This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. This paper provides recommendations on the pre-treatment clinical assessment of patients presenting with head and neck cancer.Recommendations• Comorbidity data should be collected as it is important in the analysis of survival, quality of life and functional outcomes after treatment as well as for comparing results of different treatment regimens and different centres. (R)• Patients with hypertension of over 180/110 or associated target organ damage, should have antihypertensive medication started pre-operatively as per British Hypertension Society guidelines. (R)• Rapidly correcting pre-operative hypertension with beta blockade appears to cause higher mortality due to stroke and hypotension and should not be used. (R)• Patients with poorly controlled or unstable ischaemic heart disease should be referred for cardiology assessment pre-operatively. (G)• Patients within one year of drug eluting stents should be discussed with the cardiologist who was responsible for their percutaneous coronary intervention pre-operatively with regard to cessation of antiplatelet medication due to risk of stent thrombosis. (G)• Patients with multiple recent stents should be managed in a centre with access to interventional cardiology. (G)• Surgery after myocardial infarction should be delayed if possible to reduce mortality risk. (R)• Patients with critical aortic stenosis (AS) should be considered for pre-operative intervention. (G)• Clopidogrel should be discontinued 7 days pre-operatively; warfarin should be discontinued 5 days pre-operatively. (R)• Patients with thromboembolic disease or artificial heart valves require heparin therapy to bridge peri-operative warfarin cessation, this should start 2 days after last warfarin dose. (R)• Cardiac drugs other than angotensin-converting enzyme inhibitors and angiotensin II antagonists should be continued including on the day of surgery. (R)• Angotensin-converting enzyme inhibitors and angiotensin II antagonists should be withheld on the day of surgery unless they are for the treatment of heart failure. (R)• Post-operative care in a critical care area should be considered for patients with heart failure or significant diastolic dysfunction. (R)• Patients with respiratory disease should have their peri-operative respiratory failure risk assessed and critical care booked accordingly. (G)• Patients with severe lung disease should be assessed for right heart disease pre-operatively. (G)• Patients with pulmonary hypertension and right heart failure will be at extraordinarily high risk and should have the need for surgery re-evaluated. (G)• Perioperative glucose readings should be kept within 4–12 mmol/l. (R)• Patients with a high HbA1C facing urgent surgery should have their diabetes management assessed by a diabetes specialist. (G)• Insulin-dependent diabetic patients must not omit insulin for more than one missed meal and will therefore require an insulin r...
Paroxysmal Vocal Cords Dysfunction(PVCD), also known as paradoxical vocal cord motion, is abnormal adduction of the vocal cords during inspiration. Like asthma, PCVD can be triggered by breathing in lung irritants, upper respiratory infection or exercise. However, unlike asthma, PCVD is not an immune system reaction and does not involve the lower airways. Treatment for the two conditions differs. Plasma lactate levels are usually associated with acidosis and an increased risk of poor outcome and are described in a number of disease states of circulatory and/or respiratory failure. In patients with psychogenic hyperventilation, high lactates are associated with hypocapnia and alkalosis and should not necessarily be considered as an adverse sign. We describe a case of a young patient with PCVD mimicking asthma with high plasma lactate and discuss the mechanisms involved.
Divided into 13 stations on professionalism, resuscitation, data, and equipment, OSCE 8 is mapped to the Fellowship of the Faculty of Intensive Care Medicine (FFICM) and Competency-Based Training in Intensive Care Medicine in Europe (CoBaTrICE) curricula. Structured to reflect the real exam, answers are accompanied by syllabus references for the FFICM and CoBaTrICE domains for self-assessment, along with further reading for self-assessment.
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