SIRS

Systemic Inflammatory Response Syndrome (SIRS) - is an inflammatory state affecting the whole body, frequently a response of the immune system to infection.

SIRS is a serious condition related to systemic inflammation, organ dysfunction, and organ failure. It is a subset of cytokine storm, in which there is abnormal regulation of various cytokines. SIRS is also closely related to sepsis, in which patients satisfy criteria for SIRS and have a suspected or proven infection

Criteria for SIRS are

• Body temperature less than 36°C or greater than 38°C
• Heart rate greater than 90 beats per minute
• Tachypnea (high respiratory rate), with greater than 20 breaths per minute; or, an arterial partial pressure of carbon dioxide less than 4.3 kPa (32 mmHg)
• White blood cell count less than 4000 cells/mm³ (4 x 10⁹ cells/L) or greater than 12,000 cells/mm³ (12 x 10⁹ cells/L); or the presence of greater than 10% immature neutrophils (band forms)

SIRS can be diagnosed when two or more of these criteria are present

Fever and leukocytosis are features of the acute-phase reaction, while tachycardia is often the initial sign of hemodynamic compromise. Tachypnea may be related to the increased metabolic stress due to infection and inflammation, but may also be an ominous sign of inadequate perfusion resulting in the onset of anaerobic cellular metabolism.

Complication of SIRS
SIRS is frequently complicated by failure of one or more organs or organ systems. The complications of SIRS include:

• Acute lung injury
• Acute kidney injury
• Shock
• Multiple organ dysfunction syndrome
  

Some other terms that we need to noe and differentiate it :

i) Sepsis = SIRS + known@suspected infection @ SIRS + Bacteremia

ii) Septicemia = presence of bacteria in blood(bacteremia) + severe infection with septic sign*

iii) Septic Shock = reduce tissue perfusion and reduced O2 delivery due to infection and sepsis and the MAIN criterias are 1- evidence of infection ( +ve blood culture) 2-refractory hypotension ( hypo despite adequate fluid resuscitation...BP<90..wbc>12000 ... 3-HR>90 ... 4-temp>38C ... 5-cold peripheries

iv) Severe Shock = septic shock + MODs(multiple organ dysfx) and not recovering despite treatment

Management of Septic Shock
[OVERS]

1 Oxygen therapy - put the patient with Nasal prog or FaceMask or Ventimask
2.Volume resuscitation - set 2 large branula (16G) and run fluid thru it
3.Early antibiotics - wide spectrum antibitics IV
4,Rapid sauce identification - and wound infected or do a septic workour asap
5.Support for major org dysfx - monitor patient vital sign .. brain, heart, kidney, lung, liver, intestine..

Bubonocele

Bubonocele - An inguinal hernia, especially one in which the knuckle of intestine has not yet emerged from the external abdominal ring @ incomplete inguinal hernia ( bubonocele..actually its a old term it seems... told by a surgeon when assisted her in a Hernioplasty .. )

Wound

Mechanism of wound healing has 4 stages :

1.Haemostasis -
Upon injury to the skin, a set of complex biochemical events takes place in a closely orchestrated cascade to repair the damage.Within minutes post-injury, platelets (thrombocytes) aggregate at the injury site to form a fibrin clot. This clot acts to control active bleeding (hemostasis)

2. Inflammatory
In the inflammatory phase, bacteria and debris are phagocytosed and removed, and factors are released that cause the migration and division of cells involved in the proliferative phase. We can see the 5 inflammation sign on the wound at tis stage. (red,warm,painful, edematous and loss of fx)

3.Proliferative @ Granulation
The proliferative phase is characterized by angiogenesis, collagen deposition, granulation tissue formation, epithelialization, and wound contraction. In angiogenesis, new blood vessels are formed by vascular endothelial cells. In fibroplasia and granulation tissue formation, fibroblasts grow and form a new, provisional extracellular matrix (ECM) by excreting collagen and fibronectin. Concurrently, re-epithelialization of the epidermis occurs, in which epithelial cells proliferate and 'crawl' atop the wound bed, providing cover for the new tissue

4. Maturation @ Remodeling
In the maturation and remodeling phase, collagen is remodeled and realigned along tension lines and cells that are no longer needed are removed by apoptosis

CLASSIFICATION OF SURGICAL WOUND

Thrs 4 types of surgical wound ;-
1. Clean
2. Clean Contaminated
3. Contaminated
4. Dirty

CLASS I/CLEAN WOUNDS--an uninfected surgical wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed and, if necessary, drained with closed drainage. Surgical wound incisions that are made after nonpenetrating (ie, blunt) trauma should be included in this category if they meet the criteria.

CLASS II/CLEAN-CONTAMINATED WOUNDS--a surgical wound in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, surgical procedures involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection is encountered and no major break in technique occurs

CLASS III/CONTAMINATED WOUNDS--open, fresh, accidental wounds. In addition, surgical procedures in which a major break in sterile technique occurs (eg, open cardiac massage) or there is gross spillage from the gastrointestinal tract and incisions in which acute, nonpurulent inflammation is encountered are included in this category.

CLASS IV/DIRTY OR INFECTED WOUNDS--old traumatic wounds with retained or devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the wound before the surgical procedure

Have a look at tis table.. its more easy to understand the classifications, click the below link
Surgical Wound Classification [4]

Enterocutaneous Fistula (GIT Fistula)

I had 2 ptz tat presented with enterocutaneous fistula in ward last 1 week. It is something tat i dint noe much... or better to say.. dont noe at all the management of the fistula. As always in the rounds.. Mr S asked us bout the fistula.. bout the classifications and the management and sort on.. We answered some.. and he told us to read thru it.. and the next day .. he taught us bout the fistula.. so here's the infos.. ;)

An intestinal fistula - an abnormal communication between two epithelialized surfaces. Gastrointestinal fistulas may form between the gastrointestinal tract and the skin (enterocutaneous) or an adjacent viscus (enteroenteral). They may be congenital or acquired. Primary (type-I) fistulas result from an underlying disease affecting the gut wall; secondary (type-II) fistulas occur after injury to otherwise normal gut.

Etiology - Spontaneous - Congenital
Specific Dzs - TB, Actinomycosis,
IBD - UC, Crohn's Dzs
Malignancy - Caecum Ca
Radiation
Medication - eg Steroid usage

- Post Operative - Anastomosis breakdown
Traumatic injury to the hollow organ intraop

Classification

1. Congenital @ Acquired
2. Spontaneous @ Postoperative(Traumatic)
3. Simple @ Complex
4. Low output @ Medium output @ High output
5. Small bowel @ Large Bowel

Scheme of Management of Enterocutaneous Fistula :
1. Rususcitation and control of the fistula discharge
2. Eliminate intra abdominal sepsis
3. Parenteral nutrition
4. Rehabilitation and ambulation
5. Definition of fistula and track
6. Definitive surgical treatment.

But thrs a simple way to remember the management.. told my Mr.S
4 R's
1. Resuscitation - rehydration of the ptz
replace fluid loss
correct acid base balance
correct electrolytes
2. Restitution ---> SNAP
Sepsis - threat the sepsis with antibiotics
Nutrition - keep ptz nil by mouth start parenteral nutrition
Anatomy - find the anatomy of the fistula and it communications., do a
fistulogram or US to find its wall and etc
Plan Procedure -combination of plan tat includes reducing the sepsis..
giving the ptx on parenteral nutrition... to noe the
characteristics of the fistula and to noe if the fistula will heal
spontaneously or need surgical intervention
3.Reconstrution - Plan for surgery to treat the fistula.. eg- laparatomy.. etc etc
4.Rehabilitation - Postoperative care ..to make reduce the complication such as multiple organ
failure, secondary fistula ptz mental state and so on.. ;) [No.3]

Radiating Pain .... Referred Pain...

Thrs been some cases of cholecystitis...appendicitis... in the ward.. and during the discussion of the clinical signs.. thr were some radiating pain from the intial place of pain to other part of the human body.. then my specialist Mr.S .. asked why is that thrs a radiating or refered pain to other place and not only in the place of the first pain occured? this time managed to answer..eventhou the answer wasnt complete.. haha..

Referred pain - is a term used to describe the phenomenon of pain perceived at a site adjacent to or at a distance from the site of an injury's origin . It is because, theres different part of human body tats share the same dermatomes origin. So the brain interprets the pain stimuli from a place in body as pain from all the parts of the body tat shares teh same dermatomes.. Eg. for MI... chest pain tat radiates to left arm, jaw neck and back... Eg. for Biliary colic the epigastrium or the RHC pain that radiates to the back and to the right shoulder and neck...

A part of explaination from Wiki ....
"There are several proposed mechanisms for referred pain. Currently there is no definitive consensus regarding which theory may be correct. The cardiac general visceral sensory pain fibers follow the sympathetics back to the spinal cord and have their cell bodies located in thoracic dorsal root ganglia 1-4(5). As a general rule, in the thorax and abdomen, general visceral afferent (GVA) pain fibers follow sympathetic fibers back to the same spinal cord segments that gave rise to the preganglionic sympathetic fibers. The central nervous system (CNS) perceives pain from the heart as coming from the somatic portion of the body supplied by the thoracic spinal cord segments 1-4(5). Also, the dermatomes of this region of the body wall and upper limb have their neuronal cell bodies in the same dorsal root ganglia (T1-5) and synapse in the same second order neurons in the spinal cord segments (T1-5) as the general visceral sensory fibers from the heart. The CNS does not clearly discern whether the pain is coming from the body wall or from the viscera, but it perceives the pain as coming from somewhere on the body wall, i.e. substernal pain, left arm/hand pain, jaw pain."

For a more info.. click tis link from Wiki :D http://en.wikipedia.org/wiki/Referred_pain [2]

Warthin's Tumour

Thr was a female ptz admitted to ward today.. and she has a swelling in the size of 2x2cm at the end of the mandibular angle on both right and left side. The swellings are very much palpable.. non moving... no tenderness over it and its been thr since she was 7 y/o. The specialist asked... what it was.. and as usual all the answers were wrong.. and he told its called Warthin's Tumor... and he said.. check it out urself.. and who else to ask from if not our dear Wiki... heres the infor from Wiki..

Warthin's tumor or Warthin tumour, also known as papillary cystadenoma lymphomatosum or adenolymphoma, is a type of benign tumor of the salivary glands.
The gland most likely affected is the parotid gland. Though much less likely to occur than pleomorphic adenoma, Warthin's tumor is the second most common benign parotid tumor

http://en.wikipedia.org/wiki/Warthin%27s_tumor

Its doesnt not need a biopsy as its just a benign ..and it doesnt not coz ptz with any discomfort or active pain... ;) [ No.1]

1st Entry

Hai guys.. Hehe... At last the Blog is up and running... It will be a place for me to share my Housemanship knowledge with all my Juniors especially..

My 1st posting is Surgery... so for the next 4 months its all about Surgical stuffs... and Surgical Dept here is fun ... so far .. hehe ... ;) Learning new things everyday... If thrs any wrong infos from me.. please forgive me guys... This blog will also allow me to recall easily all the stuff i learnt.. Adios..