonsils, Peyer’s

patches or lymph nodules in the intestines. Lymph patches or lymph nodules in the intestines. Lymph nodes of the neck or mediastinum are most commonly nodes of the neck or mediastinum are most commonly affected . They have a bad prognosis.affected . They have a bad prognosis.

Endothelioma; mesothelioma :Endothelioma; mesothelioma :The endothelial linings of blood vessels, lymphatic spaces The endothelial linings of blood vessels, lymphatic spaces

and serous membranes occasionally give rise to and serous membranes occasionally give rise to neoplasms. They can be malignant. They arise from the neoplasms. They can be malignant. They arise from the pleura and rarely from the pericardium or peritoneum. pleura and rarely from the pericardium or peritoneum. Asbestos inhalation may provoke their development. Asbestos inhalation may provoke their development. ‘Blue’ asbestos fibres especially have been shown to be ‘Blue’ asbestos fibres especially have been shown to be a cause. The original cells are flattened, but they a cause. The original cells are flattened, but they become spheroidal or cuboidal when neop]astic become spheroidal or cuboidal when neop]astic changes occur. The ‘endothelioma’ (meningioma) of the changes occur. The ‘endothelioma’ (meningioma) of the dura mater is thought to arise from the arachnoid dura mater is thought to arise from the arachnoid membrane, which is not an endothelial structure .membrane, which is not an endothelial structure .

Benign to malignant transformation :Benign to malignant transformation :Certain benign neoplasms are prone to undergo malignant Certain benign neoplasms are prone to undergo malignant

changes, and it is important, for both treatment and changes, and it is important, for both treatment and prognosis, to realise when this occurs. Some or all of prognosis, to realise when this occurs. Some or all of the following changes may be recognised:the following changes may be recognised:

 •  • increase in size: comparatively rapid enlargement is increase in size: comparatively rapid enlargement is always suspicious, e.g. a neurofibroma which is always suspicious, e.g. a neurofibroma which is becoming sarcomatous;becoming sarcomatous;

•  •  increased vascularity: dilated cutaneous veins, increased vascularity: dilated cutaneous veins, ulceration and bleeding in the case of a superficial ulceration and bleeding in the case of a superficial growth (e.g. melanoma);growth (e.g. melanoma);

• • fixity: due to invasion of surrounding structures;fixity: due to invasion of surrounding structures;• • involvement of adjacent structures: e.g. facial palsy sug involvement of adjacent structures: e.g. facial palsy sug

gests malignant change in an otherwise longstanding gests malignant change in an otherwise longstanding parotid pleomorphic adenoma;parotid pleomorphic adenoma;

• • dissemination: discovery of secondary deposits.dissemination: discovery of secondary deposits.

Cysts : Cysts : The word cyst is derived from the Greek word meaning The word cyst is derived from the Greek word meaning

‘bladder’. The pathological term ‘cyst’ means a swelling ‘bladder’. The pathological term ‘cyst’ means a swelling consisting of a collection of fluid in a sac which is lined consisting of a collection of fluid in a sac which is lined by epithelium or endothelium.by epithelium or endothelium.

True cysts :True cysts :True cysts are lined by epithelium or endothelium. If True cysts are lined by epithelium or endothelium. If

infection supervenes, the true lining may be destroyed infection supervenes, the true lining may be destroyed and replaced by granulation tissue. The fluid is usually and replaced by granulation tissue. The fluid is usually serous or mucoid and varies from brown-staining by serous or mucoid and varies from brown-staining by altered blood to almost colourless. In epidermoid, altered blood to almost colourless. In epidermoid, dermoid and branchial cysts the contents are like dermoid and branchial cysts the contents are like porridge or toothpaste, as a result of the shedding of porridge or toothpaste, as a result of the shedding of desquamated cells. Cholesterol crystals are often found desquamated cells. Cholesterol crystals are often found in the fluid of branchial cysts.in the fluid of branchial cysts.

False cysts (pseudocysts) :False cysts (pseudocysts) :Walled-off collections of fluid not lined by epithelium are not Walled-off collections of fluid not lined by epithelium are not

regarded as true cysts. A pseudocyst of the pancreas is an regarded as true cysts. A pseudocyst of the pancreas is an encysted collection of pancreatic enzymerich fluid lined by encysted collection of pancreatic enzymerich fluid lined by granulation tissue or fibrous tissue. Pancreatic granulation tissue or fibrous tissue. Pancreatic pseudocysts are often in the retroperitoneum deep to but pseudocysts are often in the retroperitoneum deep to but bulging into the lesser sac; they may occur anywhere in bulging into the lesser sac; they may occur anywhere in the abdominal cavity and even track into the mediastinum the abdominal cavity and even track into the mediastinum and pleural cavities. In tuberculous peritonitis, fluid may be and pleural cavities. In tuberculous peritonitis, fluid may be walled off in cystic form by adherent coils of intestine. walled off in cystic form by adherent coils of intestine. Fluid may collect in the centre of a tumour (cystic Fluid may collect in the centre of a tumour (cystic degeneration), due to haemorrhage or necrosis. This can degeneration), due to haemorrhage or necrosis. This can also happen in the brain as a result of ischaemia, and an also happen in the brain as a result of ischaemia, and an ‘apoplectic cyst’ is formed. In acute pancreatitis fluid ‘apoplectic cyst’ is formed. In acute pancreatitis fluid collections loculated by viscera and fibrin are called ‘acute collections loculated by viscera and fibrin are called ‘acute fluid collections’; these often occur in the lesser sac but fluid collections’; these often occur in the lesser sac but are neither cysts nor pseudocysts as they are not lined by are neither cysts nor pseudocysts as they are not lined by either epithelium, granulation tissue or fibrous tissue.either epithelium, granulation tissue or fibrous tissue.

A classification of cystsA classification of cystsCongenital            Sequestration dermoidsCongenital            Sequestration dermoids                                                        Tubuloembryonic (tubulodermoid)Tubuloembryonic (tubulodermoid)                                                        Cyst of embryonic remnantsCyst of embryonic remnantsAcquired              RetentionAcquired              Retention                                                        DistentionDistention                                                        ExudationExudation                                                        Cystic tumoursCystic tumours                                                         Implantation dermoidsImplantation dermoids                                                        TraumaTrauma                                                        DegenerationDegenerationParasitic                Hydatid, trichniasis, Parasitic                Hydatid, trichniasis,

cysticercosiscysticercosis  ..

Congenital cysts Congenital cysts The sequestration dermoid is due to dermal cells being buried along the The sequestration dermoid is due to dermal cells being buried along the

lines of closure of embryonic clefts and sinuses by skin fusion. The lines of closure of embryonic clefts and sinuses by skin fusion. The cyst therefore is lined by epidermis and contains paste-like cyst therefore is lined by epidermis and contains paste-like desquamated material. The usual sites are:desquamated material. The usual sites are:

•  •  the midline of the body — especially in the neck;the midline of the body — especially in the neck;•  •  above the outer canthus (external angular dermoid, ;above the outer canthus (external angular dermoid, ;•  •  in the anterior triangle of the neck (branchial cyst.in the anterior triangle of the neck (branchial cyst.Tubuloembryonic (tubulodermoid) cysts occur in the track of an Tubuloembryonic (tubulodermoid) cysts occur in the track of an

ectodermal tube used in development, e.g. a thyroglossal cyst from ectodermal tube used in development, e.g. a thyroglossal cyst from the thyroglossal duct or a postanal dermoid from the postanal gut. In the thyroglossal duct or a postanal dermoid from the postanal gut. In the brain, ependymal cysts arise from the sequestration of cells of the brain, ependymal cysts arise from the sequestration of cells of the enfolding neurectoderm.the enfolding neurectoderm.

Cysts of embryonic remnants. These arise from embryonic tubules and Cysts of embryonic remnants. These arise from embryonic tubules and ducts which normally disappear or are only present as remnants. ducts which normally disappear or are only present as remnants. They should not be confused with teratomatous cysts, e.g. dermoid. They should not be confused with teratomatous cysts, e.g. dermoid. There are many examples in the urogenital system, e.g. in the male There are many examples in the urogenital system, e.g. in the male from remnants of the paramesonephric duct (Müllerian) — the from remnants of the paramesonephric duct (Müllerian) — the hydatid of Morgagni, or from the mesonephric body and duct hydatid of Morgagni, or from the mesonephric body and duct (Wolffian) . Cysts of the urachus and the vitellointestinal duct are (Wolffian) . Cysts of the urachus and the vitellointestinal duct are other examples of cysts of embryonic remnantsother examples of cysts of embryonic remnants

Acquired cystsAcquired cysts Retention cysts are due to the accumulated secretion of a gland behind an Retention cysts are due to the accumulated secretion of a gland behind an

obstruction of a duct. Examples are seen in the pancreas, the parotid, the obstruction of a duct. Examples are seen in the pancreas, the parotid, the breast, the epididymis and Bartholin’s gland. A sebaceous cyst starts with breast, the epididymis and Bartholin’s gland. A sebaceous cyst starts with the obstruction of a sebaceous gland, but this is followed by the down-the obstruction of a sebaceous gland, but this is followed by the down-growth and the accumulation of desquamated epidermal cells, thus turning growth and the accumulation of desquamated epidermal cells, thus turning it into an epidermoid cyst. In the epididymis, if the retention cyst contains it into an epidermoid cyst. In the epididymis, if the retention cyst contains sperms, it is known as a ‘spermatocele’.sperms, it is known as a ‘spermatocele’.

Distension cysts occur in the thyroid from dilatation of the acini, or in the Distension cysts occur in the thyroid from dilatation of the acini, or in the ovary from a follicle. Lymphatic cysts and cystic hygromas are distension ovary from a follicle. Lymphatic cysts and cystic hygromas are distension cysts. Exudation cysts occur when fluid exudes into an anatomical space cysts. Exudation cysts occur when fluid exudes into an anatomical space already lined by endothelium, e.g. hydrocele, a bursa, or when a collection already lined by endothelium, e.g. hydrocele, a bursa, or when a collection of exudate becomes encrusted.of exudate becomes encrusted.

Cystic tumours. Examples are cystic teratomas (dermoid cyst of the ovary) Cystic tumours. Examples are cystic teratomas (dermoid cyst of the ovary) and cystadenomas (pseudomucinous and serous cystadenoma of the and cystadenomas (pseudomucinous and serous cystadenoma of the ovary).ovary).

Ganglia. See Chapter 29.Ganglia. See Chapter 29. Implantation dermoids arise from squamous epithelium which has been Implantation dermoids arise from squamous epithelium which has been

driven beneath the skin by a penetrating wound. They are classically found driven beneath the skin by a penetrating wound. They are classically found in the fingers of women who sew assiduously and metal workers (Fig. in the fingers of women who sew assiduously and metal workers (Fig. 12.13).12.13).

TraumaTrauma A haematoma may resolve into a cyst. This sometimes happens to haematomas of A haematoma may resolve into a cyst. This sometimes happens to haematomas of

muscle masses in the loin and anterolateral aspects of the thigh or the skin. They are muscle masses in the loin and anterolateral aspects of the thigh or the skin. They are located between muscle, facial or subcutaneous planes and contain straw- or brown-located between muscle, facial or subcutaneous planes and contain straw- or brown-coloured fluid containing cholesterol crystals. They become lined by endothelium and coloured fluid containing cholesterol crystals. They become lined by endothelium and calcium salts may be laid down. Aspiration is only of temporary value, and a cure calcium salts may be laid down. Aspiration is only of temporary value, and a cure depends upon complete excision of the lining. Within the cranium, a haematogenous depends upon complete excision of the lining. Within the cranium, a haematogenous cyst can cause the same problems as any expanding, space-occupying lesion.cyst can cause the same problems as any expanding, space-occupying lesion.

Degeneration cystsDegeneration cysts These have already been discussed under false cysts.These have already been discussed under false cysts. Parasitic cystsParasitic cysts These are encrusted forms in the life cycle of various worms:These are encrusted forms in the life cycle of various worms: •  •  Hydatid cyst of Taenia echinococcus. This is described later according to the organ Hydatid cyst of Taenia echinococcus. This is described later according to the organ

involved, e.g. liver, Chapter 52; lung, Chapter 47.involved, e.g. liver, Chapter 52; lung, Chapter 47. • • Trichiniasis. Cysts of Trichina spiralis, affecting muscle. Trichiniasis. Cysts of Trichina spiralis, affecting muscle. • • Cysticercosis. Cysts of Taenia solium. A disease of the pig, humans being rarely Cysticercosis. Cysts of Taenia solium. A disease of the pig, humans being rarely

affected. Eosinophilia is present. The cysts occur in any organ. They calcify and may affected. Eosinophilia is present. The cysts occur in any organ. They calcify and may cause clinical effects according to their situation, especially in the brain. Only those cause clinical effects according to their situation, especially in the brain. Only those cysts which are actually causing symptoms should be excised.cysts which are actually causing symptoms should be excised.

Clinical featuresClinical features The swelling usually has a smooth, spherical appearance. Fluctuation depends upon The swelling usually has a smooth, spherical appearance. Fluctuation depends upon

the pressure of fluid within: a tense cyst feels like a solid tumour, although careful the pressure of fluid within: a tense cyst feels like a solid tumour, although careful palpation between two fingers may elicit a characteristic elasticity. In addition, a palpation between two fingers may elicit a characteristic elasticity. In addition, a solid tumour is most hard at the centre; a cyst is least hard at the centre. If solid tumour is most hard at the centre; a cyst is least hard at the centre. If fluctuation is present, a cyst may be confused with a cold abscess or a lipoma. A cold fluctuation is present, a cyst may be confused with a cold abscess or a lipoma. A cold abscess usually has a peculiar rim of thickening surrounding the soft centre. A lipoma abscess usually has a peculiar rim of thickening surrounding the soft centre. A lipoma may well test clinical acumen. Transillumination,while brilliantly clear in cysts may well test clinical acumen. Transillumination,while brilliantly clear in cysts containing serous fluid, does not really distinguish between a lipoma and a dermoid containing serous fluid, does not really distinguish between a lipoma and a dermoid or branchial cyst. There is even an old axiom that ‘when in doubt, hedge on fat’. or branchial cyst. There is even an old axiom that ‘when in doubt, hedge on fat’. According to circumstances, ultrasonography, computerised tomography (CT) or According to circumstances, ultrasonography, computerised tomography (CT) or magnetic resonance imaging (MRI), a test aspiration or excision reveals the true magnetic resonance imaging (MRI), a test aspiration or excision reveals the true nature of the swelling.nature of the swelling.

Cysts may be painful, especially when infection or haemorrhage causes a sudden Cysts may be painful, especially when infection or haemorrhage causes a sudden increase in intracystic tension. Sometimes they change in size for no apparent increase in intracystic tension. Sometimes they change in size for no apparent reason. Occasionally, they diminish owing to rupture through a facial plane.reason. Occasionally, they diminish owing to rupture through a facial plane.

Effects are according to site and size. As with benign tumours, a cyst may compress Effects are according to site and size. As with benign tumours, a cyst may compress ducts and blood vessels, e.g. the main bile duct may be obstructed by a choledochal ducts and blood vessels, e.g. the main bile duct may be obstructed by a choledochal cyst, a renal cyst or a hydatid cyst. The pelvic veins may be obstructed by an ovarian cyst, a renal cyst or a hydatid cyst. The pelvic veins may be obstructed by an ovarian cyst, the patient presenting for treatment of her varicose veins. The sheer size of an cyst, the patient presenting for treatment of her varicose veins. The sheer size of an ovarian cyst (Fig. 12.14) may so increase intra-abdominal tension as to bring the ovarian cyst (Fig. 12.14) may so increase intra-abdominal tension as to bring the patient to hospital with symptoms of a hiatus hernia.patient to hospital with symptoms of a hiatus hernia.

ComplicationsComplications InfectionInfection The cyst becomes tense and painful, and adherent to surrounding tissues. An abscess The cyst becomes tense and painful, and adherent to surrounding tissues. An abscess

may form and discharge on the surface and result in an ulcer or a sinus (viz. Cock’s may form and discharge on the surface and result in an ulcer or a sinus (viz. Cock’s peculiar tumour, Chapter 13). Healing will not occur until the whole lining of the cyst peculiar tumour, Chapter 13). Healing will not occur until the whole lining of the cyst or the embryonic track is excised.or the embryonic track is excised.

HaemorrhageHaemorrhage Sudden haemorrhage, as may occur in a thyroid cyst, causes a painful increase in Sudden haemorrhage, as may occur in a thyroid cyst, causes a painful increase in

size. In this particular case, breathing may be difficult because of pressure on the size. In this particular case, breathing may be difficult because of pressure on the trachea.trachea.

TorsionTorsion Torsion may occur in cysts which are attached to neighboring structures by a Torsion may occur in cysts which are attached to neighboring structures by a

vascular pedicle. Ovarian dermoids are sometimes brought to notice in this way as vascular pedicle. Ovarian dermoids are sometimes brought to notice in this way as acute abdominal emergencies. The cyst (or cysts — they may be bilateral) turns to a acute abdominal emergencies. The cyst (or cysts — they may be bilateral) turns to a purple or black colour as the venous and then the arterial supply is cut off.purple or black colour as the venous and then the arterial supply is cut off.

CalcificationCalcification Calcification follows haemorrhage, or infection, and may be the result of reaction to a Calcification follows haemorrhage, or infection, and may be the result of reaction to a

parasite, e.g. hydatid cyst.parasite, e.g. hydatid cyst. Cachexia ovarica Cachexia ovarica   Enormous cysts are rarely seen nowadays (Fig. 12.14).Enormous cysts are rarely seen nowadays (Fig. 12.14).

UlcersUlcers An ulcer is a discontinuity of an epithelial surface. There is usually progressive An ulcer is a discontinuity of an epithelial surface. There is usually progressive

destruction of surface tissue, cell by cell, as distinct from death of macroscopic destruction of surface tissue, cell by cell, as distinct from death of macroscopic portions, e.g. gangrene or necrosis. Ulcers are classified as nonspecific, specific (e.g. portions, e.g. gangrene or necrosis. Ulcers are classified as nonspecific, specific (e.g. tuberculous or syphilitic) or malignant.tuberculous or syphilitic) or malignant.

Nonspecific ulcers are due to infection of wounds, or physical or chemical agents. Nonspecific ulcers are due to infection of wounds, or physical or chemical agents. Local irritation, as in the case of a dental ulcer, or interference with the circulation, Local irritation, as in the case of a dental ulcer, or interference with the circulation, e.g. varicose veins, are predisposing causes.e.g. varicose veins, are predisposing causes.

Trophic ulcers [trophe (Greek) = nutrition] are due to an impairment of the nutrition Trophic ulcers [trophe (Greek) = nutrition] are due to an impairment of the nutrition of the tissues, which depends upon an adequate blood supply and a properly of the tissues, which depends upon an adequate blood supply and a properly functioning nerve supply. Ischaemia and anaesthesia therefore will cause these functioning nerve supply. Ischaemia and anaesthesia therefore will cause these ulcers. Thus, in the arm, chronic vasospasm and syringomyelia will cause ulceration ulcers. Thus, in the arm, chronic vasospasm and syringomyelia will cause ulceration of the tips of the fingers (respectively painful and painless). In the leg, painful of the tips of the fingers (respectively painful and painless). In the leg, painful ischaemic ulcers occur around the ankle or on the dorsum of the foot. Neuropathic ischaemic ulcers occur around the ankle or on the dorsum of the foot. Neuropathic ulcers due to anaesthesia (diabetic neuritis, spina bifida, tabes dorsalis, leprosy or a ulcers due to anaesthesia (diabetic neuritis, spina bifida, tabes dorsalis, leprosy or a peripheral nerve injury) are often called perforating ulcers (Fig. 12.15). Starting in a peripheral nerve injury) are often called perforating ulcers (Fig. 12.15). Starting in a corn or bunion, they penetrate the foot, and the suppuration may involve the bones corn or bunion, they penetrate the foot, and the suppuration may involve the bones and joints and spread along fascial planes upwards, even involving the calf.and joints and spread along fascial planes upwards, even involving the calf.

The life history of an ulcer consists of three phases.The life history of an ulcer consists of three phases.

ExtensionExtension During the stage of extension the floor is covered with exudate and During the stage of extension the floor is covered with exudate and

sloughs, while the base is indurated. The discharge is purulent and even sloughs, while the base is indurated. The discharge is purulent and even blood stained.blood stained.

TransitionTransition The transition stage prepares for healing. The floor becomes cleaner, the The transition stage prepares for healing. The floor becomes cleaner, the

sloughs separate, induration of the base diminishes and the discharge sloughs separate, induration of the base diminishes and the discharge becomes more serous. Small, reddish areas of granulation tissue appear on becomes more serous. Small, reddish areas of granulation tissue appear on the floor and these link up until the whole surface is covered.the floor and these link up until the whole surface is covered.

RepairRepair The stage of repair consists of the transformation of granulation to fibrous The stage of repair consists of the transformation of granulation to fibrous

tissue, which gradually contracts to form a scar. The epithelium gradually tissue, which gradually contracts to form a scar. The epithelium gradually extends from the now shelving edge to cover the floor (at a rate of 1 mm extends from the now shelving edge to cover the floor (at a rate of 1 mm per day).per day).

This healing edge consists of three zones — an outer of epithelium, which This healing edge consists of three zones — an outer of epithelium, which appears white, a middle one, bluish in colour (where granulation tissue is appears white, a middle one, bluish in colour (where granulation tissue is covered by a few layers of epithelium), and an inner reddish zone of covered by a few layers of epithelium), and an inner reddish zone of granulation tissue covered by a single layer of epithelial cells. The red granulation tissue covered by a single layer of epithelial cells. The red colour of granulation tissue is due to the high density of new capillaries colour of granulation tissue is due to the high density of new capillaries (neo-angiogenesis).(neo-angiogenesis).

Clinical examination of an ulcerClinical examination of an ulcer This should be conducted in a systematic manner. The following are, with brief This should be conducted in a systematic manner. The following are, with brief

examples, the points which should be noted.examples, the points which should be noted. Site, e.g. 95 per cent of rodent ulcers occur on the upper part of the face. Carcinoma Site, e.g. 95 per cent of rodent ulcers occur on the upper part of the face. Carcinoma

typically affects the lower lip, while a primary chancre of syphilis is usually on the typically affects the lower lip, while a primary chancre of syphilis is usually on the upper lip. upper lip.

•  •  Size, particularly in relation to the length of history, e.g. a carcinoma extends more Size, particularly in relation to the length of history, e.g. a carcinoma extends more rapidly than a rodent ulcer, but more slowly than an inflammatory ulcer.rapidly than a rodent ulcer, but more slowly than an inflammatory ulcer.

•  •  Shape, e.g. a rodent ulcer is usually circular. A gummatous ulcer is typically Shape, e.g. a rodent ulcer is usually circular. A gummatous ulcer is typically circular, or serpiginous due to the fusion of multiple circles. An ulcer with a square circular, or serpiginous due to the fusion of multiple circles. An ulcer with a square area or straight edge is suggestive of ‘dermatitis artefacta’ (Fig. 12.16).area or straight edge is suggestive of ‘dermatitis artefacta’ (Fig. 12.16).

•  •  Edge (Fig. 12.17). A healing, nonspecific ulcer has a shelving edge. It is pearly, Edge (Fig. 12.17). A healing, nonspecific ulcer has a shelving edge. It is pearly, rolled or rampant if a rodent ulcer, and raised and everted if an epithelioma, under rolled or rampant if a rodent ulcer, and raised and everted if an epithelioma, under mined and often bluish if tuberculous, vertically punched out if syphilitic.mined and often bluish if tuberculous, vertically punched out if syphilitic.

•  •  Floor. The floor is that which is seen by an observer, e.g. watery or apple-jelly Floor. The floor is that which is seen by an observer, e.g. watery or apple-jelly granulations in a tuberculous ulcer, a wash-leather slough in a gummatous ulcer.granulations in a tuberculous ulcer, a wash-leather slough in a gummatous ulcer.

•  •  Base. The base is what can be palpated. It may be indurated as in a carcinoma or Base. The base is what can be palpated. It may be indurated as in a carcinoma or attached to deep structures, e.g. a varicose ulcer to the tibia.attached to deep structures, e.g. a varicose ulcer to the tibia.

•  •  Discharge. A purulent discharge indicates active infection. A blue—green coloration Discharge. A purulent discharge indicates active infection. A blue—green coloration suggests infection with Pseudo monas pyocyaneus. A watery discharge is typical of suggests infection with Pseudo monas pyocyaneus. A watery discharge is typical of tuber culosis. It is bloodstained in the extension phase of a nonspecific ulcer. tuber culosis. It is bloodstained in the extension phase of a nonspecific ulcer. Bacteriological examination may reveal colonisation by coagulase-positive Bacteriological examination may reveal colonisation by coagulase-positive staphylococci. Spirochetes are found in a primary chancre (Chapter 8).staphylococci. Spirochetes are found in a primary chancre (Chapter 8).

Lymph nodes are not enlarged in the case of a rodent ulcer, unless Lymph nodes are not enlarged in the case of a rodent ulcer, unless due to secondary infection. In the case of carci noma, they may be due to secondary infection. In the case of carci noma, they may be enlarged, hard and even fixed. The inguinal nodes draining a enlarged, hard and even fixed. The inguinal nodes draining a syphilitic chancre of the penis are firm and ‘shotty’, but contrarily syphilitic chancre of the penis are firm and ‘shotty’, but contrarily the submandibular nodes draining a chancre of the lip are greatly the submandibular nodes draining a chancre of the lip are greatly enlarged.enlarged.

•  •  Pain. Nonspecific ulcers in the extension and transition stages Pain. Nonspecific ulcers in the extension and transition stages are painful (except for the anaesthetic trophic type). Tuberculous are painful (except for the anaesthetic trophic type). Tuberculous ulcers vary, that of the tongue being very painful. Syphilitic ulcers ulcers vary, that of the tongue being very painful. Syphilitic ulcers are usually painless, but an anal chancre (of a homosexual) may are usually painless, but an anal chancre (of a homosexual) may be painful (cf. anal fissure, Chapter 61).be painful (cf. anal fissure, Chapter 61).

•  •  General examination. Evidence of debility, cardiac failure, all General examination. Evidence of debility, cardiac failure, all types of anaemia, including sickle-cell anaemia, or diabetes must types of anaemia, including sickle-cell anaemia, or diabetes must be sought.be sought.

•  •  Pathological examinations, e.g. biopsy, will confirm carcinoma. Pathological examinations, e.g. biopsy, will confirm carcinoma. The serological and Mantoux tests may be of value for syphilis and The serological and Mantoux tests may be of value for syphilis and tuberculosis, respectively.tuberculosis, respectively.

•  •  Marjolin’s ulcer. See Chapter 13Marjolin’s ulcer. See Chapter 13

local (topical) treatment of nonspecific ulcerslocal (topical) treatment of nonspecific ulcers Any underlying cause is treated, e.g. varicose veins (Chapter 16), Any underlying cause is treated, e.g. varicose veins (Chapter 16),

diabetes, arterial disease. Many lotions and nonadhesive diabetes, arterial disease. Many lotions and nonadhesive applications are used to aid the separation of sloughs, hasten applications are used to aid the separation of sloughs, hasten granulation and stimulate epithelialisation. The basic requirements granulation and stimulate epithelialisation. The basic requirements of an ideal dressing are that should:of an ideal dressing are that should:

••maintain a high humidity between the wound and the dressing;maintain a high humidity between the wound and the dressing; ••remove excess exudate and toxic compounds;remove excess exudate and toxic compounds; ••permit gaseous exchange of oxygen, carbon dioxide and water permit gaseous exchange of oxygen, carbon dioxide and water

vapour;vapour; ••provide thermal insulation to the wound surface and be provide thermal insulation to the wound surface and be

impermeable to microorganisms;impermeable to microorganisms; ••be free from particles and toxic wound contaminantsbe free from particles and toxic wound contaminants ••allow easy removal with no trauma at dressing change;allow easy removal with no trauma at dressing change; ••be safe to use and be acceptable to the patient;be safe to use and be acceptable to the patient; ••be cost-effective.be cost-effective.

Antiseptics and topical antibioticsAntiseptics and topical antibiotics Antiseptics can do more harm than good when used Antiseptics can do more harm than good when used

inappropriately. They can interfere with the normal healing inappropriately. They can interfere with the normal healing process, are toxic to fibroblasts and may permit more virulent process, are toxic to fibroblasts and may permit more virulent organisms to dominate. The routine use of antiseptic and organisms to dominate. The routine use of antiseptic and hypochlorite solutions should be avoided. If a wound needs hypochlorite solutions should be avoided. If a wound needs cleaning, this can be achieved safely and more economically with cleaning, this can be achieved safely and more economically with normal saline warmed to body temperature prior to use. If a normal saline warmed to body temperature prior to use. If a topical antiseptic is necessary, aqueous chlorhexidine 1 in 5000 topical antiseptic is necessary, aqueous chlorhexidine 1 in 5000 solution is effective against a wide range of Gram-positive and -solution is effective against a wide range of Gram-positive and -negative organisms and some fungi, but not spores. Povidone negative organisms and some fungi, but not spores. Povidone iodine has a broad spectrum of activity but its antibacterial effect iodine has a broad spectrum of activity but its antibacterial effect is reduced by contact with pus or exudate. It should not be used is reduced by contact with pus or exudate. It should not be used on patients who are sensitive to iodine. Topical antibiotics are not on patients who are sensitive to iodine. Topical antibiotics are not recommended routinely as resistance and sensitisation following recommended routinely as resistance and sensitisation following application may arise. Flamazine is a hydrophilic cream containing application may arise. Flamazine is a hydrophilic cream containing silver sulphadiazine 1% which is a broad-spectrum antibacterial silver sulphadiazine 1% which is a broad-spectrum antibacterial agent and very effective against Pseudomonas, useful for the agent and very effective against Pseudomonas, useful for the prevention of Gram-negative sepsis in patients with severe burns.prevention of Gram-negative sepsis in patients with severe burns.

Wound dressingsWound dressings Hydrocolloid dressings such as Granuflex or Comfeel consist of a thin polyurethane Hydrocolloid dressings such as Granuflex or Comfeel consist of a thin polyurethane

foam sheet bonded on to a semipermeable polyurethane film, which is impermeable foam sheet bonded on to a semipermeable polyurethane film, which is impermeable to exudate and microorganisms. When the dressing comes into contact with wound to exudate and microorganisms. When the dressing comes into contact with wound exudate it interacts to form a gel which expands into the wound. The moist exudate it interacts to form a gel which expands into the wound. The moist conditions produced under the dressing promote angiogenesis and wound healing conditions produced under the dressing promote angiogenesis and wound healing without causing maceration. They can be used in the treatment of leg ulcers, without causing maceration. They can be used in the treatment of leg ulcers, pressure sores, minor burns and many types of granulating wound. A hydrocolloid pressure sores, minor burns and many types of granulating wound. A hydrocolloid dressing can be applied to small wounds containing dry slough or necrosis: the dressing can be applied to small wounds containing dry slough or necrosis: the dressing prevents the loss of water vapour from the surface of the skin, and this dressing prevents the loss of water vapour from the surface of the skin, and this effectively rehydrates the dead tissue which is then removed by autolysis.effectively rehydrates the dead tissue which is then removed by autolysis.

Hydrogel (Intrasite gel) is a pale yellow/colourless transparent aque ous gel. When it Hydrogel (Intrasite gel) is a pale yellow/colourless transparent aque ous gel. When it comes into contact with a wound, the dressing absorbs excess exudate and produces comes into contact with a wound, the dressing absorbs excess exudate and produces a moist environment at the surface of the wound without causing tissue maceration. a moist environment at the surface of the wound without causing tissue maceration. It may be applied to many different wounds including leg ulcers, pressure sores, It may be applied to many different wounds including leg ulcers, pressure sores, surgical wounds and granulating tissue. It is particularly useful in the treatment of surgical wounds and granulating tissue. It is particularly useful in the treatment of dry, sloughy or necrotic wounds, promoting rapid débridement by facilitating dry, sloughy or necrotic wounds, promoting rapid débridement by facilitating rehydration and autolysis of dead tissue. It reduces the feeling of pain and can be rehydration and autolysis of dead tissue. It reduces the feeling of pain and can be used as a carrier of other medicines, e.g. metronidazole, for the control of odour used as a carrier of other medicines, e.g. metronidazole, for the control of odour caused by infection with sensitive organisms. (It is useful in fungating tumours where caused by infection with sensitive organisms. (It is useful in fungating tumours where the aim is not to heal the wound but to manage the distressing symptoms caused by the aim is not to heal the wound but to manage the distressing symptoms caused by it.) Intrasite should be secured with a secondary dressing such as an absorbent pad it.) Intrasite should be secured with a secondary dressing such as an absorbent pad or Tegaderm depending on the wound.or Tegaderm depending on the wound.

Alginates (Kaltostat) consist of an absorbent fibrous fleece composed of the mixed Alginates (Kaltostat) consist of an absorbent fibrous fleece composed of the mixed sodium and calcium salts of alginic acid. In the presence of exudate or other body sodium and calcium salts of alginic acid. In the presence of exudate or other body fluids containing sodium ions, the fibres absorb liquid and swell, calcium ions present fluids containing sodium ions, the fibres absorb liquid and swell, calcium ions present in the fibre are partially replaced by sodium, causing the dressing to take on a gel-in the fibre are partially replaced by sodium, causing the dressing to take on a gel-like appearance which promotes healing. The fibres are held in place with a like appearance which promotes healing. The fibres are held in place with a secondary dressing such as an absorbent pad or Tegaderm depending on the amount secondary dressing such as an absorbent pad or Tegaderm depending on the amount ofof

exudate. Alginate dressings can be used for the management of bleeding wounds exudate. Alginate dressings can be used for the management of bleeding wounds including cuts and lacerations and also for a wide range of exuding lesions including including cuts and lacerations and also for a wide range of exuding lesions including leg ulcers, pressure sores and most other granulating wounds. Most suitable for leg ulcers, pressure sores and most other granulating wounds. Most suitable for heavy to moderately exudating wounds. In the presence of low exudate the Kaltostat heavy to moderately exudating wounds. In the presence of low exudate the Kaltostat must be moistened with saline before application to avoid adherence. The alginates must be moistened with saline before application to avoid adherence. The alginates are biodegradable so it is not necessary to remove every fibre if it will damage the are biodegradable so it is not necessary to remove every fibre if it will damage the healing tissue.healing tissue.

Lyofoam is a low-adherent conformable polyurethane foam sheet. The side of the Lyofoam is a low-adherent conformable polyurethane foam sheet. The side of the dressing that is to be placed in contact with the skin has been heat treated to render dressing that is to be placed in contact with the skin has been heat treated to render it hydrophilic, whilst the outer surface remains hydrophobic. The dressing is freely it hydrophilic, whilst the outer surface remains hydrophobic. The dressing is freely permeable to gases and water vapour but resists the penetration of aqueous permeable to gases and water vapour but resists the penetration of aqueous solutions and exu date. The dressing absorbs blood and any other tissue fluids but the solutions and exu date. The dressing absorbs blood and any other tissue fluids but the aqueous component is lost by evaporation through the back of the dressing. Strike-aqueous component is lost by evaporation through the back of the dressing. Strike-through occurs laterally and not at the top of the dress ing. The dressing maintains a through occurs laterally and not at the top of the dress ing. The dressing maintains a moist warm environment at the surface of the wound, which is conducive to moist warm environment at the surface of the wound, which is conducive to granulation and epithelialisation. Foam sheet dressings may be used on a variety of granulation and epithelialisation. Foam sheet dressings may be used on a variety of exudating wounds including leg ulcers, pressure sores, sutured wounds, burns and exudating wounds including leg ulcers, pressure sores, sutured wounds, burns and donor sites.donor sites.

Tegaderm consists of a thin polyurethane membrane coated with a layer of an acrylic adhesive. The Tegaderm consists of a thin polyurethane membrane coated with a layer of an acrylic adhesive. The dressing allows for a moist environment at the surface of the wound by reducing water vapour loss dressing allows for a moist environment at the surface of the wound by reducing water vapour loss from the exposed tissue. It is permeable to both water vapour and oxygen and impermeable to from the exposed tissue. It is permeable to both water vapour and oxygen and impermeable to microorganisms, providing an effective barrier to external contamination. Scab formation is microorganisms, providing an effective barrier to external contamination. Scab formation is prevented and epidermal regeneration takes place at an enhanced rate, compared with that which prevented and epidermal regeneration takes place at an enhanced rate, compared with that which occurs in wounds treated with traditional dry dressings. Tegaderm may be used in the treatment of occurs in wounds treated with traditional dry dressings. Tegaderm may be used in the treatment of minor burns, pressure areas, donor sites, postoperative wounds and a variety of minor injuries. It is minor burns, pressure areas, donor sites, postoperative wounds and a variety of minor injuries. It is also effectively used as a protective cover to prevent skin breakdown due to friction or continuous also effectively used as a protective cover to prevent skin breakdown due to friction or continuous exposure to moisture.exposure to moisture.

Alleyvncavity wound dressing is a highly comfortable absorbent dressing consisting of a soft, Alleyvncavity wound dressing is a highly comfortable absorbent dressing consisting of a soft, polymeric outer membrane with a three-dimensional honeycomb-like structure containing a mass of polymeric outer membrane with a three-dimensional honeycomb-like structure containing a mass of hydrophilic polyurethane chips. The outer membrane is perforated to allow exudate to be drawn hydrophilic polyurethane chips. The outer membrane is perforated to allow exudate to be drawn into the interior of the dressing where it is absorbed and retained by the ‘chips’. This type of into the interior of the dressing where it is absorbed and retained by the ‘chips’. This type of dressing is used for heavily exudat ing, full-thickness sloughy wounds, usually combined with dressing is used for heavily exudat ing, full-thickness sloughy wounds, usually combined with Intrasite gel; it can be used alone with clean, deep, ex~ daring wounds.Intrasite gel; it can be used alone with clean, deep, ex~ daring wounds.

Most of the above dressings are also available with added properties which improve their basic Most of the above dressings are also available with added properties which improve their basic function, such as Kaltocarb. This is Kaltostat with a layer of activated charcoal cloth attached. This is function, such as Kaltocarb. This is Kaltostat with a layer of activated charcoal cloth attached. This is effective as a primary dressing in the management of infected malodorous wounds.effective as a primary dressing in the management of infected malodorous wounds.

As the wound heals if granulation tissue continues to grow past the epidermal layer, the dressing As the wound heals if granulation tissue continues to grow past the epidermal layer, the dressing used to stimulate granulation should be discontinued and a Lyofoam dressing should be applied. If used to stimulate granulation should be discontinued and a Lyofoam dressing should be applied. If after 1 week there is no improvement Tetra-cortil ointment containing hydrocorti sone and after 1 week there is no improvement Tetra-cortil ointment containing hydrocorti sone and oxytetracycline applied sparingly to the wound may be effec tive. This should be covered with a oxytetracycline applied sparingly to the wound may be effec tive. This should be covered with a Lyofoam dressing and should be used for no longer than 5 days. Silver nitrate may be used with Lyofoam dressing and should be used for no longer than 5 days. Silver nitrate may be used with heavy over granulating tissue but it is not recommended, usually because of its toxicity and the risk heavy over granulating tissue but it is not recommended, usually because of its toxicity and the risk of sensitivity and staining.of sensitivity and staining.

Oriental sore (syn. Delhi boil, Baghdad sore, etc.)Oriental sore (syn. Delhi boil, Baghdad sore, etc.) This disease is due to infection by a protozoal parasite, This disease is due to infection by a protozoal parasite,

Leishmania tro pica, and is a common condition in Eastern Leishmania tro pica, and is a common condition in Eastern countries which is occasionally imported to Western zones. An countries which is occasionally imported to Western zones. An indurated papule appears on an exposed surface, usually the face. indurated papule appears on an exposed surface, usually the face. If untreated, this breaks down to form an indolent ulcer, which If untreated, this breaks down to form an indolent ulcer, which eventually leaves an ugly, pigmented scar. The condition readily eventually leaves an ugly, pigmented scar. The condition readily responds to intravenous injections of antimony tartrate, but very responds to intravenous injections of antimony tartrate, but very small lesions can be treated by carbon dioxide snow, and also small lesions can be treated by carbon dioxide snow, and also curettage.curettage.

Bazin’s disease (syn. erythema induratum) is due to localised Bazin’s disease (syn. erythema induratum) is due to localised areas of fat necrosis and particularly affects adolescent girls. areas of fat necrosis and particularly affects adolescent girls. Symmetrical pur plish nodules appear, especially on the calves, Symmetrical pur plish nodules appear, especially on the calves, and gradually break down to form indolent ulcers, which leave in and gradually break down to form indolent ulcers, which leave in their wake pigmented scars. Tuberculosis may be a cause in many their wake pigmented scars. Tuberculosis may be a cause in many instances, the ulcers responding to antituberculous drugs (Fig. instances, the ulcers responding to antituberculous drugs (Fig. 12.17) (Chapter 8).12.17) (Chapter 8).

  

Sinuses and fistulasSinuses and fistulas A sinus (Latin a hollow; a bay or gulf) is a blind track (usually lined with granulation tissue) leading from an epithelial A sinus (Latin a hollow; a bay or gulf) is a blind track (usually lined with granulation tissue) leading from an epithelial

surface into the surrounding tissues. Pathological sinuses must be distinguished from normal anatomical sinuses (e.g. surface into the surrounding tissues. Pathological sinuses must be distinguished from normal anatomical sinuses (e.g. the frontal and nasal sinuses). A fistula (Latin = a pipe or tube) is an abnormal communication between the lumen or the frontal and nasal sinuses). A fistula (Latin = a pipe or tube) is an abnormal communication between the lumen or surface of one organ and the lumen or surface of another, or between vessels. Most fistulas connect epithelial lined surface of one organ and the lumen or surface of another, or between vessels. Most fistulas connect epithelial lined surfaces (Fig. 12.18). Sinuses and fistulas may be congenitalor acquired. Forms which have a congenital origin include surfaces (Fig. 12.18). Sinuses and fistulas may be congenitalor acquired. Forms which have a congenital origin include preauricular sinuses (Chapter 37), branchial fistulas (Chapter 43), tracheo-oesophageal fistulas (Chapter 50) and preauricular sinuses (Chapter 37), branchial fistulas (Chapter 43), tracheo-oesophageal fistulas (Chapter 50) and arteriovenous fistulas (Chapter 15). The acquired forms often follow inadequate drainage of an abscess. Thus, a perianal arteriovenous fistulas (Chapter 15). The acquired forms often follow inadequate drainage of an abscess. Thus, a perianal abscess may burst on the surface and lead to a sinus (erroneously termed a blind external ‘fistula’). In other cases, the abscess may burst on the surface and lead to a sinus (erroneously termed a blind external ‘fistula’). In other cases, the abscess opens both into the anal canal and on to the surface of the perineal stem resulting in a true fistula-in-ano abscess opens both into the anal canal and on to the surface of the perineal stem resulting in a true fistula-in-ano (Chapter 61). Acquired arteriovenous fistulas are caused by trauma or operation (for renal dialysis).(Chapter 61). Acquired arteriovenous fistulas are caused by trauma or operation (for renal dialysis).

  Persistence of a sinus or fistulaPersistence of a sinus or fistula   The reason for this will be found among the following:The reason for this will be found among the following: • • a foreign body or necrotic tissue is present, e.g. a suture, hairs, a sequestrum, a faecolith or even a worm (see below);a foreign body or necrotic tissue is present, e.g. a suture, hairs, a sequestrum, a faecolith or even a worm (see below); • • inefficient or nondependent drainage: long, narrow, tortuous track predisposes to inefficient drainage;inefficient or nondependent drainage: long, narrow, tortuous track predisposes to inefficient drainage; • • unrelieved obstruction of the lumen of a viscus or tube distal to the fistula;unrelieved obstruction of the lumen of a viscus or tube distal to the fistula; • • high pressure, such as occurs in fistula-in-ano due to the normal contractions of the sphincter which force faecal high pressure, such as occurs in fistula-in-ano due to the normal contractions of the sphincter which force faecal

material through the fistula;material through the fistula; • • the walls have become lined with epithelium or endothelium (arteriovenous fistula);the walls have become lined with epithelium or endothelium (arteriovenous fistula); • • dense fibrosis prevents contraction and healing;dense fibrosis prevents contraction and healing; • • type of infection, e.g. tuberculosis or actinomycosis;type of infection, e.g. tuberculosis or actinomycosis; • • the presence of malignant diseasethe presence of malignant disease • • ischaemia;ischaemia; • • drugs, e.g. steroids, cytotoxics;drugs, e.g. steroids, cytotoxics; • • malnutrition;malnutrition; • • interference, e.g. artefacta;interference, e.g. artefacta; • • irradiation, e.g. rectovaginal fistula after treatment for a carcinoma of the cervix;irradiation, e.g. rectovaginal fistula after treatment for a carcinoma of the cervix; • • Crohn’s disease;Crohn’s disease; ••high-output fistula, e.g. duodenocutaneous fistula.high-output fistula, e.g. duodenocutaneous fistula.

Treatment               .Treatment               .     The remedy depends upon e removal or specific treatment of the cause The remedy depends upon e removal or specific treatment of the cause

(see appropriate pages).(see appropriate pages).   Guinea worm (syn. dragon worm, Dracunculusmedinensis) (Fig. 12.19)Guinea worm (syn. dragon worm, Dracunculusmedinensis) (Fig. 12.19)   This is a cause of a persisting sinus on the lower leg. The larval form This is a cause of a persisting sinus on the lower leg. The larval form

enters through the wall of the stomach or duodenum in drinking water enters through the wall of the stomach or duodenum in drinking water contaminated by a tiny cyclops crustacean which has consumed the contaminated by a tiny cyclops crustacean which has consumed the larvae. Settling in the abdominal connective tissue, the male and female larvae. Settling in the abdominal connective tissue, the male and female mate, the pregnancy lasting about a year, and the female wanders in the mate, the pregnancy lasting about a year, and the female wanders in the subcutaneous tissues to select for egg laying a part of the anatomy likely subcutaneous tissues to select for egg laying a part of the anatomy likely to be submerged in water (containing the cyclops), usually the lower leg. to be submerged in water (containing the cyclops), usually the lower leg. Cellulitis, abscesses, ulcers and sinuses follow, through which the embryos Cellulitis, abscesses, ulcers and sinuses follow, through which the embryos are discharged, hopefully to be eaten by the cyclops. Baid travelled the are discharged, hopefully to be eaten by the cyclops. Baid travelled the interior of India and in 500 cases discerned a syndrome of the infestation, interior of India and in 500 cases discerned a syndrome of the infestation, presenting with conjunctivitis (allergic) in 11 per cent, fibrous contracture presenting with conjunctivitis (allergic) in 11 per cent, fibrous contracture of joints in 19 per cent, periostitis with osteomyelitis in 21 per cent and of joints in 19 per cent, periostitis with osteomyelitis in 21 per cent and acute arthritis in 65per cent.acute arthritis in 65per cent.

Wound Healing :Wound Healing :In human regeneration is limited to epithelium and the liver; most In human regeneration is limited to epithelium and the liver; most

tissues heal by repair resulting in scarring. Wound healing is the tissues heal by repair resulting in scarring. Wound healing is the summation of a number of processes which follow injury including summation of a number of processes which follow injury including coagulation, inflammation, matrix synthesis and deposition, coagulation, inflammation, matrix synthesis and deposition, angiogenesis, fibroplasia, epithelialisation, contraction, angiogenesis, fibroplasia, epithelialisation, contraction, remodelling and scar maturation . Where wound edges are apposed remodelling and scar maturation . Where wound edges are apposed healing proceeds rapidly to closure; this is known as healing proceeds rapidly to closure; this is known as healing byhealing by first intention or primary healingfirst intention or primary healing . Where the wound edges are . Where the wound edges are apart, such as when there has been tissue loss, the same biological apart, such as when there has been tissue loss, the same biological processes occur, but rapid closure is not possible. Angiogenesis processes occur, but rapid closure is not possible. Angiogenesis and fibroblast proliferation result in the formation of granulation and fibroblast proliferation result in the formation of granulation tissue. This contracts to reduce wound area and allows tissue. This contracts to reduce wound area and allows epithelialisation across its surface to achieve wound closure. This epithelialisation across its surface to achieve wound closure. This is known as is known as healing by second intentionhealing by second intention . This process is slower, . This process is slower, the contraction involved may cause contracture and functional the contraction involved may cause contracture and functional restriction ,and the resultant healed surface is a thin layer of restriction ,and the resultant healed surface is a thin layer of epithelium on scar tissue that may not prove durable in the long epithelium on scar tissue that may not prove durable in the long term. In general, healing by second intention will give a worse term. In general, healing by second intention will give a worse aesthetic outcome. It is because of the poor functional and aesthetic outcome. It is because of the poor functional and aesthetic results of healing by second intention that surgical aesthetic results of healing by second intention that surgical endeavour is usually directed towards achieving primary wound endeavour is usually directed towards achieving primary wound healing. healing.

Wound excisionWound excision

The most important step in the management of any untidy The most important step in the management of any untidy wound is wound is wound excisionwound excision. This process is sometimes . This process is sometimes called called ‘wound toilet’‘wound toilet’ or or ‘debridement’.‘debridement’. The former implies The former implies washing and the latter laying open or fasciotomy, all of washing and the latter laying open or fasciotomy, all of which may be important in wound management but do which may be important in wound management but do not describe excision of devitalised tissue which is the not describe excision of devitalised tissue which is the most important process. For this reason the term ‘wound most important process. For this reason the term ‘wound excision’ is preferred. In order to excise a wound excision’ is preferred. In order to excise a wound adequate anaesthesia — local, regional or general  must adequate anaesthesia — local, regional or general  must be provided. Where possible a bloodless field also aids be provided. Where possible a bloodless field also aids identification of structures. For superficial wounds the identification of structures. For superficial wounds the use of local anaesthetic with 1 in 200 000 adrenaline use of local anaesthetic with 1 in 200 000 adrenaline gives good haemostasis of skin edges. In the limbs a gives good haemostasis of skin edges. In the limbs a pneumatic tourniquet is used. It is helpful to use a skin pneumatic tourniquet is used. It is helpful to use a skin marking pen to plan the skin excision and any wound marking pen to plan the skin excision and any wound extensions. Excision should proceed in a systematic extensions. Excision should proceed in a systematic fashion dealing with each tissue layer in turn, usually fashion dealing with each tissue layer in turn, usually starting superficial and moving deep. starting superficial and moving deep.

Longitudinal structures such as blood vessels, nerves and Longitudinal structures such as blood vessels, nerves and tendons are identified and exposed, but left in continuity. tendons are identified and exposed, but left in continuity. With experience the surgeon learns to recognise dead With experience the surgeon learns to recognise dead tissues. Devitalised dermis is pink rather than white; tissues. Devitalised dermis is pink rather than white; devitalised fat is pink rather than yellow; devitalised devitalised fat is pink rather than yellow; devitalised muscle is a dark colour, has lost its usual sheen and muscle is a dark colour, has lost its usual sheen and turgor, and does not twitch when picked up with forceps. turgor, and does not twitch when picked up with forceps. Bone fragments with no soft-tissue attachment or non-vital Bone fragments with no soft-tissue attachment or non-vital soft tissue attachments are also discarded. This approach soft tissue attachments are also discarded. This approach to radical wound excision is sometimes called a to radical wound excision is sometimes called a ‘‘pseudotumourpseudotumour’ approach, because the entire wound is ’ approach, because the entire wound is excised with an appropriate margin back to healthy tissue . excised with an appropriate margin back to healthy tissue . At the end of wound excision the wound should resemble At the end of wound excision the wound should resemble an anatomical dissection. Normal bleeding should be an anatomical dissection. Normal bleeding should be observed from each layer. Occasionally in very extensive observed from each layer. Occasionally in very extensive wounds this radical approach must be modified. Where wounds this radical approach must be modified. Where radical wound excision would threaten the viability or radical wound excision would threaten the viability or function of the limb it is reasonable to excise what is function of the limb it is reasonable to excise what is definitely nonviable, carry out fasciotomy as appropriate definitely nonviable, carry out fasciotomy as appropriate and dress the wound, with a view to returning 48 hours and dress the wound, with a view to returning 48 hours later for a second look, and thereafter further serial wound later for a second look, and thereafter further serial wound excisions until a tidy wound is achieved.excisions until a tidy wound is achieved.

Wound closure :Wound closure :Wound closure can be achieved by number of Wound closure can be achieved by number of

differing techniques. Most tidy wounds that do not differing techniques. Most tidy wounds that do not involve loss of tissue can be closed directly. involve loss of tissue can be closed directly. Where there is tissue loss a technique to import Where there is tissue loss a technique to import appropriate tissue is needed. Reconstructive appropriate tissue is needed. Reconstructive plastic surgical techniques can range from simple plastic surgical techniques can range from simple skin grafts to complex composite free tissue skin grafts to complex composite free tissue transfers . This list used to be described as a transfers . This list used to be described as a ‘reconstructive ladder’; unfortunately this implies ‘reconstructive ladder’; unfortunately this implies that the correct approach is to use the simplest that the correct approach is to use the simplest technique and only when it fails move to a more technique and only when it fails move to a more complex technique. This approach is not complex technique. This approach is not appropriate in modern surgical practice. The appropriate in modern surgical practice. The available techniques should be regarded as a available techniques should be regarded as a ‘toolbox’ from which to select the technique that ‘toolbox’ from which to select the technique that provides most rapid healing, earliest return to provides most rapid healing, earliest return to function and superior aesthetic outcome.function and superior aesthetic outcome.

ScarsScarsThe most superficial wounds such as superficial burns and abrasions will heal The most superficial wounds such as superficial burns and abrasions will heal

by epithelialisation alone without scar formation. In these circumstances by epithelialisation alone without scar formation. In these circumstances adnexal structures are preserved and the epithelium regenerates from these adnexal structures are preserved and the epithelium regenerates from these structures. This may leave alterations in keratinisation, texture or structures. This may leave alterations in keratinisation, texture or pigmentation of the healed area, but not scarring as such. pigmentation of the healed area, but not scarring as such.

A scar is the inevitable consequence of wound repair. The final phase of wound A scar is the inevitable consequence of wound repair. The final phase of wound repair is the process of remodelling and scar maturation . The fibroblasts, repair is the process of remodelling and scar maturation . The fibroblasts, capillaries, glycosaminoglycans, and immature collagen of granulation tissue capillaries, glycosaminoglycans, and immature collagen of granulation tissue and the newly healed wound are replaced by relatively acellular, avascular and the newly healed wound are replaced by relatively acellular, avascular scar tissue composed of mature collagen with scattered fibroblasts. This scar tissue composed of mature collagen with scattered fibroblasts. This biological process is mani fested by a change in appearance of the scar from biological process is mani fested by a change in appearance of the scar from a red, raised, firm, contracting, perhaps itchy nodule to a pale, flat, softer, a red, raised, firm, contracting, perhaps itchy nodule to a pale, flat, softer, static, symptomless plaque of mature scar. The rate at which any given scar static, symptomless plaque of mature scar. The rate at which any given scar passes through this process can vary widely depending on the age of the passes through this process can vary widely depending on the age of the individual, the site of the wound, the time the wound took to heal, the individual, the site of the wound, the time the wound took to heal, the direction of the scar and the tension across it . In general, scars in younger direction of the scar and the tension across it . In general, scars in younger patients with wounds on the trunk that heal slowly, perhaps with infection or patients with wounds on the trunk that heal slowly, perhaps with infection or dehiscence, and scars that have a lot of tension across them will take much dehiscence, and scars that have a lot of tension across them will take much longer to mature than scars in older people, in thin-skinned areas, that heal longer to mature than scars in older people, in thin-skinned areas, that heal rapidly by first intention and that have minimal tension across them . It is rapidly by first intention and that have minimal tension across them . It is important to be aware of this variation in the natural history of scar important to be aware of this variation in the natural history of scar maturation in order to counsel patients regarding the likely progress and maturation in order to counsel patients regarding the likely progress and outcome of their scar, advise those having elective surgery what the outcome of their scar, advise those having elective surgery what the consequences in terms of scarring will be, and to recognise the various consequences in terms of scarring will be, and to recognise the various types of adverse scarring which can occur. One of the most frequent types of types of adverse scarring which can occur. One of the most frequent types of adverse scar, a hypertrophic scar, is one that remains red, raised, itchy and adverse scar, a hypertrophic scar, is one that remains red, raised, itchy and tender for longer than might generally be expected. tender for longer than might generally be expected.

Adverse scarAdverse scar There are many types of adverse scar (Table 3.3), many of which can be There are many types of adverse scar (Table 3.3), many of which can be

avoided or prevented by correct incision planning and adequate wound avoided or prevented by correct incision planning and adequate wound management. Some types, however, cannot be prevented and are management. Some types, however, cannot be prevented and are unpredictable in their occurrence. The appearance of some scars can be unpredictable in their occurrence. The appearance of some scars can be improved by surgical or other means, but scars can never be removed improved by surgical or other means, but scars can never be removed totally. The types of adverse scar will be discussed and suggestions for totally. The types of adverse scar will be discussed and suggestions for avoidance or management made.avoidance or management made.

  Wrong directionWrong direction Incisions that pass along ideal lines are more likely to leave acceptable Incisions that pass along ideal lines are more likely to leave acceptable

scars. There are many types of ‘lines of election’ for incisions, most of scars. There are many types of ‘lines of election’ for incisions, most of which pass along skin wrinkles or along relaxed skin tension lines (that is a which pass along skin wrinkles or along relaxed skin tension lines (that is a line along which maximal skin tension passes when the part is in a relaxed line along which maximal skin tension passes when the part is in a relaxed position). These lines have minimal tension across the wound edges. A scar position). These lines have minimal tension across the wound edges. A scar which crosses these lines will have a greater tendency to stretch or which crosses these lines will have a greater tendency to stretch or become hypertrophic, and even if not hypertrophic will usually appear become hypertrophic, and even if not hypertrophic will usually appear more conspicuous than one which follows a relaxed skin tension line. Other more conspicuous than one which follows a relaxed skin tension line. Other ideal positions for scars are at junctions between anatomical areas such as ideal positions for scars are at junctions between anatomical areas such as the nose and the cheek, the cheek and the ear or the junction between a the nose and the cheek, the cheek and the ear or the junction between a hairy and hairless areahairy and hairless area

Poor alignment of featuresPoor alignment of features Where a scar crosses the junction between distinct anatom ical features, such as the Where a scar crosses the junction between distinct anatom ical features, such as the

vermillion of the lip, it is essential that these features are accurately realigned. Such vermillion of the lip, it is essential that these features are accurately realigned. Such misalignments result in conspicuous adverse scars.misalignments result in conspicuous adverse scars.

Stretched scarStretched scar Scars from excisional wounds on the trunk and limbs often stretch. It has been shown Scars from excisional wounds on the trunk and limbs often stretch. It has been shown

that the width of a scar depends on the tension across the wound at the time of that the width of a scar depends on the tension across the wound at the time of wound closure. In general, steps to avoid excessive tension across the wound will be wound closure. In general, steps to avoid excessive tension across the wound will be rewarded with narrower scars. Where tension cannot be avoided there is evidence rewarded with narrower scars. Where tension cannot be avoided there is evidence that prolonged wound support with buried nonabsorbable or long-term absorbable that prolonged wound support with buried nonabsorbable or long-term absorbable sutures can minimise scar stretching.sutures can minimise scar stretching.

  Contracted scar Contracted scar The process of wound contraction continues in the remodeling phase of scar The process of wound contraction continues in the remodeling phase of scar

maturation such that a scar will always be shorter than the incision from which it maturation such that a scar will always be shorter than the incision from which it results. Where a linear scar crosses a flexor surface this shortening may result in a results. Where a linear scar crosses a flexor surface this shortening may result in a scar contracture which may prevent full extension of that part. This will occur on the scar contracture which may prevent full extension of that part. This will occur on the flexor surface of a finger if a straight-line incision is used. Curved or zigzag incisions flexor surface of a finger if a straight-line incision is used. Curved or zigzag incisions will avoid this problem. Where scarring is extensive such as burn scars then scar will avoid this problem. Where scarring is extensive such as burn scars then scar contractures may be inevitable. Linear scar contractures can be corrected by contractures may be inevitable. Linear scar contractures can be corrected by realignment of the scar; there are various techniques to do this including Z-plasty realignment of the scar; there are various techniques to do this including Z-plasty and multiple Y—V plasty. More extensive contractures will require release and and multiple Y—V plasty. More extensive contractures will require release and introduction of additional skin by means of grafts or flaps.introduction of additional skin by means of grafts or flaps.

Pigment alterationPigment alteration The new epidermis of a scar will often not have the same degree The new epidermis of a scar will often not have the same degree

of pigmentation as surrounding unscarred areas. Most scars are of pigmentation as surrounding unscarred areas. Most scars are hypopigmented, but hyperpigmentation can also occur. The only hypopigmented, but hyperpigmentation can also occur. The only ways to deal with this problem are cosmetic camouflage or ways to deal with this problem are cosmetic camouflage or tattooing. -tattooing. -

Contour deformityContour deformity Where wound edges are not anatomically aligned in the vertical Where wound edges are not anatomically aligned in the vertical

plane or where a bevelled cut is not repaired accurately there is a plane or where a bevelled cut is not repaired accurately there is a risk of contour irregularity in the healed scar. This can usually be risk of contour irregularity in the healed scar. This can usually be avoided by accurate wound repair, if necessary excising bevelled avoided by accurate wound repair, if necessary excising bevelled edges to restore even vertical edges for repair. A variation of this edges to restore even vertical edges for repair. A variation of this problem occurs when a curved laceration heals, in that the scar problem occurs when a curved laceration heals, in that the scar shortens and that portion of skin within the concavity of the shortens and that portion of skin within the concavity of the curved scar tends to become raised. This problem is known as curved scar tends to become raised. This problem is known as trapdooring or mushroom ing. It will often improve with time, but trapdooring or mushroom ing. It will often improve with time, but scar revision is sometimes indicated to correct it.scar revision is sometimes indicated to correct it.

Tattooing Tattooing In traumatic wounds it is possible for particles of grit, dirt or soot In traumatic wounds it is possible for particles of grit, dirt or soot

to become implanted in the wound as it heals. Thisresults in to become implanted in the wound as it heals. Thisresults in tattooed scars where the particles of foreign material show tattooed scars where the particles of foreign material show through as blue or black discoloration of the scar. Adequate through as blue or black discoloration of the scar. Adequate primary wound management can avoid this. Abra sions with primary wound management can avoid this. Abra sions with ingrained dirt should be scrubbed with a stiff brush; more deeply ingrained dirt should be scrubbed with a stiff brush; more deeply tattooed wounds should be excised. Late correction of tattooed tattooed wounds should be excised. Late correction of tattooed scars can be very difficult.scars can be very difficult.

Stitch marksStitch marks If skin sutures are left in place for more than 7 days then scars If skin sutures are left in place for more than 7 days then scars

from the stitch marks will usually result. This problem can be from the stitch marks will usually result. This problem can be avoided by using subcuticular sutures wherever possible, avoided by using subcuticular sutures wherever possible, removing skin sutures before 7 days and, where prolonged wound removing skin sutures before 7 days and, where prolonged wound support is needed, supplementing skin sutures with subcuticular support is needed, supplementing skin sutures with subcuticular sutures allowing early removal of the skin sutures. Adverse scars sutures allowing early removal of the skin sutures. Adverse scars due to prominent stitch marks can rarely be improved by scar due to prominent stitch marks can rarely be improved by scar revision.revision.

Hypertrophic scarsHypertrophic scars   In some circumstances scars remain in the remodelling phase for longer than is In some circumstances scars remain in the remodelling phase for longer than is

usual. These hypertrophic scars are more cellular and more vascular than mature usual. These hypertrophic scars are more cellular and more vascular than mature scars, there is increased collagen production and collagen breakdown, but the scars, there is increased collagen production and collagen breakdown, but the balance is such that excess collagen is produced. Clinically these scars are red, balance is such that excess collagen is produced. Clinically these scars are red, raised, itchy and tender (Fig. 3.14). Such scars will eventually mature to become pale raised, itchy and tender (Fig. 3.14). Such scars will eventually mature to become pale and flat, and it is this spon taneous resolution which distinguishes hypertrophic scars and flat, and it is this spon taneous resolution which distinguishes hypertrophic scars from keloid scars. Hypertrophic scars typically occur in wounds where healing was from keloid scars. Hypertrophic scars typically occur in wounds where healing was delayed, perhaps where complications such as infection or dehiscence occurred. They delayed, perhaps where complications such as infection or dehiscence occurred. They are more common in children and where skin tension is high such as the tip of the are more common in children and where skin tension is high such as the tip of the shoulder or any scar that runs across relaxed skin tension lines.shoulder or any scar that runs across relaxed skin tension lines.

    The risk of developing a hypertrophic scar can be minimised by ensuring quiet The risk of developing a hypertrophic scar can be minimised by ensuring quiet primary healing. Where hypertrophy does occur patience is usually rewarded by primary healing. Where hypertrophy does occur patience is usually rewarded by improvement with time. Massage of the scar with moisturising cream or the improvement with time. Massage of the scar with moisturising cream or the application of pressure to the remodelling scar can accelerate the natural process of application of pressure to the remodelling scar can accelerate the natural process of maturation. Patients with hypertrophic bum scars are supplied with custom made maturation. Patients with hypertrophic bum scars are supplied with custom made Lycra pressure garments that promote acceleration of scar maturation. Revision of Lycra pressure garments that promote acceleration of scar maturation. Revision of hypertrophic scars is appropriate where they cross skin tension lines or where a hypertrophic scars is appropriate where they cross skin tension lines or where a specific wound healing complication occurred. In the absence of these factors scar specific wound healing complication occurred. In the absence of these factors scar revision should be avoided as it will usually be met with recurrence.revision should be avoided as it will usually be met with recurrence.

Keloid scarsKeloid scars In some situations there is an extreme overgrowth of scar tissue In some situations there is an extreme overgrowth of scar tissue

that grows beyond the limits of the original wound and shows no that grows beyond the limits of the original wound and shows no tendency to resolve. Keloid scars are biologically identical to tendency to resolve. Keloid scars are biologically identical to hypertrophic scars that fn turn are an extension of normal scar hypertrophic scars that fn turn are an extension of normal scar behaviour. Whilst it is usually possible to make the distinction behaviour. Whilst it is usually possible to make the distinction between these scar types, they are best regarded as a spectrum between these scar types, they are best regarded as a spectrum of scar behaviour (Table 3.4). Keloid scars are more frequent in of scar behaviour (Table 3.4). Keloid scars are more frequent in Afro-Caribbean and oriental racial groups (Fig. 3.15).They often Afro-Caribbean and oriental racial groups (Fig. 3.15).They often occur in wounds that healed perfectlywithout complications. They occur in wounds that healed perfectlywithout complications. They are more common in certain sites such as the central chest, the are more common in certain sites such as the central chest, the back and shoulders and the ear-lobes. Many keloid scars are back and shoulders and the ear-lobes. Many keloid scars are untreatable and surgical treatment as a single modality will untreatable and surgical treatment as a single modality will usually be met with recurrence. Some keloid scars will improve usually be met with recurrence. Some keloid scars will improve with the application of pres sure. Intralesional injections of steroids with the application of pres sure. Intralesional injections of steroids such as triamcinolone can be helpful. The best cure rates are such as triamcinolone can be helpful. The best cure rates are achieved with a com bination of surgery and postoperative achieved with a com bination of surgery and postoperative interstitial radiotherapy.interstitial radiotherapy.