ECOG PERFORMANCE STATUS - ECOG
0 Fully active, able to carry on all pre-disease performance without restriction
1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
2 Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours
3 Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours
4 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair
5 Dead

Surgical Filter
Congenital
Acquired -

• It - Infective
• Is - Inflammatory
• Very - Vascular
• True - Trauma
• That - Tumour
• All - Autoimmune
• Is - Idiopathic
• Mine - Metabolic

Causes of Carpal Tunnel Syndrome

• Idiopathic- although you tend to find this in obese females,
• Pregnancy,
• Contraceptive pill,
• Endocrine causes- acromegaly, hypothyroidism,
• Rheumatoid arthritis,
• Amyloidosis,

Gradations of Murmurs

Grade 1 Very faint, heard only after listener has "tuned in"; may not be heard in all positions.

Grade 2 Quiet, but heard immediately after placing the stethoscope on the chest.

Grade 3 Moderately loud.

Grade 4 Loud, with palpable thrill (ie, a tremor or vibration felt on palpation).

Grade 5 Very loud, with thrill. May be heard when stethoscope is partly off the chest.

Grade 6 Very loud, with thrill. May be heard with stethoscope entirely off the chest.

Perioperative Medicine - Cardiac

Mechanism of Peri-operative MI:

• Plaque fissuring due to Inflammatory state and stress
• Hypercoagulability precipitating acute coronary thrombosis.
• Hypoxic state secondary to anaesthesia, hypothermia, bleeding and anaemia.

Peri-operative cardiac risk can be assessed by many different methods:

Eagle Criteria

1. Age more than 70 yrs.
2. DM - requiring therapy other than diet
3. CCF
4. MI - q wave on ECG
5. History of angina

2 Risk factors - < 5% risk
3 or more risk factors - 30 - 40 % risk

Revised Cardiac Risk Index ( Lee et al )

1. High risk surgery - AAA repair, thoracic and abdominal
2. IHD - AMI, Q wave, angina, nitrates, EST positive
3. CCF
4. CVA - stroke, TIA
5. Pre-op insulin
6. Serum creatinine > 180 micromol/L

3 risk factors - intermediate
4 or more risk factors - high risk

High Risk patient can be further assessed by doing Dobutamine Stress Echocardiogram.

• If ECG changes at high work load - 20 % risk
• If ECG changes at low work load - 70 % risk

Management,

Cardiac Prophylactic measures include:

• Coronary revascularisation ( PCI or CABG )

• Adjuvant therapies - Beta blockers & Aspirin

• No high quality evidence of decreased perioperative cardiac risk according to: other anti-anginal medications and type of surgery - open vs laproscopic
  

Coronary revascularisation ( PCI or CABG )

The underlying mechanism of perioperative cardiac event is different from usual cardiac event as described before. The decision for revascularisation should rest on proven indications in non-operative setting - for symtomatic control or for prognosis.

Indications in which PCI is beneficial for prognosis include:

1. Left main coronary lesion
2. Proximal LAD lesion
3. Triple vessel disease
4. Ejection Fraction less than 40 %

If PCI is done, surgery should be deferred for 6 weeks or longer. ( within 6 weeks - 20 % mortality, 18 % non-fatal MI and 28 % major bleeding )

Classification of Antibiotics by Target site of activity:

1. Inhibitors of cell wall synthesis

Beta - lactam:

• Penicillins

• Cephalosporins

1st generation ( cephalexin ) has good G positive cover.
2nd generation ( Cefoxitin ) has good G negative and anaerobic cover.
3rd generation ( Ceftriaxone, Cefotaxime and Ceftazidime ) has good G negative cover.
4th generation ( Cefepime ) has good cover for both G positive and negative cover.

• Carbapenem - imipenem, meropenem and ertapenem

Imipenem and meropenem are essentially the same as giving combination of ampicillin, flucloxacillin, gentamycin and metronidazole. However, they don't cover Stenotrophomonas and E. faecium.
Ertapenem does not cover Pseudomonas and Acinectobacteria
Can be used in renal failure.

• Monobactam - Aztreonam

Aztreonam has the same antibiotics spectrum as gentamycin but it does not have renal toxicity.

Glycopeptides:

• Vancomycin

• Teicoplanin

Others:

• Cycloserine

• Bacitracin

2. Inhibition of protein synthesis

30s ribosomal subunit:

• Aminoglycosides

• Tetracycline

50s ribosomal subunit:

• Chloramphenicol

• Clindamycin

• Macrolides

• Fusidic Acid

3. Inhibition of nucleic acid synthesis

Block folic acid synthesis:

• Trimethoprim

• Sulphonamides

DNA Gyrase inhibition:

• Fluoroquinolones - Norfloxacin, Ciprofloxacin, Moxifloxacin, Gatifloxacin.

Covers G negative aerobic including Legionella
Only ORAL antibiotics which cover Pseudomonas
Cipro has poor G positive cover
Moxi and Gati have good G positive cover but slightly less G negative cover than Cipro
Cipro has poor anaerobic cover but Moxi and Gati has better anaerobic cover.

RNA polymerase inhibiton:

• Rifamycin e.g., Rifampicin

4. Inhibition of cell membrane function e.g., Colistin.

5. Newer antibiotics:

• Quinupristin - dalfopristin
• Linezolid - only ORAL antibiotics that cover Vancomycin resistant MRSA ( VRSA )
• Daptomycin
• Tigecycline - affect G positive ( including VISA, VRSA, MRSA, PRSP ), G negative and anaerobes but it does not cover Proteus mirabilis, Pseudomonas aeruginosa and Burholderia cepacia.

Mechanism of Antibiotics Resistance:

Four broad categories of resistance mechanism

1. Antibiotics Inactivation
2. Alteration in antibiotics target sites
3. Decreased antibiotics permeability of the cell wall preventing drug access to its target
4. Active antibiotics efflux from the bacteria

Antibiotics Inactivation

A. Beta lactamases: can be inhibited by clavulanic acid, tazobactam and sulbactam.

B. Inducible chromosomally mediated beta - lactamase production:

• Inactivate third generation cephalosporins.
• In particular, organisms which demonstrate this important form of Beta lactamase productions are ' ESCAAPPM ' -do not treat with penicillins or cephalosporins
  

• E - Enterobacter species
• S - Serratia species
• C - Citrobacter
• A - Acinectobacter
• A - Aeromonas
• P - Proteus
• P - Providentia
• M - Morganella morganii

C. Aminoglycoside modifying enzymes

D. Others - ESBL ( extended spectrum beta lactamase )

• now being common in large hospital.
• inactivate all cephalsporins.
• Klebsiella pneumoniae and E. coli are the usual organism to harbour ESBLs.
• Treatment is with meropenum or cotrimoxazole.

E. MBL - Metallobetalamase