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Types of Lavage: 1Small amount Lavage: usually use < 10 ml of sterile saline are instilled directly into the tracheal tube before suctioning. The role of bronchoalveolar Lavage remains experimental in most diseases and plays a more important role in diagnosis than in the therapeutic management of lung pathology. Bagging: Bagging is a means of providing artificial ventilation by use of a manual resuscitator bag, which is usually connected to an oxygen supply. For the intubated patient, the mask is removed and the bag is connected directly to the tracheal tube. Bagging is performed by squeezing the bag rhythmically, to deliver a volume of gas to the patient. CFeeding tube: -Chest physical therapy before or 30 minutes after feeding to prevent vomiting. Percussion and vibration They are maneuvers used in a combination with postural drainage. Percussion * It is a rhythmic clapping with cupped hands over the involved lung segment. Mechanical Vibrators and precursors Produce vertical or rotatory movement or a combination of them. Manual vibration and percussion have the following advantages over mechanical devices. Methods of improving ventilation A-Breathing exercises Goals: 1-Assist in removal of secretions. Types: 1-Deep breathing includes diaphragmatic breathing exercise, pursed lips breathing and nose exercise. When the patient observe his/her inspired volume he/she can be encouraged to work by inhaling more and more. Types 1-Volume oriented incentive spirometers Voldyne Volurex 2-Flow-oriented incentive spirometers Triflow (Triflo) 99 3-Photoelectric?oriented incentive spirometers Spirocare Clinical application of incentive spirometers 1Evaluation and diagnosis of respiratory disorders. Effects of immobilization 1Cardiovascular system: 1vBlood volume, vplasma volume and vHb concentration. Equipment used for mobilization: 1Pulley system with overhead traction units, ropes, weights and pulleys. Correspondence: Christian Viniol, University Medical Centre Giessen and Marburg, Philipps-Universitat Marburg Dept of Medicine, Pulmonary and Critical Care Medicine Baldingerstr. The impact of risk factors and triggers such as smoking, severe airflow limitation, bronchiectasis, bacterial and viral infections and comorbidities is discussed. Antibiotic therapy should only be given to patients with presumed bacterial infection. Other aspects include choice of pharmacotherapy, including bronchodilators, inhaled corticosteroids, phosphodiesterase-4 inhibitors, longterm antibiotics and mucolytics. Better education and self-management as well as increased physical activity are important. Recent lessons learned in the management of acute exacerbation of idiopathic pulmonary fibrosis. Received: Sept 06 2017 | Accepted after revision: Jan 11 2018 Provenance: Commissioned article, peer reviewed. Some studies have demonstrated that air pollution significantly increases the risk of exacerbations [9, 10], while older studies found no relevant correlations. In summary, there is a trend towards an association of air pollution with exacerbations. Mortality was only slightly higher in the subgroup with many comorbidities and evidence of systemic inflammation. In the acute setting, adequate treatment is necessary; then, appropriate measures for prevention of a subsequent exacerbation should be initiated. Since these patients with bronchiectasis had more chronic colonisation by pathogenic microorganisms (odds ratio 7. Older studies did not find differences between the rates of isolation of bacteria from sputum during stable disease and exacerbation [15]. More recent studies found an association between exacerbation and the isolation of a new strain of a bacterial pathogen [16]. In addition, the reported efficacy of long-term antibiotic treatment with macrolides in reducing exacerbation frequency may suggest that bacteria are relevant for the induction of exacerbations, although this is a matter of debate [17].

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Int J Radiat Oncol Biol Phys predictors of radiation pneumonitis in a large series of patients treated 2009;73:442-448. A comparison of two stereotactic body radiation fractionation schedules for medically 465. Stereotactic inoperable stage I non-small cell lung cancer: the Cleveland Clinic ablative radiotherapy for centrally located early stage non-small-cell experience. Stereotactic ablative radiation radiation toxicity: hypofractionation may be beneficial in dose escalation therapy for centrally located early stage or isolated parenchymal of radiotherapy for lung cancers. Int J Radiat Oncol Biol Phys recurrences of non-small cell lung cancer: how to fly in a "no fly zone". J non-small cell lung cancer-updates of radiobiology, techniques, and Thorac Oncol 2007;2:S94-100. Fatal complications after stereotactic body radiation therapy for central lung tumors abutting Version 2. Available at: alone vs radiosurgery with whole brain radiation therapy on cognitive. Available at: resection in the management of newly diagnosed brain metastases: a. Available at: radiation therapy in the management of newly diagnosed brain. A randomized trial of hypofractionated three-dimensional conformal radiotherapy for stage surgery in the treatment of single metastases to the brain. The role of retreatment radiosurgery in the management of patients with newly diagnosed brain in the management of recurrent/progressive brain metastases: a metastases: a systematic review and evidence-based clinical practice systematic review and evidence-based clinical practice guideline. Metastatic non-small-cell lung management of brain metastases in the era of stereotactic radiosurgery. Whole brain radiotherapy for metastases in tyrosine kinase inhibitor-naive epidermal growth factor the treatment of newly diagnosed multiple brain metastases. The role of results in patients with brain metastases according to the number of chemotherapy in the management of newly diagnosed brain brain lesions: is stereotactic radiosurgery effective for multiple brain metastases: a systematic review and evidence-based clinical practice metastases? Available irradiation on chronic neurotoxicity and quality of life for patients with at. Available at: conformal avoidance of the hippocampal neural stem-cell compartment. Neurocognitive function of adjuvant systemic therapy in completely resected non-small-cell lung patients with brain metastasis who received either whole brain cancer: a systematic review. Cisplatin-based adjuvant chemotherapy in patients with completely resected non-small-cell lung 507. Available at: with brain metastases treated with radiosurgery or radiosurgery plus. Adjuvant vinorelbine plus cisplatin versus observation in patients with completely resected stage 509. Survival benefit of neoadjuvant chemotherapy in non-small cell lung cancer: an updated Version 2. Preoperative cancer: a systematic review and meta-analysis of individual participant chemotherapy followed by surgery compared with primary surgery in data. Meta-analysis of concomitant versus sequential radiochemotherapy in locally advanced 520. Available perioperative chemotherapy and surgery with surgery alone in at. Available preoperative paclitaxel and carboplatin in early-stage non-small-cell at. Available at: non-small cell lung cancer: Diagnosis and management of lung cancer. J Clin Oncol American College of Chest Physicians evidence-based clinical practice 2009;27:6251-6266. Marital status and survival improves survival in advanced non-small-cell lung cancer: a systematic in patients with cancer.

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Measures to buy time can be very helpful in croup and where the airway anatomy is abnormal. The results of correct cricothyrotomy using a cannula, 3mm endotracheal tube connector, management are excellent. Update in Anaesthesia(2004)18:44is not recommended in children due to the risks of overpressure 49. In other cases, particularly of severe anatomical dia/92df8f6507212855c41926db875627329872ec3f9b81c17cad5c78fcbaa5d71c-Large-Airway-Obstruction-in-Children-abnormalities, the safest option may be an emergency tracheostomy Update-18-2004-. If you are inexperienced with advanced life support measures in Oxford: Oxford University Press, 1997:81-108. Advanced Paediatric Life and ventilatory support with basic measures until experienced staf Support. Case Presentations in Paediatric Anaesthesia and Intensive most experienced staf present. Case Presentations in Paediatric Anaesthesia and Intensive and is correctly positioned. Sign and symptoms due to obstruction of a main must maintain spontaneous ventilation, and allow rigid The history may help in the diagnosis, for example bronchus: bronchoscopy prior to sudden onset of respiratory distress while playing. The child should be starved according to the recommended guidelines, but careful judgement of clinical priorities is required in a child with acute respiratory distress. Consider anticholinergic premedication to decrease airway secretions (atropine 20mcg. This will also reduce the vagal tone and avoid bradycardia during airway instrumentation. Hyperlucent appearance of the right lung on this expiratory chest In older children, the rigid bronchoscope only allows limited access Xray demonstrates air trapping from a foreign body lodged in the right main to the upper lobes and more distal airways. Image reproduced with kind permission of the Department of Radiology, Virginia Commonwealth University Medical Center, from The diferential diagnosis includes infective causes such as: The Stortz ventilating bronchoscope is the most commonly used rigid bronchoscope. It has a side port to which the anaesthetic respiratory distress as a late complication), breathing circuit can be attached to provide anaesthesia during airway. Acute epiglottitis (Haemophilus infuenza type B infection causes examination (see Figure 2). This allows safe examination of all children, supraglottic cellulitis with severe sore throat, fever, toxic, mufed including neonates. Peanut oil is particularly irritant to the airways and can cause local mucosal oedema as well as a chemical pneumonitis picture, which may be the only presenting factor. Storz ventilating bronchoscope with anaesthetic T-piece attached attention to examination of the airway and chest. This allows more time for airway manipulation without the child becoming too lightly anaesthetised and developing laryngospasm. Storz ventilating bronchoscope with long grasping forceps The choice will be dictated by personal experience and preference, and The anaesthetic T-piece circuit is attached to the sidearm of the also local availability. Ether is very slow in onset and difcult to use bronchoscope to allow delivery of oxygen and anaesthetic gases during for inhalational induction, and is not recommended in this context. The presence of the telescope, with the viewing end The key to successful bronchoscopy is adminstration of topical local occluded, results in a closed system, through which either spontaneous anaesthetic to the airway this allows the surgeon to insert the or controlled ventilation may occur. A safe the system is open, allowing only spontaneous ventilation, unless the dose of local anaesthetic must be used (4mg. The telescope occupies a required dose into a syringe prior to the start of anaesthesia; attach a signifcant proportion of the bronchoscope through which expiration long cannula with the needle removed. It may be necessary to remove the telescope periodically dose of local anaesthetic to the cords (see Figure 5) to allow adequate breathing through the lumen of the bronchoscope, Remember 1% lignocaine contains 10mg. A Sanders injector can be attached to the sidearm to enable controlled ventilation, when the telescope is not being used.

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Automated Fingerprint Identifcation of Coding, Filing, and Searching Palmprints; Charles C and Imaging Systems, 2nd ed. Quantitative-Qualitative Friction Ridge of Pathology and Laboratory Medicine 2000, 124 (5), Analysis: An Introduction to Basic and Advanced Ridge662?663. System Used by the Western Australian Police tion; New York State Department of Correction Division of Force for the Classifcation and Filing of Palmprints; 1959 Identifcation: New York, 1963. Commentatio de Examine Physiologico Organi Visus et Systematis Cutanei (A Commentary on the Physiological Examination of the Organs of Vision and the Cutaneous System); Vratisaviae Typis Universitatis: Breslau, Prussia, 1823. Dactiloscopia Comparada (Comparative Fingerprinting): the New Argentine System; 1904. Moses Contributing authors Peter Higgins, Michael McCabe, Salil Prabhakar, Scott Swann C O N T E N T S 3 6. McCabe, Salil Prabhakar, the late 1960s and early 1970s witnessed another era of Scott Swann civil turmoil and an unprecedented rise in crime rates, but this era happened to coincide with the development of the silicon chip. Generally critical of traditional methods used by detectives, the study placed any hopes for improvement on physical evidence in general and latent prints in particular. In a companion study, Joan Petersilia concluded that: No matter how competent the evidence technician is at performing his job, the gathering of physical evidence at a crime scene will be futile unless such evidence can be properly processed and analyzed. Since fngerprints are by far the most frequently retrieved physical evidence, making the system of analyzing such prints effective will contribute the most toward greater success in identifying criminal offenders through the use of physical evidence. The original collection of the Japanese National Police initiated projects to develop fngerprint records contained 810,188 records. This classifying, searching, and matching tenprint cards used for was in addition to the 63 million records in the civilian fle, personal identifcation. The time and human resources to accomplish this daily workload ing his problem, he asked for assistance in automating the continued to grow. These methods were based on comparing the minutiae Complete classifcation and searching against the massive. Obviously, as the size of the to be topologically equivalent, the two fngerprints were criminal fle and the daily workload increased, the amount declared to be identical?that is, having been recorded from of resources required continued to grow. After this review, and classifcation extensions were added to reduce the portion after studying additional problems inherent with the inking of the criminal fle that needed to be searched against each process, they believed that a computerized solution to autocard. Nonetheless, the manual system used for searching matically match and pair minutiae could be developed that and matching fngerprints was approaching the point of would operate in a manner similar to the techniques used being unable to handle the daily workload. Although punch card sorters could reduce the number of But to achieve this goal, three major tasks would have to fngerprint cards required to be examined based on pattern be accomplished. First, a scanner had to be developed that classifcation and other parameters, it was still necessary could automatically read and electronically capture the inked for human examiners to scrutinize each fngerprint card fngerprint image. Finally, a method had to be developed For the next 15 years, he continued to develop more reliable to compare two lists of minutiae descriptors to determine fngerprint matching software that became increasingly whether they both most likely came from the same fnger of more complex in order to account for such things as plastic the same individual. This contion of a prototype fngerprint reader to refect the experitract was for a device to automatically locate and determine ence gained from the original demonstration models with the relative position and orientation of the specifed minutiae an additional requirement for speed and accuracy. The next were also instructed to develop a proposal for a subsequent 3 years were devoted to using these readers in the convercontract to process 10 times that number of fngerprints. Thiebault, Prefecture of Police in Paris, redigital process to compare fxed logical marks to the image ported on the French efforts. Thiebault can be found in the entries listed in the Additional While the devices for fngerprint scanning and minutiae Information section of this chapter. The French approach incorporated a 1982; Wegstein and Rafferty, 1978, 1979; Wegstein et al. He developed the initial algorithms for determining transparencies of fngerprints. By 1966, the Osaka Prefecture Police department housed In order to acquire a high-contrast image that would be almost 4 million single fngerprints. An early automation easy to photograph and process, a technique was develeffort by this agency was the development of a pattern oped to record live fngerprint images photographically classifcation matching system based on a 17to 20-digit using a principle of frustrated total internal refection number encoded manually (Kiji, 2002, p 9).

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During fighting in Croatia in 1991, a Yugoslav mobile field hospital was located 5 10 km from the front: 61 % of wounded were evacuated within 30 minutes and another 22 % between 30 and 60 minutes of being injured. This was the case during much of the fghting in Beirut in the Lebanese civil war, often with evacuation times of only minutes. Although the vast majority of wounded patients arrive at the hospital within minutes under these circumstances, a few sufer considerable delay. Without an organized pre-hospital system and given an absolute absence of ambulances, civilians are often cut of from care facilities during street fghting and have to wait hours or even days for evacuation. Time until arrival in hospital Patients (n =) Died Mortality < 6 hours 3,114 172 5. The more seriously wounded die before they reach hospital when evacuation is delayed. Obviously, the wearing of body armour and the inclusion in statistics of minor or superfcial, non-penetrating wounds to the head or trunk will distort the anatomic distribution of wounds, and the ratio. With increasing delay of evacuation to over 24 hours, and even days and weeks, the ratio falls. Thus, studies of guerrilla and counter-insurgency warfare in difcult geographical terrain give much lower ratios indicating that the most seriously injured patients (critical area wounds) died before treatment (Table 5. Hospital mortality, however, has diminished greatly with medical progress (safe anaesthesia, blood transfusion, better understanding of the physiology of shock, antibiotics, and more aggressive surgical techniques) as shown in Table 5. Hospital mortality has come to be an indicator of the efciency of the management system, bearing in mind what has already been said about the paradox of early evacuation of the very severely injured. In calculating these fgures, however, one must take into account the percentage of truly vital injuries and exclude or specify the superfcial ones. Some patients will be triaged into the expectant category, and given supportive treatment only, to die without pain and with dignity (see Chapter 9). Other patients die shortly after arrival, or on-table, in an extreme attempt to save life. Then there are the truly post-operative deaths; some from irreversible shock, others from irretrievable brain injury and, others still, from surgical complications, mostly sepsis, and additional medical pathologies. Gross statistics of hospital mortality do not always take into consideration these very diferent categories of patients. Military medical services from industrialized countries may also face these constraints, but they tend to be of a diferent order of magnitude. Far more substantial is the workload and morbidity as represented by the number of operations and blood transfusions per patient and the duration of hospitalization. For statistical purposes, most patients, if well managed, undergo two operations: wound excision and delayed primary closure. Performing more than two operations per patient usually denotes a complication, typically sepsis, and is a good indication of morbidity. To simplify, the number of operations are described as two or less; three; or four and more (Figure 5. Fully two-thirds of all patients in the database had two operations or less, indicating a minimum of morbidity and good surgical management. There are a number of factors that infuence this surgical workload: delay in evacuation, severity of the wound, type of wound, and wounding mechanism. However, before rushing to such a 5 conclusion, another factor must be analysed: wound severity. If one looks at the number of operations according to Wound Grade, an important diference appears (Table 5. It would thus appear that the Red Cross Wound Score better represents morbidity and surgical workload than the delay in evacuation to hospital alone, but a combination of the two is more noteworthy. Grade 3 wounds tend to be very severe and delay does not appear to make a diference. Furthermore, some wounds classifed as being caused by fragments may well have been from fragmentation anti-personnel mines. Hospital staf have only the account of the patient to go by and, naturally, many patients are ignorant of weapons systems; they only know of bombs or guns.

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Tangent Screen 1000 mm the patient is asked to press a buzzer when the object and 40 40 not a blur is identifed. The patient has to be constantly reminded to keep his eye fxed on the central target. At least 50 50 eight meridians must be investigated, preferably 16, and the 60 r 60 object should be carried up to the fxation point, as there 70 70 80 80 may be areas inside the limits of the feld which are non90 90 seeing (scotomata). The size of the test object and its lumikinetic perimetry alone, while automated perimeters are nance are recorded as isopters or lines joining points of now utilized for static perimetry. With small, dim stimuli, relative scotomata can be found which are not demonstrable with Automated Perimeters large bright objects. Absolute scotomata are those which Automated perimetry has made perimetric examination are demonstrable with all light intensities. The normal physiologitherefore become a major screening, diagnostic and review cal response to an object in the peripheral feld is to turn modality in patients having any visual feld defect. In charting the feld of vision this norAutomated perimetry has many advantages over manual mal response must be suppressed, fxation being rigidly ways of recording the feld: maintained centrally while attention is directed to an obl Points in the visual field are tested randomly so that the ject at the periphery. Hence the frst felds taken should be subject cannot anticipate where the next stimulus will interpreted with caution. A 5 mm object used at the usual quantifies retinal sensitivity and is more accurate than distance of 33 cm (5/330), corresponds to a visual angle manual perimetry. In comparison to the wide feld recordable by l Abnormal points are re-tested automatically. If the charts of further programming done to perform customized visual the two eyes are superimposed there will be a large central field testing. The limit Threshold Test Extent of Visual Field/Number of Points of the feld for a colour is the point at which, passing from 10-2 10 degrees/68 point grid the periphery to the centre, the colour frst becomes evident. The exact limit is diffcult to 60-2 30?60 degrees/60 point grid determine, for most colours appear to change in hue and Nasal step 50 degrees/14 points saturation as the object passes from the fxation point towards the periphery. Red or green should be used frst, then Each of these could be done using different strategies: blue or yellow. In ordinary conditions, the blue feld is largSuprathreshold static perimetry uses stimuli readily visiest, slightly smaller than the white, then follow the yellow, ble to normal controls, and these are presented at selected red and green, in the order named. The machine records yellow is roughly 10 less in each direction than that for the locations where the target is seen and not seen. The limquickly screens the visual feld for gross anomalies and if its of the colour felds vary not only with the intensity of the the stimulus is not visible in any area, further evaluation light, but also with saturation of the colour and, above all, with threshold testing should be done. If these are suffciently great, Threshold perimetry records incremental threshold meacolours may be recognized almost, if not quite, at the surements at different visual feld locations that are typically periphery. Deductions made from variations in the colour arranged in a grid pattern or along meridians. Static perimetry felds are particularly unreliable, except in compressive performs a sampling of 50?100 locations of the visual feld lesions when the red feld is affected frst. A staircase threshold determination strategy or Static Perimetry bracketing technique is used to measure threshold values at Static perimetry is usually done with computerized, autoeach location. It can be plotted with the Goldmann peperceived by the patient, and is then decreased in smaller rimeter as well, keeping the location and size of the target steps to the point where it cannot be identifed. Threshold stimulus constant and gradually increasing its intensity till sensitivity measurements recorded at a given point indicate the patient sees it, and then similarly testing at different that this stimulus can be seen by the patient 50% of the time. This is time-consuming and needs a very experithe strategy most commonly used today is the Swedish enced perimetrist. This has two Chapter | 10 Assessment of Visual Function 105 pre-determined values for each locus tested, one for a glauwidespread loss present in the visual feld. A computer randomly presents stimuli of from testing a sample of 10 locations twice, to determine the varying luminance at different locations. Abnormal areas, together with the density of the visual feld defect, are computed.

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As the loss of nerve fbres extends beyond the normal physiological overlap of functional zones, visual feld defects become apparent. This loss of nerve fbres is seen to occur initially and predominantly at the superior and inferior poles. The normal distribution of nerve fbres in the retina is such that polar loss of nerve fbres translates into a loss of function in an arch above and below the macular area, ending in a horizontal line nasally, with neither crossing it (Fig. The type of glaucoma is determined by the clinical features and the status of the anterior chamber angle as determined by gonioscopy. A diagnosis of Intraocular pressure Optic nerve head primary open-angle glaucoma can be made if at least two perfusion of these three abnormalities are detected. Axoplasmic flow Optic nerve head changes associated with glaucoma are thought to be seen prior to the development of visual feld loss. The common glaucomatous visual feld defects tous field defects?only central and temporal islands are as follows (Fig. This type of loss is common in glaucoma and is pressure usually asymmetrical about the horizontal meridian. The analysis is identifed as abnormal if one or more of the fve Blinking can elevate intraocular pressure to about regions demonstrate asymmetry across the horizontal 10 mmHg, and forceful closure of the orbicularis by midline which are beyond the 1% probability level for 40?50 mmHg. It is regarded as borderline if the asymmetry is within the 1% probability level for all Types of Glaucoma fve regions, but beyond the 3% probability level for one or more regions. At least two such felds plotted on differIt is convenient to divide the glaucomas (Fig. All results need to be considered together with the A summary of the types of glaucomas and their distinclinical data. Ocular examination Early detection of glaucomatous visual feld changes is would be expected to show an open anterior chamber angle, now being tried in a number of ways, such as the use of glaucomatous optic nerve head changes, visual feld short wavelength (blue) light stimuli, frequency doubled damage and an intraocular pressure of more than 21 mmHg stimuli, contrast detection techniques, motion detection recorded on at least a few occasions. It occurs in the sensitivity of the short wave-length system to be measured elderly, rarely being seen earlier than 40 years of age, and using a large blue target. The inheritance is thought to be early detection of glaucomatous feld defects as the short multifactorial and polygenic, with many genes contributwavelength processing system may be affected early. Patients who develop glaucoma probably inherit a peripapillary retinal nerve fbre layer and optic nerve head number of abnormal genes. Field defects should be diagnosed only after at least two reliable static fields are available. They can be graded on the basis of global indices, as mentioned in the text, or descriptively, based on the pattern deviation plot. Diabetes mellitus and myopia also occur more frequently in persons with glaucoma, than in Pathogenesis the general population. An intraocular pressure of more than 21 mmHg on myopes?should be examined regularly after the age of more than one occasion, and/or a circadian variation 40 years. Ideally, everyone over the age of 40 years should in intraocular pressure of more than 8 mmHg. The presence of optic nerve head changes suggestive evaluation and a record of all parameters?intraocular of glaucomatous damage, including: pressure, perimetry, optic nerve head evaluation and l A cup: disc ratio of more than 0. Glaucomatous damage generally tends vessels suggestive of an acquired enlargement of the to occur over years, not days or weeks, giving the ophoptic cup. This can be in the form of l the intraocular pressure recorded at initial presentation a drawing, photographs, stereophotographs or objecis probably that, at which damage to the optic nerve tive topography by scanning laser ophthalmoscopy head occurred or optical coherence tomography. Visual field changes consistent with glaucomatous l associated risk factors, such as cardiovascular disease defects. Defects in the retinal nerve fibre layer, which can be seen extending from the optic nerve head in an arc from these parameters help the ophthalmologist to deterthe superior and inferior poles of the disc. Primary angle closure disease includes a spectrum of condiTreatment tions in which the peripheral iris moves forwards to block the Treatment options presently available can only lower the openings of the trabecular meshwork in an occludable angle, intraocular pressure. It accounts for about 6% of all glaucomas Medications such as betaxolol are thought to increase the among Caucasians, in whom it presents in the sixth to perfusion of the optic nerve head. In contrast, it occurs at least a decade or drugs proven to have any effcacy in protecting the retinal more earlier in Asians and accounts for 50% of primary ganglion cells. In this procedure, laser spots are applied gonioscopiatic or creeping chronic variety, males and female are cally to coagulate the trabecular meshwork. First-degree relatives are at increased risk collapsed trabecular beams to become taut, increasing the of developing the disease.

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If this is the case, ask your assistant to release the during the case (if the area is surgically prepped), and urine pressure to improve your view of the larynx. Urine output can be estimated from the of these anatomical diferences and the limited oxygen reserve, diference in weight of the diaper pre-surgery and post-surgery; relatively high oxygen requirement, and poor tolerance of one mg increase in weight in the diaper is equivalent to one ml hypoxia means that intubation can be more difcult in a of urine. A scale capable of measuring small weights must be neonate compared to an adult, but with skill and experience, used. All doses of drugs should be calculated and drawn up safe intubation becomes routine. An open window particularly if the child has been starved for a long period of producing a breeze for the surgical team may cool the time; many children are starved for far too long preoperatively. If air conditioning is available, Patients in an arid climate often have a chronically low make sure the temperature is not turned down too low. Most children haematology presenting for elective general surgery do not require dextrose -1 Anaemia with haemoglobin level (Hb) less than 8g. Most will blood sugar to increase; neonates or malnourished children be nutritional, but you should consider other causes such as: should have their blood sugar checked to make sure they are not hypoglycaemic before surgery starts. Minor but low technology devices to detect hypothermia are procedures such as hernia repair can be undertaken safely with available, and valuable, particularly in younger children. Children have a relatively elective surgery, and they live relatively close to the hospital, large surface area and little fat for insulation, especially if they should be treated with a course of iron supplements for 3 malnourished. Basic Acute malaria can produce unexpected complications and heating pads and fuid warmers are helpful but need very close increased morbidity. All children presenting for elective surgery monitoring as they may also cause burns if not used properly. In particular, the heating pad should never be applied directly Sickle disease is associated with increased perioperative to the skin, and rarely placed on high. Intraoperative hypothermia can be avoided in the following Children with sickle disease presenting for elective surgery ways: should not be allowed to become dehydrated, and should be transfused using fresh whole blood if the Hb is below 8g. If possible, warm the theatre (22-25?C, depending on the high after blood transfusion in a malaria endemic area, the age of the child). An ambient heating unit is useful to child should have blood taken to test for malaria parasites and warm the room and reduce early heat loss. Essential laboratory measurements include: A three-year-old male child was referred to a tertiary referral haemoglobin, platelet count, creatinine (allows comparison hospital in East Africa with an 8 month history of enlarging of pre and postoperative renal function) and blood type and abdominal mass. The child was previously healthy, travelled cross match, anticipating the potential for signifcant blood from a neighbouring country, had been examined by multiple loss. A minimum of two adult units of type specifc blood medical care providers, and was very malnourished. You will need to have a minimum of two blood transfusion sets in theatre, in case one becomes obstructed with blood clots during the case. Postoperative care must be planned before surgery, including where the child will be cared for after surgery. Typically tumours in sub-Saharan in the area closest to the nursing station with access to close Africa are more advanced and in Nigeria, nephroblastoma is monitoring. Anaesthesia and surgery for advanced induction and maintenance of anaesthesia tumour cases can be very challenging. A large intra-abdominal tumour may predispose the patient to regurgitation of gastric contents on induction of anaesthesia. Many of these patients present in a state of Remember, if you are having difculty viewing the glottis, ask malnutrition and their response to inhalation agents such as your assistant to reduce the cricoid pressure and/or change halothane may be more dramatic with more cardiovascular their compression direction to a more midline position. Induction of a child with a large Wilms tumor: note multiple assistants, head of bed elevated, cricoid pressure, stethoscope ready, senior anaesthesia care provider ready to assist in intubation in teaching scenario or ketamine); and muscle relaxation (succinylcholine or Figure 3. Children can have a more tube can be used if there is no urinary catheter available dramatic drop in oxygen saturation when they are apnoeic compared to adults, due to higher oxygen consumption, and in During the surgical exposure of the tumour, the surgical team this case, the child will also have a reduced functional oxygen could decrease venous return to the heart by compression reserve, so will require efcient intubation. You must watch the surgery closely so that you may assist during the induction period. The lung volumes can anticipate blood loss and be aware of the manipulation will be reduced due to elevation of the diaphragm, so check of the tumour; you should alert the surgeons when the blood more than once that the endotracheal tube is not down too pressure drops. Tere will be times when you need to have far and is in the proper position in the trachea. If you are will do best with a cufed endotracheal tube, if available, due warming the blood in a bath of warm water, make sure that it to increased intra-abdominal pressure during surgical tumour is not too hot; if you cannot keep your hand in the water for manipulation. If an uncufed endotracheal tube is all that is more than 5 seconds then it is too hot and must not be used as available, place the appropriate size tube that only has a leak you can cause haemolysis and massive infusion of potassium.