Drugs/conditions which are stopped /modified before surgery

S Smoking 6 weeks before

E Estrogen pills 4 weeks
M MAO-A irreversible 3 weeks
L Lithium 2 weeks
A Aspirin 1 weeks
W Warfarin 4days
All hypoglycemic drugs :Minor surgery < 20 min (omit the dose)
Major surgery -- shift to insulin 1 week before --(omit morning dose)

Selection of suture material (guidelines)

Skin

nylon 6/0

face

nylon 3/0

back, scalp

nylon 5/0

elsewhere

Deeper tissue

catgut 4/0

face

(dead space)

Dexon/Vicryl

elsewhere

3/0 or 4/0
Subcuticular

catgut 4/0

Small vessel
ties

plain catgut 4/0

Large vessel
ties

chromic catgut
4/0

Time after insertion for removal of sutures

Area

Days later

Scalp

Face

3 (or alternate at 2, rest

3-4)

Ear

Neck

4 (or alternate at 3, rest

4)

Chest

Arm (including hand and

fingers)

8-10

Abdomen

8-10 (tension 12-14)

Back

12

Inguinal and scrotal

Perineum

Legs

10

Knees and calf

12

Foot (including toes)

10-12

Additional aspectsIn children, tend to remove 1-2 days earlier. Allow

additional time for backs and legs, especially the calf. Nylon sutures can be
left longer because they are less reactive. Alternate sutures may be removed
earlier (e.g. face in women).
Guide to tetanus prophylaxis in wound management

History of active
tetanus
immunisation

Clean,
minor
wounds

All other
wounds

Tetanus
toxoid1

Tetanus
immune
globulin

Tetanus
toxoid1

Tetanus
immune
globulin

Uncertain, or less
than 3 doses

yes

no

yes

yes

3 doses or more

no2

no

no3

no4

1. Adult or child 8 years and overuse tetanus toxoid or ADT. Child 7 years
or less, use tetanus toxoid or CDT or DTP (if due, on routine immunisation
schedule).
2. Yes, if more than 10 years since last dose.
3. Yes, if more than 5 years since last dose.
4. Yes, if more than 10 years since last dose and tetanus-prone wound.

Postoperatively first 24-48 hrs NS is used and then changed to DNS

Hypertonic saline is cerebroprotective in closed head injury patients

Maintainence fluid therapy

1st 10 kg -100ml/kg 100*10
Next 10 kg-50ml/kg. 50*20
Next any of kgs above this 20ml/kg 20*40

Previous fluid losses can be replaced as

50% in 1st hr
25% in.2nd hr
25% in 3rd hr

0.9% NaCl/5% dextrose has a pH of 4.5, while lactated Ringer has a pH of

6.5.

a nuclear medicine scan can be obtained that may demonstrate a "hot"

lesion in the setting of FNH and a "cold" lesion in the setting of hepatic
adenoma.

Mesentric artery ischemia

Abdominal pain out of proportion to findings on physical examination is
characteristic of intestinal ischemia. The etiology of ischemia may be embolic
or thrombotic occlusion of the mesenteric vessels or nonocclusive ischemia
due to a low cardiac index or mesenteric vasospasm. Differentiation among

these etiologies is best made by mesenteric angiography. While not without

serious risks, angiography also offers the possibility of direct infusion of
vasodilators into the mesenteric vasculature in the setting of nonocclusive
ischemia. This patient, with a recent myocardial infarction and a low cardiac
index, is at risk for embolism of clot from a left ventricle mural thrombus as
well as low-flow mesenteric ischemia. If embolism or thrombosis is found
angiographically (usually involving the superior mesenteric artery),
thrombolytic therapy can be attempted in the absence of suspicion of
ischemic bowel. Otherwise, operative embolectomy or vascular bypass is
indicated to restore flow. If occlusive disease cannot be demonstrated,
efforts should be made to simultaneously increase cardiac output with
inotropic agents and dilate the mesenteric vascular bed by angiographic
instillation of papaverine, nitrates, or calcium-channel blockers. Computed
tomography is not helpful in delineating the cause of intestinal ischemia
because it does not provide a sufficiently detailed image of the mesenteric
vessels. Laparoscopy and/or laparotomy would be useful if ischemic bowel
were suspected, although laparoscopy would not allow for adequate
assessment of the visceral vessels. Flexible sigmoidoscopy, while useful in
patients with ischemic colitis, has no role in the workup of mesenteric
ischemia, which involves primarily the small intestine and right colon. Serum
lactate is helpful in raising the suspicion of intestinal ischemia, but no
absolute level should be used to decide whether or not to explore a patient.

Screening in colorectal cancer

In an average-risk patient, colorectal cancer screening according to the
American Cancer Society should begin at age 50 and then an annual fecal
occult blood test or flexible sigmoidoscopy every 5 years or air contrast
barium enema (which has a sensitivity of 90% for polyps > 1 cm in size)
every 5 years or colonoscopy every 10 years is recommended. If an
adenomatous polyp is detected, then colonoscopy is recommended every 3
years. If no polyps are detected subsequently, colonoscopy can be
performed every 5 years. If more than five polyps are detected, colonoscopy
should occur annually. For patients with HNPCC, screening should begin
either between the ages of 20 and 25 or 10 years earlier than the youngest
family member with colorectal cancer, whichever comes earlier.

Bile and the fluids found in the duodenum, jejunum, and ileum all have an
electrolyte content similar to that of Ringer lactate. Saliva, gastric juice, and
right colon fluids have high K+ and low Na+ content. Pancreatic secretions
are high in bicarbonate. It is important to consider these variations in
electrolyte patterns when calculating replacement requirements following
gastrointestinal losses.
It is worth noting that both isotonic saline and lactated Ringer are acidic with
respect to the plasma: 0.9% NaCl/5% dextrose has a pH of 4.5, while
lactated Ringer has a pH of 6.5.

Pressure ulcers
Pressure ulcers are a serious problem in the elderly. They result when skin is
damaged by compression between a bony prominence and hard surface for
prolonged periods. Pressure ulcers are classified using a standard staging
system. A Stage I ulcer consists of persistent erythema. A Stage II ulcer is
characterized by partial thickness skin loss involving the epidermis or dermis
or both. These ulcers are superficial. A stage III ulcer is characterized by full
thickness skin loss involving subcutaneous tissue but not extending through
underlying fascia. A stage IV ulcer is a stage III ulcer that extends through
fascia and results in damage to underlying structures such as muscle or
bone. The treatment of all pressure ulcers includes frequent monitoring of
the ulcer, modifying the support surface (such as prescribing a foam
mattress), frequent repositioning, and keeping the skin dry and clean from
urine and stool. Scheduled urinary voidings are preferable to Foley catheters,
which increase risk for urinary tract infection. In order to remove devitalized
tissue, debridement is recommended for stage II, III, and IV ulcers.
Hydrocolloid gels are recommended for stage II and III ulcers. Neither of
these interventions would be indicated for this patient's stage I ulcer. All
pressure ulcers eventually become colonized with bacteria. Local wound care
is the first management of these infections. Topical antibiotics are
reasonable if the ulcer is unimproved after 2 weeks of local wound care.
Intravenous antibiotics are reserved for patients with cellulitis, sepsis, or
underlying osteomyelitis.

Drugs after Renal Transplant

Routine postoperative immunosuppression for a renal transplant recipient

includes cyclosporine, azathioprine, and steroids. Cyclosporine is nephrotoxic
and is frequently withheld in the postoperative period until the creatinine
returns to normal following transplantation. Azathioprine has bone marrow
toxicity as its major side effect, and both WBC and platelet counts need to
be monitored in the immediate posttransplant period. The patient's decrease
in WBCs is secondary to azathioprine toxicity, and the most appropriate step
is to decrease the dose of azathioprine. Viral infections are a serious cause of
morbidity following transplantation. A buffy coat is the supernatant of a
centrifuged blood sample that contains the WBCs. Viral cultures from this
supernatant as well as localization of inclusion bodies can identify transplant
patients infected with CMV. This patient has CMV pneumonitis and needs to
be treated with high-dose gancyclovir.

An elevation in creatinine at 3-month follow-up can be secondary to

rejection, anastomotic problems, urologic complications, infection, or
nephrotoxicity of various medications. With a normal ultrasound, no fever,
and no graft tenderness, the most likely cause is cyclosporine-induced
nephrotoxicity and the most appropriate step is a reduction in the
cyclosporine dose. Finally, at 6 months with graft tenderness, fever, and an
edematous kidney on ultrasound, rejection must be suspected. Negative
cultures make infection unlikely, and a steroid boost is appropriate. Addition
of monoclonal antibodies to CD3 (OKT3) or pooled antibodies against
lymphocytes (ALGs) is also appropriate in the treatment of a first rejection.

Skull fractures
Most skull fractures do not require surgical treatment unless they are
depressed or compound. A general rule is that all depressed skull fractures
defined as fractures in which the cranial vault is displaced inwardshould be
surgically elevated, especially if they are depressed more than 1 cm, if a
fragment is over the motor strip, or if small, sharp fragments are seen on xray (as they may tear the underlying dura). Compound fractures, defined as
fractures in which the bone and the overlying skin are broken, must be
cleansed and debrided and the wound must be closed. When a skull fracture
occurs in the area of the paranasal sinuses, the mastoid air cells, or the
middle ear, a tear in the meninges may result in cerebrospinal fluid drainage
from the ear or nose. The presence of rhinorrhea or otorrhea requires
observation; although meningitis is a serious sequela, the role of
prophylactic antibiotics is controversial. Otorrhea usually heals within a few

days. Persistent cerebrospinal fluid from the nose or ear for more than 14
days requires surgical repair of the torn dura.

Undescended testes
Chorionic gonadotropin therapy for 1 month; operative placement into the
scrotum before age one if descent has not occurred.