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Surgery - Assessment of pelvic pathology
Positioning and examination
The examination is conducted in a maximum of three positions: supine (for transabdominal palpation of the 'false' pelvis); supine with hips flexed and abducted (for vaginal and bimanual palpation, which may assist in evaluating rectal pathology); and left lateral position with hips flexed (for rectal palpation and rigid endoscopy). Any personal examination should always be conducted with a chaperone present, especially during pelvic examinations.
• Examination of the perineum. Is the anus malformed? Is there evidence of mucosal or rectal prolapse present? Is the vaginal introitus appearing normal? Is there vaginal prolapse or indications of a cystocele? Are there any scars from prior surgeries, indications of sinus issues, or signs of sepsis? Examine for supplementary or atypical tissue. Are there skin tags, external hemorrhoids, warts, or atypical skin regions, such as anal intraepithelial neoplasia (AIN)? Is an exterior punctum, as observed in a fistula, or the outer boundary of a fissure discernible? Palpation Palpate the inferior abdominal quadrants.
Digital rectal examination
Is the anal tone normal and is the sphincter symmetrical? Is the prostate of normal size with an intact central sulcus? Is the rectal mucosa exhibiting normal characteristics? Is there any lump or pain anterior to the upper rectum (Douglas pouch)? The aforementioned conditions may result from sigmoid disease, small bowel located in the pelvis, a pelvic appendix, or ovarian disease.
• Vaginal examination is frequently excluded unless there is a definitive indication that it may yield significant information. Is the cervix intact and functioning normally? Is the vagina of standard caliber and texture? Is there tenderness in either vaginal fornix? Inquiries Rigid proctoscopy (also known as anoscopy) is conducted in outpatient settings without the need of sedation. Visualizes the inferior rectum and anal canal, facilitating the evaluation of hemorrhoids. It may be supplemented with therapeutic interventions such as banding, injection, or cryotherapy. Rigid sigmoidoscopy, more accurately referred to as 'proctoscopy'
• Conducted procedures on outpatients without the need of anesthesia.
• Seeks to see the rectum up to the recto-sigmoid junction. The sigmoid colon is not sufficiently visualized with this. Results may be suboptimal if conducted without enema preparation.
Transabdominal/transvaginal ultrasonography
• Simple and secure; eliminates radiation exposure.
• Effective for the diagnosis of ovarian pathology (e.g., in right iliac fossa pain). Endoanal/transrectal ultrasound: A 360° scanning endoanal/endorectal probe performed without anesthesia. Endoanal examinations for evaluating anal sphincter integrity. Transrectal imaging for the evaluation of certain rectal tumors, prostate conditions (including biopsy), and presacral abnormalities.
CT imaging
• Preferred diagnostic approach for unexplained pelvic complaints and postoperative complications.
Magnetic Resonance Imaging
Typically conducted with a normal body scanner with external coils, although it may occasionally be executed with an endorectal coil.
• Preferred diagnostic modality for evaluating advanced rectal, gynecological, and urological malignancies, as well as intricate pelvic and anal infections.
The true pelvis is situated between the pelvic inlet, defined by the sacral promontory, iliopectineal lines, and symphysis pubis, and the outlet, delineated by the coccyx, ischial tuberosities, and pubic arch. The 'false pelvis' is situated superior to the pelvic inlet and can be palpated during abdominal examination. The pelvic floor muscles, including the levator ani, are essential for the support and functionality of the anorectum, vagina, and bladder. They receive innervation from the anterior primary rami of S2, S3, and S4. • The anterior relations of the rectum (palpable during a PR examination) are (from inferior to superior): • Women: vagina, cervix, pouch of Douglas. • Men: prostate, seminal vesicles, recto-vesical pouch.
Positioning and examination
The examination is conducted in a maximum of three positions: supine (for transabdominal palpation of the 'false' pelvis); supine with hips flexed and abducted (for vaginal and bimanual palpation, which may assist in evaluating rectal pathology); and left lateral position with hips flexed (for rectal palpation and rigid endoscopy). Any personal examination should always be conducted with a chaperone present, especially during pelvic examinations.
• Examination of the perineum. Is the anus malformed? Is there evidence of mucosal or rectal prolapse present? Is the vaginal introitus appearing normal? Is there vaginal prolapse or indications of a cystocele? Are there any scars from prior surgeries, indications of sinus issues, or signs of sepsis? Examine for supplementary or atypical tissue. Are there skin tags, external hemorrhoids, warts, or atypical skin regions, such as anal intraepithelial neoplasia (AIN)? Is an exterior punctum, as observed in a fistula, or the outer boundary of a fissure discernible? Palpation Palpate the inferior abdominal quadrants.
Digital rectal examination
Is the anal tone normal and is the sphincter symmetrical? Is the prostate of normal size with an intact central sulcus? Is the rectal mucosa exhibiting normal characteristics? Is there any lump or pain anterior to the upper rectum (Douglas pouch)? The aforementioned conditions may result from sigmoid disease, small bowel located in the pelvis, a pelvic appendix, or ovarian disease.
• Vaginal examination is frequently excluded unless there is a definitive indication that it may yield significant information. Is the cervix intact and functioning normally? Is the vagina of standard caliber and texture? Is there tenderness in either vaginal fornix? Inquiries Rigid proctoscopy (also known as anoscopy) is conducted in outpatient settings without the need of sedation. Visualizes the inferior rectum and anal canal, facilitating the evaluation of hemorrhoids. It may be supplemented with therapeutic interventions such as banding, injection, or cryotherapy. Rigid sigmoidoscopy, more accurately referred to as 'proctoscopy'
• Conducted procedures on outpatients without the need of anesthesia.
• Seeks to see the rectum up to the recto-sigmoid junction. The sigmoid colon is not sufficiently visualized with this. Results may be suboptimal if conducted without enema preparation.
Transabdominal/transvaginal ultrasonography
• Simple and secure; eliminates radiation exposure.
• Effective for the diagnosis of ovarian pathology (e.g., in right iliac fossa pain). Endoanal/transrectal ultrasound: A 360° scanning endoanal/endorectal probe performed without anesthesia. Endoanal examinations for evaluating anal sphincter integrity. Transrectal imaging for the evaluation of certain rectal tumors, prostate conditions (including biopsy), and presacral abnormalities.
CT imaging
• Preferred diagnostic approach for unexplained pelvic complaints and postoperative complications.
Magnetic Resonance Imaging
Typically conducted with a normal body scanner with external coils, although it may occasionally be executed with an endorectal coil.
• Preferred diagnostic modality for evaluating advanced rectal, gynecological, and urological malignancies, as well as intricate pelvic and anal infections.
The true pelvis is situated between the pelvic inlet, defined by the sacral promontory, iliopectineal lines, and symphysis pubis, and the outlet, delineated by the coccyx, ischial tuberosities, and pubic arch. The 'false pelvis' is situated superior to the pelvic inlet and can be palpated during abdominal examination. The pelvic floor muscles, including the levator ani, are essential for the support and functionality of the anorectum, vagina, and bladder. They receive innervation from the anterior primary rami of S2, S3, and S4. • The anterior relations of the rectum (palpable during a PR examination) are (from inferior to superior): • Women: vagina, cervix, pouch of Douglas. • Men: prostate, seminal vesicles, recto-vesical pouch.
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Surgery - Abdominal Investigations
Fecal occult blood testing may be chemical or immunological/quantitative—specifically, the quantitative fecal immunochemical test (qFIT). The primary application is as the initial community test for colorectal carcinoma, as outlined in the National Bowel Cancer Screening Programme.
Flexible sigmoidoscopy
• Minimal risk (perforation <1 in 10,000), typically conducted without sedation. • should visualize up to the descending colon. facilitates small therapeutic interventions (polypectomy, biopsy, injection). commonly employed for: diagnosis and evaluation of colitis colonic neoplasia, investigation anorectal hemorrhage.< />pan>
Colonoscopy: Low risk (perforation 1 in 1000); conducted with or without intravenous sedation or Entonox®; necessitates bowel preparation.
• The entire colon should be visualized in over 95% of cases. Permits minimal therapeutic interventions—polypectomy, including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), injection, tattoo marking, and biopsy. Applicable when comprehensive colonic evaluation is warranted or when colonic and/or terminal ileal pathology is suspected.
Transabdominal ultrasonography
Simple, secure, non-invasive, and eliminates radiation exposure. Common applications encompass: • 1° examination of the biliary tree for gallstones, bile duct dimensions, and liver parenchymal characteristics. • Detection of ovarian pathology, for instance, in cases of suspected appendicitis. Evaluation of the hepatic and splenic parenchyma. Detection of free fluid in abdominal trauma.
Computed Tomography scanning
• Simple and non-invasive; necessitates considerable radiation exposure and intravenous/oral contrast.
• Common applications encompass:
• Initial evaluation of all intra-abdominal masses.
• Staging of intra-abdominal and pelvic neoplasms.
• Examination of acute stomach pain (gaining prevalence).
• Examination of potential intestinal blockage.
• Assessment of probable postoperative sequelae.
MRI scanning
• Eliminates radiation exposure.
• Can be conducted using specific contrast agents.
• Commonly employed for: • Examination of suspected bile duct pathology—magnetic resonance cholangiopancreatography (MRCP).
Evaluation of hepatic pathology and potential metastases. Evaluation of the pancreatic.
Evaluation of pelvic and retroperitoneal soft tissue pathology, such as pelvic malignancies and intricate perianal sepsis.
• Evaluation of the small intestine where radiation exposure should be minimized (magnetic resonance enterography)
Standard abdominal radiograph
• may detect intestinal blockage, urinary tract calculi, free intra-abdominal air, and intra-abdominal fluid.
The Barium/Gastrografin® enema can be performed as either a single contrast, where contrast material fills the colon to detect strictures and blockages, or a double contrast, which involves a dilute contrast and air to cover the mucosal surface of the colon, however the latter is currently hardly utilized.
Computed Tomography Colonography • Necessitates comprehensive bowel preparation and rectal catheter placement; entails considerable radiation exposure with intravenous or oral contrast.
• Generally employed as an alternative to colonoscopy when it is contraindicated or unfeasible, such as in cases of advanced age, frailty, known strictures, or unsuccessful colonoscopy attempts. Studies on intestinal transit
• Serial abdominal X-rays (AXR) are utilized to monitor the progression of ingested radio-opaque markers.
• They are employed to evaluate intestinal motility and transit duration. PET scanning involves the injection of a radioactive metabolic substrate to identify metabolically active tissues, such as malignancies or areas of inflammation/infection. It is combined with high-resolution CT scanning to accurately locate 'hot spots.' Commonly employed to detect unrecognized metastatic tumor deposits or to distinguish fibrosis from remaining tumor following surgery.
Physiological assessment
• Manometric evaluation of the esophagus, encompassing the lower esophageal sphincter and the anal canal. Pressure sensitivities of the esophagus and anal canal. pH assessment of the esophageal contents (either isolated or continuously over 24 hours).
• used to evaluate anorectal function, esophageal motility and function, and gastroesophageal reflux
Fecal occult blood testing may be chemical or immunological/quantitative—specifically, the quantitative fecal immunochemical test (qFIT). The primary application is as the initial community test for colorectal carcinoma, as outlined in the National Bowel Cancer Screening Programme.
Flexible sigmoidoscopy
• Minimal risk (perforation <1 in 10,000), typically conducted without sedation. • should visualize up to the descending colon. facilitates small therapeutic interventions (polypectomy, biopsy, injection). commonly employed for: diagnosis and evaluation of colitis colonic neoplasia, investigation anorectal hemorrhage.< />pan>
Colonoscopy: Low risk (perforation 1 in 1000); conducted with or without intravenous sedation or Entonox®; necessitates bowel preparation.
• The entire colon should be visualized in over 95% of cases. Permits minimal therapeutic interventions—polypectomy, including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), injection, tattoo marking, and biopsy. Applicable when comprehensive colonic evaluation is warranted or when colonic and/or terminal ileal pathology is suspected.
Transabdominal ultrasonography
Simple, secure, non-invasive, and eliminates radiation exposure. Common applications encompass: • 1° examination of the biliary tree for gallstones, bile duct dimensions, and liver parenchymal characteristics. • Detection of ovarian pathology, for instance, in cases of suspected appendicitis. Evaluation of the hepatic and splenic parenchyma. Detection of free fluid in abdominal trauma.
Computed Tomography scanning
• Simple and non-invasive; necessitates considerable radiation exposure and intravenous/oral contrast.
• Common applications encompass:
• Initial evaluation of all intra-abdominal masses.
• Staging of intra-abdominal and pelvic neoplasms.
• Examination of acute stomach pain (gaining prevalence).
• Examination of potential intestinal blockage.
• Assessment of probable postoperative sequelae.
MRI scanning
• Eliminates radiation exposure.
• Can be conducted using specific contrast agents.
• Commonly employed for: • Examination of suspected bile duct pathology—magnetic resonance cholangiopancreatography (MRCP).
Evaluation of hepatic pathology and potential metastases. Evaluation of the pancreatic.
Evaluation of pelvic and retroperitoneal soft tissue pathology, such as pelvic malignancies and intricate perianal sepsis.
• Evaluation of the small intestine where radiation exposure should be minimized (magnetic resonance enterography)
Standard abdominal radiograph
• may detect intestinal blockage, urinary tract calculi, free intra-abdominal air, and intra-abdominal fluid.
The Barium/Gastrografin® enema can be performed as either a single contrast, where contrast material fills the colon to detect strictures and blockages, or a double contrast, which involves a dilute contrast and air to cover the mucosal surface of the colon, however the latter is currently hardly utilized.
Computed Tomography Colonography • Necessitates comprehensive bowel preparation and rectal catheter placement; entails considerable radiation exposure with intravenous or oral contrast.
• Generally employed as an alternative to colonoscopy when it is contraindicated or unfeasible, such as in cases of advanced age, frailty, known strictures, or unsuccessful colonoscopy attempts. Studies on intestinal transit
• Serial abdominal X-rays (AXR) are utilized to monitor the progression of ingested radio-opaque markers.
• They are employed to evaluate intestinal motility and transit duration. PET scanning involves the injection of a radioactive metabolic substrate to identify metabolically active tissues, such as malignancies or areas of inflammation/infection. It is combined with high-resolution CT scanning to accurately locate 'hot spots.' Commonly employed to detect unrecognized metastatic tumor deposits or to distinguish fibrosis from remaining tumor following surgery.
Physiological assessment
• Manometric evaluation of the esophagus, encompassing the lower esophageal sphincter and the anal canal. Pressure sensitivities of the esophagus and anal canal. pH assessment of the esophageal contents (either isolated or continuously over 24 hours).
• used to evaluate anorectal function, esophageal motility and function, and gastroesophageal reflux
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Surgery -Assessment of Breast Pathology
The fundamental principle of breast evaluation is Triple Assessment: This includes a physical examination, subsequent radiological imaging, and biopsy (either fine needle or core biopsy).
Clinical assessment
Placement and examination
Breasts are optimally assessed in a semi-recumbent position followed by an upright position. Initially, the arms are positioned at the sides in a semi-recumbent posture. Subsequently, they ought to be examined in an upright position, with hands placed on the hips (first in a relaxed state and subsequently applying forceful pressure on the hips to engage the pectoral muscles), and ultimately abducted gradually above the head.
Inspection is essential and should focus on the following aspects.
• comprehensive symmetry and placement. Are the breasts of identical size? Is there a deformity resulting from an underlying disease? Is the position standard? • Dermal appearance. Is the skin erythematous or edematous? Is there a fixed form of lymphoedema in the skin known as 'peau d’orange'? Are there any scars from prior surgery?
• Dermal adhesion. Is the skin mobile when the arms are elevated? Tethering indicates the presence of underlying intraparenchymal scarring or a tumor.
Nipples. Are the nipples retracted, displaced, or ulcerated (indicative of retroareolar tumor or infection)? Is there any excretion?
Palpation
For palpation, the hands should be repositioned to the hips, and the patient may recline in a semi-recumbent position once again. Employ the flat surfaces of all four fingers simultaneously. Initially palpate the 'normal' breast. Be systematic and avoid 'kneading' the breast. A typical sequence is: upper outer quadrant; lower outer quadrant; lower inner quadrant; higher inner quadrant; center (retroareolar) region; supraclavicular fossa; and axillary region. Essential characteristics to consider comprise:
• Tangible mass. Is it hard, uneven, and fixed (cancer) or smooth, spherical, and movable (cysts or fibroadenoma)? Diffuse nodularity. Characteristic of a benign condition. Discharge from the nipple upon probing of the central region. Blood indicates a tumor; pus indicates an infection; serous or milky fluid may be inconsequential.
• Axillary and supraclavicular lymphadenopathy. Is it multifocal and attached (cancer)? Ultrasound Imaging
• Simple to execute and devoid of discomfort— often conducted at a breast outpatient clinic. Avoids radiation exposure in young women.
• Extremely adept in distinguishing between solid tumors and cysts. Mammography is utilized for both population screening and diagnostic evaluation. Very unpleasant for the majority of women and entails a minimal radiation exposure.
• Capable of detecting imperceptible lesions
. • Capable of recognizing premalignant lesions, such as ductal carcinoma in situ (DCIS). Mammographic characteristics indicative of malignancy encompass spiculated microcalcifications, irregularities, and stellate outlines.
Biopsy Aspiration cytology
• Well-tolerated, facile to execute, and rapid to report—typically conducted within half a day at the breast outpatient clinic. • Lacks histological data; offers solely cellular information and depends on cellular atypia for malignancy diagnosis. • Fails to distinguish between invasive and in situ cancer. • Occasionally therapeutic for cysts. High sensitivity and specificity.
Guided core biopsy
• Conducted under ultrasound or mammographic supervision utilizing a Trucut® needle or comparable instrument. Can be performed under general anesthesia or local anesthesia. Delivers precise histological data—facilitates cancer grading. Capable of distinguishing between invasive cancer and carcinoma in situ. Extremely delicate and specific.
Alternative (less frequently utilized)
Computed tomography (CT) scanning is beneficial for evaluating significant local invasion and for regional and systemic staging.
CT positron emission tomography (PET) imaging
Valuable for examining ambiguous lesions and detecting unrecognized metastatic illness.
Magnetic Resonance Imaging (MRI) scanning
Periodically employed for diagnostic purposes, such as in women with breast implants.
Essential topics—breast anatomy
The breast consists of epithelial ductal tissue, epithelial secretory lobules, adipose tissue, and connective tissue. It is segmented into four quadrants and a peri- / retroareolar central zone for the clinical characterization of anomalies. The arterial supply originates from segmental perforators of the internal thoracic artery (ITA). Lymphatic drainage is crucial in the therapy of breast cancer.
• Non-pathological lymphatic drainage predominantly occurs to the axillary nodes.
• The medial half may occasionally drain to the internal mammary nodes. Axillary lymph nodes are categorized into three levels: Level 1 is located inferior to the pectoralis minor, Level 2 is situated posterior to it, and Level 3 is positioned superior to the pectoralis minor.
The fundamental principle of breast evaluation is Triple Assessment: This includes a physical examination, subsequent radiological imaging, and biopsy (either fine needle or core biopsy).
Clinical assessment
Placement and examination
Breasts are optimally assessed in a semi-recumbent position followed by an upright position. Initially, the arms are positioned at the sides in a semi-recumbent posture. Subsequently, they ought to be examined in an upright position, with hands placed on the hips (first in a relaxed state and subsequently applying forceful pressure on the hips to engage the pectoral muscles), and ultimately abducted gradually above the head.
Inspection is essential and should focus on the following aspects.
• comprehensive symmetry and placement. Are the breasts of identical size? Is there a deformity resulting from an underlying disease? Is the position standard? • Dermal appearance. Is the skin erythematous or edematous? Is there a fixed form of lymphoedema in the skin known as 'peau d’orange'? Are there any scars from prior surgery?
• Dermal adhesion. Is the skin mobile when the arms are elevated? Tethering indicates the presence of underlying intraparenchymal scarring or a tumor.
Nipples. Are the nipples retracted, displaced, or ulcerated (indicative of retroareolar tumor or infection)? Is there any excretion?
Palpation
For palpation, the hands should be repositioned to the hips, and the patient may recline in a semi-recumbent position once again. Employ the flat surfaces of all four fingers simultaneously. Initially palpate the 'normal' breast. Be systematic and avoid 'kneading' the breast. A typical sequence is: upper outer quadrant; lower outer quadrant; lower inner quadrant; higher inner quadrant; center (retroareolar) region; supraclavicular fossa; and axillary region. Essential characteristics to consider comprise:
• Tangible mass. Is it hard, uneven, and fixed (cancer) or smooth, spherical, and movable (cysts or fibroadenoma)? Diffuse nodularity. Characteristic of a benign condition. Discharge from the nipple upon probing of the central region. Blood indicates a tumor; pus indicates an infection; serous or milky fluid may be inconsequential.
• Axillary and supraclavicular lymphadenopathy. Is it multifocal and attached (cancer)? Ultrasound Imaging
• Simple to execute and devoid of discomfort— often conducted at a breast outpatient clinic. Avoids radiation exposure in young women.
• Extremely adept in distinguishing between solid tumors and cysts. Mammography is utilized for both population screening and diagnostic evaluation. Very unpleasant for the majority of women and entails a minimal radiation exposure.
• Capable of detecting imperceptible lesions
. • Capable of recognizing premalignant lesions, such as ductal carcinoma in situ (DCIS). Mammographic characteristics indicative of malignancy encompass spiculated microcalcifications, irregularities, and stellate outlines.
Biopsy Aspiration cytology
• Well-tolerated, facile to execute, and rapid to report—typically conducted within half a day at the breast outpatient clinic. • Lacks histological data; offers solely cellular information and depends on cellular atypia for malignancy diagnosis. • Fails to distinguish between invasive and in situ cancer. • Occasionally therapeutic for cysts. High sensitivity and specificity.
Guided core biopsy
• Conducted under ultrasound or mammographic supervision utilizing a Trucut® needle or comparable instrument. Can be performed under general anesthesia or local anesthesia. Delivers precise histological data—facilitates cancer grading. Capable of distinguishing between invasive cancer and carcinoma in situ. Extremely delicate and specific.
Alternative (less frequently utilized)
Computed tomography (CT) scanning is beneficial for evaluating significant local invasion and for regional and systemic staging.
CT positron emission tomography (PET) imaging
Valuable for examining ambiguous lesions and detecting unrecognized metastatic illness.
Magnetic Resonance Imaging (MRI) scanning
Periodically employed for diagnostic purposes, such as in women with breast implants.
Essential topics—breast anatomy
The breast consists of epithelial ductal tissue, epithelial secretory lobules, adipose tissue, and connective tissue. It is segmented into four quadrants and a peri- / retroareolar central zone for the clinical characterization of anomalies. The arterial supply originates from segmental perforators of the internal thoracic artery (ITA). Lymphatic drainage is crucial in the therapy of breast cancer.
• Non-pathological lymphatic drainage predominantly occurs to the axillary nodes.
• The medial half may occasionally drain to the internal mammary nodes. Axillary lymph nodes are categorized into three levels: Level 1 is located inferior to the pectoralis minor, Level 2 is situated posterior to it, and Level 3 is positioned superior to the pectoralis minor.
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Surgery - Assessment of the neck region
Placement and examination
Position the patient upright at rest, ensuring the head is oriented straight ahead. Examine the neck from the anterior, lateral, and, if required, posterior perspectives.
• examine the neck in a stationary position and while swallowing (a glass of water). Inspect rotation to the left and right if required.
• Examine the neck while instructing the patient to protrude the tongue. Examination (criteria for assessment) Overall symmetry and nodules. Are there discernible lumps? Are they singular or plural? Is the mass positioned in or around the midline? Does the lump exhibit mobility when swallowing, indicating a potential thyroid-related lesion?
• Dermatological irregularities. Are there any ulcers or sinuses indicative of a chronic infection, such as tuberculosis?
• Related structures. Is there evidence of venous distension or observable collateral vessels? Examination by touch Adopt a systematic approach; palpate the cervical areas sequentially. Utilize both hands with the flat of the fingers to assess each side, but manipulate only one hand at a time to avoid 'cross-palpation.' A standard palpation sequence is: anterior triangle (bottom to top); submental region; submandibular region; posterior triangle (top to bottom); supraclavicular fossae; and parotid, preauricular, and postauricular regions. Repalpate the neck as the patient swallows a mouthful of water, focusing on the anterior triangle. Finally palpate the carotid arteries particularly.
• Mass. Is it singular or plural? Multiple strongly indicates lymphadenopathy. Is it precisely located along the midline, potentially associated with the thyroid? Does it exhibit movement during swallowing, typically indicating a thyroid-related issue? What are the overarching characteristics? Thyroid nodule. Is it one-sided or two-sided? Does it exhibit movement with tongue protrusion? Carotid arteries. Are they normal, ectatic, or aneurysmal? Supraclavicular fossae. Is there accompanying lymphadenopathy indicative of malignancy? Auscultation Auscultate the carotid arteries and any significant masses for bruits, indicating hypervascularity or stenosis.
Inquiries Ultrasonography
• Simple to execute and devoid of pain. Avoids exposure to radiation dosage.
• Extremely adept in distinguishing between solid tumors and cysts
Aspirational cytology
Simple to execute and rapid to document.
• Generally widely accepted in outpatient settings. Offers solely cellular information and depends on cellular atypia for the diagnosis of cancer. Does not furnish histology information.
• intermittently beneficial for cysts. High sensitivity and specificity. Contraindicated in cases of suspected vascular lesions. CT scanning is beneficial for evaluating substantial local invasion and for regional and systemic staging of tumors.
• Facilitates the assessment of the thorax in some thyroid neoplasms. CT PET scanning is occasionally employed to evaluate ambiguous lesions detected on standard CT and to find unanticipated metastatic illness. MRI scanning is beneficial for the comprehensive evaluation of local tumor invasion.
Placement and examination
Position the patient upright at rest, ensuring the head is oriented straight ahead. Examine the neck from the anterior, lateral, and, if required, posterior perspectives.
• examine the neck in a stationary position and while swallowing (a glass of water). Inspect rotation to the left and right if required.
• Examine the neck while instructing the patient to protrude the tongue. Examination (criteria for assessment) Overall symmetry and nodules. Are there discernible lumps? Are they singular or plural? Is the mass positioned in or around the midline? Does the lump exhibit mobility when swallowing, indicating a potential thyroid-related lesion?
• Dermatological irregularities. Are there any ulcers or sinuses indicative of a chronic infection, such as tuberculosis?
• Related structures. Is there evidence of venous distension or observable collateral vessels? Examination by touch Adopt a systematic approach; palpate the cervical areas sequentially. Utilize both hands with the flat of the fingers to assess each side, but manipulate only one hand at a time to avoid 'cross-palpation.' A standard palpation sequence is: anterior triangle (bottom to top); submental region; submandibular region; posterior triangle (top to bottom); supraclavicular fossae; and parotid, preauricular, and postauricular regions. Repalpate the neck as the patient swallows a mouthful of water, focusing on the anterior triangle. Finally palpate the carotid arteries particularly.
• Mass. Is it singular or plural? Multiple strongly indicates lymphadenopathy. Is it precisely located along the midline, potentially associated with the thyroid? Does it exhibit movement during swallowing, typically indicating a thyroid-related issue? What are the overarching characteristics? Thyroid nodule. Is it one-sided or two-sided? Does it exhibit movement with tongue protrusion? Carotid arteries. Are they normal, ectatic, or aneurysmal? Supraclavicular fossae. Is there accompanying lymphadenopathy indicative of malignancy? Auscultation Auscultate the carotid arteries and any significant masses for bruits, indicating hypervascularity or stenosis.
Inquiries Ultrasonography
• Simple to execute and devoid of pain. Avoids exposure to radiation dosage.
• Extremely adept in distinguishing between solid tumors and cysts
Aspirational cytology
Simple to execute and rapid to document.
• Generally widely accepted in outpatient settings. Offers solely cellular information and depends on cellular atypia for the diagnosis of cancer. Does not furnish histology information.
• intermittently beneficial for cysts. High sensitivity and specificity. Contraindicated in cases of suspected vascular lesions. CT scanning is beneficial for evaluating substantial local invasion and for regional and systemic staging of tumors.
• Facilitates the assessment of the thorax in some thyroid neoplasms. CT PET scanning is occasionally employed to evaluate ambiguous lesions detected on standard CT and to find unanticipated metastatic illness. MRI scanning is beneficial for the comprehensive evaluation of local tumor invasion.
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Anatomy -Occipitofrontalis
Latin, frons, the forehead, the anterior part of the head; occiput, the posterior part of the head. The occipitofrontalis has two muscular bellies, the frontal and occipital, interconnected by an aponeurosis known as the galea aponeurotica, named for its resemblance to a helmet (Latin galea).
Source Frontal belly: epidermis of the eyebrows.
Occipital belly: lateral two-thirds of the superior nuchal line of the occipital bone. Mastoid process of the temporal bone. Insertion: Galea aponeurotica. Facial nerve (VII), including the posterior auricular and temporal branches.
Action : The frontal belly elevates the eyebrows and creates horizontal creases on the forehead.
Occipital belly: retracts the scalp posteriorly. Fundamental functional movement Enables facial expressions, such as displaying surprise or frowning.
Latin, frons, the forehead, the anterior part of the head; occiput, the posterior part of the head. The occipitofrontalis has two muscular bellies, the frontal and occipital, interconnected by an aponeurosis known as the galea aponeurotica, named for its resemblance to a helmet (Latin galea).
Source Frontal belly: epidermis of the eyebrows.
Occipital belly: lateral two-thirds of the superior nuchal line of the occipital bone. Mastoid process of the temporal bone. Insertion: Galea aponeurotica. Facial nerve (VII), including the posterior auricular and temporal branches.
Action : The frontal belly elevates the eyebrows and creates horizontal creases on the forehead.
Occipital belly: retracts the scalp posteriorly. Fundamental functional movement Enables facial expressions, such as displaying surprise or frowning.
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Surgery - Assessment of peripheral vascular disease
Placement and examination The patient ought to be assessed in a heated setting while at rest. Ensure to assess the pulse and blood pressure, inspect the belly for aneurysms and scars, and conduct a comprehensive cardiovascular examination, including all peripheral pulses, heart sounds, and carotid auscultation.
Examine the leg in the supine position, subsequently elevated (passively), and ultimately in a dependent position. Fully expose the leg, encompassing the foot or hand, to facilitate a comprehensive examination and eliminate any bandages. The patient should be assessed in an upright position for venous disease. During supine examination,
observe the following:
Appearance Are there any regions with confirmed skin necrosis (dry gangrene, such as the tips of fingers or toes, interdigital spaces, or the heel of the foot)? Are there alterations in chronic venous stasis (such as varicosities, venous dermatitis, lipodermatosclerosis, or leg ulcers)?
Color - Waxy white indicates critical or acute ischaemia; blue and mottled coloration denotes potentially irreversible acute ischaemia; dark red or purple signifies chronic ischaemia.
Color alterations occur with positional modifications. Observe the angle at which the skin of the limb becomes pale when lifted passively (Buerger’s test). Normal extremities may have no blanching whatsoever. An angle of 15° or less indicates significant ischaemia. Observe the occurrence and latency of color change when the limb is in a dependent position. Ischaemic limbs gradually assume a vivid scarlet hue (reactive hyperaemia).
Ulcers-What is the site (digital or pedal) indicative of arterial disease? Ensure to examine the areas between the toes and fingers, as well as the plantar surface of the foot, particularly in cases of diabetes.
• Examination of venous structures. Assist the patient in standing upright. Examine for varicose veins. Are they located within the long saphenous or short saphenous distribution?
Palpation
• Temperature. Is the skin seen as chilly or warm? Is there a transitional phase? Compression and filling of skin capillaries. The standard is 2 seconds or fewer. A delay over 5 seconds indicates markedly diminished perfusion.
• Peripheral pulsations. Commence with the most proximal (major) vessels and go distally. Document whether the pulse is normal (++), diminished (+), or missing (–). Document any discernible excitement.
• In venous pathology, assessments of venous competence may be conducted (% Varicose veins). Surgical grafts. Examine the pathway of any surgical grafts and document the existence or nonexistence of pulses. Auscultation Assess for bruits. Are there bruits in the proximal vessels indicative of stenosis?
Inquiries Handheld Doppler (at the bedside), followed by Duplex ultrasound or CT angiography, are the primary modalities for examining vascular disease.
Portable Doppler ultrasonography • A simple and portable "bedside" assessment for preliminary evaluation. • used to: • Verify the existence of flow within a vessel or graft. • Assess the ankle-brachial pressure index (ABPI). Assess the existence of venous reflux.
Duplex Ultrasound (USS) • Integrates two-dimensional (2D) ultrasound imaging with Doppler-derived flow, shown in color and superimposed in real time. • Arterial duplex: utilized for the evaluation of stenoses and occlusions. Venous duplex: utilized for evaluating reflux or thrombosis in deep and superficial veins.
Computed Tomography Angiography Requires a multi-slice rapid acquisition ('helical'/'spiral') scanner. Images obtained during the arterial and/or venous phase following intravenous contrast administration.
Three-dimensional (3D) reconstruction facilitates the generation of 'virtual angiogram' images. This process is rapid, non-invasive, and comparatively safe. Utilizes iodinated contrast, which is nephrotoxic (relatively contraindicated in renal impairment) and poses a minor risk of allergic reaction. The presence of vessel wall calcification may hinder the visibility of the lumen.
Digital subtraction angiography (DSA) involves X-ray imaging subsequent to the injection of contrast material into the target vessel, effectively eliminating background structures (such as bone) to render the vessel lumen in black. This technique is primarily employed when endovascular intervention is necessary during the same procedure or when prior investigations yield inconclusive results. It is an invasive procedure that necessitates arterial puncture, which carries inherent risks, including the potential for false aneurysm or retroperitoneal hemorrhage associated with groin puncture. • Necessitates iodinated contrast, necessitating vigilance in cases of renal impairment and allergies.
Magnetic resonance angiography produces images of the arterial network by detecting arterial flow throughout the scanning process. • Safe and non-invasive: does not necessitate iodinated contrast, typically employing gadolinium to accentuate circulating blood. • Often overestimates the extent of stenosis due to the underrepresentation of very low flow.
Placement and examination The patient ought to be assessed in a heated setting while at rest. Ensure to assess the pulse and blood pressure, inspect the belly for aneurysms and scars, and conduct a comprehensive cardiovascular examination, including all peripheral pulses, heart sounds, and carotid auscultation.
Examine the leg in the supine position, subsequently elevated (passively), and ultimately in a dependent position. Fully expose the leg, encompassing the foot or hand, to facilitate a comprehensive examination and eliminate any bandages. The patient should be assessed in an upright position for venous disease. During supine examination,
observe the following:
Appearance Are there any regions with confirmed skin necrosis (dry gangrene, such as the tips of fingers or toes, interdigital spaces, or the heel of the foot)? Are there alterations in chronic venous stasis (such as varicosities, venous dermatitis, lipodermatosclerosis, or leg ulcers)?
Color - Waxy white indicates critical or acute ischaemia; blue and mottled coloration denotes potentially irreversible acute ischaemia; dark red or purple signifies chronic ischaemia.
Color alterations occur with positional modifications. Observe the angle at which the skin of the limb becomes pale when lifted passively (Buerger’s test). Normal extremities may have no blanching whatsoever. An angle of 15° or less indicates significant ischaemia. Observe the occurrence and latency of color change when the limb is in a dependent position. Ischaemic limbs gradually assume a vivid scarlet hue (reactive hyperaemia).
Ulcers-What is the site (digital or pedal) indicative of arterial disease? Ensure to examine the areas between the toes and fingers, as well as the plantar surface of the foot, particularly in cases of diabetes.
• Examination of venous structures. Assist the patient in standing upright. Examine for varicose veins. Are they located within the long saphenous or short saphenous distribution?
Palpation
• Temperature. Is the skin seen as chilly or warm? Is there a transitional phase? Compression and filling of skin capillaries. The standard is 2 seconds or fewer. A delay over 5 seconds indicates markedly diminished perfusion.
• Peripheral pulsations. Commence with the most proximal (major) vessels and go distally. Document whether the pulse is normal (++), diminished (+), or missing (–). Document any discernible excitement.
• In venous pathology, assessments of venous competence may be conducted (% Varicose veins). Surgical grafts. Examine the pathway of any surgical grafts and document the existence or nonexistence of pulses. Auscultation Assess for bruits. Are there bruits in the proximal vessels indicative of stenosis?
Inquiries Handheld Doppler (at the bedside), followed by Duplex ultrasound or CT angiography, are the primary modalities for examining vascular disease.
Portable Doppler ultrasonography • A simple and portable "bedside" assessment for preliminary evaluation. • used to: • Verify the existence of flow within a vessel or graft. • Assess the ankle-brachial pressure index (ABPI). Assess the existence of venous reflux.
Duplex Ultrasound (USS) • Integrates two-dimensional (2D) ultrasound imaging with Doppler-derived flow, shown in color and superimposed in real time. • Arterial duplex: utilized for the evaluation of stenoses and occlusions. Venous duplex: utilized for evaluating reflux or thrombosis in deep and superficial veins.
Computed Tomography Angiography Requires a multi-slice rapid acquisition ('helical'/'spiral') scanner. Images obtained during the arterial and/or venous phase following intravenous contrast administration.
Three-dimensional (3D) reconstruction facilitates the generation of 'virtual angiogram' images. This process is rapid, non-invasive, and comparatively safe. Utilizes iodinated contrast, which is nephrotoxic (relatively contraindicated in renal impairment) and poses a minor risk of allergic reaction. The presence of vessel wall calcification may hinder the visibility of the lumen.
Digital subtraction angiography (DSA) involves X-ray imaging subsequent to the injection of contrast material into the target vessel, effectively eliminating background structures (such as bone) to render the vessel lumen in black. This technique is primarily employed when endovascular intervention is necessary during the same procedure or when prior investigations yield inconclusive results. It is an invasive procedure that necessitates arterial puncture, which carries inherent risks, including the potential for false aneurysm or retroperitoneal hemorrhage associated with groin puncture. • Necessitates iodinated contrast, necessitating vigilance in cases of renal impairment and allergies.
Magnetic resonance angiography produces images of the arterial network by detecting arterial flow throughout the scanning process. • Safe and non-invasive: does not necessitate iodinated contrast, typically employing gadolinium to accentuate circulating blood. • Often overestimates the extent of stenosis due to the underrepresentation of very low flow.
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Anatomy - “Temporoparietalis
Latin, tempus (temple); parietalis (pertaining to the walls of a cavity)”
Origin: Fascia superior to the ear.
Insertion Lateral margin of the galea aponeurotica. Facial nerve (VII), temporal branch.
Action Constricts the scalp.
Elevates auditory organs
Latin, tempus (temple); parietalis (pertaining to the walls of a cavity)”
Origin: Fascia superior to the ear.
Insertion Lateral margin of the galea aponeurotica. Facial nerve (VII), temporal branch.
Action Constricts the scalp.
Elevates auditory organs
- Published on
Surgery – Post Operative Nausea and Vomiting
One challenging and unpleasant side effect of anesthesia and surgery that can lengthen recovery is post-operative nausea and vomiting (PONV). The type of operation and case mix have an impact on the incidence of PONV. According to estimates, the incidence of PONV without prophylaxis is 30% when General Anesthesia is used with inhalational medicines. In addition to being a side effect of post-operative opioids, PONV is also caused by patient-specific variables, especially a history of PONV
Apfel PONV prediction system
Opioids used after surgery (1 point)
Gender - female (1 point) ♀
Non-smoker (1 point)
Motion sickness/PONV history (1 point)
The baseline risk of PONV can be decreased using a number of effective treatments. Among these are:
Steer clear of nitrous oxide (N2O)
avoiding anesthetics that are volatile
reduction of opioids used during and after surgery
Drink enough water.
Ondansetron, unless contraindicated, is one of two antiemetics with distinct mechanisms of action that should be administered to patients at risk for PONV. Usually administered orally (PO)
Preoperative antiemetics can also be administered intravenously. Ondansetron 8–16 mg PO is one preoperative antiemetic that can be administered as a single dosage. Prochlorperazine 3–6 mg buccal or 5 mg tablets PO; Cyclizine 50 mg PO. With the exception of dexamethasone, which is administered at induction.
Intraoperative antiemetics can be administered intravenously (IV) at the conclusion of the procedure: • Dexamethasone 3.3–6.6 mg IV (at induction). • 4 mg of ondansetron. Cyclizine (20–50 mg). • 625–1250 micrograms of droperidol.
Post-operative antiemetics: routinely evaluate patients to identify PONV.
Regular intravenous antiemetics should be administered to individuals who are vomiting.
Only mild to moderate nausea can be treated with oral and buccal antiemetics, such as ondansetron 4 mg 6 hours per day, cyclizine 50 mg 8 hours per day, and buccal pro-chlorperazine 12 hours per day.
One challenging and unpleasant side effect of anesthesia and surgery that can lengthen recovery is post-operative nausea and vomiting (PONV). The type of operation and case mix have an impact on the incidence of PONV. According to estimates, the incidence of PONV without prophylaxis is 30% when General Anesthesia is used with inhalational medicines. In addition to being a side effect of post-operative opioids, PONV is also caused by patient-specific variables, especially a history of PONV
Apfel PONV prediction system
Opioids used after surgery (1 point)
Gender - female (1 point) ♀
Non-smoker (1 point)
Motion sickness/PONV history (1 point)
The baseline risk of PONV can be decreased using a number of effective treatments. Among these are:
Steer clear of nitrous oxide (N2O)
avoiding anesthetics that are volatile
reduction of opioids used during and after surgery
Drink enough water.
Ondansetron, unless contraindicated, is one of two antiemetics with distinct mechanisms of action that should be administered to patients at risk for PONV. Usually administered orally (PO)
Preoperative antiemetics can also be administered intravenously. Ondansetron 8–16 mg PO is one preoperative antiemetic that can be administered as a single dosage. Prochlorperazine 3–6 mg buccal or 5 mg tablets PO; Cyclizine 50 mg PO. With the exception of dexamethasone, which is administered at induction.
Intraoperative antiemetics can be administered intravenously (IV) at the conclusion of the procedure: • Dexamethasone 3.3–6.6 mg IV (at induction). • 4 mg of ondansetron. Cyclizine (20–50 mg). • 625–1250 micrograms of droperidol.
Post-operative antiemetics: routinely evaluate patients to identify PONV.
Regular intravenous antiemetics should be administered to individuals who are vomiting.
Only mild to moderate nausea can be treated with oral and buccal antiemetics, such as ondansetron 4 mg 6 hours per day, cyclizine 50 mg 8 hours per day, and buccal pro-chlorperazine 12 hours per day.
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Surgery - Antibiotic administration in surgical procedures
The tenets of effective antibiotic prescription Over the past 40 years, antibiotic resistance has escalated significantly. The development of new antibiotics is limited, and there is an urgent necessity to preserve the effectiveness of current antibiotics. The UK Department of Health has released a 'Start Smart – then Focus' systematic strategy to guarantee the effective and optimal use of antibiotics.
Start smart
Commence antibiotics only in the presence of unequivocal evidence of infection. Conduct a comprehensive medication allergy history assessment. Examine regional antibiotic prescribing protocols. Commence early and effective antibiotic therapy within one hour of diagnosis (or as soon as feasible) in patients with severe sepsis or life-threatening illnesses. Refrain from the improper application of broad-spectrum antibiotics• Record the clinical indication (including disease severity), drug name, dosage, and administration route in the drug chart and clinical notes. • Include a review or cessation date, or specify the duration. Acquire cultures before initiating therapy where feasible (but do not postpone therapy). • Administer single-dose antibiotics for surgical prophylaxis in instances where their efficacy has been demonstrated. • Specify the precise indication on the medication chart for clinical prophylaxis instead of referring to long-term prophylaxis.
Subsequently, concentrate on evaluating the clinical diagnosis and the ongoing necessity for antibiotics at 48–72 hours, while establishing a definitive plan of action—the 'antibiotic prescribing decision.' All intravenous antibiotics have should be evaluated at 48 hours.
The five alternatives for 'antibiotic prescribing decisions' are: Discontinue antibiotics in the absence of infection evidence. Transition antibiotics from intravenous to oral administration. Alter antibiotics, preferably to a narrower range, or broader if necessary.Proceed to record the subsequent review and cessation date.
Outpatient parenteral antibiotic therapy (OPAT) involves administering parenteral antibiotics to patients outside of an inpatient environment.
Antibiotic prophylaxis in surgical procedures
Antibiotic prophylaxis is an efficacious measure for mitigating surgical site infections (SSI) in specific surgical procedures.
Numerous additional risk variables also influence the occurrence of SSIs. When prescribing antibiotics for surgical prophylaxis, it is essential to weigh the associated risks against the advantages of treatment.
Factors influencing the incidence of SSIs
Patient Extremes of age
Poor nutritional status
Obesity (>20% of ideal body weight)
Diabetes mellitus (DM)
Smoking
Coexisting infections at other sites
Bacterial colonization (e.g. nasal colonization with
Staphylococcus aureus)
Immunosuppression
Prolonged post- operative stay
Operation
Length of surgical scrub
Skin antisepsis
Preoperative skin preparation
Length of operation
Antibiotic prophylaxis
Operating theatre ventilation
Foreign material in surgical site
Surgical technique
Post- operative hypothermia
Advantages of antibiotic prophylaxis
The efficacy of antibiotic prophylaxis in surgical procedures correlates with the frequency and severity of surgical site infections (SSIs).
Surgical site infections can elevate the likelihood of patient morbidity and prolong hospital stays.
The duration of hospitalization related to SSIs is contingent upon the type of surgery performed on the patient.
Evidence suggests that preventing wound infections correlates with reduced durations of stay and expedited patient recovery.
Risks associated with prophylaxis (and antibiotic usage in general)
Optimizing surgical antibiotic prophylaxis is essential to mitigate the unexpected repercussions of antibiotic utilization.
Significant concerns linked to antibiotic prescribing encompass: penicillin allergy, Clostridium difficile infection (CDI), and antibiotic resistance.
Penicillin allergy—penicillins and cephalosporins are the most frequently utilized kinds of antibiotics. Mislabeling patients as penicillin-allergic can jeopardize their antibiotic treatment.
Obtaining a comprehensive medical history, encompassing the specifics of the patient's reported reactions to penicillins or other antibiotics, is a crucial step in determining the patient's allergy status.
Individuals with a confirmed penicillin allergy should not receive β-lactam antibiotics due to cross-sensitivity with penicillins.
Examples of antibiotics in penicillin allergy
Antibiotics that must be avoided in serious
penicillin allergy
Amoxicillin (e.g. co- amoxiclav/ Augmentin® HeliClear®)
Ampicillin (co- fluampicil/ Magnapen®) Benzylpenicillin/ penicillin G
Flucloxacillin (co- fluampicil/ Magnapen®)
Phenoxymethylpenicillin/ penicillin V
Piperacillin- tazobactam (in Tazocin®)
Pivmecillinam
Ticarcillin (in Timentin®)
Antibiotics to be avoided in serious penicillin
allergy and used with caution in non- severe
penicillin allergy (e.g. minor rash only)
Cephalosporins: cefaclor, cefadroxil, cefalexin, cefixime, cefotaxime, cefpirome, cefpodoxime, cefprozil, cefradine, ceftazidime, ceftriaxone, cefuroxime
Other β-lactam antibiotics: aztreonam, imipenem, meropenem, ertapenem
Antibiotics considered safe in penicillin allergy
Amikacin, ciprofloxacin, clarithromycin, clindamycin, colistin, co- trimoxazole, doxycycline, erythromycin gentamicin, linezolid, metronidazole, nitrofurantoin,
minocycline, rifampicin, sodium fusidate, teicoplanin, tetracycline, tobramycin, trimethoprim, vancomycin
The risk of getting C. difficile infection is elevated in patients who have undergone recent gastrointestinal surgery,had an extended hospitalization. Are administered proton pump inhibitors (PPIs),Are aged individuals. Patients now receiving or who have recently received antibiotics, particularly broad-spectrum antibiotics, are at an increased risk of Clostridioides difficile infection (CDI).
The prevalence of antibiotic resistance is rising worldwide, particularly in healthcare environments. The emergence and proliferation of antibiotic resistance within a population is associated with the population's exposure to antibiotics. Inappropriate and excessive use of antibiotics might result in antibiotic resistance. Not all surgical procedures necessitate antibiotic prophylaxis. The NICE recommendations advise against the routine use of antibiotic prophylaxis for uncomplicated clean non-prosthetic surgeries.
Three Prophylaxis is necessary for the following surgical procedures: Clean surgeries that involve the insertion of a prosthesis or implant. Clean-contaminated surgical procedure. Operative intervention on a contaminated or infected wound necessitates antibiotic therapy, alongside prophylactic measures.
Selecting an antibiotic for prophylaxis
A diverse array of bacteria can induce infections in people. Selecting the suitable antibiotic will depend on patient-specific characteristics, the probable site of infection, and local susceptibility patterns.
Initially, consult your local hospital's antibiotic prescribing guidelines. These policies are formulated by MDTs and are grounded in the most reliable evidence and clinical competence. Timing of antibiotic treatment for surgical prophylaxis The route, dosage, and pharmacokinetic characteristics of antibiotics determine the duration required for an antibiotic to attain effective concentrations in particular human tissues. Administering prophylactic antibiotic dosages either too late or too early can diminish their effectiveness and elevate the risk of surgical site infections (SSIs).
Intravenous prophylactic antibiotics for surgical patients should be administered within 60 minutes prior to skin incision, as near to the time of incision as feasible.Three Vancomycin, when warranted, should be administered by IV infusion commencing 90 minutes before the skin incision.Three In most cases, a solitary preventive dose of antibiotic is adequate—always consult the local policy to ascertain the appropriate amount and frequency of administration.
The tenets of effective antibiotic prescription Over the past 40 years, antibiotic resistance has escalated significantly. The development of new antibiotics is limited, and there is an urgent necessity to preserve the effectiveness of current antibiotics. The UK Department of Health has released a 'Start Smart – then Focus' systematic strategy to guarantee the effective and optimal use of antibiotics.
Start smart
Commence antibiotics only in the presence of unequivocal evidence of infection. Conduct a comprehensive medication allergy history assessment. Examine regional antibiotic prescribing protocols. Commence early and effective antibiotic therapy within one hour of diagnosis (or as soon as feasible) in patients with severe sepsis or life-threatening illnesses. Refrain from the improper application of broad-spectrum antibiotics• Record the clinical indication (including disease severity), drug name, dosage, and administration route in the drug chart and clinical notes. • Include a review or cessation date, or specify the duration. Acquire cultures before initiating therapy where feasible (but do not postpone therapy). • Administer single-dose antibiotics for surgical prophylaxis in instances where their efficacy has been demonstrated. • Specify the precise indication on the medication chart for clinical prophylaxis instead of referring to long-term prophylaxis.
Subsequently, concentrate on evaluating the clinical diagnosis and the ongoing necessity for antibiotics at 48–72 hours, while establishing a definitive plan of action—the 'antibiotic prescribing decision.' All intravenous antibiotics have should be evaluated at 48 hours.
The five alternatives for 'antibiotic prescribing decisions' are: Discontinue antibiotics in the absence of infection evidence. Transition antibiotics from intravenous to oral administration. Alter antibiotics, preferably to a narrower range, or broader if necessary.Proceed to record the subsequent review and cessation date.
Outpatient parenteral antibiotic therapy (OPAT) involves administering parenteral antibiotics to patients outside of an inpatient environment.
Antibiotic prophylaxis in surgical procedures
Antibiotic prophylaxis is an efficacious measure for mitigating surgical site infections (SSI) in specific surgical procedures.
Numerous additional risk variables also influence the occurrence of SSIs. When prescribing antibiotics for surgical prophylaxis, it is essential to weigh the associated risks against the advantages of treatment.
Factors influencing the incidence of SSIs
Patient Extremes of age
Poor nutritional status
Obesity (>20% of ideal body weight)
Diabetes mellitus (DM)
Smoking
Coexisting infections at other sites
Bacterial colonization (e.g. nasal colonization with
Staphylococcus aureus)
Immunosuppression
Prolonged post- operative stay
Operation
Length of surgical scrub
Skin antisepsis
Preoperative skin preparation
Length of operation
Antibiotic prophylaxis
Operating theatre ventilation
Foreign material in surgical site
Surgical technique
Post- operative hypothermia
Advantages of antibiotic prophylaxis
The efficacy of antibiotic prophylaxis in surgical procedures correlates with the frequency and severity of surgical site infections (SSIs).
Surgical site infections can elevate the likelihood of patient morbidity and prolong hospital stays.
The duration of hospitalization related to SSIs is contingent upon the type of surgery performed on the patient.
Evidence suggests that preventing wound infections correlates with reduced durations of stay and expedited patient recovery.
Risks associated with prophylaxis (and antibiotic usage in general)
Optimizing surgical antibiotic prophylaxis is essential to mitigate the unexpected repercussions of antibiotic utilization.
Significant concerns linked to antibiotic prescribing encompass: penicillin allergy, Clostridium difficile infection (CDI), and antibiotic resistance.
Penicillin allergy—penicillins and cephalosporins are the most frequently utilized kinds of antibiotics. Mislabeling patients as penicillin-allergic can jeopardize their antibiotic treatment.
Obtaining a comprehensive medical history, encompassing the specifics of the patient's reported reactions to penicillins or other antibiotics, is a crucial step in determining the patient's allergy status.
Individuals with a confirmed penicillin allergy should not receive β-lactam antibiotics due to cross-sensitivity with penicillins.
Examples of antibiotics in penicillin allergy
Antibiotics that must be avoided in serious
penicillin allergy
Amoxicillin (e.g. co- amoxiclav/ Augmentin® HeliClear®)
Ampicillin (co- fluampicil/ Magnapen®) Benzylpenicillin/ penicillin G
Flucloxacillin (co- fluampicil/ Magnapen®)
Phenoxymethylpenicillin/ penicillin V
Piperacillin- tazobactam (in Tazocin®)
Pivmecillinam
Ticarcillin (in Timentin®)
Antibiotics to be avoided in serious penicillin
allergy and used with caution in non- severe
penicillin allergy (e.g. minor rash only)
Cephalosporins: cefaclor, cefadroxil, cefalexin, cefixime, cefotaxime, cefpirome, cefpodoxime, cefprozil, cefradine, ceftazidime, ceftriaxone, cefuroxime
Other β-lactam antibiotics: aztreonam, imipenem, meropenem, ertapenem
Antibiotics considered safe in penicillin allergy
Amikacin, ciprofloxacin, clarithromycin, clindamycin, colistin, co- trimoxazole, doxycycline, erythromycin gentamicin, linezolid, metronidazole, nitrofurantoin,
minocycline, rifampicin, sodium fusidate, teicoplanin, tetracycline, tobramycin, trimethoprim, vancomycin
The risk of getting C. difficile infection is elevated in patients who have undergone recent gastrointestinal surgery,had an extended hospitalization. Are administered proton pump inhibitors (PPIs),Are aged individuals. Patients now receiving or who have recently received antibiotics, particularly broad-spectrum antibiotics, are at an increased risk of Clostridioides difficile infection (CDI).
The prevalence of antibiotic resistance is rising worldwide, particularly in healthcare environments. The emergence and proliferation of antibiotic resistance within a population is associated with the population's exposure to antibiotics. Inappropriate and excessive use of antibiotics might result in antibiotic resistance. Not all surgical procedures necessitate antibiotic prophylaxis. The NICE recommendations advise against the routine use of antibiotic prophylaxis for uncomplicated clean non-prosthetic surgeries.
Three Prophylaxis is necessary for the following surgical procedures: Clean surgeries that involve the insertion of a prosthesis or implant. Clean-contaminated surgical procedure. Operative intervention on a contaminated or infected wound necessitates antibiotic therapy, alongside prophylactic measures.
Selecting an antibiotic for prophylaxis
A diverse array of bacteria can induce infections in people. Selecting the suitable antibiotic will depend on patient-specific characteristics, the probable site of infection, and local susceptibility patterns.
Initially, consult your local hospital's antibiotic prescribing guidelines. These policies are formulated by MDTs and are grounded in the most reliable evidence and clinical competence. Timing of antibiotic treatment for surgical prophylaxis The route, dosage, and pharmacokinetic characteristics of antibiotics determine the duration required for an antibiotic to attain effective concentrations in particular human tissues. Administering prophylactic antibiotic dosages either too late or too early can diminish their effectiveness and elevate the risk of surgical site infections (SSIs).
Intravenous prophylactic antibiotics for surgical patients should be administered within 60 minutes prior to skin incision, as near to the time of incision as feasible.Three Vancomycin, when warranted, should be administered by IV infusion commencing 90 minutes before the skin incision.Three In most cases, a solitary preventive dose of antibiotic is adequate—always consult the local policy to ascertain the appropriate amount and frequency of administration.
- Published on
Surgery -medical history and case presentation
Fundamentals
Begin with the individual's name, age, occupation, and the mode of presentation, such as Accident and Emergency (A&E), general practitioner referral, or admission from a clinic.
• Address all key aspects of the comprehensive medical history, as outlined below. Chief complaint This is a concise statement of the patient's primary symptoms, such as "right iliac fossa (RIF) pain," "abdominal pain and vomiting," or "bleeding per rectum (PR)."
• Do not record a diagnosis here in emergency admissions (e.g. ischemia leg). The referral diagnosis may prove to be incorrect. In elective admissions, it is appropriate to state, for example, 'elective admission for anterior resection for rectal cancer.' Chronology of presenting complaint This is a comprehensive delineation or examination of the primary symptom(s) and must encompass the pertinent systems inquiry
. • Begin with pertinent historical context to provide the framework for the presenting issue.
• Prioritize significant positives, such as "right-sided lower abdominal pain, exacerbated by movement and coughing, accompanied by anorexia."
• Include pertinent negatives, such as "no vomiting, no rectal bleeding." Clearly delineate the sequence of events. In a complex history or with numerous symptoms, utilize titles such as 'Previous Episodes/Operations for This Issue,' 'Current Episode,' and 'Results of Investigations.' Systematically summarize the findings of prior investigations: hematological analyses, microbiological assessments, histopathological examinations, radiological evaluations, and specialist diagnostic procedures. Previous medical history
• Enumerate particular medical diagnoses. • Include pertinent negatives, as it is prudent to inquire about cardiorespiratory and renal conditions that influence the patient's operative and anesthetic risk, such as ischemic heart disease (IHD), heart failure, chronic obstructive pulmonary disease (COPD), and renal impairment, in addition to those specific to the presenting complaint, such as neurological diagnoses in neurosurgery or ear, nose, and throat (ENT) conditions, as well as risk factors for atherosclerosis in vascular surgery. •
• Enumerate and date all prior operations. Inquire whether any prior complications associated with anaesthesia. Methodical investigation This is crucial, however frequently overlooked—it is essential to exclude alternative diagnoses (e.g., gynaecological etiology for lower abdomen pain) and to evaluate the patient's surgical and anaesthetic risk
. • Cardiovascular. Chest pain, exertional dyspnoea, orthopnoea, nocturnal dyspnoea, palpitations, edema of the ankles, strokes, transient ischemic attacks (TIAs), claudication.
• Respiratory. Dyspnea, cough, sputum production, wheezing, hemoptysis.
• Gastrointestinal. Anorexia, alteration in appetite, weight reduction (specify the amount and duration).
• Genitourinary (GU). Sexual activity, dyspareunia (intercourse-related pain), abnormal discharge, and last menstrual cycle (all female patients). Neurological. Three Fs: fits; fainting; humorous episodes. Nil by mouth (NBM) duration: what was the last time they consumed food or beverages? for urgent admissions Societal history Inquire regarding the individual responsible for the patient's care. Do they require assistance with mobility and/or activities of daily living?
• History of smoking and alcohol consumption. •
profession.
Two Recommendations for Case Presentation
• Engage in practice. Each instance represents a potential presentation to an individual. Consistently establish the context appropriately. Commence with the individual's name, age, occupation (if elderly, include general fitness and independence), pertinent medical history, mode of referral, and presenting complaint, e.g., ‘78-year-old male, typically fit and well, with a previous history of open anterior resection for rectal adenocarcinoma, presents with a 3-day history of abdominal pain and vomiting.’ • Adhere to a chronological order. Commence with the onset of any pertinent prodrome or accompanying symptoms, as they are likely to constitute a significant aspect of the presenting history, e.g., 'He was in good health until... when he began suffering... the current symptoms commenced...
• Summarize the past medical history succinctly. Only elaborate on aspects that you genuinely believe may be pertinent to the diagnosis or management. •
• Initially, summarize the overall look and vital signs. Present the most critical findings initially, adhering to a methodical approach, such as 'upon examination . . . , during palpation . . . , upon percussion . . . , and by auscultation.'
• Concisely outline further systemic observations. Elaborate on them if they are directly pertinent to the diagnosis or treatment.
• Ultimately, condense and integrate. Attempt to categorize symptoms and indications into clinical patterns that inform the proposed diagnoses or differential diagnosis list.
• Be prepared to discuss which diagnostic or additional evaluation tests may be required.
Fundamentals
Begin with the individual's name, age, occupation, and the mode of presentation, such as Accident and Emergency (A&E), general practitioner referral, or admission from a clinic.
• Address all key aspects of the comprehensive medical history, as outlined below. Chief complaint This is a concise statement of the patient's primary symptoms, such as "right iliac fossa (RIF) pain," "abdominal pain and vomiting," or "bleeding per rectum (PR)."
• Do not record a diagnosis here in emergency admissions (e.g. ischemia leg). The referral diagnosis may prove to be incorrect. In elective admissions, it is appropriate to state, for example, 'elective admission for anterior resection for rectal cancer.' Chronology of presenting complaint This is a comprehensive delineation or examination of the primary symptom(s) and must encompass the pertinent systems inquiry
. • Begin with pertinent historical context to provide the framework for the presenting issue.
• Prioritize significant positives, such as "right-sided lower abdominal pain, exacerbated by movement and coughing, accompanied by anorexia."
• Include pertinent negatives, such as "no vomiting, no rectal bleeding." Clearly delineate the sequence of events. In a complex history or with numerous symptoms, utilize titles such as 'Previous Episodes/Operations for This Issue,' 'Current Episode,' and 'Results of Investigations.' Systematically summarize the findings of prior investigations: hematological analyses, microbiological assessments, histopathological examinations, radiological evaluations, and specialist diagnostic procedures. Previous medical history
• Enumerate particular medical diagnoses. • Include pertinent negatives, as it is prudent to inquire about cardiorespiratory and renal conditions that influence the patient's operative and anesthetic risk, such as ischemic heart disease (IHD), heart failure, chronic obstructive pulmonary disease (COPD), and renal impairment, in addition to those specific to the presenting complaint, such as neurological diagnoses in neurosurgery or ear, nose, and throat (ENT) conditions, as well as risk factors for atherosclerosis in vascular surgery. •
• Enumerate and date all prior operations. Inquire whether any prior complications associated with anaesthesia. Methodical investigation This is crucial, however frequently overlooked—it is essential to exclude alternative diagnoses (e.g., gynaecological etiology for lower abdomen pain) and to evaluate the patient's surgical and anaesthetic risk
. • Cardiovascular. Chest pain, exertional dyspnoea, orthopnoea, nocturnal dyspnoea, palpitations, edema of the ankles, strokes, transient ischemic attacks (TIAs), claudication.
• Respiratory. Dyspnea, cough, sputum production, wheezing, hemoptysis.
• Gastrointestinal. Anorexia, alteration in appetite, weight reduction (specify the amount and duration).
• Genitourinary (GU). Sexual activity, dyspareunia (intercourse-related pain), abnormal discharge, and last menstrual cycle (all female patients). Neurological. Three Fs: fits; fainting; humorous episodes. Nil by mouth (NBM) duration: what was the last time they consumed food or beverages? for urgent admissions Societal history Inquire regarding the individual responsible for the patient's care. Do they require assistance with mobility and/or activities of daily living?
• History of smoking and alcohol consumption. •
profession.
Two Recommendations for Case Presentation
• Engage in practice. Each instance represents a potential presentation to an individual. Consistently establish the context appropriately. Commence with the individual's name, age, occupation (if elderly, include general fitness and independence), pertinent medical history, mode of referral, and presenting complaint, e.g., ‘78-year-old male, typically fit and well, with a previous history of open anterior resection for rectal adenocarcinoma, presents with a 3-day history of abdominal pain and vomiting.’ • Adhere to a chronological order. Commence with the onset of any pertinent prodrome or accompanying symptoms, as they are likely to constitute a significant aspect of the presenting history, e.g., 'He was in good health until... when he began suffering... the current symptoms commenced...
• Summarize the past medical history succinctly. Only elaborate on aspects that you genuinely believe may be pertinent to the diagnosis or management. •
• Initially, summarize the overall look and vital signs. Present the most critical findings initially, adhering to a methodical approach, such as 'upon examination . . . , during palpation . . . , upon percussion . . . , and by auscultation.'
• Concisely outline further systemic observations. Elaborate on them if they are directly pertinent to the diagnosis or treatment.
• Ultimately, condense and integrate. Attempt to categorize symptoms and indications into clinical patterns that inform the proposed diagnoses or differential diagnosis list.
• Be prepared to discuss which diagnostic or additional evaluation tests may be required.
