Lecture อ.ชนินทร์ ล่ำซำ

ใจความสำคัญของ lecture วันนี้

1. การเรียนรู้หัตถการ พอจำขั้นตอนได้แล้ว ให้จำด้วยว่าขั้นตอนขั้นนั้นสำเร็จแล้วหรือยังก่อนจะทำขั้นถัดไป

2. เวลากระดูกหัก periosteum จะขาด แต่ periosteum ส่วนที่ไม่ขาดจะยืดไม่ได้

OR

Fasciotomy c thromboembolectomy

Round

Round
Aug 18, 6:19 PM
Amputation stump - downstream pulse, warmth, infection

Acute thrombosis->antiplatelet therapy
Risk factor: smoking, DM, homocystinemia
5-10 min rest cure claudication walk 100 m; location of claudication -
Lerisch syndrome; sleep pain sit relieve
Subside slowly - venous claudication
Neuropathic most common in diabetes; calluses cause ischemia
Gangrene dry: bypass->amputation; wet: amputate->bypass
Skin and subcutaneous atrophy; Buerger test,angle = vascular angle;
drop->reactive hyperemia
Clinical diagnosis
Medial calcification
Velocity wave form
PVR 60 mmHg; TBI<0.7
Exercise therapy in claudication 30-60 min 3/wk 3 mo: better tolerance
CT angiography for revascularization
Anticoagulant->prevent obstruction, repeated surgery

<1cm telangiectasia (spider vein)
1-3 reticular vein
>3 varicose vein
Fix with aethoxysklerol not >5cm
Dilatation, tortuous, deformity
Sclerotherapy
Tight venous pain, chronic venous insufficiency

Fluid resuscitation for surgery: isotonic; urine SpG <1.02
Antibiotic prophylaxis: clean contaminated wound needs one.; vs
antibiotic therapeutic
Anaerobe: Bacteroides MTX
Set OR, define the skin to operate
Bowel preparation: exacerbate peritonitis, perforation; not in appendicitis
Post-op fluid NSS/2 for how long? + 5% dextrose just to maintain catabolic state
Morphine/pethidine for analgesia, naloxone antidote/on respirator; MO
0.05-0.1 mg/kg

Endothelial injury, stasis, hypercoagulable state; SCD sequential
compressive device; lifestyle; lupus, antiphospholipid syndrome; CA
lung; smoking; protein C,S deficiency; always check pulse
Acute compartment syndrome: sensory loss 1st dorsal web space
Sure DVT -> D-dimer, not sure -> Doppler, duplex, ascending
venography, CTA; Doppler normally like respiration, variable:
respiratory variation, augmentation; heparin keep APTT/PT loading 80
MT 18 cc/kg stimulate ATIII switch warfarin, pressurize leg; warfarin
cause prothrombotic state so start heparin first. Primary DVT 3-6 mo +
FU, secondary treat cause first or lifelong; late complication
alba->cerulea need surgery drip heparin + consult surgery

Patarapol Withayasakpunt
5101006 SIMD/B

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Round

Round
Aug 17, 5:04 PM
Case AAA: pre-op; need stress test/Thallium scan; echo not suffice
Chronic limb ischemia: pulse may be 1+; segmental pressure - ABI, AP;
triphasic-biphasic-monophasic-flat line; ABI unreliable cuff 60 look
for dicrotic notch; CNO cannot occlude; see TP instead; some measure
TCOM; inflow, outflow/distal runoff; 5 steps; 4. CT angiogram 5.
Bypass/EVAR; control risk factor + good wound dressing; ABCDDEF
anti-platelet, BP, cholesterol, diet, don't smoke, exercise, foot care

PVR - pulse-volume recorder

Clexane before Heparin for DVT because faster
Triple Vessel Disease coronary
NG tube gastric content 80 OK
Stroke indication for surgery >50+symptomatic

Patarapol Withayasakpunt
5101006 SIMD/B

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Round

Round
Aug 16, 7:59 PM
Groove of pressure ulcer - bedridden

1. 6p
2. Position
3. Severity
4. Source cause
5. General status
6. Choice of management

Patarapol Withayasakpunt
5101006 SIMD/B

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Round

Round
Aug 15, 7:25 PM
Vascular
14 Expansile mass abdomen 5 cm; umbilicus - bifurcation, xiphoid -
renal artery - upper border of mass; >1.5x aortic aneurysm, 5 cm
rupture to peritoneum, retro-peritoneum, distal duodenum, IVC;
anatomical/extra-anatomical bypass; endovascular aortic aneurysmal
repair (EVA) + occlude common iliac artery

Aortoenteric fistula
3sbe
Triad of aortoiliac occlusive disease
Ischemic rest pain - night pain
Non-healed ulcer >2wk + lab ABI, ankle pressure, toe pressure
ABI<0.9 disease <0.5 severe
Ankle pressure <50, <70 in DM indication Tx
Segmental pressure
Error: hard artery; ABI>1.3; monophasic; toe pressure <30, <50
TCOM transcutaneous oximetry >40, <20 - enough oxygen to heal?; lift
leg 5 min decrease>10

AVF - rule of six
Carotid stenosis - Amalurosis fugax, check retina, TIA/stroke -
differentiate symptomatic or not, degree of stenosis; surgery
complication nerve injury ESP. 12,10,9,mandi7, hyperperfusion syndrome
of brain - edema, stroke

Chemical debridement
Wet dressing
1. AgZnSulfa
2. Non-adhesive
3. Hydration
4. Absorptive
5. Coverage
6. Immobilize

Patarapol Withayasakpunt
5101006 SIMD/B

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OR

OR
Aug 10, 10:16 AM
Monday
Hypospadias repair
Removal of right renal mass

Wednesday
Big thread for stitching fat
IORT, think of penetration 0.5 cm
Rt breast mass -> myeloid sarcoma

Patarapol Withayasakpunt
5101006 SIMD/B

Sent from my iPod