Page 485 - WSAVA2018
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Review where you are today;
Evaluate current performance, Interview key staff, Assess how effective they feel, What issues frustrate them today?
Honest assessment of current strengths and then agree where you need to be in the future;
Creating the right organisation
1. 1. Select the appropriate structure to reflect business situation and needs
2. 2. Owner(s) decide which roles they wish to retain and have time to perform to an appropri- ate standard
Delegate with sufficient authority and re-
5. 5. Hire or train appropriate staff
6. 6. Continually review their roles with a view to delegating further
Your Singapore, the Tropical Garden City
P. Maguire1 1Singapore
Most (85%) diaphragmatic hernias are a result of trauma. However, not all patients have a history of trauma, nor
do they always present with respiratory symptoms. The diagnosis is usually straight forward for those with a history of trauma and respiratory compromise, however it is not uncommon that a patient will present signs such as chronic weight loss, gastrointestinal signs or symptoms related to a hepatopathy or other organ dysfunction. Trauma may have taken place months or years prior, unbeknownst to the owner. The hernia can also be
an incidental finding during imaging performed for seemingly unrelated reasons.
In cases of acute traumatic herniation, the time to address the hernia should be carefully considered. Rapid control of the airway and ventilation must be weighed against the value of further patient stabilization. Stabilization over several hours to days prior to intervention may be prudent to minimize anaesthetic and surgical risk. The trauma that has resulted in the hernia has very often caused other injuries. Attempts should be made to resolve hemodynamic instability prior to anaesthesia and surgical intervention. An otherwise stable patient is much more likely to survive the repair. In cases of chronic herniation without decompensation the surgery can be scheduled at the surgeon’s convenience.
Ventilation must be provided following anaesthetic induction in all cases of diaphragmatic hernia. The pleuroperitoneal pressure gradient has been abolished and respiratory attempts under anaesthesia will be particularly ineffective. Most anaesthetics impair respiration to some extent and as such decompensation following induction is possible without adequate
support. ETCO2 should be monitored throughout these procedures to ensure ventilation is adequate. Inspiratory pressures should be initially limited to 10 or 15cm of water but increased up to (but not beyond) 20cm of water as needed. A typical starting ventilation rate of 6-8 breaths per minute is recommended and adjusted accordingly based on ETCO2.
Once the abdomen has been entered, both sides of
the diaphragm should be evaluated. It is not uncommon to have multiple hernias or tears. Circumferential and radial tears of the musculature generally predominate. The falciform fat and liver are most frequently herniated however the small intestine, stomach, spleen, omentum, pancreas, colon, cecum and uterus can also be herniated. Gentle traction on the herniated organs usually facilitates reduction however chronic hernias can
  3. 3.
Delegate to their staff the other roles
4. 4. sponsibility

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