*Important Notice : Guided tours to the Parliament Chamber are suspended until further notice as a preventative measure in response to Covid-19


Anita Vashi, MD

  • Department of Emergency Medicine
  • Mount Sinai School of Medicine
  • New York, New York

To this end heart attack man buy cheap carvedilol, skin grafts and donor sites must be kept soft and supple by regular massage and application of moisturising cream for many months blood pressure glucose chart carvedilol 25 mg with amex. Splints and physiotherapy may be needed to mobilise joints and prevent joint contractures hypertension foods to avoid order carvedilol uk. Elastic pressure garments and silicone dressings may help to prevent the development of hypertrophic scars hypertension journal article order carvedilol now. In spite of this pulse pressure ecg discount 6.25mg carvedilol with visa, secondary reconstructive procedures may be required over many years to release contractures or restore form and function. Psychological support is essential for patients having difficulty coming to terms with their disfigurement and physical limitations. The signs of inflammation are classically present and the condition usually spreads due to enzymatic activity of the invading organisms. Group A -haemolytic Streptococcus is frequently implicated, although the condition is usually polymicrobial including anaerobes and gram-negative aerobes. In the presence of organisms such as Clostridium, gas may accumulate under the subcutaneous tissue and may be visible on x-ray and palpable as crepitus. These infections can be difficult to recognise in their early stages, but incredibly rapid progression and disproportionate pain are suggestive. Aggressive antimicrobial treatment is essential but urgent surgical debridement of all affected tissue is necessary and life saving. Skin and soft tissue lesions Diagnosis A thorough assessment of any lesion is necessary to determine its site, size, shape and consistency and whether or not it is attached to the skin or deeper structures such as muscle or nerve. Surface changes often indicate an epidermal origin, whereas the surface overlying dermal lesions appears normal. Commensal organisms such as Staphylococcus aureus are most commonly involved, whilst streptococci usually cause more aggressive and prolonged infections. Abscesses should be drained and cellulitis treated with appropriate empirical antibiotics that are modified once the results of culture and sensitivities are available. Cellulitis this is a nonsuppurative invasive infection commonly caused by -hemolytic streptococci, staphylococci and Clostridium species. Often there is a history of a minor injury or bite that progresses to spreading erythema and inflammation, which should be carefully monitored. Note the blackening of the skin with exudation and partial sloughing of skin in places. Hidradenitis suppurativa this is a chronic and cicatrising suppurative infection of the apocrine sweat glands that occurs commonly in females during their twenties and thirties. Patients, who are often obese and smoke, present with repeated episodes of painful swelling and discharge of pus from abscesses. Antianaerobic therapy (clindamycin, metronidazole) is often required, but lifestyle changes should be encouraged. If this fails, complete surgical excision may be needed to remove all subcutaneous tracts. Congenital dermoid cysts are found at the sites of embryonic fusion, commonly at the root of the nose, the forehead, the occiput and in the midline of the neck. External angular dermoids lie adjacent to the lateral brow in the line of fusion of the maxilla and frontal bones and are the most common congenital dermoid cyst. Implantation or inclusion cysts are found at any site of injury, notably the palmar surfaces of the hands and fingers. They are lined by squamous epithelium and contain sebum, degenerate cells and, in some cases, hair. Any troublesome cysts can be excised but care should be taken with congenital dermoids as they may extend deeply. In some cases, the inflammation destroys the cyst lining making excision unnecessary. Tumours of the skin Epidermal tumours are common and can arise from the basal cells, keratinocytes or melanocytes, whereas dermal tumours arising from connective tissue elements are relatively rare (Table 18. The skin may also be involved with metastatic tumour deposits from melanoma, breast cancer, oropharyngeal cancers and less commonly renal, lung, gastrointestinal and uterine cancers. Dermal neoplasms (rare) Benign lesions Papillomas Papillomas (or warts) are common sessile or pedunculated benign skin neoplasms that project from the skin surface. They are common in children and immunosuppressed patients, often regressing spontaneously but may need to be treated with acetic acid, laser or cryotherapy. Parts of the lesion may fall off spontaneously but unsightly lesions may be treated by curettage or excision. Normal epidermis Basal cell layer with melanocytes Fibro-epithelial polyps (acrochordon or skin tags) these are typically small flesh-coloured lesions on a stalk of normal epithelium that appear around the neck, armpits, groins and eyelids. They are thought to represent a stage between chronic inflammation and a benign neoplasm. Junctional naevus Keratoacanthoma (molluscum sebaceum) these usually present as solitary lesions on the face, neck and hands of fair skinned individuals, most commonly in the sixth decade. Growth ceases for a similar period of time before the lesion regresses spontaneously. Dermal naevus Benign naevi (moles) the total number of melanocytes in our skin is relatively fixed (approximately 800/mm2), regardless of the colour of the individual, yet the amount of pigment produced varies greatly. The former are present at birth, tend to be larger and grow with the individual, often becoming darker, thicker and hairy with age. Congenital melanocytic naevi over 20 cm are known as giant hairy naevi and occur in around 0. Acquired naevi are of three types: junctional, compound or intradermal depending upon the depth of the melanocytes within the skin. Their number is largely genetically driven but fair skin and sunburn are associated with increased incidence. They tend to be similarly coloured but more elevated with a rougher surface and are hair bearing. Such lesions are typically paler or even skin coloured and more prominent than compound naevi. The vast majority of moles are asymptomatic and rarely undergo malignant transformation (1 in 100,000). Transformation is more likely in the presence of growth, deepening pigmentation, irregular shape or colour, ulceration, itch or bleeding. Special types of naevi Blue naevi are round, flat or elevated and have a blue hue from the relatively deep location of the melanocytes within the dermis. Occasionally, the immune system targets a particular naevus giving rise to a halo naevus with a characteristic ring of depigmentation around the original naevus which itself fades and eventually disappears. It can occur anywhere on the skin but typically on sun-exposed areas, especially the legs. Treatment following targeted biopsy is as above for actinic keratosis, and the prognosis is similarly excellent. Treatment options following diagnostic biopsy include cryotherapy or laser ablation, topical chemotherapy (5-fluoro-uracil, imiquimod, diclofenac), photodynamic therapy or surgical excision. Basal cell carcinoma (rodent ulcer) this is the most common type of primary skin malignancy that typically presents on the head, neck (80%) and trunk. They classically present as firm nodules with pearlescence, telangiectatic, rolled borders and occasional central ulceration. Clinical subtypes include superficial, nodular, sclerosing (morphoeic), infiltrative, cystic and pigmented lesions. It arises from the stratum spinosum of the epidermis and may affect any area although is particularly common on exposed parts such as the ear, cheeks, lower lips and backs of the hands. The lesions appear as hard erythematous nodules, which proliferate and occasionally ulcerate. The regional lymph nodes can be involved early and should be examined at diagnosis and throughout follow-up. Treatment is by complete surgical excision (>4 mm margin) or radiotherapy if surgery is not possible. The role of sentinel lymph node biopsy is currently under review but positive nodal involvement necessitates formal regional lymphadenectomy with adjuvant radiotherapy in many cases. The incidence is highest in old burn scars followed by osteomyelitic wounds; however, they also occur in areas of venous insufficiency and on pressure sores. The lesions are typically slow to develop and metastasise late but are very aggressive thereafter. Treatment involves excision with wide (>4 mm) margins and appropriate reconstruction. Sentinel lymph node biopsy may also be undertaken but the role of radio/chemotherapy is less well established. Malignant melanomas are more common in females, often on the legs, whilst on men they are more common on the trunk. A preinvasive phase lasts for up to 2 years during which the malignant cells spread outwards (horizontal growth) in the epidermis. The surface is slightly raised, the outline is indistinct; pigmentation is patchy and there may be a range of colours. Invasion of the dermis (vertical growth) occurs when the lesion is still relatively small and produces an indurated nodule, which often ulcerates or bleeds. Nodular melanoma this elevated, deeply pigmented melanoma can occur at any site and at any age but is particularly common on the legs of females. The nodule grows and darkens progressively and the surface may ulcerate, itch and bleed readily. The well-defined edge of the lesion may appear serrated and the surface pigmentation is typically variable. The lack of pigment on clinical examination can lead to misdiagnosis although histological examination will demonstrate pigment in virtually every case. It resembles superficial spreading melanoma in its behaviour, although the thick skin of the affected regions may mask some of the features and late presentation is the norm. Subungual melanomas develop beneath a nail, typically the thumb or great toe, in the middle-aged and elderly. Pigmentation is not usually visible in the early stages and the lesion is often misdiagnosed as subungual haematoma. Desmoplastic melanomas are rare, aggressive, scar-like lesions accounting for 1% of all melanomas. Spread of malignant melanoma Malignant melanomas spread readily via the lymphatics and bloodstream and such spread can be unpredictable. In transit, metastases may develop in the lymphatics, forming painless dark nodules between the primary tumour and the regional nodal basin. Lymph node metastases most often present as firm enlargement of a node within the primary nodal basin from where the disease spreads to adjacent regional and central nodes. This technique employs radioisotopes and blue dye injected around the primary tumour, which then migrates to and concentrates in the primary draining lymph nodes that are then easily identified and excised. This reduces the morbidity associated with a block dissection of the regional lymph nodes and allows the pathologist to concentrate their efforts on the two or three nodes that are most likely to be involved. However, if the sentinel nodes are involved or clinically enlarged nodes are present, regional completion or therapeutic lymphadenectomy is indicated. There is no role for elective (prophylactic) lymph node dissection in the absence of clinically involved nodes. For metastatic disease confined to a single limb, isolated limb perfusion with cytotoxic drugs can be used in patients with recurrent disease or multiple in-transit lesions. Blood-borne metastases can occur at any site but are common in the brain, liver, lungs, skin and subcutaneous tissues. In about 5% of cases, metastases are present in the absence of a recognisable primary site. Sentinel lymph node biopsy should be considered as a staging technique in appropriate patients, i. Prognosis depends upon tumour size and mitotic rate, the presence of ulceration, evidence of vascular, perineural or lymphatic invasion and metastatic disease. The presence of tumour infiltrating lymphocytes and features of regression can also influence prognosis. They are broadly classified according to the presence of mitotic activity into vasoproliferative lesions (haemangiomas) and vascular malformations. The latter are subdivided into low flow (capillary, venous and lymphatic) or high flow (arteriovenous) malformations. Infantile haemangiomas (strawberry naevi) these lesions occur in up to 10% of all newborns, making it the most common tumour of infancy. They commonly present at or shortly after birth especially in premature Caucasian females, as bright-red raised lesions with an irregular bosselated surface. Deep-seated lesions are more likely to present as a soft subcutaneous mass imparting a bluish hue to the overlying skin. The lesions typically appear during adolescence as numerous flesh-coloured, sessile or pedunculated nodules on or beneath the dermi. The skin is the most commonly affected organ, especially in the head and neck (60%), trunk (25%), and extremities (15%).

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It is not necessary to wait until bowel sounds have returned or flatus has been passed pulse pressure healthy range cheap 6.25mg carvedilol otc. Nasogastric tubes are uncomfortable and may prevent coughing with expectoration heart attack follow me buy generic carvedilol 12.5mg on-line, and so they should not be retained for longer than necessary heart attack ukulele order 12.5 mg carvedilol with amex. If a urinary catheter has been placed prehypertension with low heart rate generic 6.25mg carvedilol with visa, it should be removed once the patient is mobile arrhythmia 3 year old order carvedilol 25mg visa. Complications of anaesthesia and surgery General complications Nausea and vomiting can be caused by surgery and/or anaesthesia, and an antiemetic can prove useful and can be considered prophylactically if nausea has been associated with previous anaesthetic procedures. Transient hiccups in the immediate postoperative period are usually no more than a nuisance. Persistent hiccups are more serious, exhausting the patient and interfering with sleep, and may be due to diaphragmatic irritation, gastric distension or metabolic causes, such as renal failure. If no precipitating cause can be found, small doses of chlorpromazine may be helpful. Spinal anaesthesia may cause headache from leakage of cerebrospinal fluid, and patients should remain recumbent for 12 hours when this occurs. Myalgia affecting the chest, abdomen and neck is a specific complication of suxamethonium administration, and may last for up to a week. Intravenous administration of irritant drugs or solutions can cause bruising, haematoma, phlebitis and venous thrombosis. Intravenous cannulae placed in large veins should be securely sealed to guard against air embolism. Sites of cannula insertion should be checked regularly for signs of infection, and the cannula replaced if necessary. Arterial cannulae and needle punctures are the most common cause of arterial injury, and may rarely lead to arterial occlusion and gangrene. Standard intravenous fluid requirement for an adult is 3 L/day, of which 1 L should ordinarily be normal (isotonic) saline and 2 L should be 5% dextrose. In the first 24 hours after surgery, normal saline can be omitted and replaced by 5% dextrose because of sodium conservation as a result of metabolic response. The daily fluid requirement must take care of extra losses due to environmental temperature in tropical countries where higher insensible fluid loss is not uncommon. Allowance must be made for body fluid losses like nasogastric aspirate and replaced appropriately by Na, K and fluid volume. A mixed gastric aspirate of 1 L must be replaced by 120 mEq of Na and 10 mEq of K over and above the normal requirements for the next 24 hours. This replacement of abnormal losses should be done every 8 hours in paediatric surgery. Intravenous fluid therapy is discontinued once oral fluid intake has been established. Pulmonary complications Blood transfusion Haemoglobin measurement will be a guide to the need for postoperative blood transfusion. A full blood count should be undertaken within 24 hours of surgery and, as a general rule, blood is administered if the haemoglobin is less than 80 g/L with a low haematocrit (<24). Above this level, patients can be prescribed oral iron, unless they have cardiovascular instability or are symptomatic from their anaemia. Needless transfusion is avoided, especially in patients with colorectal malignancies since it has been linked to recurrence of malignancy. Respiratory complications remain the largest single cause of postoperative morbidity and the second most common cause of postoperative death in patients over 60 years of age. Once a patient has fully recovered from anaesthesia, the main respiratory problems are pulmonary collapse and pulmonary infection. Patients are at risk of hypoxaemia immediately after surgery due to ventilation perfusion imbalance, diffusion of anaesthetic gases into lungs, respiratory depression from narcotics and anaesthetic drugs, and shivering (increased muscular oxygen utilisation). Hypoxia is detected by low oxygen saturation on pulse oximetry with the probe attached to a finger. Saturation below 90% is considered low and corresponds to PaO2 of 60 mmHg, which is dangerously low for a postoperative patient. Supplemental oxygen may need to be administered by a venturi mask or nasal prongs until the patient is able to maintain a saturation of 95% or more on room air. Low values on the finger probe may be due to factors such as vasoconstriction, low pulse volume, low blood pressure and shivering. Pulse oximeters function normally in anaemic patients, but such patients with normal saturation would not be able to deliver oxygen adequately to the tissues due to low haemoglobin levels. Pulmonary collapse Inability to breathe deeply and cough up bronchial secretions is the primary cause of pulmonary collapse after surgery. Contributory factors include paralysis of cilia by anaesthetic agents, impairment of diaphragmatic movement, over-sedation, abdominal distension and wound pain. When there is complete obstruction of a bronchus or bronchiole, air in the lung distal to the obstruction is absorbed, the alveolar spaces close (atelectasis), and the affected portion of the lung contracts and becomes solid. Small bronchioles (1 mm or less) are prone to close when lung volume reaches a critical point (closing volume). The closing volume is higher in older patients and in smokers, owing to the loss of elastic recoil of the lung, which increases the risk of atelectasis. The extent of collapse varies from closure of a small segment to collapse of a lobe or, when a main bronchus is obstructed, the entire lung. Atelectasis is a very common complication of surgery and usually occurs within 24 hours. It is of clinical relevance because it leads to increased work of breathing and impaired gas exchange; if untreated, secondary bacterial infection will supervene, causing lobar or bronchopneumonia. The clinical signs of pulmonary collapse include rapid respiration, tachycardia and mild pyrexia, with diminished breath sounds and dullness to percussion over the affected segment. Postoperatively, pulmonary collapse is prevented by encouraging the patient to breathe deeply, cough and mobilise. Placement of an epidural catheter in patients undergoing major abdominal surgery may help alleviate postoperative wound pain. Hypoxia is treated by giving oxygen by mask or nasal prongs, and bronchospasm is relieved by inhalation of salbutamol. When hypoxia is severe, endotracheal intubation, assisted ventilation and repeated bronchial aspiration may be needed. Posture is important and the patient should initially be placed on the unaffected side to aid expansion of the collapsed lung. The chest signs are those of collapse with absent or diminished breath sounds, often in association with bronchial breathing and coarse crepitations from surrounding areas of partial bronchial occlusion. The patient is encouraged to cough, and antibiotics are prescribed after sputum is sent for bacteriological examination. Most pulmonary infections are caused by the respiratory commensals Streptococcus pneumoniae and Haemophilus influenzae, but many postoperative pulmonary infections are caused by gramnegative bacilli acquired by aspiration of oropharyngeal secretions. Blood gas determinations are the key to its early recognition and should be repeated frequently in patients with previous respiratory problems. In type 1 respiratory failure there is hypoxia and in type 2 there is hypercarbia with hypoxia. They may be secondary to other pulmonary pathology, such as collapse/consolidation, pulmonary infarction or secondary tumour deposits. Small effusions may be left alone to reabsorb if they do not interfere with respiration. It may result from pulmonary or systemic sepsis, following massive blood transfusion, or as a consequence of aspiration of gastric contents. Many minor and transient cases recover spontaneously, whereas in a proportion of cases, progressive respiratory insufficiency occurs. Tachypnoea with increasing ventilatory effort, restlessness and confusion develop. Hypoxia initially responds to an increase in the oxygen content of inspired air, but progressively increasing concentrations are required to prevent the PaO2 from falling. The pathophysiology is unclear, but endotoxin-activated leucocytes may be deposited in the pulmonary capillaries, releasing oxygen-derived free radicals, cytokines and other chemical mediators. Damage to the vascular endothelium results in increased capillary permeability and leakage of fluid, causing widespread interstitial and alveolar oedema. There is also an enhanced risk of pneumothorax in patients on positive-pressure ventilation, presumably owing to rupture of preexisting bullae. The insertion of an underwater seal drain is usually followed by rapid expansion of the lung. Cardiac complications the risks of anaesthesia and surgery are increased in patients suffering from cardiovascular disease. Whenever possible, arrhythmias, unstable angina, heart failure or hypertension should be corrected before surgery. Valvular disease, especially aortic stenosis, impairs the ability of the heart to respond to the increased demand of the postoperative period. The administration of fluids to patients with severe aortic or mitral valve disease should be carefully monitored. Patients with ischaemia may complain of gripping chest pain, but this is not invariable (particularly in the elderly diabetic patient or in the early postoperative period) and hypotension may be the only sign. The absence of symptoms after operation is thought to be due to the residual effects of anaesthesia and to the administration of postoperative analgesia. Postoperative pain, the effects of anaesthesia and drugs, and difficulties in initiating micturition while lying or sitting in bed may all contribute. When its normal capacity of approximately 500 mL is exceeded, the bladder may be unable to contract and empty itself. Frequent dribbling or the passage of small volumes of urine may indicate overflow incontinence, and examination may reveal a distended bladder. Clinical manifestations are progressive dyspnoea, hypoxaemia and diffuse congestion on chest x-ray. Treatment consists of avoiding further fluid overload, and the administration of diuretics and cardiac inotropes. Urinary tract infection Urinary tract infections are most common after urological or gynaecological operations. Preexisting contamination of the urinary tract, urinary retention and instrumentation are the principal factors contributing to postoperative urinary infection. Cystitis is manifested by frequency, dysuria and mild fever, and pyelonephritis by high fever and flank tenderness. Treatment involves adequate hydration, proper drainage of the bladder and appropriate antibiotics. Renal failure Acute renal failure after surgery results from protracted inadequate perfusion of the kidneys. The most common cause of postoperative oliguria is prerenal vascular insufficiency from hypovolaemia, water depletion or extracellular fluid depletion. Hypoperfusion of the kidney may be aggravated by hypoxia, sepsis and nephrotoxic drugs. Patients with preexisting renal disease and jaundice are particularly susceptible to hypoperfusion, and are more likely to develop acute renal failure. The complication can largely be prevented by adequate fluid replacement before, during and after surgery, so that urine output is maintained at 0. The importance of monitoring hourly urine output means that bladder catheterisation is needed in all patients undergoing major surgery, and in those at risk of renal failure. Early recognition and treatment of Arrhythmias Sinus tachycardia is common and may be a physiological response to hypovolaemia or hypotension. Tachycardia increases myocardial oxygen consumption and may decrease coronary artery perfusion. Sinus bradycardia may be due to vagal stimulation by neostigmine, pharyngeal irritation during suction, or the residual effects of anaesthetic agents. Fast atrial fibrillation may result in haemodynamic disturbances and may require pharmacological intervention. Postoperative shock Shock is defined as a failure to maintain adequate tissue perfusion. Hypovolaemic shock may be caused by inadequate replacement of pre- or perioperative fluid losses, or postoperative haemorrhage, whereas cardiogenic shock is usually secondary to acute myocardial ischaemia/infarction or an arrhythmia. Hypovolaemic and cardiogenic shock are characterised by tachycardia, hypotension, sweating, pallor and vasoconstriction. Septic shock is characterised in the early stages by a hyperdynamic circulation with fever, rigors, a warm vasodilated periphery and a bounding pulse. Without appropriate management, shock will result in oliguria and the development of multisystem organ failure, and may lead to death. Management involves the restoration of an adequate circulating intravascular compartment by the administration of intravenous fluids. Diuretics may be administered only if the patient is well hydrated; however, they should not be continually prescribed if the patient remains oliguric.

Biopsy may be performed to confirm the diagnosis and the rejection can be treated with daily boluses of methylprednisolone given over 3 days prehypertension foods to avoid discount carvedilol 6.25 mg mastercard. It is rare blood pressure of 120/80 order carvedilol 12.5mg without a prescription, with modern immunosuppression sinus arrhythmia cheap carvedilol 6.25 mg with visa, for acute rejection to cause complete failure of the graft arrhythmia exam order line carvedilol. Patients with acute liver failure fare less well arrhythmia technology institute purchase 25 mg carvedilol overnight delivery, with approximately 70% surviving at 1 year. The vast majority of recipients report a very good quality of life but there remains the need, in most patients, to take immunosuppression in the long-term. In common with the recipients of other transplant organs, patients can experience nephrotoxicity and other side effects from immunosuppressive medication. However, without the liver transplant procedure, the outcome would have been certain death and so this procedure remains one of the miracles of modern medicine. However, this comes with significantly increased risk in terms of perioperative morbidity and mortality, with the potential for the pancreas transplant to affect adversely the outcome of the renal transplant. Thus, careful recipient selection is essential: cardiovascular comorbidity is the most important factor leading to postoperative mortality, and may not be apparent in the history. This should be suspected in obese patients, those with late-onset diabetes or those requiring high insulin doses. It is important to counsel patients and relatives that a pancreas transplant is a major undertaking and one that is life-enhancing rather than life-saving, as in the case of a liver transplant. Most patients will require a simultaneous renal transplant and the results for such combined transplants are better than for solitary pancreas. Pancreas transplantation Transplantation of the pancreas offers the only treatment that reliably offers insulin independence and normal glucose metabolism for patients with type 1 diabetes mellitus. There is little doubt that diabetic patients with renal failure should be offered a kidney transplant if they are fit enough. Showing arterial Y graft using donor iliac vessels onto superior mesenteric and splenic arteries to create a single arterial conduit for anastomosis. Dysfunction of islets occurs as a late sign of rejection, which may then be less amenable to treatment. Outcome There has been considerable improvement in the 1-year patient and graft survival following pancreas transplantation over the last decade, with 95% patient survival, 92% kidney graft survival and 82% of pancreas graft survival. There is 89% patient survival at 5 years and there is also increasing evidence to suggest that pancreas transplantation has a favourable influence on diabetic complications and survival prospects. It is implanted intraperitoneally on the right side the venous anastomosis is performed between donor portal vein and the distal inferior vena cava the arterial conduit constructed on the back table is anastomosed to the recipient common iliac artery. Pancreatic islet transplantation Transplantation of islets alone offers an attractive alternative to whole-pancreas transplantation and is associated with less serious morbidity. Indications for islet cell transplantation differ from those of solid-pancreas transplant, and the primary indication is severe hypoglycaemic unawareness. It leads to long-term insulin independence in a small number of patients, and renders glucose control more predictable with less hypoglycaemic unawareness. Isolated islets from two pancreata are infused into the portal venous system, under sedation. Postoperative management and complications Patients are often managed in the intensive care unit postoperatively, where close monitoring and early identification of postoperative complications are likely to improve early outcome. Pancreas transplantation is associated with a higher incidence and a greater range of complications than kidney transplant due to a requirement for greater immunosuppression in a high-risk diabetic population with impaired infection resistance, poor healing and high levels of comorbidity. Between one-fifth and one-quarter of patients require relaparotomy in the early postoperative period. Risk factors for complications include increasing donor age, prolonged preservation time, and donor and recipient obesity. Rejection of a pancreas transplant alone is difficult to diagnose, with no reliable early markers. Acute rejection of the pancreas affects exocrine function first and gives rise to an inflammatory response, 25 Heart and lung transplantation Indications and patient assessment Heart Heart transplantation is undertaken to prolong life and improve its quality. Implantation starts with the bronchial anastomosis, followed by the left atrial and pulmonary arterial anastomoses. Some patients develop ventricular dysfunction, which requires supportive management with inotropes. Routine endocardial biopsies are taken from the right ventricle of heart transplant recipients using x-ray screening and right internal jugular venous access. Rejection can also cause rapidly progressive coronary artery disease, with thickening and narrowing of the coronary arteries. Because the donor heart is denervated, the patient will not experience angina, and therefore coronary angiography is performed annually from 2 years onwards. Beyond 5 years, cardiac allograft vasculopathy and late graft failure are the most common causes of death. Potential candidates for heart transplant are patients with advanced heart failure who are on maximal medical therapy, including vasodilators, digoxin, diuretics and -blockers. Patients should be considered if they have increasing medication requirements, frequent hospitalisations or overall deterioration in clinical status. Lung the lung has been the most challenging of the human organs to be transplanted in clinical practice. Bilateral lung transplantation is indicated when all native lung must be removed. Single lung transplantation is an attractive option for the treatment of lung failure, as it can be performed with reduced risk of acute lung injury and without the requirement for cardiopulmonary bypass. The operative procedure Heart Cold ischaemic time must be kept to a minimum, such that the recipient operation may be commenced once the donor heart has been visualised and assessed for suitability. The heart usually starts to beat and, if ventricular fibrillation occurs, the heart is promptly defibrillated. Reperfusion is followed by the pulmonary arterial, inferior and superior vena caval anastomoses. Lungs Apical and basal chest drains are placed perioperatively and patients are managed in the intensive care unit. Infection is a major cause of postoperative morbidity in lung transplant patients. Antibiotic prophylaxis with flucloxacillin and metronidazole is commenced and adjusted as microbiological results from donor and recipient samples become available. Postoperative acute lung injury, occurring as a result of reperfusion injury, causes problems with ventilation, requiring meticulous supportive management of fluids, optimisation of ventilation and microbiology input. Another life-threatening complication of lung transplantation is dehiscence of the tracheal or bronchial anastomosis, with prolonged air leak and mediastinitis. Transbronchial biopsies are performed regularly in the weeks and months posttransplant to diagnose rejection, which can be treated in the standard fashion. For a single lung transplant, a lateral thoracotomy is performed and the native lung is excised with ligation of inferior and superior pulmonary veins and pulmonary artery. The pericardium is then incised, and the pulmonary veins and artery are mobilised for subsequent anastomoses. Combined heart and lung transplant Combined heart and lung transplant was the most common form of lung transplant, but its use has declined significantly over the last 15 years. Indications for the combined procedure are now confined to pulmonary hypertension without congenital heart disease. The operation is performed via a median sternotomy, and requires cardiopulmonary bypass. One of the greatest challenges facing transplantation is the shortage of organs for donation and this chapter has described specific strategies aimed at combating this: namely, use of extended criteria donors, living donors and donors after circulatory death. Outcome Survival following heart transplant is approximately 65% at 5 years, 50% at 10 years and 30% at 15 years. The success of cardiac transplantation, as is the case with other solid-organ transplants, has raised expectations that cannot be fulfilled, with the shortage of organs for donation and high death rates on cardiac transplant waiting lists. The 5-year survival of lung transplant recipients is close to 50%, and 25% after a decade. Summary Solid-organ transplantation provides excellent treatment for patients with end-stage organ failure, with 1-year graft survival exceeding 80% for most organs. It is lined by squamous epithelium and contains ceruminous glands that produce wax. There is very little subcutaneous tissue, and soft tissue swelling is very painful. The head of the malleus is attached to the body of the incus in the space superior to the middle ear known as the attic. The middle ear is lined by simple cuboidal epithelium containing some mucus-secreting cells. The middle-ear space is connected to the nasopharynx by the Eustachian tube, which maintains the middle ear at atmospheric pressure. Incus Malleus Stapes the inner ear the inner ear membrane encloses a labyrinth filled by a fluid called endolymph. This is surrounded by a bony labyrinth, the otic capsule, which is filled with perilymph. The cochlea, the hearing component of the inner ear, is a tube linking the oval and round windows, coiled up like a shell. The cochlear and vestibular nerves combine in the internal auditory meatus and pass medially to the brainstem. The facial nerve enters the temporal bone through the internal auditory meatus and passes laterally to the geniculate ganglion, where it turns posteriorly (the first genu). It passes through the middle ear above the oval window and turns inferiorly (the second genu) to exit at the stylomastoid foramen. Patients with ear disease occasionally fall to the ground but never lose consciousness. Examination the ear canal and tympanic membrane are inspected with an otoscope, a rigid telescope or a microscope. In health or sensorineural deafness, a tuning fork is heard better via the ear canal (air conduction) than via the mastoid process (bone conduction). If a conductive hearing loss is present in one ear, the tuning fork is heard better in the deaf ear (confirmed by occluding one ear and applying the fork to your own head). Conversely, in unilateral sensorineural deafness, the sound is louder in the good ear. The tympanic membrane lever mechanism, the ossicular lever mechanism and the large size of the drum relative to the stapes footplate act as an impedance-matching transformer. Vibrations in air are thus transferred to the cochlear fluids without excessive loss of energy. The cochlea converts these endolymph vibrations into electrical impulses in the auditory nerve by stimulation of hair cells in the organ of Corti. Auditory neurons connect via the brainstem to the auditory cortex, where again different groups of cells are stimulated by nerve impulses coded for different frequencies. The hair cells in the ampullae of the semicircular canals are stimulated by angular acceleration. Audiometry Hearing by air conduction can be assessed by pure tone audiometry, in which sounds of known pitch and loudness are presented to each ear in turn via headphones. Bone conduction (cochlear function) can be separately tested by applying sounds to the mastoid process. A contralateral masking tone is needed if each cochlea is to be tested separately. The amount of sound from a probe reflected back from the drum is measured while the pressure in the ear canal is made to vary. The compliance is maximal when the pressure in the ear canal equals the pressure in the middle ear, because at this point the drum is maximally mobile. Tympanometry is most often used to confirm the presence of fluid in the middle ear. Assessment Clinical features Disorders of the external or middle ear can impair sound transmission to the inner ear and cause conductive deafness. Ear pain (otalgia) may be due to ear disease but may also be referred from other sites (Table 26. Ear-related disorders of balance usually cause a sensation of movement (vertigo), most often -10 0 10 Hearing level (decibels) 20 30 40 50 60 70 80 90 100 110 120 125 250 500 1k 2k Frequency (Hz) Bone conduction Air conduction 4k 6k Table 26. Trauma Trauma to the ear may result in a haematoma, which strips the perichondrium off the underlying cartilage. Diseases of the external auditory meatus Wax Wax (cerumen) is normally found in the ear canal. The ear canal has a migratory epithelium that carries wax to the opening of the external auditory meatus. Sodium bicarbonate ear drops should be used regularly by those with a tendency to build up excess cerumen.


  • Gordon hyperkaliemia-hypertension syndrome
  • Absence of gluteal muscle
  • Curly hair ankyloblepharon nail dysplasia syndrome
  • Oculocutaneous albinism type 1
  • Gardner Diamond syndrome
  • Neuronal interstitial dysplasia
  • Prolidase deficiency
  • Cerebellar hypoplasia endosteal sclerosis

In the presence of effective collateralisation pulse pressure 42 buy generic carvedilol 6.25 mg on-line, especially in younger patients blood pressure unit of measure order carvedilol 6.25mg overnight delivery, pulses may sometimes be present at rest high blood pressure medication toprol xl purchase carvedilol amex, despite significant proximal arterial disease blood pressure young age purchase carvedilol 25 mg overnight delivery. Ankle/brachial pressure index the severity of ischaemia in the leg can be simply estimated by determining the ratio between the ankle and brachial blood pressures blood pressure medication effects libido buy carvedilol mastercard. Without revascularisation, such patients will often lose their limb, and sometimes their life, in a matter of months. It is classically felt at night and is relieved by sleeping with feet hanging over the bed or sleeping on a chair. The diabetic foot this refers to the combination of ischaemia, neuropathy and immunocompromise that renders the feet of diabetic patients particularly susceptible to sepsis, ulceration and gangrene. If there is ischaemia as well, the priority is to revascularise the foot, if possible. Unfortunately, many patients fail to comply and, in particular, continue to smoke. In many cases, the first manoeuvre is to cross the lesion with a stent and in this circumstance steps C and D may be omitted. This is the treatment of choice for disease segments that are less than 10 cm long. The arterial lesion to be treated (stenosis or occlusion) is identified and crossed with a wire. In patients with total occlusions and complex disease, metal stents may be deployed across the lesion to improve patency and reduce distal embolic complications. Sometimes these balloons and stents are coated with drugs that reduce the arterial scarring (neointimal hyperplasia) that follows such intervention and can lead to restenosis and reocclusion (drugeluting balloons and stents). Endoluminal repair of the aortoiliac segment is the treatment of choice because of its high patency rates and low morbidity compared to open surgery. There is controversy with regard to its role in the femoropopliteal and infrapopliteal segments because of a perceived lack of durability of benefit. A previous claudicant may now have acute limbthreatening ischaemia, which then forces the surgeon or radiologist to re-intervene. Secondary interventions are technically more difficult, are associated with higher risk and a lower patency rate. However, the role for endovascular therapy may increase in the future as technology improves. Although the risk of surgery is higher, the long-term patency rates of such grafts are excellent, and one operation deals with both legs. Whatever the treatment being considered, patients and their families must be made fully aware of the risks and benefits so that they can give fully informed consent. The main advantage of vein is that it is lined by endothelium that is actively antithrombotic and profibrinolytic, and therefore much less liable to induce coagulation than even the most inert of man-made materials. It is generally agreed that, wherever possible, vein from the leg or arm should be used for infrainguinal reconstruction. Reconstruction of an occluded aortoiliac segment by means of aortobifemoral bypass grafting. Long-term major complications include infection and graft occlusion, for which outcome is better when identified early. It is rare in Caucasians but more common in people from the South-East Asia, India, North Africa and the Middle East. Thromboangiitis obliterans refers to the inflammatory reaction of the arterial wall with involvement of the neighbouring vein and nerve, ultimately leading to thrombosis of the artery. These extraanatomic grafts do not have as good long-term patency as anatomic aortoiliac reconstructions. However, they are lesser procedures, and so the preferred option in high-risk patients or those that have a limited life expectancy. Arteriography typically shows segmental narrowing or occlusion of arteries with skip lesions with a corkscrew appearance in the affected limb, but relatively healthy vessels above that level. It is important to conserve the knee joint if at all possible, as the energy required to walk on a below-knee prosthesis is much less than that required to walk on an above-knee prosthesis. However, if the patient has other comorbidity or disability that would make walking with a prosthesis impossible, there is no point in attempting to conserve the knee joint at the expense of healing. A common situation is where a patient presents with a fixed flexion contracture of the knee. A below-knee amputation in such a patient is usually ill-advised because the contracture will prevent the patient from ever walking and will also result in the stump wound resting on the bed or chair, leading to poor healing and wound breakdown. However, if the patient continues to smoke, then bilateral below-knee amputation is a frequent outcome. Failure to make the diagnosis often leads to avoidable limb loss and is a source of medicolegal activity. Surgical principles A number of important principles must be observed if primary healing and satisfactory rehabilitation are to be achieved. The in-hospital mortality for major limb amputation may be as high as 20%, and can exceed 30% in the elderly undergoing above-knee amputation. The decision to amputate, the level of amputation and the procedure itself requires direct input from an experienced vascular surgeon. Amputation Indications Amputation should only be considered where arterial reconstruction is considered by a vascular surgeon to be inappropriate or impossible. Approximately 70% of below-knee amputees and 30% of aboveknee amputees eventually walk, although many of these patients do not persist with their prosthesis. This is important to appreciate as due to the prolonged hospital admission, rehabilitation, home modifications and, in some cases, long-term care, amputation can be a much more expensive option than revascularisation leading to limb salvage. With appropriate drug therapy such as gabapentin, reassurance and time, it usually settles but can take a long time to do so. There is some evidence that if the patient goes to theatre pain-free, the risk of phantom pain can be reduced. The presentation and management principles are similar to that for the lower limb. Left subclavian artery (occluded) Arterial disease of the upper limb Overview Occlusive arterial disease is about ten times more common in the leg than in the arm. Nevertheless, when the arm is affected, treatment can be difficult, and the loss of an arm (especially the dominant one) is even more devastating for the patient than loss of a leg. Cerebrovascular disease Definitions Stroke Stroke may be defined as an episode of focal neurological dysfunction lasting more than 24 hours, of presumed vascular aetiology. In this case the stenosis is estimated at greater than 70% and so further investigation with a view to surgery is warranted. Atheroemboli entering the ophthalmic artery leads to amaurosis fugax or permanent monocular blindness on the same side (ipsilateral). If they enter the middle cerebral artery they may cause hemiparesis and hemisensory loss on the opposite side (contralateral). The arterial blood to the brain from the origins of the great vessels from the aortic arch to the circle of Willis and cerebral arteries within the skull. The image confirms that there is a tight stenosis at the origin of the right internal carotid artery (arrow). Such a bruit may arise from the external carotid artery or be transmitted from the heart. Furthermore, in the presence of a very tight internal carotid artery stenosis, flow may be so slow that no audible turbulence is present. The exact timing remains controversial and is a matter of judgment for each patient but, in general, the sooner the better. Patients who do not fulfil these criteria should, in most cases, be treated medically. The carotid bifurcation is dissected, heparin is given and the arteries are clamped. In the meantime, carotid endarterectomy should remain the treatment of choice for patients suitable for surgery. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis: an interim analysis of a randomised controlled trial. So, even if one could halve that risk with intervention (relative risk reduction of 50%) the absolute risk reduction would be only 1% per year. Vertebrobasilar disease the vertebrobasilar system feeds the occipital cortex, cerebellum and brain stem. Patients with vertebrobasilar insufficiency may complain of (bilateral) cortical blindness, vertigo and loss of balance. The anaesthetist and surgeon, in consultation with the patient, should decide which anaesthetic technique to use on an individual basis. Intravenous thrombolysis or mechanical thrombectomy In acute stroke due to thromboembolic event, intravenous thrombolysis or mechanical thrombectomy (removing clot via endovascular route) has been increasingly used as a method of treatment in selected cases. However, all patients should have prompt access to all options to ensure maximal therapy. There is usually sudden onset of excruciating abdominal pain, collapse, bloody diarrhoea and peritonitis. Unfortunately, extensive bowel necrosis is often already present at the time of surgery and mortality exceeds 50%. Endovascular techniques have little to offer, as the exclusion of bowel infarction requires laparotomy. Surgery is associated with significant morbidity Aetiology Acute limb ischaemia is caused most frequently by acute thrombotic occlusion of a preexisting stenotic arterial segment (60%), thromboembolism (30%) and trauma, which may be iatrogenic. Distinguishing between thrombosis and embolism is important because investigation, treatment and prognosis are different (Table 21. Thrombosis in situ may arise from acute plaque rupture, hypovolaemia, increased blood coagulability. Incomplete acute ischaemia (usually due to thrombosis in situ) can often be treated medically, at least in the first instance. Complete ischaemia (usually due to embolus) will normally result in extensive irreversible tissue injury within 6 hours unless the limb is revascularised. Irreversible ischaemia mandates early amputation or, if the patient is elderly and unfit, end-of-life care. In the presence of ischaemia, pain on squeezing the calf indicates muscle infarction and impending irreversible ischaemia. As the spasm relaxes over the next few hours and then fills with deoxygenated blood, mottling appears. This appears light blue or purple, has a fine reticular pattern, and on pressure, so-called nonfixed mottling. As ischaemia progresses, blood coagulates in the skin, leading to mottling that is darker in colour, coarser in pattern and does not blanch. Attempts at revascularisation at this late stage are futile and will lead to life-threatening reperfusion injury (see later). Such patients may also present with paraplegia due to ischaemia of the cauda equina, which may be irreversible. Acute embolus Thrombosis in situ Embolic occlusion of the brachial artery is not usually limbthreatening and, in an elderly patient, nonoperative treatment is reasonable. Younger patients should undergo embolectomy to prevent subsequent claudication, especially where the dominant arm is affected. A leg affected by embolus is nearly always threatened and requires immediate surgical revascularisation. Femoral embolus is usually associated with profound ischaemia to the level of the upper thigh because the deep femoral artery is also affected.

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