Postoperative Health Dictionary

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Ananas Comosus

(Linn.) Merrill

Family: Bromeliaceae.

Habitat: Native to South America; cultivated mostly in Tamil Nadu, coastal Andhra Pradesh, Assam, Kerala, Karnataka, West Bengal, Tripura and Orissa.

English: Pineapple.

Ayurvedic: Anaanaasa, Bahunetra.

Unani: Anannaas.

Siddha/Tamil: Annanshippazham, Annasi.

Action: Anti-inflammatory (fresh juice used as a gargle for sore throat). A proteolytic enzyme, bromelain, is derived from the stem—anti-inflammatory, smooth muscle relaxant, digester, inhibitor of blood platelet aggregation. (It is used for cellulitis, post-operative oedema, sinusitis and for promoting digestion of proteins.)

Key application: Bromelain, the proteolytic enzyme, is used in acute postoperative and post-traumatic conditions of swellings, especially of the nasal and paranasal sinuses. (German Commission E.) In Europe, a patented tape that contains bromelain is used for debriding escharotic skin. (Internally, bromelain's bioavailability has been questioned.)... ananas comosus

Appendicitis

This is an in?ammatory condition of the APPENDIX, and is a common surgical emergency, affecting mainly adolescents and young adults. It is usually due to a combination of obstruction and infection of the appendix, and has a variable clinical course ranging from episodes of mild self-limiting abdominal pain to life-threatening illness. Abdominal pain beginning in the centre of the abdomen but which later shifts position to the right iliac fossa is the classic symptom. The patient usually has accompanying fever and sometimes nausea, vomiting, loss of appetite, diarrhoea, or even constipation. The precise symptoms vary with the exact location of the appendix within the abdomen. In some individuals the appendix may ‘grumble’ with repeated mild attacks which resolve spontaneously. In an acute attack, the in?ammatory process begins ?rst in the wall of the appendix but, if the disease progresses, the appendix can become secondarily infected and pus may form within it. The blood supply may become compromised and the wall become gangrenous. Eventually the appendix may rupture, giving rise to a localised abscess in the abdomen or, more rarely, free pus within the abdomen which causes generalised PERITONITIS. Rupture of the appendix is a serious complication and the patient may be severely unwell. Surgeons recognise that in order to make sure patients with appendicitis do not progress to peritonitis, a certain percentage of normal appendixes are removed when clinical signs are suspicious but not diagnostic of disease.

Treatment The best treatment is prompt surgical removal of the diseased appendix, usually with antibiotic cover. If performed early, before rupture occurs, APPENDICECTOMY is normally straightforward and recovery swift. If the appendix has already ruptured and there is abscess formation or free intra-abdominal pus, surgery is still the best treatment but postoperative complications are more likely, and full recovery may be slower.... appendicitis

Heart Surgery

Open-heart surgery permits the treatment of many previously inoperable conditions that were potentially fatal, or which made the patient chronically disabled. CORONARY ARTERY VEIN BYPASS GRAFTING (CAVBG), used to remedy obstruction of the arteries supplying the heart muscle, was ?rst carried out in the mid1960s and is now widely practised. Constricted heart valves today are routinely dilated by techniques of MINIMALLY INVASIVE SURGERY (MIS), such as ANGIOPLASTY and laser treatment, and faulty valves can be replaced with mechanical alternatives (see VALVULOPLASTY).

Heart transplant Replacement of a person’s unhealthy heart with a normal heart from a healthy donor. The donor’s heart needs to be removed immediately after death and kept chilled in saline before rapid transport to the recipient. Heart transplants are technically demanding operations used to treat patients with progressive untreatable heart disease but whose other body systems are in good shape. They usually have advanced coronary artery disease and damaged heart muscle (CARDIOMYOPATHY). Apart from the technical diffculties of the operation, preventing rejection of the transplanted heart by the recipient’s immune system requires complex drug treatment. But once the patient has passed the immediate postoperative phase, the chances of ?ve-year survival is as high as 80 per cent in some cardiac centres. A key di?culty in doing heart transplants is a serious shortage of donor organs.... heart surgery

Aprepitant

n. an antiemetic drug used for the treatment of chemotherapy-induced and postoperative nausea. It blocks activation of neurokinin–1 receptors in the vomiting centres of the brain by substance P, a peptide released by chemotherapy.... aprepitant

Bupivacaine

n. a potent local anaesthetic used for regional *nerve block, including *epidural anaesthesia during labour and to relieve postoperative pain. It is significantly longer acting than many other local anaesthetics.... bupivacaine

Central Island

an area of significant irregular astigmatism seen on *corneal topography after laser refractive surgery. It may affect the postoperative outcome.... central island

Epidural Anaesthesia

suppression of sensation in the lower part of the body by the injection of a local anaesthetic into the *epidural space. The injection site is often the sacral or lumbar regions of the vertebral column, and a special blunt needle with a side-hole is used to reduce the chance of penetrating the dura. A fine catheter is passed through the needle to enable repeated or continuous infusion of anaesthetic solution. Epidural anaesthesia is particularly useful for providing pain relief during childbirth, to reduce the need for deep general anaesthesia, and for postoperative analgesia.... epidural anaesthesia

Intensive Therapy Unit

(ITU, intensive care unit) a hospital unit designed to give intensive care, provided by specialist multidisciplinary staff, to a selected group of seriously ill patients or to those in need of special postoperative techniques (e.g. those patients undergoing complex heart or lung procedures).... intensive therapy unit

Pain

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International Association for the Study of Pain, 1979). Pain is perceived in the cerebral cortex (see BRAIN) and is always subjective. Sometimes sensations that would usually be benign can be perceived as painful – for example, allodynia (extreme tenderness of the skin) or dysaesthesia (unpleasant skin sensations resulting from partial damage to sensory nerve ?bres, as in herpes zoster, or shingles).

Acute pain is caused by internal or external injury or disease. It warns the individual that harm or damage is occurring and stimulates them to take avoiding or protective action. With e?ective treatment of disease or injury and/or the natural healing process, the pain resolves – although some acute pain syndromes may develop into chronic pain (see below). Stimuli which are su?ciently intense potentially to damage tissue will cause the stimulation of speci?c receptors known as NOCICEPTORS. Damage to tissues releases substances which stimulate the nociceptors. On the surface of the body there is a high density of nociceptors, and each area of the body is supplied by nerves from a particular spinal segment or level: this allows the brain to localise the source of the pain accurately. Pain from internal structures and organs is more di?cult to localise and is often felt in some more super?cial structure. For example, irritation of the DIAPHRAGM is often felt as pain in the shoulder, as the nerves from both structures enter the SPINAL CORD at the same level (often the structures have developed from the same parts of the embryo). This is known as referred pain.

The impulses from nociceptors travel along nerves to the spinal cord. Within this there is modulation of the pain ‘messages’ by other incoming sensory modalities, as well as descending input from the brain (Melzack and Walls’ gate-control theory). This involves morphine-like molecules (the ENDORPHINS and ENKEPHALINS) amongst many other pain-transmitting and pain-modulating substances. The modi?ed input then passes up the spinal cord through the thalamus to the cerebral cortex. Thus the amount of pain ‘felt’ may be altered by the emotional state of the individual and by other incoming sensations. Once pain is perceived, then ‘action’ is taken; this involves withdrawal of the area being damaged, vocalisation, AUTONOMIC NERVOUS SYSTEM response and examination of the painful area. Analysis of the event using memory will occur and appropriate action be taken to reduce pain and treat the damage.

Chronic pain may be de?ned in several ways: for example, pain resistant to one month’s treatment, or pain persisting one month beyond the usual course of an acute illness or injury. Some doctors may also arbitrarily choose the ?gure of six months. Chronic pain di?ers from acute pain: the physiological response is di?erent and pain may either be caused by stimuli which do not usually cause the perception of pain, or may arise within nerves or the central nervous system with no apparent external stimulation. It seldom has a physiological protective function in the way acute pain has. Also, chronic pain may be self-perpetuating: if individuals gain a psychological advantage from having pain, they may continue to do so (e.g. gaining attention from family or health professionals, etc.). The nervous system itself alters when pain is long-standing in such a way that it becomes more sensitive to painful inputs and tends to perpetuate the pain.

Treatment The treatment of pain depends upon its nature and cause. Acute pain is generally treated by curing the underlying complaint and prescribing ANALGESICS or using local anaesthetic techniques (see ANAESTHESIA – Local anaesthetics). Many hospitals now have acute pain teams for the management of postoperative and other types of acute pain; chronic pain is often treated in pain clinics. Those involved may include doctors (in Britain, usually anaesthetists), nurses, psychologists and psychiatrists, physiotherapists and complementary therapists. Patients are usually referred from other hospital specialists (although some may be referred by GPs). They will usually have been given a diagnosis and exhausted the medical and surgical treatment of their underlying condition.

All the usual analgesics may be employed, and opioids are often used in the terminal treatment of cancer pain.

ANTICONVULSANTS and ANTIDEPRESSANT DRUGS are also used because they alter the transmission of pain within the central nervous system and may actually treat the chronic pain syndrome.

Many local anaesthetic techniques are used. Myofascial pain – pain affecting muscles and connective tissues – is treated by the injection of local anaesthetic into tender spots, and nerves may be blocked either as a diagnostic procedure or by way of treatment. Epidural anaesthetic injections are also used in the same way, and all these treatments may be repeated at intervals over many months in an attempt to cure or at least reduce the pain. For intractable pain, nerves are sometimes destroyed using injections of alcohol or PHENOL or by applying CRYOTHERAPY or radiofrequency waves. Intractable or terminal pain may be treated by destroying nerves surgically, and, rarely, the pain pathways within the spinal cord are severed by cordotomy (though this is generally only used in terminal care).

ACUPUNCTURE and TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) are used for a variety of pain syndromes, particularly myofascial or musculoskeletal pain. It is thought that they work by increasing the release of endorphins and enkephalins (see above). It is possible to implant electrodes within the epidural space to stimulate directly the nerves as they traverse this space before passing into the spinal cord.

Physiotherapy is often used, particularly in the treatment of chronic backache, where pain may be reduced by improving posture and strengthening muscles with careful exercises. Relaxation techniques and psychotherapy are also used both to treat chronic pain and to help patients cope better with their disability.

Some types of chronic pain are caused by injury to sympathetic nerves or may be relieved by interrupting conduction in sympathetic nerves. This may be done in several ways. The nerves may be blocked using local anaesthetic or permanently destroyed using alcohol, phenol or by surgery.

Many of these techniques may be used in the management of cancer pain. Opioid drugs are often used by a variety of routes and methods, and management of these patients concentrates on the control of symptoms and on providing a good quality of life.... pain

Papaverine

n. an alkaloid, derived from opium, that relaxes smooth muscle. In combination with *morphine and *codeine, it is administered for relief of postoperative pain and severe chronic pain, but is now rarely used. It may cause abnormal heart rate. Papaverine may also be given by injection into the corpora cavernosa of the penis to treat erectile dysfunction.... papaverine

Pulmonary Embolism

The condition in which an embolus (see EMBOLISM), or clot, is lodged in the LUNGS. The source of the clot is usually the veins of the lower abdomen or legs, in which clot formation has occurred as a result of the occurrence of DEEP VEIN THROMBOSIS (DVT) – THROMBOPHLEBITIS (see VEINS, DISEASES OF). Thrombophlebitis, with or without pulmonary embolism, is a not uncommon complication of surgical operations, especially in older patients. This is one reason why nowadays such patients are got up out of bed as quickly as possible, or, alternatively, are encouraged to move and exercise their legs regularly in bed. Long periods of sitting, particularly when travelling, can cause DVT with the risk of pulmonary embolism. The severity of a pulmonary embolism, which is characterised by the sudden onset of pain in the chest, with or without the coughing up of blood, and a varying degree of SHOCK, depends upon the size of the clot. If large enough, it may prove immediately fatal; in other cases, immediate operation may be needed to remove the clot; whilst in less severe cases anticoagulant treatment, in the form of HEPARIN, is given to prevent extension of the clot. For some operations, such as hip-joint replacements, with a high risk of deep-vein thrombosis in the leg, heparin is given for several days postoperatively.... pulmonary embolism

Recovery Position

If an individual is unconscious – whether as a result of accident or illness or when in the postoperative recovery unit – but is breathing and has a pulse, he or she should be placed in the recovery position. The individual is turned on his or her side to allow the tongue to fall forwards and so reduce the likelihood of pharyngeal obstruction (see PHARYNX). Fluid in the mouth can also drain outwards instead of into the TRACHEA and LUNGS. The person can lie on either side with upper or lower leg ?exed. Sometimes the semi-prone position is used; this gives better drainage from the mouth and greater stability during transport, but makes it more di?cult to observe the face, colour or breathing. (See APPENDIX 1: BASIC FIRST AID.)... recovery position

Bromelain

Ananassa sativa, Ananas comosus. Proteolytic enzyme derived from the stem of the pineapple plant.

Action. Anti-inflammatory, smooth muscle relaxant, digestant, anti-oedema. Stimulates production of prostaglandin El-like compounds. Inhibitor of blood platelet aggregation thus preserving the normal consistency of the blood.

Uses: Cellulitis, to remove layers of fat. Has some reputation as a digestant in terminal disease. Sinusitis, weak digestion in the elderly, oedema following surgical operation, to promote postoperative healing. Used by natives of the Far East for quinsy. Part of the Bristol Cancer Diet to promote digestion of proteins.

“It is of value in modulating tumour growth, blood coagulation and inflammatory changes in the de?bridement of third degree burns. As an inflammatory it has been used for rheumatoid arthritis, thrombophlebitis, haematomas, oral inflammation, diabetic ulcers, rectal and perirectal inflammation, athletic injuries and general oral and plastic surgery.” (Kay van Rietschoten, British Journal of Phytotherapy, Vol 1, Nos 3/4)

Preparations: 1-2 200mg Bromelain tablets/capsules between meals thrice daily. Patient preference: vegetarian hypoallergenic yeast-free: as an aid to digestion, 250-500mg at meals. ... bromelain

Gastrectomy

Removal of the stomach (total gastrectomy) or, more commonly, part of the stomach (partial gastrectomy). Total gastrectomy is used to treat some stomach cancers. Partial gastrectomy used to be a treatment for peptic ulcers but has largely been replaced by drug treatment.

Possible postoperative complications are fullness and discomfort after meals; regurgitation of bile, which may lead to gastritis, oesophagitis, and vomiting of bile; diarrhoea; and dumping syndrome. Other complications include malabsorption, which may lead to anaemia or osteoporosis. After total gastrectomy, patients cannot absorb vitamin B12 and are given it in the form of injections for the rest of their lives.... gastrectomy

Cervical Cancer

(cervical carcinoma) cancer of the neck (cervix) of the uterus. The tumour may develop from the surface epithelium of the cervix (squamous carcinoma) or from the epithelial lining of the cervical canal (adenocarcinoma). In both cases the tumour is invasive, spreading to involve surrounding tissue and subsequently to neighbouring lymph nodes and adjacent organs, such as the bladder and rectum. Cancer of the cervix can be detected in an early stage of development (see cervical screening) and diagnosis is established by biopsy (see colposcopy). In carcinoma in situ (see cervical intraepithelial neoplasia) the tumour is confined to the epithelium: there is no invasion of surrounding tissue but, if untreated (by local ablation, *LLETZ, or surgical excision), it can become invasive. Common early features of invasive disease are abnormal vaginal bleeding and a foul-smelling blood-stained vaginal discharge. Treatment is by surgery with or without postoperative radiotherapy. See also human papillomavirus.... cervical cancer

Possum Scoring

physiological and operative severity score for the enumeration of morbidity and mortality: a tool used by anaesthetists in the perioperative period to determine the risks associated with surgery in an individual patient. This can be used to guide such decisions as the appropriateness of surgery and the requirement for intensive care postoperatively.... possum scoring

Post

prefix denoting 1. following; after. Example: postoperative (after an operation). 2. (in anatomy) behind. Example: postoral (behind the mouth).... post

Sandwich Therapy

a combination of treatments in which one type of therapy is ‘sandwiched’ between exposures to another therapy. For example, surgical removal of a tumour may be ‘sandwiched’ between pre- and postoperative courses of chemotherapy. See also combined therapy.... sandwich therapy

Subphrenic Abscess

a collection of pus below the diaphragm, usually affecting the right side. Causes include postoperative infection (particularly after stomach or bowel surgery) and perforation of an organ (e.g. perforated peptic ulcer). Prompt treatment with antibiotics together with radiological or surgical drainage of the abscess is usually required.... subphrenic abscess

Cholangiography

n. imaging of the bile ducts in order to demonstrate congenital anatomical abnormalities (such as biliary atresia), biliary diseases, and the presence of gallstones or strictures. It may be combined with imaging of the pancreatic duct (cholangiopancreatography), as in endoscopic retrograde cholangiopancreatography (see ERCP). Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive *magnetic resonance imaging technique that has largely superseded ERCP for diagnostic purposes. ERCP following MRCP is used for therapeutic intervention. In operative (or on-table) cholangiography, a radiopaque *contrast medium is injected into the bile ducts during *cholecystectomy, to ensure that there are no remaining gallstones in the ducts. Percutaneous transhepatic cholangiography (PTC) is an invasive technique in which a catheter is manipulated under direct fluoroscopic guidance through the anterior abdominal wall, across the liver, and into a bile duct; contrast solution is injected to outline the bile ducts. Using a *Seldinger technique, drains or stents can be placed to treat infection or malignant strictures. T-tube cholangiography involves the postoperative injection of radiopaque contrast material via a drain (T-tube) left in the main bile duct after cholecystectomy.... cholangiography

Colorectal Cancer

malignancy of the large intestine (i.e. the colon, appendix, and rectum). It is the fourth most common cause of death from cancer: one million people are diagnosed each year. Most cases should be preventable by screening and surveillance protocols (including the *faecal occult blood test) and modifiable lifestyle factors. Risk factors include older age, increased consumption of red meat and fatty foods, excessive alcohol intake, smoking, and sedentary lifestyle. Clinical symptoms include change in bowel habit, rectal bleeding, loss of appetite and weight, anaemia, and gastrointestinal obstruction. Diagnosis is made following analysis of samples taken during *colonoscopy. CT scanning of the chest, abdomen, and pelvis defines the extent of the disease; MRI and PET scanning may yield additional radiological information. These findings are assessed using the *TNM classification. Early localized disease is amenable to surgery, preoperative chemoradiation, and postoperative chemotherapy; advanced disease with metastases necessitates a palliative approach.... colorectal cancer

Laryngectomy

n. surgical removal of the larynx in the treatment of laryngeal carcinoma. Postoperatively the patient breathes through a *tracheostomy. Speech is lost following the operation but can be restored by teaching the patient to swallow air and then belch it in a controlled fashion. Alternatively, a battery-powered vibrating device can be held in the mouth or underneath the chin to produce speech (see electrolarynx). Speech can also be facilitated by a one-way valve surgically implanted between the tracheostomy and the upper oesophagus, allowing the patient to divert air into the throat. Partial laryngectomy conserves part of the larynx and allows patients to breathe and speak normally. However, it is only suitable for a few patients with small tumours.... laryngectomy

Lymphangiography

(lymphography) n. X-ray examination of the lymphatic vessels and lymph nodes after a contrast medium has been injected into them (see angiography). Lymphatic vessels in the upper part of the foot are dissected and cannulated after injecting methylene blue into the web space to identify them. Then a viscous contrast medium (Lipiodol) is injected into them at a very slow rate. Its main uses are in the investigation of the extent and spread of cancer of the lymphatic system, the investigation of lymphoedema, and postoperative collection from lymphatic damage. Newer techniques involve injection of contrast medium directly into the lymph nodes (intranodal lymphangiography). Alternatively, the lymphatic system can be imaged using a gamma camera following the injection of a radioactive tracer. This examination has now largely been replaced by other *cross-sectional imaging techniques.... lymphangiography

Pseudo-obstruction

(Ogilvie’s syndrome) n. functional impairment of intestinal peristalsis without evidence of an obstructing lesion (acute colonic pseudo-obstruction). It presents with vomiting, marked abdominal distension, and constipation. It commonly occurs in hospitalized patients with serious illness, probably caused by abnormalities in colonic autonomic regulation and often associated with trauma, sepsis, the postoperative state following abdominal, pelvic, or orthopaedic surgery, or cardiac dysfunction (heart failure, myocardial infarction). Management is usually conservative and involves treatment of the underlying condition, the ‘drip and suck’ approach (see ileus), decompression of the colon, and prokinetic agents (such as neostigmine). Surgery is required when the conservative approach fails or in cases of perforation.... pseudo-obstruction

Vasoligation

n. the surgical tying of the vas deferens (the duct conveying sperm from the testis). This is performed to prevent infection spreading from the urinary tract and causing recurrent *epididymitis. It is sometimes performed at the same time as *prostatectomy to prevent the complication of epididymitis in the postoperative period.... vasoligation

Who Checklist

a process introduced by the World Health Organization to improve patient safety and reduce errors during surgical procedures. There are three phases: checking before induction of anaesthesia; checking after administration of anaesthesia but before start of surgery (referred to as ‘time out’); and checking at the end of the procedure with identification of key concerns for the immediate postoperative period (referred to as ‘sign out’).... who checklist

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