Surgery - Carotid Artery Disease  (Atherosclerosis)
Introduction 
Atherosclerosis-induced carotid artery narrowing is a common cause of stroke.

Etiology 
By causing distal embolization, thrombosis, or poor flow, atheromatous plaque at the common carotid bifurcation or any of the carotid branches might result in stroke or blindness. Atherosclerosis is widespread in the carotid artery bifurcation, a region of the vascular tree. Local hemodynamics, such as low shear stress and "turbulence affecting the outer walls opposite the flow divider," in conjunction with systemic risk factors, predispose to the formation of atheroma, luminal constriction, and the risk of plaque rupture, thrombosis, or embolism.

Epidemiology 
frequent, a major contributor to long-term impairment and the third greatest cause of death in the UK, frequency increases with age and is more frequent in men.

History 
frequently asymptomatic.
Amaurosis fugax: An embolism into the ophthalmic artery (an internal carotid artery branch) causes a transient unilateral vision loss that is described as "like a curtain coming down."
Temporary ischemic episodes (TIAs): Severe symptoms that persist less than a day could be a sign of an impending stroke. Following a TIA, people with an ABCD2 score of 4 (which requires immediate examination and treatment) are more likely to get a stroke.
Factor ABCD2  

Age over 59 years old: 1 point 
Presentation BP of 140/90 (1 point)
Clinical Characteristic :

Disturbance in speech but no weakness (1 point)
One-sided vulnerability (2 points)

Duration (minutes): 10–59  (1  point) 
>60   (2  points)
Diabetes (1 point)

Crescendo TIAs are TIAs that get longer, more severe, or happen more frequently. This is linked to a significant internal carotid artery stenosis.
Stroke: Long-lasting neurological impairment (based on the infarct-affected region).


Examination 

Examined normally shows no abnormalities if asymptomatic.
The degree of stenosis is not indicated by the presence of a carotid bruit.
symptoms of a TIA or CVA, such as limb weakness, dysphasia, or dysarthria.


Investigations 

This non-invasive imaging method uses duplex Doppler carotid ultrasound to measure the degree of stenosis.
Brain and carotid imaging using CT, CTA, MRI, and MRA (Fig. 35).
Angiography: Very accurate measurement of the severity of stenosis, invasive (stroke risk ∉1%).

Management 

The 90-day risk of recurrent stroke was found to be 80% lower with prompt assessment and treatment, according to the Early Usage of Existing Preventive Strategies for Stroke (EXPRESS) research. A TIA clinic should see everyone who has had a TIA or mild stroke (urgency evaluated by ABCD2 rating).

Medical treatment for: asymptomatic stenosis, <70% internal carotid artery stenosis (ECST criteria), <50% (NASCET criteria), or inoperable illness; low-dose aspirin; cessation of smoking; and treatment of additional risk factors, hypercholesterolemia, hypertension, and diabetes.

Surgical intervention: Carotid endarterectomy, however associated with a high perioperative risk, lowers the risk of further stroke in ECST and NASCET trials when performed within two weeks following a stroke or TIA.
May be taken into consideration in cases of crescendo TIAs that do not respond to therapy, symptomatic stenosis of 70–99% (ECST criteria), or 50–99% (NASCET criteria).
It is debatable whether surgery should be used to treat a disease that shows no symptoms.
Angioplasty, with or without stenting: A comparison with carotid endarterectomy for symptomatic illness is now being conducted.

Complications 
Disease-related complications: thromboembolic or watershed stroke.
Surgical complications: Cardiac ischaemia or infarction (3%), nerve injury (2–7%, mandibular branch of facial nerve, recurrent laryngeal or hypoglossal nerves), haematoma, hypertension, hypotension, perioperative stroke (1–5%). There is a 0.5-2.8% perioperative mortality rate.

Prognosis 
The annual stroke rate is 10–20% with carotid artery stenosis greater than 70%.
In patients with severe stenosis, surgical correction can result in a six- to eight-fold reduction in stroke risk when compared to the best medical therapy alone.

Surgery -  Carotid Body Tumor 
A chemodectoma is a tumor that develops from chemoreceptor cells at the carotid bifurcation.

Etiology 
 connected to changes in the mitochondrial succinate dehydrogenase complex subunits. With autosomal dominant inheritance, one-third are family (more likely to be bilateral and numerous).
Shamblin has classified:. Type I: Carotid bifurcation-derived little tumors that are easily dissected. Type II: More expansive and sticky, involving but not encasing vessels. Type III: Encircling the carotid bifurcation, large in size.

Risk factors linked to von Hippel-Lindau syndrome, MEN II, and NF1.
People who spend extended periods of time living at high elevations have a "incidence."


The study of epidemiology 
uncommon. Present at any age; however, women are more likely than males to do so between the ages of 50 and 70.


History 
Most frequently manifests as a gradually expanding lump in the neck. Symptoms include dysphagia, choking, and hoarseness may be brought on by pressure on surrounding cranial nerves.

Examination 

A neck lump with transmitted pulse that is located in the carotid triangle of the neck. Horner syndrome with paresis or palsy of the cranial nerves VII, IX, X, and XI may be present.

Pathophysiology 

Paragangliomas, which include glomus jugulare tumors, pheochromocytomas, and vagal body tumors, are tumors produced from neural crest tissue. One type of paraganglioma is the carotid body tumor.
Vascular tumor with sustentacular cells encircling clusters of zellballen of epithelioid "chief cells" Although they have the capacity to release catecholamines, the cells are often nonsecretory.

Investigations 

Imaging: The link between the carotid bifurcation can be demonstrated by ultrasound and duplex scanning; angiography, which can be either CT or MR, verifies the typical splaying of the internal and external carotid arteries as well as the wine-glass-shaped tumor blush.
A CT or MRI scan is used to ascertain the tumor's extent. Metaiodobenzylguanidine (131I-MIBG) scintigraphy in functioning tumors.
Pharyngoscopy, both direct and indirect, can be used to evaluate pharyngeal invasion or involvement of cranial nerves.
Urine: VMA, metanephrine, and catecholamines.

Management 

Surgery: Risk based on tumor size and extent. Due to their high vascularity, big tumors may be embolized prior to surgery (a controversial procedure), and preoperative blood should be cross-matched. Excision of the tumor surgically: Tumor size and place determine the incision. cautious jugular vein dissection and control, detection of nerves, and carotid artery dissection. Following the ligation of the cancer feeding vessels, the tumour is meticulously removed from the carotid vessels. Internal carotid artery replacement or sacrifice is frequently necessary for type II tumors.
Radiotherapy: For individuals who are weak, have a lot of coexisting conditions, or have cancers that come back frequently.

Chemotherapy: Vincristine, dacarbazine, cyclophosphamide, and 131I-MIBG are among the agents utilized in systemic metastases.


Complications  
Tumor: Local invasion leading to distal metastases and cranial nerve palsies.
Bleeding, nerve injury (15 percent, mandibular branch of VII, IX, X, particularly the recurrent laryngeal nerves, XII), and stroke risk are associated with surgery.

Prognosis 
Young people with heritable tumors are most at risk; the majority are benign, with 5-7% malignant with the ability to spread to the lung, liver, and bones. Typically slow-growing; surgery can cure the majority of patients.

Surgery - Deep Vein Thrombosis 
Introduction 
thrombus formation in the deep veins, usually in the thigh or calf.

Etiology 
Virchow's triad: blood hypercoagulability, vascular wall damage, and venous stasis.

Risk Factors 
Factor V Leiden, deficits in Protein C or Protein S deficienceis  Prothrombin mutation, and insufficient Antithrombin III are all inherited.

Oral contraceptive pill, heparin-induced thrombocytopenia, immobility, obesity, pregnancy, polycythemia, anti-phospholipid syndrome, smoking, nephrotic syndrome, and aggressive cancer are among the acquired conditions.

Epidemiology 
Frequent, particularly in hospitalized patients; precise prevalence is unclear. Venous insufficiency and ulceration, long-term consequences of DVT, afflict 0.5 percent of the population. Around 145 per 100,000, around.

History 
asymptomatic or soreness or edema in the lower limbs. may exhibit pulmonary embolus signs and symptoms.

Examination 
Check for any swelling or soreness in the calf.
It is uncommon to have severe leg cyanosis and oedema (phlegmasia cerulea dolens).
checking the airways for indications of a pulmonary embolus.

Investigations 

Ultrasound Doppler: The gold standard. Less sensitive in calf veins, but good sensitivity in femoral veins.
Bloods: Only low-risk individuals can benefit from the sensitive but very non-specific D-dimers (fibrinogen degradation products) as a negative predictor. Before beginning anticoagulation, a thrombophilia screen should be sent if necessary (e.g., recurring occurrences).
FBC (platelet count before beginning heparin), coagulation, and U&E.
ABG, CXR, and ECG: If there is a possibility that PE may be present.

Management 

Anticoagulation: While waiting for a therapeutic INR from warfarin anticoagulation, patients should receive heparin treatment. Anticoagulation is prescribed for three months for DVTs that do not extend above the knee and for six months for those that do. Warfarin may be needed for a long time if DVTs recur. Interventional radiology should install an IVC filter, such as the Greenfield filter, if active anticoagulation is contraindicated or there is a high risk of embolization in order to prevent embolus to the lungs.
Using graded compression stockings is one way to prevent. mobilizing, if at all possible. Hospital patients who are considered to be at-risk should receive preventive heparin, such as low-molecular-weight heparin, provided there are no contraindications.

Complications 
Disease symptoms include pulmonary embolus, impaired vein valves, and persistent lower limb venous insufficiency (post-thrombotic syndrome). Venous infarction, or phlegmasia cereulea dolens, is uncommon.
Heparin-induced thrombocytopenia and bleeding are side effects of treatment.

Prognosis 
based on the severity of DVT. More proximal DVTs have a higher chance of propagation and embolization, which, if significant, may be deadly. Below-knee DVTs have a decreased risk of embolus.

Surgery - Acute Ischemic Lower Limb 
Introduction 
abrupt blockage of the supplying artery resulting in limb ischaemia.

Etiology 
Pathophysiology: Abrupt stoppage of blood flow. Emboli typically settle in the locations where vessels split. Cell injury occurs in two stages: ischemic injury, which occurs when tissues are cut off from blood flow, and reperfusion injury, which occurs when blood flow is restored.
Thrombosis: Low flow conditions, such as hypovolemia, aneurysm, graft stenosis, atherosclerosis, and thrombotic states.
Heart: 90%, great vessels: 9%, and other: 1% are the sources of embolism. Atrial fibrillation, myxoma of the atrium, aneurysms, valvular heart disease, and recent MI.
Trauma or dissection are two examples of vascular damage.

Epidemiology 
14 cases out of 100,000 are estimated.
Pallor, pain, paraesthesia, pulselessness, paralysis, and a perishingly cold limb are the six Ps.The location of occlusion, length of ischaemia, and level of collateral circulation all affect the symptoms and signs.

Embolus is more likely to occur in cases of severe, abrupt onset, and recognizable possible cause, such as atrial fibrillation.
Thrombosis is typically less severe if collaterals are present, there is a history of peripheral vascular disease or claudication, and there isn't an identifiable embolus source.

Examination 
Pale limb with no pulse; capillary return is slow.
After a few hours, there is capillary rupture-related venous stagnation, which causes a mottled appearance and, in later stages, permanent staining. There are changes in sensation, and if the ischemia is severe, there may be muscle paralysis and anesthesia, indicating that the limb may not be viable.

Investigations 
Blood tests: thrombophilia screen, coagulation profile, G&S, FBC, and U&Es.
Imaging: CXR, Doppler or duplex blood flow scans, arteriography to show the occlusion site and, if the limb is still viable, to arrange an operation.
ECG: Checking for irregular heartbeat.

Management 

Immediate: Heparin anticoagulation, analgesics, and ABCs to stop the spread of thrombus.
Surgery: Revascularization in six hours to save the limb. When cardiac disease is present, there is frequently a substantial operational risk. Anticoagulation after surgery is crucial.

If an embolus is found, an embolectomy will be performed, which entails artery isolation, arteriotomy, and the insertion of a Fogarty balloon-tipped catheter that will be inserted past the embolus and then withdrawn to recover the embolus.

If the thrombosis is acute or chronic, collateral development may allow the limb to survive longer. In this case, percutaneous intervention such as suction, intraarterial thrombolysis with local infusion of t-PA, and angioplasty of underlying stenoses are viable options.


In the event that thrombosis is required for this treatment but the limb is not expected to survive for 12 to 24 hours: If physically feasible, urgent reconstructive surgery using synthetic (PTFE or Dacron) or autogenous (saphenous vein) bypass grafting is needed. 

Fasciotomy is necessary if compartment syndrome is a concern.

Amputation of the limb in question.

Complications 
From disease: death, limb loss, and gangrene.
From intra-arterial thrombolysis: severe bleeding, CVA, and mortality (1-2%).
Reperfusion syndrome, compartment syndrome, rhabdomyolysis, and rethrombosis are post-treatment complications.

Prognosis 
There is a 30% chance of losing a limb; 10% of people die from it, with heart disease being the main cause of death.

Surgery - Chronic Lower Limb Ischemia 
Introduction 
Chronic vascular insufficiency of the lower extremities can cause ulcers or gangrene, as well as pain during exercise known as intermittent claudication.

Etiology 
Atherosclerosis in the leg arteries (femoral, iliac, and lower aorta).

Risk Factors 
Diabetes, high blood pressure, smoking, high cholesterol, and family history.

Epidemiology 
Common, occurrence 7–15% of senior citizens; male to female ratio is 2:1. In the UK, the yearly incidence of critical limb ischaemia is 50–100/100,000.

History 
La Fontaine's severity classification system:

I. Lack of symptoms.
II. Claudication that is intermittent. Calf cramps that occur during exercise after a continuous distance (claudication distance) and go away a few minutes after the exercise is stopped.
III. Pain while rest. severe aching pain in the foot or lower limb that usually goes away at night when the leg is draped over the edge of the bed.
IV. Gangrene or ulceration of the leg.

Critical ischaemia: Severe arterial insufficiency endangering the limb's survival when there is rest pain lasting more than two weeks, ulceration, or gangrene.
The Leriche syndrome: when lower aortoiliac blockage causes impotence and claudication in the buttocks and thighs.

Examination 
Check for evidence of hyperlipidemia, abdominal aortic aneurysm, carotid bruits, and signs of ischemic heart disease in the cardiovascular system.
Severe lower limb ischaemia is characterized by shining atrophic skin, atrophic nails, hair loss, and painful, punched-out ulcers (under toes, for example, or traditionally over the lateral malleolus). With weak or nonexistent pulses and a protracted capillary return time, the peripheries are chilly to the touch. 
Keep an ear out for bruits.
Buerger's examination: Pallor and venous guttering are the first signs of elevation of the leg, and dependent rubor follows.

The index of ankle-brachial pressure (ABPI): calculated by dividing the brachial pressure by the systolic ankle pressure, using a portable Doppler device. 0.8–0.6 for claudication; normal >0.9.
<0.5 or ankle systolic <50mmHg or toe systolic <30mmHg is considered critical ischaemia (numbers may be erroneously high in diabetics due to weakly compressible arteries).

Investigations 

Imaging: CT, MR, or arterial duplex angiography. Those receiving intervention can use digital subtraction angiography.
Bloods: FBC, lipids, glucose, coagulation, and preintervention group and save.

Management 
Medical: It has been demonstrated that supervised programs are beneficial; quit smoking and promote exercise. Treatment of other cardiovascular risk factors, such as aspirin, statins, and antihypertensives (avoid b-blockers). Patients with serious ischemia who are not responding to previous treatments may occasionally receive prostacyclin infusions.
Endovascular surgery includes arterial stenoses stenting and/or balloon angioplasty.
Surgical: For severe ischaemia or intermittent claudication that is incapacitating.
Revascularization: The technique varies according on the occlusion site.
Aortoiliac occlusive disease: unilateral iliac disease (femoro-femoral or ilio-femoral bypass), aorto-bifemoral bypass, or occasionally axillo-bifemoral bypass.

The term "femoropopliteal disease" refers to conditions involving the grafting of autogenous tissue, such as saphenous vein (either reversed or in situ with valves damaged with a valvulotome), or synthetic tissue, such as PTFE, for bypass purposes. In the case of the latter, longer-term patency rates are considerably increased by a vein patch (Millar cuff) at the distal anastomosis. 
observation of the graft with duplex scanning after surgery.
In cases of end-stage atherosclerotic disease, amputation is recommended if revascularization is not feasible, there is a substantial amount of necrosis, or sepsis is spreading. Revascularization may make it possible to amputate below the knee as opposed to above; the former is linked to improved mobility and the usage of prosthetic limbs after surgery.


Complications 
If wet, there is a danger of systemic sepsis, multiorgan failure, pain, ulceration, and gangrene.
3–4% risk with angioplasty, including thrombosis, embolism, dissection, flap, and failure.
From bypass grafting: . Early: Edema, infection, lymphocoele, hemorrhage, cardiac events, and graft thrombosis. Late: Graft stenosis, anastomotic false aneurysm, and thrombosis. Overall, patency rates above the knee (70–80% at 3 years) are higher than those below.

Prognosis 
Patients with lower limb ischaemia have an elevated risk of MI and stroke because it is a sign of atherosclerosis throughout the arterial tree. About 40% of people with intermittent claudication get better, 40% stay stable, and 20% worsen over the course of five years and need medical attention.

​Surgery - Varicose Veins 
Introduction 
veins that have gotten longer, wider, and more twisted; these are typically the lower limbs' superficial veins. These smaller superficial venous telangiectasias and varicosities are referred to as thread veins, spider veins, or reticular veins.

Etiology 
Primary: As a result of decreased elasticity, gradual dilatation, and valvular incompetence brought on by a hereditary or developmental weakening of the vein wall.
Klippel-Trenaunay syndrome (port wine stains, varicose veins, and related hypertrophic limb tissue) and Parkes Weber syndrome (like KT, but with arteriovenous fistulas) are two congenital diseases linked to varicose veins.
Secondary: Obstacles to venous outflow include ascites, lymphadenopathy, ovarian cysts, pregnancy, pelvic cancer, and retroperitoneal fibrosis.
Damage to valves: After deep vein thrombosis (DVT). Arteriovenous fistula: high flow rate.

Epidemiology 
Common, rising with age; prevalence: 10-15% for men and 20-25% for women in adulthood.

History 
The patient may express dissatisfaction with their outward look or report experiencing symptoms like leg pain that worsens at the end of the day or after standing for extended periods of time; swelling, itching, or consequences including ulceration, bleeding, or infection. Ask about predisposing factors, vascular risk factors, and prior history of DVT.

Examination 
Examine the venous distribution, skin alterations (such as varicose eczema, lipodermatosclerosis, oedema, atrophie blanche, or ulceration) while the patient is standing.
Palpation: Incompetent perforators' sites, the facial deformities along the dilated veins, may be felt.One could feel a cough impulse across the SFJ. The tap test is a procedure whereby an impulse, which is typically absent due to competent valves, is felt distally along the vein after tapping over the SFJ. Foot pulses should be recorded if they are present. An AV fistula is indicated by the palpation of a thrill or the auscultation of a bruit.
Trendelenburg test: Capable of pinpointing valvular incompetence locations. The leg is lifted and the veins are emptied while the patient is supine. The SFJ is compressed using a hand or tourniquet. The leg is positioned dependently, and either before or after the tourniquet or hand is released, the veins are seen to be filling.
Hand Held  Doppler: Capable of displaying the valvular incompetence location.
Examining the pelvis or the rectum may be necessary if secondary reasons are thought to be present.

Pathogenesis 
Varicose vein etiology theories include primary valvular incompetence and the development of venous wall weakness as a result of anomalies in collagen and elastin, culminating in advanced stages of tunica media fibrosis. Hormonal fluctuations and venous hypertension are two more reasons that are implicated.

Investigations 
Visualization: Duplex ultrasound: Identifies reflux or incompetence locations. Moreover, to rule out DVT (essential if surgery is being considered). MR venography: reserved for complicated situations.

Management 
Conservative: Exercise recommendations (which enhance the calf muscle pump) and elevating the legs when at rest. Class II support stockings can help decrease edema and facilitate venous return.
Surgical procedures include SFJ ligation, lengthy saphenous vein stripping up to the knee, and varicosity avulsion using tiny stab incisions. To protect the sural nerve, the short saphenous vein is ligated rather than stripped.
Endovenous operations are becoming more and more common and can be carried out under local anesthesia. The long saphenous vein is ablateted using endovenous laser treatment (EVLT) after a tumescent local anesthetic is injected around the vein under ultrasound supervision. 
Thermal damage and ablation are also involved in radiofrequency ablation. With foam sclerotherapy, endothelial damage, inflammation, and subsequent vein fibrosis are caused by injecting sclerosing foam along the vein with the help of ultrasound guidance. The legs are wrapped following all treatments, and early mobilization is advised.
Using laser sclerotherapy or microinjection for reticular veins and venous telangiectasia.

Complications 
eczema, lipodermatosclerosis, venous ulcers, superficial thrombophlebitis, and venous pigmentation.
Treatment outcome: Recurrence. Intravenous therapy: Burns to the skin, nerve damage, bruises, emboli, and DVT. Surgical complications: bleeding, infection, nerve damage, or paraesthesia (up to 6%).

Prognosis 
generally progressing slowly. After surgery, recurrence rates can reach 40%.

Clinical Procedures - Consent 
Overview
A person's consent is their permission to be subjected to anything, including medical examinations and surgical operations. It is illegal to perform an act on a competent adult without that adult's consent.

Ability • The patient must be able to comprehend the nature of the procedure and the potential repercussions of making or not making a decision. It is presumed that all adults possess capacity unless proven differently:
 It is crucial to remember that "capacity" only pertains to the particular choice that is being discussed.

Evaluating ability
The patient needs to be able to: • Recognize the knowledge and its implications
• Preserve the data; • Consider the data while making decisions; • Share their conclusion.

A patient who is incapable

• It is important to fully explain your reasoning for thinking a patient lacks the capacity to make a certain decision.
• A patient may have extreme confusion, which could render them momentarily debilitated. In these situations, treatment may only be administered if it cannot be reasonably postponed until the impairment is remedied. If so, the patient's best interests must be taken into consideration while choosing a course of therapy.

Voluntary Consent: Patients should be seen alone when there is a chance of external influence in order for them to form their own opinion. Consent is only legitimate if it is provided voluntarily, free from coercion from friends, family, or medical professionals.

In order for patients to make an informed choice, they must be given enough information. 
Information needs to be provided about: • What the process involves and why it is being done; • Any accessible alternatives.
• Serious dangers:
• This encompasses not only risks that are judged serious by an authoritative body of medical opinion (the Bolam test), but also any "significant risk which would affect the judgement of a reasonable patient." 
If you don't communicate these hazards, you could be found negligent.
• Patients who deny information about a surgery should have this carefully documented and given the chance to discuss it at a later time. • Any other operations that might be required under the same anesthesia should be discussed during the first consent.
Consent Documents

• Consent is invalid regardless of the presence of a consent form if it is not voluntary, there is insufficient information, or the patient lacks ability. Written consent is proof that consent has been requested but does not validate its validity.
• Written consent is required for some procedures (as listed in the Mental Health Act and the Human Fertilization and Embryology Act). • Oral or non-verbal consent may also be accepted.

Who Has to Request Consent?
• The expert requesting consent must, at the very least, be knowledgeable enough to comprehend and describe the procedure, its indications, and any associated risks.
It is your duty to approach colleagues for assistance if you are asked to give consent for a procedure but are unsure about it; failing to do so could result in your consent being deemed invalid.

Refusing to Give Consent 
Even if a patient's refusal will result in their death or the death of their unborn child, an adult with capacity who refuses to consent to a procedure must be respected (with the exception of certain situations listed in the Mental Health Act). In these situations, a thorough assessment of the patient's competence is required. The same is true if the patient withdraws consent at any point while they are still capable.

• In certain situations, it could be challenging to determine capacity because, for example, a patient experiencing discomfort could momentarily lose capacity during a procedure.

Advance Refusal: • It is applicable when the patient lacks capacity • It is valid when made during a period when the patient is competent and sufficiently informed • Failure to abide by the refusal may result in legal action • If there is any uncertainty as to its legitimacy, the courts must be contacted.

Adults Without Capacity
• May be transient, ongoing, or fluctuating; ► In the absence of a valid Lasting Power of Attorney, no one may provide consent on behalf of an incompetent adult; ► Patients must be treated in their best interests (not just medical interests), taking into account their psychological, spiritual, and economical well-being.
• When there is uncertainty regarding the patient's best interests or capacity, the High Court may render a decision. • When the patient has expressed previously that they should not be involved, those closest to them should be involved; independent patient advocacy services are available for consultation in this situation.

• Temporary incapacity: when competent, get consent; if not, act in the person's best interests.
Lasting Power of Attorney  (Mental Capacity Act of 2005)

• A document made by someone (the "donor") granting permission to a named person or people (the "donees") to consent to research or treatment (among other things).
• Needs to be registered;
• Only good while the sufferer is incapable of
• The donee must be expressly given permission to decide on their own welfare and medical care:
• unless otherwise indicated, do not include choices for life-sustaining medical care.

Patients under the age of eighteen (16–17):
​• If competent, they may accept or reject an intervention; if not, someone with parental responsibility may give consent.
Less than 16: Gillick 1 Competence.
If a kid under the age of 16 is able to comprehend the entire scope of an intervention, they may provide their consent to treatment. This may apply to certain therapies but not others.
• Parental consent is not necessary if a child is Gillick competent, but it is a good idea to encourage a child to tell their parents unless doing so would be against their best interests.

deciding factors: younger than 18
• Refusal should take into account the person's wellbeing overall; it can be overruled by the courts or by someone with parental responsibility. In an emergency, it is acceptable to preserve life when a person with parental responsibility is unreachable or refuses consent for life-saving treatment that seems to be in the best interests of the child. This may involve sharing information that the child does not wish to share; necessary if refusal puts the child at serious risk.

​Clinical Procedures - Aseptic Non-Touch Technique
The highest level of asepsis, designed to minimize or completely remove the chance of contamination is known as 'aseptic non-touch technique (ANTT) Although local practices and rules may differ, the principles behind it are universal.
When to use ANTT
◦ Insertion, repositioning, or dressing invasive devices such as catheters, drains, and intravenous lines
◦ Dressing wounds healing by primary intention (surgical wounds, burns)
◦ Suturing
◦ When sterile body areas are to be entered
◦ If there is tracking to deeper areas or the patient is immunocompromised.
Two-person technique
◦ An assistant can be very helpful in maintaining the position of the patient, opening packs, and decanting solutions for the person performing the procedure
◦ The 'clean practitioner' must wear the sterile glove and open the first pack to establish a sterile field. The second ('dirty) practitioner can then open all the other equipment and drop onto the sterile field.
◦ Interruptions
◦ If the sterile procedure is interrupted for more than 30 minutes, new sterile packs should be opened.
Clean Technique
◦ This is a modified aseptic technique, aiming to prevent the introduction or spread of micro-organisms and to prevent cross-infection to patients and staff. This is used when true asepsis is not required (e.g. when dealing with contaminated sites or when removing drains and catheters)
◦ Sterile equipment is not always used
◦ 'Clean technique allows the use of tap water, non-sterile gloves, multi-pack dressings, and multi-use containers of creams and ointments.
When to use clean technique
◦ Removing sutures, drains, urethral catheters
◦ Endotracheal suction, management of tracheostomy site
◦ Management of enteral feeding lines
◦ Care of stomas
Instillation of eye-drops.

You should always consider the sterility of the items to be touched before you begin each procedure. If some or all items need to remain sterile, an aseptic technique should be used.
Aseptic Non- Touch Technique Procedure
Before
◦ Wash hands with soap and water or alcohol gel
◦ Put on disposable apron and any other protective items
◦ Clean trolley/tray with wipes and dry with a paper towel
◦ Gather equipment and put on the lower shelf of the trolley
◦ Take trolley/tray to the patient.
During
◦ Wash hands with alcohol gel
◦ Remove sterile pack outer packaging and slide the contents on to the top shelf of the trolley or onto the tray, taking care not to touch the sterile pack
◦ Open the dressing pack using only the corners of the paper, taking care not to touch any of the sterile equipment
◦ Place any other required items on the sterile field ensuring that the outer packaging does not come into contact with the sterile field
◦ Put a pair of non-sterile gloves on to remove any dressings on the patient and ensure that they are positioned appropriately
◦ Discard gloves and wash hands
◦ Put sterile gloves on.
After
◦ Dispose of contaminated equipment in the rubbish bag from the dressing pack. Dispose of all packaging
◦ Dispose of aprons and gloves in the appropriate waste as per local policy
◦ Wash hands
Clean the trolley with detergent wipes and dry with a paper towel.

​Clinical Procedures –  Hand Hygiene
When?
The WHO World Alliance for Patient Safety, in 2006, identified '5 moments' for hand hygiene. These are:
• Before patient contact:
• Before touching a patient, when approaching him/her
• Before an aseptic task
• After body fluid exposure risk:
• Immediately after exposure or potential exposure to body fluid (and after removing your gloves)
• After patient contact:
• After touching a patient and his/her immediate surroundings, when you leave the patient's side
• After contact with a patient's surroundings:
• After touching any object or furniture in the patient's immediate surrounding when leaving even if you haven't touched the patient.
Soap or Alcohol Gel?
Repeated washing with soap and water can cause skin dryness and can be time consuming. For these reasons, alcohol gel has become commonplace in clinical settings.
There are no hard and fast rules but:
• Alcohol gel should not be a substitute for soap and water your hands are visibly soiled or if you are undertaking an aseptic procedure
• Remember that alcohol gel is not effective against
Clostridium difficile.
Should visitors also be cleaning their hands?
There is little solid evidence that this is effective in reducing hospital infections. However, visitors are encouraged to clean their hands in most clinical areas, partly because it raises the public profile of the importance of hand hygiene.

Soap and Water Technique
• Adhere to 'bare below elbow' rule
• Wet hands with water
• Apply soap (from a dispenser) to cover all hand surfaces
• Ensure all 7 parts of the hands are thoroughly cleaned:
• Rub hands palm-to-palm
• Rub back of each hand with the palm of the other, fingers interlaced
• Rub hands palm-to-palm with fingers interlaced
• Lock hands together and rub backs of fingers against opposite palm
• Rub thumbs in rotational movement with opposite hand
• Rub tips of fingers into opposite palms
• Rub each wrist with opposite hand
• Hold hands under running water, rub vigorously to remove all suds
. Turn off taps using elbow
• Dry thoroughly with paper towel
• Dispose of paper towels in appropriate clinical bin (using foot pedal to open)
• DO NOT TOUCH any other objects until task is undertaken and completed.
Alcohol Gel Technique
Essentially the same technique as above but no need to rinse or dry with paper towel.
• Squirt small amount of gel onto centre of palm
• Ensure all 7 parts of the hands are thoroughly cleaned as above
• Allow 20-30 seconds for hands to dry, holding hands up
• Following disinfection, DO NOT TOUCH any other objects prior to commencing procedure.

​Clinical Procedures – Subcutaneous injection
Subcutaneous injections can be administered at essentially any site with adequate subcutaneous tissue. Usual sites are upper arms and the abdomen, particularly the periumbilical region.
Ensure that you comply with the local policy regarding drug administration. In hospital, two healthcare professionals should usually check and administer medication.

Equipment
• Appropriate syringe (dependent upon quantity of drug to be administered)
• 25G (orange) needle (usually)
• Prescribed drug
• Prescription chart
• Antiseptic swab
• Plaster.

Procedure
• Assess patient for drugs required (i.e. for pain relief, vomiting etc.)
• Refer to prescription chart, double-checking the appropriate drugs and dosage to be given:
• Always ensure you are fully aware of any possible side effects of any drugs you are due to administer
• Double-check the prescription chart for date and appropriate route for administration
• Check administration of previous dose not too soon after last dose?
• Ensure that the drug to be given is within its use-by date
• Check patient and chart for any evidence of allergies, or relevant drug reactions
• Always comply with the local hand-hygiene practices
• Once all above completed as per hospital policy, draw-up required drug and check appropriate needle size
• Complete appropriate documentation
Documentation
• Drugs should always be signed for as per local policy
• Signature and time should be clearly recorded
• Site drug administered
• Reason for drug administration, time given, and any impact on the patient should be recorded in the nursing notes
• Immediate vital signs should be recorded in notes
• Any causes for concern arising from administration of drugs should be clearly documented in the medical notes
• Signature, printed name, and contact details.

• Once checked by suitably qualified staff take drug and prescription chart to the patient
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Check with patient: name and date of birth (if capable):
• If incapable, check name band with another healthcare professional
•© The patient may need to be assisted to change position, if unable to move themselves, and to enable access to an appropriate site
• Select appropriate site, and cleanse with the antiseptic wipe
• Grasp skin firmly between thumb and forefinger of your left hand
• Insert needle at 45° angle into the pinched skin, then release skin from your grip
• Draw syringe plunger back, checking for any blood. If none, inject drug slowly:
• D If any blood is noted on pulling the plunger back, withdraw and stop procedure provide reassurance and explanation to the patient
• Once the procedure is completed without complication, withdraw needle and discard into a sharps bin
• Monitor patient for any negative effects of the drug.