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Severe and more prolonged heart failure results in delicate fbrous strands radiating from the central veins. Instead, a combination of some common toxic effects and inherited abnormality of copper metabolism has been suggested. M/E Following features are generally seen: 407 i) Liver cell injury ranging from ballooning degeneration to signifcant damage to hepatocytes. The condition may run a variable natural history ranging from indolent to severe rapid course. This form of hepatitis has prominent autoimmune etiology is supported by immunologic abnormalities and a few other characteristic diagnostic criteria as under: 1. Exclusion of chronic hepatitis of other known etiologies (viral, toxic, genetic etc). M/E Autoimmune hepatitis is morphologically indistinguishable from chronic hepatitis of viral etiology. There are features of burnt out chronic autoimmune hepatitis accompanied with cirrhosis. The condition is seen more commonly in affuent western societies, has a strong association with obesity, dyslipidaemia and type 2 diabetes mellitus. Similar condition described from Japan has been named as idiopathic (primary) portal hypertension with splenomegaly. The type common in India, particularly in young males, is related to following etiologic factors: 1. Exposure to trace elements, particularly chronic arsenic ingestion in drinking water. Infections, particularly of umbilical cord, infective diarrhoea and sepsis, causing infection in portal circulation and leading to thrombophelebitis. G/A the liver is small, fbrous and shows prominent fbrous septa on both external as well as on cut surface. M/E the salient features are as under: i) Standing out of portal tracts due to their increased amount of fbrous tissue in triad without signifcant infammation. The ultimate causes of death are hepatic coma, massive gastrointestinal haemorrhage from oesophageal varices (complication of portal hypertension), intercurrent infections, hepatorenal syndrome and development of hepatocellular carcinoma. Portal veins have no valves and thus obstruction anywhere in the portal system raises pressure in all the veins proximal to the obstruction. However, unless proved otherwise, portal hypertension means obstruction to the portal blood fow by cirrhosis of the liver. Rare cases of idiopathic portal hypertension showing non-cirrhotic portal fbrosis are encountered. Intrahepatic portal hypertension Cirrhosis is by far the commonest cause of portal hypertension. Other less frequent intrahepatic causes are metastatic tumours, non-cirrhotic nodular regenerative conditions, hepatic venous obstruction (Budd-Chiari syndrome), veno-occlusive disease, schistosomiasis, diffuse granulomatous diseases and extensive fatty change. Posthepatic portal hypertension this is uncommon and results from obstruction to the blood fow through hepatic vein into inferior vena cava.

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The response to acute events cannot Mayet J,Steer P,Somerville J 1998 Marfan syndrome, always be predicted. The use of Management of the parturient with severe aortic epidural anaesthesia, or a drug with mild alpha incompetence. However, adequate preload must first reduction and preload augmentation improve the be achieved. In acute aortic regurgitation, anesthetic management of patients with cardiac Medical disorders and anaesthetic problems A failure and valvular regurgitation. The long term anaesthesia, the risks of noncardiac surgery and prognosis depends upon the degree of stenosis; parturition have decreased (Lao et al 1993, fi0. Acquired disease anaesthesia was said to be contraindicated, but in results from degeneration and calcification of the the presence of invasive monitoring, combined valve leafiets, and is more likely to occur in with techniques that allow gradual induction of congenitally bicuspid valves (Carabello & regional blocks, some anaesthetists believe that 46 Crawford 1997). In some units minimally invasive aortic blood by the left ventricle in aortic stenosis is surgery is being undertaken (Hearn et al 1996). A pressure gradient across the valve of >50 mmHg is considered severe, and <20 mmHg mild. These gradients are increased Preoperative abnormalities by tachycardia and exercise. The onset of symptoms occurs relatively overcome the obstruction, left ventricular late in the disease and includes dyspnoea, hypertrophy occurs and this is associated with a intolerance of exercise, angina, and syncope. The pulse is slow rising and of decreased Once symptoms occur, the prognosis is poor. A pulse pressure of <30 mmHg However, even those with moderate disease are refiects severe disease. Conversely, if the systolic at risk, and those with valve areas from 2 blood pressure is >180 mmHg, the disease is not 0. In a study of the natural history of aortic the base and radiating into the right side of the stenosis, 21% (66 patients) in the moderate neck. The intensity of the murmur correlates group died in the short term from causes well with the Doppler aortic jet velocity (Munt attributed to aortic stenosis (Kennedy et al et al 1999), although echocardiography is still 1991). In another longitudinal study, half of a needed to reliably exclude severe obstruction. Left atrial enlargement and dilatation of the atrial function by arrhythmias or fiuid overload aortic root may be seen later.

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Chromic gut sutures are useful for It is important to administer adequate anesthesia for deep closure; fine nylon or proline stitches are useful for wound closure if the closure is to be made under local skin closure. Typically, injectable 1% lidocaine with epipolyglycolic acid (eg, Dexon) can also be used for deep nephrine mixed 1:100,000 is adequate to obtain anesstitches, they can sometimes become infected due to thesia for closure. This preparation can be injected with sluggish absorption, which can lead to their eventual a fine, 27-gauge needle and a control-type syringe. Other dissolvable toxic dose of lidocaine with epinephrine is 7 mg/kg and monofilament sutures may also be used for deep closhould be noted. These types of stitches may also be useful in children to prevent the need for future stitch removal or when Wound Irrigation patient follow-up is doubtful. When taking care of patients with heavy beards or dark facial hair, it is best Once anesthesia takes effect, the wound should be irrito use a skin suture color other than black to facilitate gated to help prevent future infection. Blue proline suture works well in these tion can only be done effectively if the patient is comcircumstances. Saline can usually be used to irrigate the If wound coverage is difficult because of lost skin, wound with a 60-mL syringe. Howforeign material is suspected to be in the wound, a finever, these flaps are rarely necessary. If they are ger can be used to probe the wound and remove the required, it is often best to accomplish the closure in foreign material. Sometimes the skin is abraded so the operating room setting as instrument sets and nursbadly that the area needing to be anesthetized would be ing assistance become more critical. The risk in using too large to safely administer lidocaine to the patient transposition flaps is that the wound is usually contamiwithout causing lidocaine toxicity. In these cases, it is nated; utilizing these flaps may increase the risk of tisbest to proceed to the operating room so that general sue loss if the wound becomes infected. In some wounds contaminated by tar, tracture process with a subsequent plan, if necessary, for as sometimes occurs in motorcycle accidents or other wound revision. Once the wound is Allowing a bite injury to heal by first-intention healing thoroughly clean, povidone-iodine, commonly known should be considered carefully because the wound is likely as Betadine, can be used to create a sterile environment to be contaminated. Any small bleeding areas can be mary closure is still recommended for these wounds after handled with a disposable electric cautery or by using thorough irrigation and with concomitant antibiotic individual clamps and suture ties. The antibiotic coverage should be directed at a polymicrobial spectrum including Wound Closure hemolytic streptococci, Staphylococcus aureus, and anaerFacial wound closure should heal by first intention (priobes such as Bacteroides.

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