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Trim the plaster dorsally up to the mtp then every 4months till age 3 buy genuine levitra extra dosage on-line, every 6 months till age 4 cheap levitra extra dosage 40 mg with mastercard, joints purchase levitra extra dosage 40 mg otc, leaving the plantar surface intact to support the toes then every year till skeletal maturity order generic levitra extra dosage on line. Do not pronate or evert the foot because this increases Start removing it at the thigh. Do not allow a long interval the cavus and does nothing to unlock the calcaneus locked between re-casting because you may lose considerable under the talus, and will result in a bean-shaped foot. Do not abduct the foot at the mid-tarsal joints by pressing on the cuboid with the thumb, because this will Finally, correct equinus by dorsiflexing the foot. Do not externally rotate the foot while the calcaneus tenotomy of the Achilles tendon, unless the Pirani score is remains in varus, because this produces posterior <1 for hindfoot and midfoot deformity and the talar head is displacement of the lateral malleolus. Do not forget to immobilize the foot after each Do not perform a tenotomy if the heel is in varus, because manipulation, with ligaments at maximal stretch. Do not apply below-knee casts, because these do not hold the forefoot abducted and tend to slip. Do not perform an incomplete tenotomy, because it will the tendon, turn the blade transversely and cut the tendon not give enough release and the tendon anyway heals across 1cm above the calcaneus; you will feel a sudden rapidly in infants. Do not attempt to obtain a perfect anatomical Apply a 5th cast with the forefoot abducted 60-70 with correction, because it is a functional correction that you respect to the front of the tibia (32-21I). When you remove the cast, 30 of dorsiflexion should be possible in a well-corrected foot. The tenotomy scar is If there is an adductus or varus relapse, recognized by minute. Now apply an abduction brace for 23hrs/day at supination of the forefoot (with the child walking towards 3months (i. You may you), and heel varus (with the child walking away), have to adjust this brace as the child grows, and should go back to manipulating and casting as from infancy. Make sure the brace is fitted to open- If there is an equinus relapse at 1-2yrs, apply casts toe high-ankle straight-laced shoes, with 75 external to get the calcaneus at least into a neutral position. The knees late relapse at 3-5yrs, check if the foot dorsiflexes to 10 are free so that the child can stretch the gastrosoleus and perform a tenotomy as before. Otherwise more tendon, and the bend in the brace helps to stretch the complex surgery is necessary. You can get If there is persistent varus and supination during a skilled cobbler to make the Steenbeek brace (32-21K) walking, usually because of non-compliance, with readily obtained materials. It is best to do this between 3-5yrs of again with serial casting, with possibly another Achilles age, but always after ossification of the lateral cuneiform tenotomy. Teach parents how to put on and started elsewhere before 28months, you should start the take off the brace, and encourage the child to move both Ponseti method as for a newborn: results are just as good. There should be no negotiations If treatment fails, check for a neurological cause; about wearing the brace with the child. Rest at the hot spot stage is the only way to Someone is able to work with a paralysed hand, but if he avoid the serious damage that starts the downhill road to cannot walk, he will probably be unable to undertake the amputation. Many diabetics who are being adequately treated medically, are being The risk of an anaesthetic foot developing an ulcer allowed to walk about on ulcerated feet. The dressings that depends partly on the shoe (if there is one), and partly on cover their ulcers do not prevent them from deepening, and how much it is injured by walking. In a normal person ischaemia soon causes pain, Moulded shoes are more difficult to make, and many so that the ischaemic part is moved, and its blood supply hospitals manage without them. In an insensitive foot there is diminished pain sensation (though some sensation to touch remains), With a little instruction a local cobbler should be able to so that the ischaemic tissue is allowed to become necrotic make a suitable unmoulded shoe in the local style, with the and ulcerates. Also, an unnoticed fracture will produce necessary insoles and straps, and using only the local deformity because the bone fragments are not immobilized. If you want him to make a moulded shoe, (2),A strong force which cuts, shears or tears the tissues. It is not the same as the foam plastic used for cheap which cause inflammation and so weakens the tissues. Car tyres make good soles, and inner This is an important cause of ulcers, so try to minimize the tubes can make uppers. This is a light thermoplastic (4) Forces which spread infection to soft tissues and bone. It resists wetting and is easily cleaned, but it does An infected foot is so painful to a normal person, that there need an oven. If a patient has never had an ulcer, he may escape without It will not burn him, and will set in the shape of the sole (32-23D,E). If however he has already had many Be sure to support this moulded material with microcellular rubber, or ulcers, he will probably not notice getting one more. When the tissues have been damaged, (1) Recognize that his anaesthesia is abnormal. Antibiotics without rest thorns, and recognize and care for any wound, either open will not heal ulcers. Ulcers commonly start in the deeper tissues, and develop (4) Rest the limbs when they are injured. A hot spot is a warm area of skin, usually with swelling, that occurs after activity, and persists during at least 2hrs of rest. Any of these may break (2),Walking must be limited if there is a hot spot, through to the surface, and form an ulcer. Place a piece of paper on the inked mat Look for swellings, injuries and callosities. The greater the pressure, the blacker the toes pushed apart (with oedema from an injury)? If you are really interested in the care of leprosy feet, Examine the arches of the feet on standing, and look for get a footprint mat. You can easily miss a Press deeply over the common sites of ulceration dropped foot, if it is also short. Finally, do not forget to look at his peripheral pulses and the temperature of the skin. Denervation of the skin reduces its natural secretions and makes it dry, so that it more easily cracks, fissures, and becomes infected. Softening dry skin reduces these dangers, and may allow any fissures that have formed to heal. So ask the patient himself to get plain water, without detergents, into the dry feet (or hands) by soaking them for 15-20mins at least twice a day. Then ask him to cover the skin with petroleum jelly, or any kind of grease or oil (including car oil). Beware cockroaches which like the oil: advise a patient whose living conditions are poor to get a cat, or use insect repellents. Pare away thick corn with a surgical blade, or ask the patient himself to rub it away with a pumice or other stone. Remove rough corns regularly, because it may split and crack, or cause ulcers by pressure. If there is a foot drop, fit a toe B, dark areas indicate where there is increased pressure on walking. It has remained free from ulcers because the patient limited his walking, and because the shoe has a Insist on wearing a thick sock. Look for: Make the straps broad, and adjustable with buckles or (1) swelling of the sole, laces, so as to allow for swelling or bandages. The possibilities include: (1),A resilient insole in a shoe, which is one size larger than one usually worn. Do not make the insole too thick, and make sure the shoe is well fastened, so that it does not slip and produce blisters. A shoe for a foot like this needs to be moulded, to take the weight off the metatarsal heads, and spread it evenly over the entire sole. Such a foot will however do fairly well in a simple car-tyre and microcellular rubber sandal, if the corn is kept well pared down. When the base has set firm, build microcellular rubber up underneath it, and then fit this to a car-tyre sole. It needs a shoe which is moulded to conform to it completely, and has a rigid sole. A, right kind of microcellular rubber can be squeezed to half its rubber sandals, if their owner looks after them carefully.

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Despite surgery being performed on patients with higher risk purchase 40 mg levitra extra dosage free shipping, overall surgical mortality has not increased buy levitra extra dosage. Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease order levitra extra dosage discount. Fifteen year trends in risk severity and operative mortality in elderly patients undergoing coronary artery bypass discount levitra extra dosage 40mg on line. The MitraClip device is a transcatheter-based extension of the surgical edge-to-edge repair technique first described by Ottavio Alfieri and co-workers in 2001 (Alfieri O, J Thorac Cardiovasc Surg 2001). It allows for beating-heart approximation of the free edges of the anterior and posterior mitral leaflets at the origin of the regurgitant jet by use of a polyester fabric-covered cobaltchromium clip. All patients received an annuloplasty band and one or more of the following: leaflet resection, secondary chordal transposition and/or neochordal replacement and edge-to-edge repair. There were no differences in preoperative characteristics between the initial and recent cohorts. The incidence of anterior and posterior leaflet prolapse was similar in both groups while Barlow syndrome was higher in group 2. Conclusions: Most complications occurred in the early experience using the first generation daVinci robot. Introduction Surgical mitral repair is the gold standard for the treatment of degenerative mitral disease. Carpentier (1) continues to be the foundation for mitral valve repair including leaflet resection, annuloplasty and later the introduction of artificial chordae (2). Innovations in the surgical approach led to minimally invasive access to the mitral valve. The advancement began with right thoracotomy then endoscopy and presently the robotic assisted technique (3-6). Chitwood pioneered the use of the da Vinci Robotic Surgical System (Intuitive Surgical, Inc, Sunny Vale, California) for mitral valve repair. Methods Three hundred patients underwent intent-to-treat robotic assisted mitral valve repair between June 2005 and October 2012. There was 1 intraoperative conversion to a right minithoracotomy before completion of the repair. The conversion was due to an external instrument conflict with the robotic arms which could not be resolved due to space limitations from working in a small right hemithorax. Therefore, 299 patients achieved successful completion of the robotic mitral valve repair. The data presented in this retrospective review were obtained from our Cardiothoracic Surgery Quality Assurance Database. The initial 74 cases were performed using the first generation da Vinci Robotic Surgical System. For these cases, the handle of the atrial septal roof retractor (Cardiovations, Irvine, California) was inserted just lateral to the right intrathoracic artery. All patients received an annuloplasty band and one or more of the following: leaflet resection, secondary chordal transfer and/or neochordal replacement or edge-to- edge repair. The edge-to-edge repair served as a commissural closure or in the p1-a1 and p3-a3 location in cases with residual regurgitation after testing the valve. Patient Follow-up All surviving patients were examined and clinically evaluated within 2 weeks following their hospital discharge. Further clinical follow-up was obtained through annual questionnaires, direct patient contact or through routine communication with the referring physicians including post-discharge echocardiogram reports. Statistical Methods Numeric variables were summarized as means standard deviations or medians (ranges). Numerical variables were compared across groups by the t-test or the Wilcoxon rank sum test, as appropriate. There were no significant differences in preoperative characteristics between groups, including age (58. In addition, the frequency of leaflet cleft was higher in the last 180 patients compared to the first 120 patients (8. The type of mitral valve repair differed between groups with greater use of triangular resection, and cleft closures in the last 180 patients compared to the first cohort (Table 2). In the last 180 patients there were 5 patients that presented with a prior MitraClip Medimond. Cross clamp times decreased from 11630 minutes in the first group to 9122 minutes in the second group (p<0. Two of the 4 patients in group 1 had persistent deficits and the 2 patients in group 2 recovered completely prior to hospital discharge. Rare complications occurred only in the first 120 cases such as diaphragm paralysis, 1(0. One patient in group 2 was readmitted two weeks post op for revision of the annuloplasty band. Three additional patients in group 1 underwent repeat mitral valve surgery including revision of repair at 8 and 16 months and mitral valve replacement at 2. Two patients in group 2 underwent mitral valve replacement at 2 and 13 months respectively. The overall mean post-discharge echocardiographic follow-up was 99061days for group 1 and 267204days for group 2. Discussion Our robotic assisted mitral valve repair program was initiated in 2005. All patients with repairable significant mitral regurgitation are conducted using the da Vinci system. As our experience improved and outcomes showed comparable results to the sternotomy approach our referral base increased to more complex mitral pathology including a greater proportion of patients with bileaflet and Barlows pathology. Our first 74 cases were done using the older da Vinci robotic system which lacked an adjustable fourth arm. Our subsequent 226 procedures were performed with the next generation system that includes the forth adjustable arm. All early failed mitral repairs requiring valve replacement occurred using the first generation robot. The newer generation da Vinci system greatly improved valve exposure and the conduct of the operation. The adjustable arm allows efficient control of retraction that improves visualization of any given stich. Furthermore, the ability to release retraction and test the valve also increased our success. There was 1 death and 10 failed repairs in the first 120 patients while no death and 3 failed repairs in the last 180 patients. Our practice is to use a complete ring for those with annular dilatation because a partial ring may not provide the adequate annular stabilization at different loading conditions. A sternotomy was performed in 8 of the 9 cases and a minimally invasive mitral replacement for the other. The rate of failure and use of sternotomy decreased between our first 120 and the second 180 cases. The reason for using sternotomy in the 8 cases varied from poor visualization or access to endocarditis and was dependent on the time from initial repair to reoperation. We have not use the robot for valve replacement as we feel we require more experience. Currently with increased experience and the reports of other centers we are expanding our program to include robotic mitral valve replacement. After examining our results we found that over time we had increased success, decreased clamp times while performing procedures in more complex cases. Our repair failures that required a second operation was reduced significantly in our last 180 patients despite the increase in more complex pathology and repairs. We strongly believe that team experience and center volume are crucial components to a successful program and results. We have methodically begun training a new mitral surgeon on the da Vinci system in a stepwise fashion. While 1 had persistent deficits in the first cohort none had any residual deficit in the second. We routinely evaluate the coronary arteries for disease and for right or left dominance. These occurrences are a result of a lack of tactile sensation of depth with the robot instruments.

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A pelvirectal abscess (rare) presents with fever cheap levitra extra dosage 60 mg amex, but no local anal or rectal signs 40 mg levitra extra dosage mastercard. With your finger in the anus 60mg levitra extra dosage for sale, you may be able to feel fluctuation above and lateral to the anorectal ring generic 40 mg levitra extra dosage with amex. Do not delay treatment in the hope that an anorectal abscess will cure itself: always incise it. A large incision will not necessarily give a better result; recurrence depends on whether or not there is a tiny communication between the abscess and the anal canal. As anal glands are mostly posterior, most abscesses and most fistulae are posterior. These glands extend into the sphincters, so that pus can track in various directions: (1) downwards to cause a perianal abscess; (2);laterally, through the sphincters, to cause an ischiorectal abscess. The ischiorectal spaces connect with one another behind the anus, so that infection on one side can spread to the other side (horseshoe abscess); (3);rarely, medially under the mucosa of the anal canal to Fig. If you probe unwisely, you may create an abscess over its most prominent or fluctuant part. Do not break down any natural barriers to (3) If an abscess lies anteriorly, consider the possibility the spread of infection. He was found to have a perianal swelling, given a course of antibiotics, and sent home for readmission later for examination under and the patient is well anaesthetized, probe carefully to anaesthesia. The urine was tested and was If there is no fistula, cut off the corners of the flaps to found to contain sugar. Do not lay open the fistula even if it is a low type, Recognize Fourniers gangrene early! Insert a pad with chloramphenicol and metronidazole, and look if there inside the underwear. Rarely, if there is severe neutropenia due to bone If there is an abscess on both buttocks, marrow failure, you should use antibiotics rather than use circumferential incisions 3-5cm apart on both sides performing an incision, as in this case there will be no pus! Feel if there is an indurated upward extension of the abscess under the mucosa 3cm or more above the internal If there is an internal opening which communicates with sphincter. Feel the extent of the abscess, and for the point the ischiorectal fossa above the anorectal ring, (rare) of maximum fluctuation. The abscess commonly arises in the bulbar urethra, probably in Cowpers para-urethral glands, and is usually caused by gonococci to begin with; but these are soon replaced by secondary invaders. The danger is that the urine may leak from the abscess cavity, extravasate widely, and cause extensive cellulitis or a fistula (27. The urine is infected, so this kind of cellulitis is more dangerous than that following traumatic rupture of the urethra. There may or may not be retention of urine due to an inflamed stricture, which will prevent you passing a catheter, so you may have to drain the bladder with a suprapubic cystotomy (27. Use ampicillin, or chloramphenicol, until you have the results of culture of the urine and pus, if this is possible. Incisions circumferential to the anal canal 3-5cm on both sides without crossing the midline: a loop drain between them keeps the If catheterization is successful, drain the abscess by a space open. If there is a supralevator abscess (very rare), explore the If the stricture is short and the sepsis minimal, gently abdomen and drain the abscess, preferably pass a bougie until the stricture is reached. Replace the bougie plus chloramphenicol or a cephalosporin and perform a by a urethral catheter. Insert a soft rubber drain and If there is a recurrent abscess (common), there is almost encourage showering bd. To begin This is rare; the symptoms are the same as with an abscess with they cause a prostatitis, and later a frank abscess. There may also be pain suprapubically, The prostate is enlarged, usually more so on one side than in the back, or down the inner side of the thighs. Push a haemostat into it, drain it, (3) the perineum, and close the wound lightly round a drain. Do not confuse a prostatic abscess with: (1);An ischiorectal abscess: the swelling is to one side of the midline. If proper cleaning with chlorhexidine (or similar) fails, If the prostate is not fluctuant, see what antibiotics alone either because of the severity of the infection or because will do in 48hrs. Try to find an expert urologist, there is phimosis or underlying ulceration, use an who can drain the abscess into the urethra with a antibiotic such as cloxacillin, and arrange circumcision resectoscope. The ideal if antibiotics fail to cause a marked improvement in 48hrs, or the abscess is fluctuant, is endoscopic drainage If gangrenous patches develop, this is phagedaena and by a urologist using a resectoscope. This will involve removing the foreskin, If this passes easily, leave it in place. If sepsis is extensive, insert a urethral catheter in order to show you where the urethra is and avoid damaging it To drain the abscess, pass a metal sound, and cut down on during debridement. Put your finger through the incision into the prostatic urethra, and then If pain and swelling develop with explosive rapidity in through its posterior wall into the abscess cavity. Pack the wound loosely with a dry dressing and leave it open, or suture the skin edges loosely over it. Alternatively septic micro-emboli travel directly to the testis resulting in septic necrosis. The infection is inside the scrotum rather than in the scrotal wall; the scrotal skin is normal until the sepsis points through. Explore the scrotum through a transverse incision; if the testis and/or epididymis are severely infected, perform an orchidectomy (27. B, when it affects the penile Cellulitis can occur anywhere and is especially dangerous shaft as well. Surgery and Clinical Pathology in the Tropics, Livingstone 1960 with kind permission. There is a high It is caused by a synergistic combination of organisms, fever, which can develop quickly into bacteraemia with including anaerobes. Excise all dead tissue as soon as possible, sacrificing some living tissue if necessary. Frequently you amount of blood, so transfuse especially if he is anaemic to will have to perform a below or above-knee amputation to start with. Inspect the wound bd, and skin graft the defect when it is Mixed infection in the superficial and deep fascial tissues clean. You can speed up this process dramatically by using with aerobes and anaerobes can cause extremely rapid suction dressings (11. Whilst intravenous saline was poured in, under oxygen alone all the necrotic fascia was cut away: it hardly bled, and mucormycosis (fungal infestation), which can occur in gave off ammonia fumes! Towards the end of the procedure he started extensive natural disasters such as volcanic eruptions. He then explained that the scrotal swelling It can occur anywhere: in the abdomen it is known as began after someone forcibly removed a urethral catheter that had been inserted when hed been admitted with cerebral malaria. The urethral from a colostomy, or in the scrotum as Fourniers stricture was later successfully dilated, and the extensive abdominal gangrene (6. There is marked swelling and tenderness with areas of blistering, patchy central necrosis and crepitus; the patient is much sicker than with cellulitis, and pain extends beyond the confines of visible inflammation. Air sometimes escapes Suspect that it may occur if: into the tissues from under the skin. In ischaemic gangrene (1) There are extensively lacerated muscles, or a missile (35. The diagnosis is usually or axillae, or the retroperitoneal muscles following an clear. Gas gangrene is probably developing if there has been satisfactorily progress, and then sudden deterioration. Do not let these features mislead you: (1);There may not always be the smell of death, and even if there is, there may not be gas gangrene. As infection progresses along a muscle, There are however 2 other conditions where the diagnosis it changes from brick red to purplish black (6-17). Both require drainage and penicillin or At first the wound is relatively dry; later, you can express doxycycline but neither needs radical muscle excision. Sometimes the whole (1);Always perform a thorough wound toilet, especially in abdominal wall is involved. Start immediately after the redness and swelling originating in a stinking discharging injury for a maximum of 24hrs. Make radical incisions through the deep fascia to relieve tension and provide Once gas gangrene has developed, do not delay exploring drainage. Although clostridia are not sensitive to metronidazole, some other anaerobic bacteria are and may co-exist in the wound, so use it.

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Further detailed recommendations can be found in the 2008 British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients42 discount 40 mg levitra extra dosage with amex. The HbA1c If the starvation period is short purchase cheap levitra extra dosage on-line, pump therapy should be measured to assess the level of pre- should be continued and patients should remain admission blood glucose control as this may on their basal rate until they are eating and influence subsequent diabetes management buy levitra extra dosage with amex. Stress hyperglycaemia Peri-operative hypotension can decrease skin Stress hyperglycaemia may occur in people not perfusion and reduce insulin absorption therefore previously known to have diabetes generic levitra extra dosage 60 mg online. Recent data normal hydration and blood pressure must be suggest that this group is at particularly high risk maintained. If the episode but after recovery re-assessment is blood glucose cannot be maintained in the target required. The patient needs to be warned that their blood glucose may vary for a few days post-operatively and that corrections in their doses may need to be made. Consider the use of individualised goal directed Maintain normal electrolyte concentrations therapy42. Ensure arrangements are in place to admit high function risk patients to critical care if necessary. Implement surgical and anaesthetic principles anti-emetics to enable an early return to a of the Enhanced Recovery Partnership normal diet and usual diabetes regimen Programme to promote early return to normal Avoid pressure damage to feet during surgery. Use anaesthetic techniques to reduce the Action plan incidence of postoperative nausea and vomiting 1. The anaesthetic record should document blood glucose levels, fluids and drugs (including insulin) 5. This results in increased Partnership Programme (see page 15) insulin resistance and consequent hyperglycaemia. Glucose control during this period is unpredictable and difficult, requiring skill and experience on the part of Action plan the clinicians50. Staff skilled in diabetes management should supervise surgical wards routinely and regularly. During the pre-operative, operative and immediate post-operative recovery period patients are normally 2. Allow patients to self-manage their diabetes as cared for by experienced anaesthetic staff, ensuring soon as possible, where appropriate. Monitor electrolytes and fluid balance daily and hyperglycaemia and ketogenesis and it is crucial to prescribe appropriate fluids. Health has added insulin maladministration to the The wide range of preparations and devices available list of Never Events for 2011-1261. Of these 972 incidents resulted in Uses any abbreviation for the words unit or moderate harm with severe or fatal outcomes in a units when prescribing insulin in writing further 1821. Nursing staff may not be recommendations to promote safer use of insulin authorised to administer glucose without a 21,62 : prescription glucose products are not always readily available in clinical areas. The recent introduction of A training programme should be put in place for national guidelines for the management of all healthcare staff (including medical staff) hypoglycaemia should address this problem57 expected to prescribe, prepare and administer insulin All staff prescribing or administering insulin should Policies and procedures for the preparation and receive training in the safe use of insulin. Trusts administration of insulin and insulin infusions in should specify an appropriate training programme clinical areas are reviewed to ensure compliance and it is recommended that this be mandatory. Insulin is included in the list of top ten high Patients often return to surgical wards from theatre alert medicines worldwide26,58,59. The following errors with an intravenous insulin infusion in place but no account for 60% of all insulin-related incidents directions for its withdrawal. Doctors are often Wrong kind of insulin unaware of how to do this and infusions are Wrong dose (either wrong prescription or misread continued or discontinued inappropriately. Treatment requirements may differ from usual in the immediate post-operative period where there is a risk of both hypo and hyperglycaemia and clinical staff may need to take decisions about diabetes management. Training in blood glucose management is essential for all staff dealing with patients with diabetes64. The diabetes specialist team should be consulted if there is uncertainty about treatment selection or if the blood glucose targets are not achieved and maintained. Emergency surgery By definition, emergency surgery is unplanned and the additional metabolic stress of the emergency situation is likely to lead to hyperglycaemia. The diabetes specialist team should be involved at an early stage to optimise blood glucose management. Involve the diabetes specialist team if diabetes operative assessment process in collaboration with related delays in discharge are anticipated. The patient or carers defined discharge criteria to prevent unnecessary ability to manage the diabetes should be taken delays when the patient is ready to leave hospital. Discuss with the diabetes Multidisciplinary teamwork is required to manage all specialist team if necessary. Systems should be in place to ensure effective The diabetes specialist team should be involved at an communication with community teams, early stage if blood glucose is not well controlled35. Diabetes expertise should be available to support safe discharge and the team that normally looks after the patients diabetes Aims should be contactable by telephone. Etzwiler68 described three phases of patient education: acute or survival education, in depth Action plan education, and continuing education. In consultation with the patient, decide the skills are limited to topics essential in the short term clinical criteria that the patient must meet for safe patient discharge. Identify whether the patient has simple or last for several days and patients and/or carers should complex discharge planning needs and plan be advised about blood glucose management during how they will be met. The hospital pharmacist has a Nutritional intake crucial role to play in ensuring that the discharge medication is safe and that the patent has the Blood glucose lowering medications equipment and education required to manage safely Activity levels at home. Ensure that the diabetes specialist team is inpatient stay and this may be continued on involved if necessary discharge. Education must be provided to ensure that the patient or carer has sufficient understanding to In partnership with the patient or their carer agree manage independently. Patients already established diabetes therapy on discharge depending on on insulin may experience variations in insulin clinical status, social support and ability to self- requirements on discharge. Specialist advice on manage diabetes management should be available in the Agree a blood glucose monitoring plan with self- immediate post-discharge period. Arrange community support for those who require blood glucose monitoring but are unable to Self-monitoring of blood glucose self-care Patients who normally monitor their blood glucose Agree blood glucose targets and provide a record may wish to increase the frequency of monitoring in book the immediate postoperative period until glycaemic Revise principles of dose adjustment for patients control and treatment are stable. Those who have on insulin therapy who are able to self-care been commenced on insulin or sulphonylureas during Discuss any treatment changes with the individual admission should be taught to self-monitor before and also ensure these are communicated to their discharge. Clear blood glucose targets should be usual provider of diabetes care documented as part of the discharge care plan and Review advice for identification and treatment of patients should be able to access specialist advice if hypoglycaemia they are concerned about their blood glucose level. Medicines management on discharge Care should be taken to ensure that there is no interaction between the patients usual medication 33 Controversial areas - glycaemic control What is the evidence that tight glycaemic increase expression of leukocyte and endothelial control improves the outcome of surgery? High glucose values were tolerated these glucose-induced changes is to enhance on the basis that permissive hyperglycaemia was inflammation and increase vulnerability to safer than rigorous blood glucose control with the infection. A number of these deleterious effects can be shown is studies have looked at the impact of tight blood surprisingly uniform, usually greater than 9 or 10 glucose control on post-operative outcomes, with mmol/L, which is similar to the values at which varying conclusions. It also outcome was not improved in patients with reduces the risk of variability in blood glucose, tight control regardless of diabetes status72 which is more likely to occur if the target is less A retrospective cohort study found that than 6. In a recent study of patients Trials in which strict glucose control was undergoing hip and knee arthroplasty patients with implemented, typically less than 6. An upper limit between 64-75 mmol/mol Close and effective coordination with other (8 and 9%) is acceptable, depending on individual specialist teams involved in caring for the patient circumstances. HbA1c is achievable, but for those at high risk of hypoglycaemia a higher target may be appropriate. An elevated pre-operative HbA1c is associated with Does optimisation of co-morbidities improve poorer outcomes whether diabetes has been outcomes? There may be a role for Cardiac and renal dysfunction are common long- routine measurement of HbA1c at pre-operative term complications of diabetes. Previous assessment in undiagnosed patients with risk myocardial infarction, atrial fibrillation and a factors for diabetes. It is likely that the incidence of Can input from the diabetes specialist team peri-operative morbidity and mortality among improve outcomes? The recommended carbohydrate load or short stay and if the starvation period is short it of 180 g glucose per day was designed to may be possible to manage the diabetes without minimise catabolism associated with starvation and 90-94 an insulin infusion. Alberti and Thomas described the data available demonstrated that this approach is use of other intravenous fluids in conjunction with 94 safe. A recent prospective study of 106 patients Diabetic surgical patients are not only at risk of the requiring laparotomy found that 54% suffered at inherent complications associated with standard least one iatrogenic complication as a result of fluid and electrolyte management, but are at post-operative fluid and electrolyte higher risk of hyponatraemia through the use of mismanagement99.