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rheumatic heart disease pathology

PRE-MEDICAL DEVICE EVALUATION OF DENTAL PATIENT

PRE-MEDICAL DEVICE EVALUATION OF DENTAL PATIENT

Author:

Dr. Altaf Malik H

Department of Oral and Maxillofacial Surgery,

Govt. Dental College, Srinagar.

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Co-authors: Â

Dr Ajaz Shah A

Associate Professor and Chief

Department of Oral and Maxillofacial Surgery,

Govt. Dental College, Srinagar.

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Dr. Suhail Lato

Responsible

Department of Pathology and Microbiology,

Govt. Dental College, Srinagar.

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Dr. Manzoor Ahmad Malik

J & K Health Services, SDH Banipora

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Dr. Rubeena Tabasum

Resident

CD Hospital, Srinagar.

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Dr. Shazia Qadir

Department of Oral and Maxillofacial Surgery,

Govt. Dental College, Srinagar.

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INTRODUCTION

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Knowledge of € ™ s health of patients is of paramount importance in patient management and care before and after surgery. A detailed history will internally any professional you need. Relevant information on patients € ™ s overall health and the physical state

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Classification of the physical SYSTEM

In 1962, the American Society of Anesthesiology adopted the ASA classification system. This system identifies the medical risks to a patient undergoing surgery. The system Classification is as follows:

ASA I: Â Â Â Â Â Â One patient without systemic disease, a normal, healthy patient

ASA II: Â Â Â Â Â A patient with mild systemic disease

ASA III: Â Â Â Â a patient with a systemic disease that limits activity holidays, but it is disabling

ASA IV: AAA a patient with incapacitating systemic disease is a constant threat to life

ASA V: Â Â Â Â Â Â A moribund patient not expected to survive 24 hours with or without surgery.

ASA E: Â Â Â Â Â emergency operations of any kind, E above the number of the ASA, indicating the patient € ™ s fitness.

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Heart disease.

While all types of heart disease are at high risk of serious complications when undergoing surgery under general anesthesia, certain conditions such as unstable angina, congestive heart failure, valvular defects Septala, and increase the risk of myocardial infarction four folds. A history of bypass, angioplasty or valve replacement is of great importance. Although heart disease is not an absolute importance. Well as heart disease not an absolute indication-cons, the surgeon must weigh the benefits and risks before deciding on the choice of anesthesia.

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Preoperative Search

1. 1. Â Â Â Â Â routine chest radiograph posteroanterior view.
2. 2. Â Â Â Â Â Electrocardiogram
3. Echocardiography

4Â Â Â Â Â Â Â Stress Test

1. Research such as lipid profile in blood and bleeding time, clotting time and prothrombin time and index finger if the patient is under long-term anticoagulant

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Preoperative drugs

If the patient is a case of rheumatic heart disease or have had valve replacement, appropriate antibiotic prophylaxis should be given. If the patient is penidura infusion every three weeks, surgery should be scheduled immediately after the intended dose to reduce the risk of infective endocarditis. Patients on long-term treatment with anticoagulants should stop taking blood thinners for at least 4 to 5 days before surgery with Physicians ™ € s consent. If the interruption treatment by oral anticoagulation is not recommended, the patient should be transferred to anticoagulants such as heparin by IV. The patient € ™ s bleeding time and coagulation point is checked in the day of surgery after the failure of anticoagulant.

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Intra-and postoperative

1. All patients should be intra-and post-operative follow-up means of ECG, pulse oximeter and arterial line.
2. A central venous pressure (PVC) decrease can be made if necessary.
3. The patient should be kept in the heart of drug intravenously until they receive oral feeding
4. Fluid overload should be reversed, especially in cases of congestive heart failure. The fluid volume may be tried by the SVC.

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HYPERTENSION

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Hypertension is regarded as the elevation blood pressure above 140/190 mmHg.

The uncontrolled hypertension can lead to complications of anesthesia and after surgery.

1. It discusses the patient's heart condition, which increases the complications of cosmetic
2. He discusses the state patient's heart, which increases the risk of anesthesia patient.
3. Cause excessive bleeding in the operation site, which complicates surgery and blood loss important for the patient.

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Preoperative Investigations

1. The chest radiograph shows anterior view for the detection of heart enlargement.
2. ECG
3. Assistant kidney
4. Pailledema and ophthalmologic evaluation for retinal hemorrhage.

Tests of renal function (creatinine serum in the blood urea nitrogen and serum electrolytes).

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Preoperative medication and Management

The Patient ™ € s blood pressure should be monitored and controlled within normal limits allowed before surgery. If the patient is on the dose of antihypertensive medication in the morning before surgery should be administered with sips of water.

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Intra-and postoperative.

1. Blood pressure should be monitored continuously intra-and postoperatively.
2. Patient € ™ s heart function should be monitored on the ECG machine and pulse oximeter pulse.
3. Should continue antihypertensive intra and postoperative.
   1. If the patient is treated with diuretics, patients should be completed postoperatively with intravenous potassium supplements.
   2. If the procedure is performed under local anesthesia, then aneasthetic Local bupivacaline or without epinephrine, which did not effect significant impact on cardiac status, will be used.

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RESPIRATORY DISEASE

Respiratory diseases can be classified obstructive pulmonary disease and infiltration. Obstructive pulmonary disease includes chronic obstructive pulmonary diseases like chronic asthma, chronic bronchitis, emphysema and pneumothorax. Infiltrative disease is inclusive of diseases that cause inflammatory changes in the cell walls. Any respiratory disease was first characterized by dyspnea.

Patients with decreased pulmonary reserve is a major threat to the procedures under general anesthesia. The patient should be asked for a complete history of beedi / cigarette, and history of tuberculosis. If the patient suffers from tuberculosis, while the details their drug plans and asked the duration of treatment. From the perspective of surgeons, the most important aspect is the '™ € s reserve of the patient's breathing and ability to tolerate general anesthesia. If patients treated with local anesthesia, broncho-dilator inhaler must be kept ready for emergencies.

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Preoperative Investigations

1. Chest radiography routine € "postero.
2. Pulmonary function tests.
3. Investigations of blood, such as arterial blood gases.
4. Sputum AFB / culture.
5. Bronchoscopy, if needed

         Patients should be advised to interrupt beedi / cigarette before surgery. Any acute infection should be treated with antibiotics. The patient should be placed on bronchodilators previous intra-and postoperatively. The patient should take his inhaler with him for use in emergencies.

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Intra and postoperative treatment

1. Monitoring of arterial blood gases should also be made intra-and postoperatively.
2. Avoiding fluid overload
   1. Blood loss should be replaced by blood or red blood cells to prevent reducing the carrying capacity of blood oxygen.

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DISEASES OF KIDNEY

Patients with kidney disease, renal failure, acute glomerulonephritis and nephrotic syndrome are a surgery at high risk. Alterations in renal function leads to changes in acid-base balance, calcium and phosphorus retention Water and electrolyte concentration. A patient with chronic infection may develop postoperative sepsis. These patients secondary hypertension were also associated with fluid retention and anemia.

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Preoperative investigations.

1. Renal profile BUN, serum cretinine, serum electrolytes.
2. Creatinine clearance test.
3. Serum calcium and phosphorus.
4. Urinalysis-microscopic and physical.
5. Assistant kidney.
6. Renal Doppler studies.
7. Echocardiography for renal clearance time

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Intra-and postoperative

1. Fluid balance, acid-base balance and electrolyte balance should be closely monitored.
2. Tests Profile kidney must be performed within and after surgery.
3. Replacement of blood is composed of washed red blood cells.
4. Overloading potassium during fluid resuscitation should be avoided.
   1. The patient must be covered by broad-spectrum antibiotics to prevent sepsis. As most antibiotics are excreted by the kidneys, only a few were safe to use. Amoxicillin, doxycycline and minocycline, an antibiotic recommended by some.

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MANAGEMENT Transplantation Kidney Patient

1. Patients transplanted kidney € ™ s come in the risk category of American society Anaesthsiologist III (which needs medical attention)

2. Stressed reduction:

Patient must take a good rest last night.

Quotations should be short.

Benzodiazepines and barbiturates can be used in normal quantities.

Combination of nitrous nitrogen-oxygen is a good anxiolytic.

Maintain a non-threatening way.

Appointment of the Morning.

Consultation with Patient Medical € ™ s need for additional steroids.

Dose of steroids can be doubled on the previous day in the day, 2 days after dental surgery.

The graft survival -> 90% in one year with an overall mortality of 5%

Immunocompromised patients require steroids over with a corticosteroid-sparing drugs (azathioprine) to prevent rejection cyclosprim raft.

Treatment:

Those with symptoms of chronic renal € "Treatment of CRF

Immune suppression> steroid + antibiotic prophylaxis.

Common Hepatitis patients stayed away from the source of infection

.- Candidiasis amphoterecin topical nystatin, miconazole,

Patients on immunosuppressive therapy in renal transplant patients have a risk of developing â € "diseases malignancies (lymphoma, skin, cancer of the cervix and lips) leukoplakia, Kaposi's sarcoma

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Drugs that can be used in transmutation renal patients

SaferDrugs-Cloxoacillin, penicillin, minocycline, erythromycin, a

                     Refampicin, lidocaine. Chloral hydrate, diazepam

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Ampicicilin Indeed, amoxicillin, penicillin, clotrimazole, Â Â

                   metronidozole codeine, the barbiturates, phenothiazines.

Less Secure Aminoglycosites cephalosporin, pracetamol, acetoaminophin, Â

                pethidine, opioids, antihistamines,

Drug Prevention sulphonaimides tetracycline aspirin NSAID € ™ s

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Liver

1. Â Â Â Â Â

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Search preoperative

1. Liver enzymes SGOT "€ (serum glutamic transaminise)

 SGPT (serum glutamic transaminse).

1. Total bilirubin, direct bilirubin and indirect.
2. The serum albumin.
3. Serum alkaline phosphates.
4. Bleeding time and clotting time.
5. The prothrombin time and index.
6. Liver USG.
7. Australia antigen test.

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Intra-and postoperative

1. Avoid unsightly gas that is metabolized in the liver, such as halothane.
2. Correcting deficiencies in coagulation Vitamin K by intravenous transfusion of fresh frozen plasma frozen.
3. In a careful and volume of postoperative blood, cardiac output, volume Urine and co0mposition.
4. Supplements of potassium replacement fluids.
5. Appropriate precautions and sterilization techniques to prevent transmission of disease is a viral hepatitis.

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DIABETES MELLITUS

Diabetes mellitus is caused by an absolute or relative deficiency of insulin in the body can be classified as type 1 (insulin-dependent) and type 2 (insulin-dependent). Type 1 is most common in young patients and type 2 diabetes in adults. A patient can be classified as a diabetic when its Rates of fasting glucose are consistently above 140mg/dl.

The nature of the problems encountered by the surgeon in managing patients with diabetes to know are the following.

1. The blood sugar levels remain optimal during the procedure and postoperatively to prevent hypoglycemia or hyperglycemia and ketoacidosis. Both diseases can be fatal for the patient.
2. The patient is exposed to infection and must be adequate pre-and postoperative broad-spectrum coverage with antibiotics to prevent infection.
3. The patient may have other systemic complications, including kidney failure, heart disease and problems of blindness and generalized vascular disease due to longstanding diabetes.

         For a diabetic surgical effects can be classified into three groups:

1. The blood sugar levels controlled by diet and oral hypoglycemic agents.
2. The rate of blood sugar controlled by insulin.
   1. â € € œBrittle Diabetes is usually the appearance of children, which is labile metabolic needs and have long legacy of diseases such as renal failure, retinopathy and generalized vascular disease.

Elective surgery can usually be performed without complications in the first two types. In the third type, although the meaning remains the same, the rigid control exercised amore intra-and postoperatively.

Preoperative Investigations

1. Radiography chest routine for posterior.
2. Electrocardiogram
3. Investigations of blood as:

         A. The fasting and postprandial

         b. Glucose tolerance test

         v. Renal Profile (BUN, SC, SE)

1. The sugar in the urine.

         If the patient is on oral hypoglycemic agents, he / she should be shifted to insulin in day of surgery. The general principle of management of the patient under general anesthesia is to provide at least 200 g carbohydrate, with adequate insulin to meet this need.

Sugar levels and insulin

Sugar Levels (mg%) Â Â Â Â Â Â Â Â Â Â Â Â insulin

80 € â "120A Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Plain dextrose 5% (D)

120-180A Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â 4 units of glucose 5%

180-250A Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â 8 units of glucose 5%

250-300A Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â 14 units of glucose 5%

Above 300 Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â 14 units in a normal saline

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Intra-and postoperative

1. Check € ™ s patients and blood sugar levels in urine of the morning surgery using hemoglucose and urostrips strips or a meter.
2. Prepare for Action Insulin sliding scale to follow during the operation on the basis of patients € ™ s sugar levels.
3. Pre-and postoperative broad-spectrum antibiotic coverage.
4. Intra and under close monitoring post-operative fat and sugar levels in urine.
5. Prevents the patient went into ketoacidosis or hypoglycemia.

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Signs of hypoglycemia: The patent is anxious, agitated, agitated, the skin is clammy and pale, and no tachycardia. Patients were then slipped into a coma.

Treatment: In a conscious patient, carbohydrates are now They collect the blood glucose levels. In an unconscious patient IV administration of 50% glucose solution consciousness restores from 5 to 10 minutes or 1 mg IM mimetic recovered consciousness within 15 minutes.

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The signs of diabetes ketoacidosis, vomiting, tachypnea, Kussmaul (rapid deep breathing at regular intervals) for respiration, dehydration and circulatory collapse.

Treatment: The administration of insulin to normalize the body's metabolism and restoration of body fluids and electrolytes.

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6.Shift the patient as possible, first to his food and regular oral antidiabetic drugs.

Disorders thyroid

Patients suffering from eating disorders can be divided into 3 groups â € "hypothyroidism, hyperthyroidism and euthyroid. euthyroid Outside these patients pose no risk for surgical procedures. Both anda hyperthyroidism hypoglycemia, elective surgery is best postponed until the patient is euthyroid.

A sense of hypothyroidism are water and retention mucopolysacharide, slowing the metabolic process leading to bradycardia, constipation and letheargy hypothermia. Hypothyroidism patients not Treaties do not respond well to stress and move into a coma.

Hyperthyroidism is a hypermetabolic in the body causing catabolic state of tachycardia, diarrhea and heat intolerance. If the patient is under stress, which is called a thunderstorm œthyroid € €, which is a state of metabolic hyperactivity long 24 to 48 hours. This is a severe exacerbation of signs and Symptoms of hyperthyroidism and is usually accompanied by hyperthermia. The condition is potentially fatal and requires mastery of hyperthermia, tachycardia and heart failure.

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Preoperative investigations

1Â Â Â Â Â Â Â thyroid hormone levels â € "T3, T4, TSH

2     Serum electrolytes  Â

3Â Â Â Â Â Â Â serum proteins

4Â Â Â Â Â Â a Radionuclide thyroid scanning to examine the gland.

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Intra and post surgical treatment.

1. Monitoring hormone levels after surgery in

2. Continuous monitoring of vital parameters, blood pressure, pulse and a

  Temperature.

3. Check the signs and symptoms of hypo / hyperthyroidism

4. Continuous monitoring of cardiac function in especially during the crisis of the thyroid. Infuse thyroid hormones, if the patient shows signs of hypothyroidism.

5. If the patient Storm is in the thyroid, treatment by cooling the patient, an intravenous glucose and intravenous fluids and steroids sugar

6. The use of narcotics agents and anesthetic drugs judiciously patients hypothyroidism, which can have a profound depressing.

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Adrenal Disease.

Two common adrenal disorders must be treated during surgeries are Cushing's syndrome (excessive production) and Addison's disease (in production)

Symptoms of Cushing's syndrome are diabetes, retention excretion of sodium and potassium in the water, hypertension and fat redistribution. The patient also tendency to osteoporosis, wound healing and the formation of the purple. During surgery, attention must be paid to maintain optimal levels of carbohydrates in the body, sodium and levels of potassium ion and blood pressure. There may be problems with bleeding postoperative healing.

         The production may occur due to adrenal suppression insufficient due to exogenous steroids or because of disease caused by adrenal gland (Addison € ™ s disease). In general, all patients who received steroids for more than two weeks in a year before the surgery should be considered as a candidate for failure adrenal.

Preoperative Investigations

Profile 1.Renal.

2.Serum electrolytes.

3.Fasting sugar in the blood.

4.Platletcount.

Profile 5.Coagulation.

Patients with adrenal insufficiency must be completed with sufficient exogenous steroids before the procedure to help the patient fight against stress

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Intra-and postoperatively.

1.Continuous monitoring vital signs.

2. Adequate corticosteroid supplementation intravenously to prevent adrenal crisis.

3. Maintain fluid and electrolyte balance.

4. The sugar levels blood.

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Neurological Disorders

Neurological disorders can be classified cerebrovascualar patients disorders, seizures and patients with head trauma. key factors considered in these patients is to maintain cerebral perfusion adequate in and after the operation and control of all the episodes of crisis during this period. Patients seizure disorders do not usually pose a major problem for the operational management within forums unless asthamaticus state, where there may be potentially fatal complications. The surgeon must weigh the risks and benefits of stroke, aneurysms and congenital areteriovenous are candidates for high-risk cons are absolute indications for surgical procedures.

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Preoperative Investigations

1.Routine radiographs of the skull and lateral view.

2.CT CT and MRI of the brain.

3.EEG.

Function 4.Liver tests.

         If the patient is an epileptic, adequate control of episodes of crisis must be performed before surgery. Anticonvulsants should be continued until the morning of surgery. The dose is administered in the morning with small sips of water.

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Intra-and postoperative

1.The patient must be given intravenously anti-seizure during the operation.

2.Postoperatively the patient must be transferred to his normal dose of anticonvulsants as soon as possible.

3.Throughout the procedure, hypotension / hyoxia should be avoided and adequate cerebral perfusion must be maintained.

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Diseases of the hematopoietic system

Disorders of the hematopoietic system can be grouped in anemia, disorders of leukocytes and changes in coagulation factors (hemophilia). Anami including anemia Iron deficiency, thalassemia, sickle cell anemia and abnormal white blood cells include leukocytosis and agranulocytosis.

Any modification of the hematopoietic system

1. Predisposes the patient to a prolonged bleeding during surgery, which can not be controlled by hemostatic routine.

2. May cause severe internal bleeding due to injury after intubation Blunt, if undetected condition can seriously complication.

3.Leukemic thalassemia patients and may be repeated transfusions of blood and liver disorders may be due to excessive deposits of hemosiderin.

4.The rate of postoperative infection and slow healing of the wound is very high, especially agranulocytosis, leukemia and anemia.

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Preoperative investigations.

CBC 1.Complete

2.Bleeding time and clotting time.

Time and rate 3.Prothrombin

Thromboplastin time 4.Partial.

The level test 5.Coagulation factor (in case of anomalies factor).

Tell 6.Platlet

7.Haemoglobin.

8.Liver Function Tests

         Before the procedure, the patient € ™ s blood count should be built with normal values by transfusion of whole blood, red blood cells, plasma or plasma components and clotting factors. For a level of factor VIII haemophilia should be at least 50 to 70 per cent before the procedure. Once blood levels are normal, the patient may be treated as a normal patient compared to surgery required Loans for intraoperative transfusion, if necessary. To Leukemic, the patient should be covered with broad spectrum antibiotics before and after surgery.

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Intra-and postoperative

1. Avoid excessive trauma in the tissue at a procedure performed.

2. Prevent entry into deep tissue spaces in the dark, thus preventing any internal bleeding.

3. Complete hemostasis must be achieved before wound closure.

4. Intraoperative blood transfusion or blood products if deemed necessary.

5. Monitoring of hemoglobin, complete blood count intra and postoperative.

6. The maintenance of blood volume adequate throughout the procedure and at the same time to avoid overloading the heart.

7. Monitoring vital signs monitor any change in fluid volume indicated by the pulse and blood pressure.

8. After surgery, the patient can be maintained in oral K and systemic coagulation vitamin for 3-5 days.

9. Cover the patient with appropriate broad-spectrum antibiotics.

10. Avoid drugs that exacerbate the disease in May Thea underlying, especially in agranculocytosis.

         With the increase in blood transmission of diseases like AIDS, hepatitis B and hepatitis C, the government made it mandatory for the three viruses before storing the blood blood bank. But the decision to transfuse blood and blood products remains to be done carefully weigh the risks and benefits.

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Management a haemophiliac patient

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Classically, hemophilia is two types of hemophilia A (factor VIII deficiency) and hemophilia B (factor IX deficiency). The disorder is sex-linked recessive 50 per cent of women trait.Approximatley € ™ s descendants are carriers of the disease and 50 percent of male descendants of € ™ s have a bleeding disorder. Havea these patients bleeding disorder. These patients have a tendency to bruise and bleed easily extended.

Successful management of a hemophiliac is dependent on proper maintenance of antihemophilic globulin. The normal PDF is 50 to 100 percent. As a hemophiliac, good for hemostasis, factor levels should be 20 percent above normal, although a normal level is also acceptable.

Thromboplastin time of regeneration not only determines deficiency of factor VIII, but it also stands a deficiency of factor IX. Factor VIII can be obtained by blood, plasma, fresh frozen plasma and cryoprecipitate. This is the alternative because it offers the only factor low.

Management

1. Build level of factor VIII from 50 to 70 percent.

2. Avoid injection into the deep tissue spaces, ie avoid blocking techniques. Use of anesthesia infiltration.

3. Traumatic ablation surgical procedure.

4. Avoiding unnecessary trauma to soft tissues, avoiding suture if necessary.

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Immunocompromised patients

Immunocompromised patients may be grouped in patients with poorly-cell mediated, humoral immunity, neutorphils supplements, patients on immunosuppressive drugs such as chemotherapeutic agents and steroids, and patients with long debilitating diseases such as diabetes and nutritional deficiencies.

         These patients are very susceptible to infections and should be given

broad spectrum antibiotics she.

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Preoperative investigations.

FBC

A liver function tests

Kidney function tests

Serum proteins

Sugar levels in the blood.

Analysis of urine.

Chest X-ray routine.

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Intra-and postoperative

The management varies depending on the condition that the patient suffers. Usually, it is almost impossible to correct the causative factor and treatment is only symptomatic.

Constant monitoring vital parameters.

The coverage of broad spectrum antibiotics.

Although the handling of patients infected with HIV, care Special must be exercised to prevent disease transmission.

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Autoimmune disorders

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The group of autoimmune diseases including lupus erythematosus, scleroderma, rheumatoid arthritis, disease collagen Shjogrenâ € ™ s syndrome, polyartertis nodosa, etc. These patients have significant cardiac May, kidney and bone marrow, which cons-May elective surgery. The patients, whenever possible should be operated during the remission. Some patients may be a long-term therapy corticosterioid therefore precautions to prevent adrenal insufficiency should be taken.

Some of these patients have a loss of flexibility in joints, particularly the chest and joints of the neck, which poses problems in intubation and ventilation. When problems intubation and ventilation. In patients with scleroderma have a limited mouth opening and limited expansion of the chest wall.

Patients with disorders of collagen May also be delayed in the post-operative healing.

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Pregnancy and lactation.

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Each patient woman of childbearing age should be raised in the story pregnancy, menstrual cycles. Great care must be taken with pregnant women since the surgeon have to address not only the mother but also to avoid undue harm to the fetus. Is it safe to perform procedures under local anesthesia in the second quarter. In the first quarter, is a risk of abortion stress and teratogenicity, while in the third quarter there is a risk of stress-induced, while in the third quarter there is a risk of stress-induced premature labor. General anesthesia is a cons-indication in the third quarter, unless Emergency Rescue in the third quarter, unless the Tax Act is an emergency procedure to save his life. In the first and second quarters should be prudent to prevent fetal anoxia.

A Again, the risks and benefits must be weighed before the procedure, the mother must be fully explained the risks before performing any procedure. The mother should be fully explained the risks before proceeding. drugs teratogens such as tetracyclines, salicylates, and chloramphenicol should be avoided. Amoxicillin, cloxacillin, ampicillin and paracetamol may be prescribed safely.

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CONCLUSION

The conclusion of this chapter, few points should be highlighted, which will define a basic protocol to follow when managing a patient's medical commission.

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With knowledge of l '€ ™ s the patient's medical history should be obtained.

The surgeon should also have knowledge of medications taken by the patient and the patient's regularity in its manufacture.

Written consent to The surgical procedure must be obtained from a specialist in the field before the procedure.

Appropriate and necessary, Pre-operative research must be performed.

The patient must be informed about the risks and benefits of surgery in terms of written consent together and demonstrated the procedure and as a high risk consent must be obtained from the patient.

         The operating room should be well equipped systems to support life and functional emergency cart updated in case of emergency. The same applies to the recovery room after surgery.

The decision whether or not to be found with the surgeon and he / it should make your choices carefully weigh the advantages and disadvantages compared to the benefits of surgical risks and anesthetics

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