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Leafy vegetables (g) 4 50–75 Overall fucidin 10gm free shipping virus attack, it is the defciency of calories (energy) order fucidin 10gm free shipping antibiotic resistance nz, whereas Other vegetables (g) 14 30–50 protein intake is purchase fucidin 10 gm fast delivery antibiotic resistance prevention, by and large cheap fucidin 10 gm free shipping virus movie, satisfactory. A noteworthy Fruits (g) 7 40–50 observation is that diet of children belonging to the higher Milk and milk products (g) 80 200 strata of society show intake of protein that is in excess. It Fats and oils (g) 4 20–25 is, therefore, important to lay stress on total intake of food Flesh foods (g) 4 30 rather than just protein as is often done in practice. Fruits, vegetables and nuts and seeds are Calcium (mg) 193 400 rich in vitamins, micronutrients, minerals, antioxidants Vitamin A (mg) 220 400 and fber (Figs 11. Foodstufs Calories Proteins Foodstufs Calories Proteins Leafy vegetables Flesh foods z Onion tops 61 4. Fats carry fat-solubles vitamins (A, D, E and K) are precursors of hormones and prostaglandins B. The low glycemic index foodstuff (wheat, maize and pulses) are recommended for diabetic patients B. Antioxidants are substances in food that signifcantly decrease the adverse effects of free radicals B. A Clinical Problem-solving Review 1 A 7-year-old child presents with poor appetite and generalized weakness. Would not it be all right to schedule this child’s recommended intake chart according to his actual weight? Review 2 A teenager athelete is upset that on account of his being a vegetarian, he was on a biologically incomplete protein diet. Since he was unlikely to get converted to a nonvegetarian, his concern appeared to be well-founded. Thus, the child is falling short of 200 kcal and 13 g protein in his daily dietary consumption. Thus requirement at 2 year-1100 kcal, 3 years-1200 kcal, 4 years-1300 kcal, 5 years-1400 kcal, 5 years-1400, 6 years-1500 and 7 years-1600 kcal. Since standard weight at 7 years is 22 kg, his total requirement of protein comes to nearly 62 g. They provide a good deal of essential amino acids, namely—lysine, leucine, isoleucine, tryptophan, valine, methionine, phenylalanine, threonine and histidine. Proteins of vegetable origin are usually biologically incomplete since they lack one or more of the essential amino acids. When different vegetable sources of protein are combined, result is a product that is likely to provide all the essential amino acids. Higher amounts of vegetable proteins are needed to make allowance for low biological value. So, this boy get make up his defciency but consuming higher amounts of varying vegetable sources of proteins in combination. Biologic value is the fraction of absorbed nitrogen retained in the body for growth or maintenance. It is 100 for egg protein which is regarded as the reference protein, 75 for milk and fsh and 67 for rice. It is a must to meet nutritional as well as emotional and psychological needs of the infant. Most appropriate feeding strategy for infants and young children is: Early initiation of breastfeeding. Following these recommendations in letter and spirit is crucial for the proper growth and development of infants and children and for reducing the prevalence of malnutrition which directly or indirectly leads to high Fig. Prolactin level milk expressed or from a wet nurse as the predominant reaches the peak around 30 minutes of initiation of source of nourishment). However, the infant may also breastfeeding, thereby getting the milk ready for the have received liquids (water and water-based drinks, next feed. Complementary food: Hygienically prepared home- Oxytocin milk ejection refex: Suckling by the baby made mashed food given to an infant after six months sends sensory impulses from the nipple to the posterior of age when breastfeeding alone is likely to be inade- pituitary gland (Fig. T us, milk, which has collected in the alveoli, fows along the ducts to the lactiferous sinuses. From alveoli, about 20 small Rooting refex, guides the infant to reach the nipple ducts carry milk to their own dilated ends, lactiferous and to have his mouth properly attached to the breast. From A good attachment (termed laching) with nipple and these sinuses, milk passes on to the nipple for supply to the enough of areola into infant’s mouth is essential for infant. Infant’s proper attachment (laching) with infant’s wide open mouth, everted lower lip, maximum areola in his mouth, and his chin touching the breast is crucial for success of breastfeeding. Incorrect attachment on right is in the form of only nipple in infant’s narrowly-open mouth with lower lip not turned outward and chin not touching the breast. Suckling refex, helps the infant to draw out milk Composition from mother’s breast. Also, it assists in gradually Timeline At outset of feed At tailend of feed establishing the organism, Lactobacillus bifdus, Appearance Watery in the baby’s intestine. Furthermore, it contains agents Highlights of Rich in proteins, lactose, Rich in fat composition vitamins, minerals and water against Staphylococcus group of organisms which are Role/function In addition to meeting In addition to meeting responsible for septicemia of the newborn. Te mother derives much satisfaction and a sense of Composition of foremilk (milk secreted at the outset fulfllment from nursing her baby successfully. In short, hind milk is relatively richer in fats Protection against ulcerative colitis: It has now been which contribute to energy. Hence, both fore milk and hind demonstrated by several investigations that adults milk are important for infant’s growth and development. Miscellaneous: Hypernatremic dehydration which Composition of colostrum (milk secreted in first may prove disastrous to an infant’s brain seldom 3–4 days of birth), transitional milk (milk secreted between occurs in breastfed babies. Evidence has also pooled 3–4th day and 14th day) and mature milk (milk secreted up, suggesting that incidence of obesity in breastfed after two weeks) too difers (Table 12. Breastfeeding helps in spacing children since chance Advantages/Benefts of Human Milk of conception in a lactating mother are less, provided For the Infant her periods have not resumed. Breastfeeding also helps in slimming by enabling Tailor-made composition: Human milk has a compo- uterus to return to normal size and also drains away sition that is ideally tailored to the requirements of a extra fat accumulated during pregnancy. Incidence of breast cancer in such mothers is relatively Readymade: No preparation needed. It is perhaps because of this factor also that It is inexpensive, costing virtually nothing and thus incidence of respiratory and gastrointestinal infections economical for individual family, community and the in breastfed infants is far less than that reported in nation. It contributes to reduction in infant morbidity and Breastfed babies have seven times less chances of an mortality. Its secretory IgA provides Exclusive breast milk: Breastfeeding should be started protection against respiratory and gastrointestinal within frst half to one hour after birth and continued infections. It contains lactoferrin, a substance that exclusively up to the age of six months. Timeline 14th days of birth Soon after birth Cues do point out that the baby is hungry and needs onwards feeding.

D: The return cycle remains essentially fixed as the S1S2 is decreased to 240 msec cheap fucidin 10gm overnight delivery virus undead. E: As the S1S2 is further decremented below 240 msec order 10 gm fucidin with visa antibiotic resistance by maureen leonard, the return cycle increases until discount fucidin 10 gm amex virus 7zip, at an S1S2 of 180 msec discount 10 gm fucidin with amex infection from bee sting, the return cycle had increased to 480 msec. The resetting response of ventricular tachycardia to single and double extrastimuli: implications for an excitable gap. As shown in Figure 11-163, in some cases a flat curve may be seen with single extrastimuli, and it is only by using double extrastimuli that an increasing component of the resetting response curve can be observed. This further demonstrates that double extrastimuli more fully characterize the excitable gap than single extrastimuli. In this example, single extrastimuli produce a flat response, while double extrastimuli produce a flat response followed by an increasing response, and finally, termination of the tachycardia. The entire excitable gap demonstrated in Figure 11-164 was 155 msec and occupied 35% of the tachycardia cycle length. The resetting response of ventricular tachycardia to single and double extrastimuli: implications for an excitable gap. Moreover, in all cases in which single extrastimuli reset the tachycardia, double extrastimuli delivered from the same site produced an identical or expected resetting curve. Thus, if single extrastimuli produce a flat curve, double extrastimuli produce a flat or a flat plus increasing curve, depending on whether or not the second extrastimulus encroaches on refractory components of the excitable gap. If single extrastimuli exhibit an increasing or mixed curve, double extrastimuli also exhibit an increasing or mixed curve, respectively. Although the type of curve is unrelated to tachycardia cycle length, the absolute duration of the curve does seem to relate to tachycardia cycle length. This mechanism has no fully excitable gap and would 341 not be possible to reset by stimulation performed at a distant site. The proposed mechanisms for the three types of curves observed in our patients are schematically shown in Figure 11-165. The flat curves with return cycles less than the tachycardia cycle length and the mixed or smoothly increasing curve have never been documented in triggered activity that is due to late afterdepolarizations. In triggered activity, extrastimuli produce either a return cycle at 100% to 110% of tachycardia cycle length or a return cycle that decreases as stimuli become more premature. A: Schemas of the three types of curves we have observed (flat, increasing, and mixed). B, C: A theoretical mechanism of what is occurring in the reentrant circuit is shown at coupling intervals of X and X-50. The reentrant circuit is depicted as having a separate entrance and exit in each pattern. Each tachycardia impulse is followed by a period of absolute refractoriness (thick dark area), which is then followed by a period of relative refractoriness (stippled area) of a variable duration. A: On the left, a flat curve results when the stimulated impulse reaches the tachycardia circuit and finds a fully excitable gap between the head and tail of the tachycardia impulse. This curve results when the initial impulse producing resetting enters the tachycardia circuit when the excitable gap is partially refractory. The curve continues to increase at a coupling interval of X-50 because the tissue is still in a relatively refractory state. A mixed curve results when extrastimuli delivered at long coupling intervals find the reentrant circuit fully excitable and reset it, as in the typical flat curve shown on the left. However, at a coupling interval of X-50 the impulse finds the excitable gap partially refractory, and an increasing component of the curve results. Changes in circuit length or wavelength might result in changes in the characteristics of the excitable gap; (4) different effects of intervening tissue (anisotropy, curvature, impedance mismatch) on conduction of the stimulated wavefront into the circuit. This phenomenon suggests that the barriers (lines of block) and, consequently, the size of the circuit are at least partially functionally determined and can be markedly influenced by nonuniform anisotropy and/or that the stimulated wavefronts P. It is highly likely that all tissue in the reentrant circuit is not the same and that conduction velocity, excitability, and refractoriness vary at different sites along the reentrant pathway. The variable directions of the incoming wavefronts, due to the different sites of stimulation, will necessarily be associated with different 29 51 52 311 conduction velocities dependent on the arrangement of fibers that the wavefront encounters. Corrected coupling intervals of extrastimuli are shown on the X axis and the return cycles on the Y axis. Note that the slopes of the increasing component of the resetting curves from both sites is similar. The variable contribution of functional and anatomic barriers in human ventricular tachycardia. In these cases, the use of multiple extrastimuli, more commonly overdrive pacing, can demonstrate resetting. The use of overdrive pacing at decreasing cycle lengths with the addition of an incremental number of extrastimuli to each train of pacing at each cycle length can allow one to recognize (a) how many extrastimuli are required before the tachycardia is first reset and (b) the phenomenon of continuous resetting (entrainment). As noted earlier, the requirement for multiple extrastimuli to influence the tachycardia depends on the tachycardia cycle length, the duration of the excitable gap of that tachycardia, refractoriness at the stimulation site, and conduction time from the stimulation site to the tachycardia circuit. With overdrive pacing, a variable number of extrastimuli in the train are used to allow a single extrastimulus to reach the circuit in time to interact with the tachycardia. We refer to the first stimulus in a train that resets the circuit as the nth stimulus. If pacing were stopped at that point, one would assess the influence of a single extrastimulus on the tachycardia circuit. If pacing at that cycle length is continued, continuous resetting of the reset (by the nth stimulus) tachycardia circuit is observed. Entrainment is defined as a specific response to overdrive pacing: Following the first beat of a train of stimuli that penetrates and resets the tachycardia (nth stimulus), subsequent stimuli interact with the reset circuit. Depending on the degree that the excitable gap is pre- excited by the nth stimulus, the subsequent stimuli will fall on either fully excitable or partially excitable tissue. Entrainment is said to be present when two consecutive stimuli conduct orthodromically through the circuit with the same conduction time while colliding antidromically with the preceding paced wavefront. At shorter drive cycle lengths, fewer extrastimuli will be necessary before one resets the tachycardia. Regardless of cycle length used, we have found that the return cycle following the nth stimulus is identical to that during resetting at comparably premature coupling intervals. The influence of the drive cycle length on number of extrastimuli required to reset of the tachycardia (i. Although the initial impulse that resets the tachycardia (nth) does so as described earlier (see the discussion of resetting), if pacing is continued, the reset tachycardia circuit is continuously reset. It is important that the investigator realize that continuous resetting of the circuit (i. Only the first extrastimulus that resets the tachycardia (nth stimulus) interacts with the tachycardia. Consequently, all stimuli following the nth stimulus interact with the “reset circuit,” which has an excitable gap that has been foreshortened by the degree of prematurity with which it was reset. Just as the cycle length chosen influences the number of extrastimuli required to produce resetting, it also affects the number of extrastimuli required to produce entrainment.

Each quadrant is cleaned methodically order 10gm fucidin mastercard antibiotics quiz questions, starting at the right upper quadrant buy fucidin 10gm overnight delivery antibiotic used to treat mrsa, going to the left fucidin 10gm on-line bacterial infection, moving down to the left lower quadrant order 10gm fucidin visa antibiotics for diverticulitis, and then fnally over to the right. Fibrous membranes are removed as much as possible, since they may contain bacteria. However, if taking out fbrin attachments means injuring the intra-abdominal viscus, it should be done conservatively. Management of the upper quadrants requires the surgeon to stand between the patient’s legs. For the lower quadrants the surgeon should move to the right side of the patient, who should be tilted in Trendelenburg to give access to the pelvis. Special care- should be taken to irrigate and aspirate between the loops of the small bowel. Once all this has been done, the patient is tilted back to the normal position for the surgeon to close the perforation. Closure of the Perforation with an Omental Patch The perforation is closed using an omental patch (Fig. It is advisable to insert the omental patch in the knot (true Graham patch), rather than use the tails of the knot to fx the patch as a result of which a small space remains between the knot itself and the omental patch, thereby diminishing the effcacy of the patch (Fig. The classic technique follows the same rules as with the original open Graham patch. The assistant holds the omental patch while the surgeon uses both hands to knot the ties. It is not necessary to place an abdominal drain if the procedure has been conducted appropriately. Endosc Surg Allied Technol 2(2):117–118 Eypasch E, Stuttmann R, Jahn M, Troidl H, Doehn M (1995) Anesthesia for laparoscopic closure of perforated peptic ulcer–any harm or beneft? Endosc Surg Allied Technol 3(4):171–173 Fujita T (2009) Open or laparoscopic resection of a large gastric gastrointestinal stromal tumor. Arch Surg 144(2):193–194 Gagner M, Pomp A (1994) Laparoscopic pylorus-preserving pancreatoduodenectomy. Arch Surg 144(6):559–564 Jagot P, Sauvanet A, Berthoux L, Beighiti J (1996) Laparoscopic mobilization of the stom- ach for oesophageal replacement. J Laparoendosc Surg 4(6):447–450 Johansson B, Hallerback B, Glise H, Johnsson B (1996) Laparoscopic suture closure of perforated peptic ulcer. Endosc Surg New Technol 2:7–9 Katkhouda N (1995) Laparoscopic treatment on gastroesophageal refux disease; defn- ing a gold standard. Surg Endosc 9:765–767 Katkhouda N, Mouiel J (1991) A new technique of surgical treatment of chronic duode- nal ulcer without laparotomy by videocoelioscopy. Am J Surg 161:361–369 Katkhouda N, Iovine L, Mouiel J (1993) Right vagotomy and anterior fundic seromyot- omy in the treatment of non complicated duodenal ulcer. J Coeliosurg 7:5–9 (in French) Katkhouda N, Heimbucher J, Mouiel J (1994a) Laparoscopic posterior vagotomy and anterior seromyotomy. Endosc Surg New Technol 2:95–99 Katkhouda N, Heimbucher J, Mouiel J (1994b) Laparoscopic posterior truncal vagotomy and anterior seromyotomy. Arch Surg 134:845–850 116 Chapter 6  Gastric Surgery Katkhouda N, Friedlander M, Grant S, Mavor E, Achanta K, Essani R, Mouiel J (2000) Laparoscopic repair of intrathoracic volvulus. Ann Surg 248(5):793–799 Kitano S, Iso Y, Moriyama M, Sugimachi K (1994) Laparoscopy-assisted Billroth I gas- trectomy. Surg Laparosc Endosc 4(2):146–148 Kojima K, Yamada H, Inokuchi M, Kawano T, Sugihara K (2008) A comparison of Roux- en-Y and Billroth-I reconstruction after laparoscopy-assisted distal gastrectomy. Ann Surg 250(2):349–350 Liorente J (1994) Laparoscopic gastric resection for gastric leiomyoma. Arch Surg 140(9):841–846 Matsuda M, Nishiyama M, Hanai T, Saeki S, Watanabe T (1995) Laparoscopic omental patch repair for perforated peptic ulcer. Ann Surg 222(6):761–762 Miserez M, Eypasch E, Spangenberger W, Lefering R, Troidl H (1996) Laparoscopic and conventional closure of perforated peptic ulcer. Surg Endosc 10(8):831–836 Mouiel J, Katkhouda N (1991) Laparoscopic vagotomy in the treatment of chronic duo- denal ulcer disease. Prob Gen Surg 83:358–365 Mouiel J, Katkhouda N (1993) Laparoscopic vagotomy for chronic duodenal ulcer. World J Surg 7:34–39 Mouiel J, Katkhouda N, Gugenheim J, Fabiani P, Goubaux B (1990) Treatment of duode- nal ulcer by posterior truncal vagotomy and anterior fundic seromyotomy by video- coeliocopy. Chirurgie 116:546–551 (in French) Mouiel J, Katkhouda N, Gugenheim J, Fabiani P, DiMarzo L, Bertrandy M (1991) Elective laparoscopic surgery in duodenal ulcer. La Lettre Chir 8:100 Mouiel J, Katkhouda N, Gugenheim J, Fabiani P (1995) Posterior truncal vagotomy and seromyotomy by laparoscopy. J Coeliosurg 15:53–57 (in French) Otani Y, Furukawa T, Yoshida M, Saikawa Y, Wada N, Ueda M, Kubota T, Mukai M, Kameyama K, Sugino Y, Kumai K, Kitajima M (2006) Operative indications for rela- tively small (2-5 cm) gastrointestinal stromal tumor of the stomach based on analysis of 60 operated cases. Surg Endosc 13:738–741 Uyama I, Ogiwara H, Takahara T, Kato Y, Kikuchi K, Lida S (1994) Laparoscopic and mini- laparotomy Billroth I gastrectomy for gastric ulcer using an abdominal wall-lifting method. Am J Surg 171(6):600–603 Yamashita Y, Kurohiji T, Kakegawa T, Bekki F, Ogata M (1995) Laparoscopy-guided extra- corporeal resection of early gastric carcinoma. A foley catheter is always placed as in other pelvic or lower abdominal procedures to decrease the risk of injury to the bladder during port placement. The surgeon and the assistant both stand on the left side of the patient facing the monitor located on the right side of the patient (Fig. Pneumoperitoneum is created in the standard fashion using either the Hasson technique or a Veress needle. Care must be taken in patients who have had a longer course of disease if using a Veress needle, as the infammation of the omentum and sur- rounding small bowel increase the risk of injury to the small bowel or other structures. Two 5 or 10 mm ports are inserted, one in the left lower quadrant in a position corresponding but opposite to McBurney’s point, and the second is placed in a suprapubic position. In a male patient, the right trocar is inserted in a position cor- responding to the left (Fig. In a female patient, both trocars can be hidden in the pubic hair line if cosmesis is an issue (Fig. If an additional trocar is needed for bowel retraction or suctioning, a 5-mm port can be placed in the right upper quadrant. Care must be taken to avoid a “knitting needle” effect between instruments and the laparoscope; all ports should be placed in such a way that they have free movement and do not interfere with one another. The body habitus of the patient will infuence place- ment of the ports to achieve this goal. The surgeon’s right hand operates a Kelly grasper to create windows in the mesoappendix. If the appendix is not clearly identifable because it is retrocecal, the cecum needs to be mobilized and retracted medially (Fig. A telescope; B surgeon’s right hand; C surgeon’s left hand 122 Chapter 7  Appendectomy Fig. The adhesions from the appendix to the surrounding organs and the mesentery are divided using the harmonic scalpel or bipolar forceps. Another loop is then inserted next to the frst two loops and the appendix is transected between the two proximal loops and the distal loop.

Shivering is the body’s attempt to increase heat production and raise body temperature and may be associated with intense vasoconstriction cheap 10 gm fucidin with amex antibiotics for acne minocycline. Shivering may also be a nonspecific neurologic sign that is sometimes exhibited during emergence from anesthesia order 10 gm fucidin visa antibiotic cefdinir. It is most common after long surgeries and with the use of greater concentrations of volatile agent order 10 gm fucidin mastercard 3m antimicrobial mask. Deleterious effects of shivering: Occasionally cheap fucidin 10 gm with amex antibiotic resistance due to overuse of antibiotics, shivering can induce hyperthermia (38°–39ºC) and metabolic acidosis. Shivering can also be seen after spinal and epidural anesthesia because these techniques lower the shivering threshold and vasoconstrictive response to hypothermia. Shivering increases oxygen consumption by as much as five times, decreases arterial oxygen saturation, and is associated with an increased risk of myo- cardial ischemia. Unintentional hypothermia increases with extremes of age, abdominal surgery, surgeries of long duration, and cold ambient operating room temperature. An uncontrolled increase in intracellular calcium occurs in skeletal muscle and causes sustained muscle contraction. Sympathetic system overactivity causes tachycardia, arrhythmias, hypertension, and mottled cyanosis. Hyperthermia may be a late sign; core temperature can rise as much as 1°C every 5 minutes. A mixed metabolic and respiratory acidosis with a high base deficit, hyperkalemia, hypermagnesemia, and reduced mixed-venous oxygen saturation may occur. Halothane-caffeine contracture test may be performed if the diagnosis remains in doubt postoperatively. A biopsy of living skeletal muscle is obtained and exposed to caffeine, halothane, or combination of the two. This test has a 10% to 20% false-positive rate, but it has close to a zero false-negative rate. Pro to co l fo r Im m e d ia te Tre a tm e n t o f Ma lign a n t Hyp e rth e rm ia 1. Institute cooling m easures (lavage, cooling blanket, cold intravenous solutions). Treat severe hyperkalem ia with dextrose, 25–50 g intravenously, and regular insulin, 10–20 units intravenously (adult dose). Adm inister antiarrhythm ic agents if needed despite correction of hyperkalem ia and acidosis 7. Dietary fats and carbohydrates normally supply most of the body’s energy requirements for cellular function. Dietary proteins provide amino acids for protein synthesis, and amino acids can also function as energy substrates. Healing of wounds requires energy, protein, lipids, electrolytes, trace elements, and vitamins. Depletion of any of these substrates may delay wound healing and predispose to infection. Patients with critical illness should undergo whatever initial hemodynamic resuscitation they require before initia- tion of nutritional support. Absorption, distribution, and metabolism of nutrients require tissue blood flow, oxygen, and carbon dioxide removal. Perioperative Nutrition Considerations Malnourished patients benefit from nutritional repletion via either enteral or parenteral routes before elective surgery. For example, hypophosphatemia is a serious and often unrecognized complication that can contribute to postoperative muscle weakness and respiratory failure. Administering a carbohydrate “load” to nondiabetic patients shortly before surgery favorably increases plasma insulin concentrations and decreases postoperative insulin resistance. Overfeeding with excess amounts of glucose can increase energy requirements and production of carbon dioxide. Mild elevations of serum transaminases and alkaline phosphatase may reflect fatty infiltration of the liver resulting from overfeeding. Refeeding of severely malnourished patients may result in refeeding syndrome with acute decreases in cir- culating levels of potassium, magnesium, and phosphate. Discuss the risks of airway trauma with the patient with a more in- depth discussion if the patient has a previous or suspected difficult airway Intraoperative management: Prepare for difficult intubation if preoperative examination is concerning for difficult intubation Postoperative management: Sore throat and dysphagia are usually self-limited. Permanent injury such as dental injury may require the involvement of the institution’s risk management department. One retrospective study of 600,000 surgical cases found that one in 4500 patients needed dental intervention and repair. Esophageal perforations: Patients present with delayed-onset pneumothorax or subcutaneous emphysema. Death occurred in five of 13 patients with perforation Pharyngoesophageal perforation: Associated with age older than 60, female gender, and difficult intuba- tion. Patients present initially with cough, sore throat, cervical pain that progresses to fever, dyspnea, or dysphagia after mediastinitis, abscess, or pneumonia develops. Anaphylactoid reactions resemble anaphylaxis but do not require IgE antibody interaction with an antigen. In anaphylactoid reactions, the drug can cause release of histamine directly from mast cells. Clinical manifestations: Occurs within minutes of exposure to triggering agent Diagnosis: Hypotension, tachycardia, arrhythmias, bronchospasm, cough, dyspnea, pulmonary edema, laryn- geal edema, hypoxia, urticaria, facial edema, and pruritus are all manifestations of a hypersensitivity reaction. Predisposition includes young age, pregnancy, history of atopy, and previous drug exposure. Prophylactic treatment with steroids and H blockers such 2 as ranitidine and diphenhydramine may be indicated. Surgical procedures associated with a higher incidence of recall include cardiac surgery, major trauma surgery, and obstetrics. In large part, this is attributable to the exacerba- tion of previously existing hemodynamic instability when anesthetic is added. Recall under general anesthesia is more likely in women and when the anesthetic technique avoids volatile agents with use of opioids and neuromuscular blockers. Cardiovascular intolerance to anesthesia; medication errors; young age; smoking; and chronic use of alcohol, opiates, or amphetamines are all risk factors. Clinical manifestations: Anxiety, posttraumatic stress disorder, sleep disturbances, nightmares, and social difficulties Diagnosis: Patient exhibits recall on postanesthetic evaluation. If the patient is undergoing monitored anesthetic care, explain to the patient that he or she will be awake but sedated and may hear conversations during the procedure. In addition, prolonged surgical time com- bined with positions other than supine, deliberate hypotension, and anemia contribute. Diagnosis: Made postoperatively on postanesthetic examination, likely in the postanesthetic care unit Preoperative management: If the anesthetic plan is for monitored anesthetic care, the patient must be edu- cated to stay still, especially if the operative field includes the eye. Consider placing the pulse oximeter probe on a finger other than the index finger to minimize the risk of corneal abrasion during emergence if the patient tries to rub his or her eyes. Position the patient head up and minimize abdominal compression to augment venous outflow. Consider staging the procedure in high-risk patients if it is acceptable with the surgical team.