Pleural effusion management

Posted on May 11, 2013 by loverock

The pleura is a thin membrane that lines the surface of the lungs and the inside of the chest wall outside the lungs. In pleural effusions, fluid accumulates in the space between the layers of pleura. Normally, only teaspoons of watery fluid are present in the pleural space, allowing the lungs to move smoothly within the chest cavity during breathing.

Numerous medical conditions can cause pleural effusions. Some of the more common causes are:

Congestive heart failure
Pneumonia
Liver disease (cirrhosis)
End-stage renal disease
Nephrotic syndrome
Cancer
Pulmonary embolism
Lupus and other autoimmune conditions

Standard posteroanterior and lateral chest radiography remains the most important technique for the initial diagnosis of pleural effusion. Free pleural fluid flows to the most dependent part of the pleural space. In the
upright position, this is the subpulmonic region, and accumulation of fluid causes apparent elevation of the hemithorax, lateral displacement of the dome of the diaphragm, and blunting of the costophrenic angle.

However, at least 250 mL of fluid must accumulate before it becomes visible in a posteroanterior radiograph.

Transudative effusions are usually managed by treating the underlying medical disorder. However, whether transudates or exudates, large, refractory pleural effusions causing severe respiratory symptoms, even if the cause is understood and disease-specific treatment is available, can be drained to provide relief.

The management of exudative effusions depends on the underlying etiology of the effusion. Pneumonia, malignancy, or TB causes most diagnosed exudative pleural effusions, with the remainder typically deemed idiopathic. Complicated parapneumonic effusions and empyemas should be drained to prevent development of fibrosing pleuritis. Malignant effusions are usually drained to palliate symptoms and may require pleurodesis to prevent recurrence.

Although small, freely flowing parapneumonic effusions can be drained by therapeutic thoracentesis, most larger effusions and complicated parapneumonic effusions or empyemas require drainage by tube thoracostomy.

Traditionally, large-bore chest tubes (20-36F) have been used to drain thick pleural fluid and to break up loculations in empyemas. However, such tubes are not always well tolerated by patients and are difficult to direct correctly into the pleural space. However, small-bore tubes (7-14F) inserted at the bedside or under radiographic guidance have been shown to provide adequate drainage, even when empyema is present. These tubes cause less discomfort and are more likely to be placed successfully within a pocket of pleural fluid. Using 20-cm water suction and flushing the tube with normal saline every 6-8 hours may prevent occlusion of small-bore catheters.

Treatment for pleural effusions may often simply mean treating the medical condition causing the pleural effusion. Examples include giving antibiotics for pneumonia, or diuretics for congestive heart failure.

Large, infected, or inflamed pleural effusions often require drainage to improve symptoms and prevent complications. Various procedures may be used to treat pleural effusions, including:

Thoracentesis (described above) can remove large amounts of fluid, effectively treating many pleural effusions.

Tube thoracotomy (chest tube): A small incision is made in the chest wall, and a plastic tube is inserted into the pleural space. Chest tubes are attached to suction and are often kept in place for several days.

Pleurodesis: An irritating substance (such as talc or doxycycline) is injected through a chest tube, into the pleural space. The substance inflames the pleura and chest wall, which then bind tightly to each other as they heal. Pleurodesis can prevent pleural effusions from recurring, in many cases.

Pleural drain: For pleural effusions that repeatedly recur, a long-term catheter can be inserted through the skin into the pleural space. A person with a pleural catheter can drain the pleural effusion periodically at home.

Pleural decortication: Surgeons can operate inside the pleural space, removing potentially dangerous inflammation and unhealthy tissue. Decortication may be performed using small incisions (thoracoscopy) or a large one (thoracotomy).

VY Flap Technique

Posted on April 10, 2013 by loverock

The V-Y plasty technique is an island pedicle flap procedure. While most local flaps rotate into a wound from nearby tissues, bringing the blood supply with the intact portion of the flap, island pedicle flaps receive the blood supply from below, in the capillaries immediately beneath the dermis. This capillary supply must not be disrupted by undermining the tissue when creating an island pedicle flap.

At first glance, the performance of pedicle flaps may seem daunting, but a simple V-Y plasty pedicle flap easily can be advanced to cover the defect left by fingertip injury. The V-Y plasty advancement flap technique should be used when the injury leaves more pulp than nail bed. Attempts to use this technique when the opposite situation occurs results in undue tension on the flap and failure of the procedure. Physicians must consider their experience level when deciding to perform this procedure. The technique is not difficult to learn but, at centers with readily available hand and plastic surgeons, referral may be considered.

Thyroidectomy

Posted on February 28, 2013 by loverock

Thyroidectomy is the removal of all or part of your thyroid gland. Your thyroid is a butterfly-shaped gland located at the base of your neck. It produces hormones that regulate every aspect of your metabolism, from your heart rate to how quickly you burn calories.

Your surgeon may do the procedure through a surgical cut in your neck.

Your surgeon will make a 3-inch to 4-inch cut in the middle of your neck, right on top of the thyroid gland. Then the surgeon will remove all or part of the gland.
The surgery can also be done using a smaller surgical cut that is less than 2 inches long.
Your surgeon will be very careful not to damage the blood vessels and nerves in your neck.
Your surgeon may place a small tube (catheter) into the area to help drain blood and other fluids that build up. The drain will be removed in 1 or 2 days.
Surgery to remove your whole thyroid may take up to 4 hours. It may take less time if only part of the thyroid is removed.

There are three main types of thyroid surgery:

Total Thyroidectomy — Complete Removal of the Thyroid
This is the most common type of thyroid surgery, and is often used for thyroid cancer, and in particular, aggressive cancers, such as medullary or anaplastic thyroid cancer. It is also used for goiter and Graves’/hyperthyroidism treatment.

Subtotal/Partial Thyroidectomy — Removal of Half of the Thyroid Gland
For this operation, cancer must be small and non-aggressive — follicular or papillary — and contained to one side of the gland. When a subtotal or partial thyroidectomy is performed, typically, surgeons perform a bilateral subtotal thyroidectomy which leaves from 1 to 5 grams on each side/lobe of the thyroid. A Harley Dunhill procedure is also popular, in which there’s a total lobectomy on one side, and a subtotal on the other, leaving 4 to 5 grams of thyroid tissue remaining.

Thyroid Lobectomy — Removal of Only About a Quarter of the Gland
This is less commonly used for thyroid cancer, as the cancerous cells must be small and non-aggressive.
The issue of a subtotal/partial, vs. total thyroidectomy is controversial. Some practitioners prefer to perform a partial thyroidectomy whenever possible, believing that they will leave behind enough thyroid tissue to prevent hypothyroidism. (A total thyroidectomy has nearly a 100 percent chance of causing hypothyroidism). The risk of hypothyroidism with subtotal thyroidectomy is, however, quite high, and some experts say that more than 70 percent of patients receiving a subtotal thyroidectomy will become hypothyroid. Since one of the main reasons for subtotal thyroidectomy is to prevent hypothyroidism, and that goal is achieved in only a minority of cases, experts increasingly believe that there is no added benefit to subtotal thyroidectomy, and are more routinely recommending a total thyroidectomy.

Managing Burn Wound In US

Posted on February 20, 2013 by loverock

Most burns are small; patients with small burns are appropriately treated in an outpatient setting if the burns do not involve critical areas such as the face, hands, genitals, or feet. The outpatient setting is the primary focus of this section. Outpatient burn management can be taxing and, when poorly performed, can cause unnecessary suffering and compromise long-term results. In some situations, the best plan is to coordinate outpatient management with the burn unit’s team of doctors, nurses, and therapists because their expertise may facilitate attaining optimal outpatient results. However, most small burns can be properly managed by community-based providers with burn center consultation as needed.

The AIMS OF BURN MANAGEMENT are to:

Avoid infection
Reduce pain
Promote effective wound healing
Minimise scarring and psychological trauma
Restore or replace damaged skin and normal movement

Wound cleansing and dressing techniques must be taught to the person who changes the dressings. Ideally, document this instruction.

The choice of the many medications or membranes to place on burn wounds remains unclear, but certain basic principles apply to all situations. Gently clean the wound of debris and exudate on a regular basis. This usually requires daily removal of accumulated exudate and topical medications. Small superficial burns managed in this setting present a low risk of infection, thus, a clean rather than sterile technique is reasonable. Patients may clean the burn with lukewarm tap water and mild soap.

The seriousness of a burn is determined not only by its classification according to thickness or depth, but also by the extent that the burn covers the body. Several scoring systems have been developed to help determine if the burn represents minor, moderate, or major insult to the burn victim. The fastest assessment tool for evaluating burn coverage is the rule of nines. Developed for use with adult patients, the rule of nines divides the body into sections and assigns a percentage of total body surface (TBS) to each section. The clinician can quickly assess which segments of the body are burned and add up the predetermined percent areas assigned to each section to reach a reasonable estimate of TBS affected. The rule of nineteen is a similar scoring system developed for pediatric burn patients. Both rules are useful for initial assessment when speed is critical.

Full-thickness burn wounds heal by secondary intention, where the wound bed is filled by granulation tissue consisting of connective tissue and blood vessels, and by epithelialization where a new epidermis grows over granulation tissue to seal the wound. Large full-thickness burns often require the use of skin grafts to hasten closure once a sufficient bed of granulation tissue is available. In major burn victims, there is often not enough of the patient’s own healthy skin to provide sufficient skin for grafting, and this has spurred the development of a number of forms of skin substitutes.

Benign Breast Tumor

Posted on February 18, 2013 by loverock

During a breast self-exam, you find a lump. Now what?

If you notice any breast changes, you should notify your doctor right away, but don’t panic. Eighty percent of all breast lumps are benign, which means they’re not cancerous. Benign breast lumps usually have smooth edges and can be moved slightly when you push against them. They are often found in both breasts.

There are several common causes of benign breast lumps, including normal changes in breast tissue, breast infection or injury, and medicines that may cause lumps or breast pain.

The majority of breast tumors detected by mammography are non-cancerous, or benign. Benign breast tumors include fibroadenomas, granular cell tumors, intraductal papillomas, and phyllodes tumors. A condition known as fat necrosis is frequently mistaken for a breast tumor upon initial examination, and is therefore also discussed in this section.

Fibroadenomas appear as marble-like lumps in the breast that can range in size from microscopic to several inches in diameter. They are composed of both glandular and connective tissue. These tumors may appear singly in some women, while other women develop multiple fibroadenomas. Although these benign tumors may appear at any age, they are more common in women in their twenties and thirties, and occur in African-American women more than in any other racial or ethnic group. Fibroadenomas can be diagnosed by fine needle aspiration or core needle biopsy.

What increases the risk of benign breast conditions?

A few factors can increase the risk of benign breast conditions, including :

Menopausal hormone use (postmenopausal hormone use)
A family history of breast cancer or benign breast conditions (Women with a family history of breast cancer who have a benign breast condition appear to have an increased risk of breast cancer compared to those without a family history.)
The timing of certain lifestyle factors may be important to risk of benign breast conditions. For example, although alcohol use in adulthood does not appear to impact risk of benign breast conditions, drinking alcohol during adolescence may increase risk. This is an active area of study.

Types of benign breast conditions

There are many benign breast conditions, including:

Hyperplasia
Cysts
Fibroadenomas
Intraductal papillomas
Sclerosing adenosis
Radial scars
Benign phyllodes tumors
Diabetic mastopathy (also called lymphocytic mastitis and sclerosing lymphocytic lobulitis)

Escharotomy

Posted on February 13, 2013 by loverock

Full-thickness circumferential and near-circumferential skin burns result in the formation of a tough, inelastic mass of burnt tissue (eschar). The eschar, by virtue of this inelasticity, results in the burn-induced compartment syndrome. This is caused by the accumulation of extracellular and extravascular fluid within confined anatomic spaces of the extremities or digits. The excessive fluid causes the intracompartmental pressures to increase, resulting in collapse of the contained vascular and lymphatic structures and, hence, loss of tissue viability. The capillary closure pressure of 30 mm Hg, also measured as the compartment pressure, is accepted as that which requires intervention to prevent tissue death.

An escharotomy is a surgical procedure performed to allow greater circulation to a part of the body. A severe injury, such as a burn, can cause skin and tissue to swell so much that blood no longer flows easily past the injury.
For example, a severe burn on the upper arm can cause the skin and tissue to become so tight that the hand does not get the blood flow it should.

The need for escharotomies is relatively common in the treatment of burn injuries. The need arises because the tight eschar may interfere with the circulation to a limb causing demarcation and loss of the limb or in the case of the chest, may cause interference with respiration such that the expansion in the lungs is interfered with causing atelectasis and pneumonia. In the neck the oedema in the tissue may cause obstruction to the trachea. Indications for escharotomy rest on clinical grounds with tension in the limb under the burn and the state of circulation to the periphery being important. Added to this is the use of Doppler ultrasound, clinical presence of peripheral pulses and at times compartmental pressure measurements.

The aim of the escharotomy is to release the pressure over the involved deeper tissues and to restore their circulation. Technique: Under sterile conditions make incisions through the eschar until the tissue gapes such as to release the pressure particularly on the vascular supply. These should avoid flexion increases and be designed to release pressure in all compartments if necessary. In the case of electrical burns this may need to be combined with a fasciotomy for diagnostic and therapeutic purposes. Bleeding must be controlled and the escharotomy is then treated as a burn injury being packed with Silvazine cream. Elevation of the limbs is important also to help limit the oedema.

Surgical Site Infection, Local Infection After Surgery

Posted on February 7, 2013 by loverock

Infection is the main enemy of the surgeon. There are a number of reasons for this: cosmetic and functional outcomes after surgery are compromised by infection , trauma often results in infection due to the contamination and devitalisation of tissues , deep infections in mesothelial cavities are life threatening,lives can be ruined by careless exposure to bloodborne viruses.

A surgical site infection may range from a spontaneously limited wound discharge within 7–10 days of an operation to a life-threatening postoperative complication, such as a sternal infection after open heart surgery. Most surgical site infections are caused by contamination of an incision with microorganisms from the patient’s own body during surgery. Infection caused by microorganisms from an outside source following surgery is less common. The majority of surgical site infections are preventable. Measures can be taken in the pre-, intra- and postoperative phases of care to reduce risk of infection.

Surgical site infections can have a significant effect on quality of life for the patient. They are associated with considerable morbidity and extended hospital stay. In addition, surgical site infections result in a considerable financial burden to healthcare providers. Advances in surgery and anaesthesia have resulted in patients who are at greater risk of surgical site infections being considered for surgery. In addition, increased numbers of infections are now being seen in primary care because patients are allowed home earlier following day case and fast-track surgery.

CDC, in collaboration with other organizations, has developed guidelines for the prevention of SSIs healthcare-associated infections. Facilities can monitor the rates of SSI and assess the effectiveness of prevention efforts through CDC’s National Healthcare Safety Network (NHSN).

Find it in here: http://www.cdc.gov/hai/

Thoracotomy Procedure

Posted on February 6, 2013 by loverock

A thoracotomy is a major surgical procedure that allows surgeons to access the chest cavity during surgery. The procedure is performed in the operating room under general anesthesia.

A thoracotomy is a common but major surgery with significant risks and potential complications. You may have less invasive treatment options available depending on your specific circumstances. You should consider getting a second opinion about all your treatment choices before having a thoracotomy.

Types of thoracotomy :

The types of thoracotomy procedures include:

Limited anterior or lateral thoracotomy is an incision between your ribs on the front or side of your chest. It is a smaller incision and allows access to the structures and organs in the front of your chest cavity.

Posterolateral thoracotomy is an incision across the side and around the back of your chest. It is a larger incision that allows access to more of your chest, including an entire lung.

Sternal splitting thoracotomy is an incision down the front of your chest and through your sternum (breastbone). It allows access to your entire chest, including both lungs.

In the case of an emergency thoracotomy, the procedure performed depends on the type and extent of injury. The heart may be exposed so that direct cardiac compressions can be performed; the physician may use one hand or both hands to manually pump blood through the heart. Internal paddles of a defibrillating machine may be applied directly to the heart to restore normal cardiac rhythms. Injuries to the heart causing excessive bleeding (hemorrhaging) may be closed with staples or stitches.

Once the procedure that required the incision is completed, the chest wall is closed. The layers of skin, muscle, and other tissues are closed with stitches or staples. If the breastbone was cut (as in the case of a median sternotomy), it is stitched back together with wire.

Thoracotomy is widely recognized as being one of the most painful surgical procedures. Acute post-thoracotomy pain is aggravated by the constant movement of breathing. However, vigorous physiotherapy and incentive spirometry are encouraged to prevent atelectasis and secretion retention. Pain relief is, therefore, essential to facilitate coughing and deep breathing and to promote early mobilization.

Abdominal Packing for Surgically Uncontrollable Hemorrhage

Posted on February 5, 2013 by loverock

Planned intra-abdominal packing for surgically uncontrollable hemorrhage from liver and retroperitoneal injuries exacerbated by hypothermia, acidosis, and coagulopathy regained popularity over the past decade. Using abdominal packs is often a life-saving technique for uncontrollable bleeding during operations. It prevents worsening of the hypothermia, coagulopathy and acidosis which usually accompanies massive bleeding till they may be corrected and the packs removed later. However, packing may be associated with a mortality of 56 to 82 % due to continued bleeding, intra-abdominal abscesses and the compartment syndrome.

The use of packing with abdominal swabs is often a lifesaving technique to control bleeding which cannot be controlled by conventional techniques like suturing. This usually follows emergency procedures like liver trauma or pancreatic necrosectomy. This may also occur after elective operations where there may be massive bleeding from raw hypervascular surfaces, for instance, after the excision of large cancers, pelvic operations, liver tumours and liver transplantation.

Success depends upon early recognition of the limitation to control the haemorrhage and early intervention in the form of adequate pack insertion followed by the appropriate timing of pack removal. The main aim of packing is to forestall the worsening of acidosis, hypothermia, and coagulopathy and restoration of haemodynamic stability[2]. The subsequent relook laparotomy to remove the packs must be timed before infection occurs.

The decision to insert abdominal packs is a difficult one. It implies a technical failure on the surgeon’s part to control bleeding and also means that the patient usually has to be transferred on a ventilator to an intensive care unit and undergo a second operation for pack removal. Packing is also associated with complications like intra-abdominal abscesses or compartment syndrome. However, the timely and judicious use of packing may save a patient’s life and we consider using packs early as soon as the patient with bleeding has received 6 units of blood during operation, develops hypothermia, acidosis or inability of blood to clot.

This policy is especially useful in countries where there is a shortage of blood for transfusion and where facilities for doing complex procedures are not always available especially when massive bleeding occurs.

Damage Control Surgery for Unstable Patients

Posted on February 5, 2013 by loverock

Damage control surgery is one of the major advances in surgical technique in the past 20 years. The principles of damage control have been slow to be accepted by surgeons around the world, as they contravene most standard surgical teaching practices – that the best operation for a patient is one, definitive procedure.

However it is now well recognized that multiple trauma patients are more likely to die from their intra-operative metabolic failure that from a failure to complete operative repairs. Patients with major exsanguinating injuries will not survive complex procedures such as formal hepatic resection or pancreaticoduodenectomy. The operating team must undergo a paradigm shift in their ‘mindset’ if the patient is to survive such devastating injuries.

A combination of profound acidosis, hypothermia, and coagulopathy, also known as the “lethal triad” is commonly seen in these patients. It often precludes the completion of the operation. In this context, the concept of “damage control” has emerged. Borrowed from the United States Navy it represents “the capacity of a ship to absorb damage and maintain mission integrity”. In surgery, “damage control” refers to those maneuvers designed to ensure patient
survival. It is a staged strategy for the treatment of severe exsanguinating injury occurring from either blunt or penetrating mechanisms.

In trauma patients predicted to require massive transfusion, administration of fresh frozen plasma, packed red blood cells, and platelets in a 1:1:1 ratio (of individual units) is associated with improved survival Recombinant factor VIIa, cryoprecipitate, and tranexamic acid can be considered adjunctive treatments for coagulopathy.

Damage control surgery is a surgical strategy aimed at restoring normal physiology rather than anatomical integrity; however, this component of damage control resuscitation should not be applied in isolation

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