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Q. Arokkh, M.B. B.CH. B.A.O., Ph.D.

Assistant Professor, University of Texas Rio Grande Valley School of Medicine

Iodine supplementation for the prevention of mortality and adverse neurodevelopmental outcomes in preterm infants. Preterm infants fed nutrient-enriched formula until 6 months show improved growth and development. Characterization of the transition technique from enteral tube feeding to breastfeeding in preterm newborns. Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants. Formula milk versus donor breast milk for feeding preterm or low birth weight infants. Effect of iron supplementation on development of iron deficiency anemia in breastfed infants. Health Canada; Canadian Paediatric Society; Dietitians of Canada; Breastfeeding Committee for Canada. El inicio temprano de la lactancia mterna: la clave para supervivencia y desarrollo. Effects of hospital policies and practices on initiation and duration of breastfeeding. Alternative strategies for the management of respiratory failure in the newborn-clinical realities. Respiratory disorders in preterm and term neonates: an update on diagnostics and therapy. Mechanical ventilation for newborn infants with respiratory failure due to pulmonary disease. Congestive heart failure in the newborn infant in the absence of primary cardiac disease. Surfactant therapy in neonates with respiratory failure due to haemorrhagic pulmonary oedema. Pathogenesis of hemorrhagic pulmonary edema and massive pulmonary hemorrhage in the newborn. Acute pulmonary edema due to transient myocardial dysfunction: an uncommon cause of respiratory distress in the term neonate.

What additional blood component administration, in addition to surgical control, is appropriate to best achieve hemostasis Current practice entails separation of donor whole blood into each of these components to allow for targeted use of this limited resource to correct the specific blood component deficiency in the individual patient. Generally speaking, there are three primary indications for blood component therapy: 1. Insufficient oxygen carrying capacity/delivery thought to be at least partially due to inadequate total red blood cell mass. Replacement of coagulation cascade constituents to correct severe Patient Case: A 56-year old man with atrial fibrillation on warfarin therapy is admitted with melena. Inadequate quantity and/or dysfunction of platelets the aim of this chapter is to discuss the indications for each of the commonly transfused blood components as well as other considerations including storage, safety, and complications of transfusion. Specific Blood Components Whole Blood Unfractionated whole blood is, as its name implies, equivalent to circulating blood: erythrocytes, leukocytes, plasma (including clotting factors), and platelets are present in their normal ratios. Whole blood has a shorter storage life and higher risk of donorrecipient interactions, and has largely been phased out in favor of targeted blood component therapies. Its use in trauma and acute bleeding, to replace shed whole blood, is a subject of renewed interest. Most centers in the United States routinely filter leukocytes from donated blood (leukoreduction) to reduce the risk of febrile non-hemolytic transfusion reactions and alloimmunization. The threshold at which anemia necessitates transfusion has been examined in several large, prospective, randomized, controlled trials. They have shown, nearly universally, that there is no benefit, and may be harm, from transfusion thresholds above 7-8 g/dL. Possible exceptions are patients with ongoing blood loss (see later) or active ischemia, although prospective studies in high-risk populations such as post-cardiac surgical and active, nonexsanguinating upper gastrointestinal bleeding patients have generally supported restrictive erythrocyte transfusions. These include all endogenous pro- and anti-coagulant factors, fibrinogen, albumin, and immunoglobulins. Each unit is usually 250-350 mL in volume and can be stored frozen for up to a year. This may occur in the setting of blood loss due to a combination of consumption and/or dilution of clotting factors by replacement fluids, acute or chronic organ failure with deficient production, unregulated consumption (sepsis, disseminated intravascular coagulation, medications, etc. In these cases, primarily genetic deficiencies, it is usually preferable to replace only the needed factors with human-derived or recombinant factor concentrates. They are expensive and carry the risk of pro-thrombotic sequelae, so the risks and benefits must be weighed before their use. Cryoprecipitate When frozen plasma is slowly thawed, a semi-solid precipitate is formed, called cryoprecipitate (cryo). Previously referred to as "cryoprecipitated antihemophilic factor" for its use in hemophilia A and von Willibrand disease, in the modern era, the primary indication for the use of cryo is hypofibrinoginemia, as purified factor concentrates have largely replaced its use in genetic single-factor deficiencies. The development of fibrinogen concentrate could potentially reduce the use of cryo for this indication. Fibrinogen concentrates are available in a lyophilized form which can quickly be reconstituted. Fibrinogen concentrates are currently only available as a humanderived, heat-treated preparation and the relative advantages and disadvantages of cryo versus fibrinogen concentrate are currently under investigation. Platelets 340 Traditionally obtained by separation from donated whole blood and transfused as pooled units (a "six-pack"), single-donor units of platelets obtained by apheresis have become more common. Both types contain a similar quantity of platelets, and classically increase the platelet count by approximately 50 x 109/L. Unique among blood products, platelets are stored at room temperature to prevent denaturation of proteins, and this limits their storage life to 5 days. The storage requirements may also be responsible for the higher incidence of bacterial contamination. The indications for platelet transfusion vary by clinical circumstance to a greater degree than other blood products, but have also not been examined in high-quality randomized clinical trials.

The junior surgical residents assigned to each surgical patient will order diagnostic tests and therapeutic measures under the supervision of the chief resident and attending staff. The junior resident will assume the role of primary physician to ward patients, maintaining communication with patient and family and informing them of progress and future courses. The operating surgeon is responsible for a handwritten pre-op note on the day of the operation. This note should include the pre-diagnosis, the indications for operation, and the proposed operation. The names of the attending staff surgeons should be given with a statement that the case has been discussed and there was agreement on the plan of action. A statement should also be included to the effect that the indications for operation, the type of surgical procedure, and its implications have been discussed with the patient, who agrees to the procedure. If the patient desires, provision should be made to inform the immediate family of the condition of the patient immediately after the operation. In every case, the procedure will have been cleared and scheduled with the appropriate attending surgeon. The chief resident should become familiar with the various plans for scheduling operations at the various hospitals as well as be considerate of the multiple obligations of the surgical faculty. Operating Room Sterile techniques and standard operating room policy must be followed at all times. Residents are to be in the operating room 10 minutes before a case is scheduled to begin and facilitate patient transfer, if necessary. Complete cooperation and communication with the operating room team is imperative for the conduct of a safe operation. Careful planning before operation by the surgeon will eliminate problems during the operative period. The pathology form is a request for consultation, and complete pertinent data should be provided. Operative notes are equally vital parts of the record and a further essential part of your own professional qualifications which you must document for American Board of Surgery certification and American College of Surgeons fellowship. Operative notes are to be dictated immediately after operation by the operating surgeon, preferably in the operating room. Postoperative Management and Recovery Room Surgical residents are responsible for respiratory care for their patients even while patients are in the recovery room, in collaboration with the anesthesiologist. In cases in which the primary indication for prolonged intensive (or special) respiratory care is anesthesia related, the anesthesiologist is responsible for such services until it is mutually agreed to transfer such care to the surgeon. The anesthesiologist is responsible for the discharge of patients from the recovery room. The prevailing attitude between surgeons and anesthesiologists in this program is one of excellent cooperation. Differences between individuals representing vital aspects of the success of a surgical endeavor must be minimized, and cooperation is the anticipated standard. Charts the careful and accurate completion of medical records is an important physician responsibility. Developing good habits of record keeping serves 6 essential purposes: (1) (2) (3) (4) (5) Your record is an aide-memoir when you next see the patient. A clear, accurate note is a guide for colleagues who may need a quick review when seeing the patient in years to come for continuity of care. The clinic summary should be a concise summation of the many hours of thought, investigation, and consultation that were spent with the patient and record review. It is a record of all diagnostic terms that are required for case retrieval in clinical investigations. It affords a justification of payment by third parties, particularly where significant diagnostic efforts have been made. It should be made clear when an attending physician transfers patient care to another physician.

Clinically, severe hypermagnesemia is rarely seen except in those patients with advanced renal failure treated with magnesium-containing antacids. Greater elevations of magnesium produce progressive weakness, which culminates in flaccid quadriplegia and in some cases respiratory arrest due to paralysis of the chest bellows mechanism. Hypotension may occur because of the direct arteriolar relaxing effect of magnesium. Changes in mental status occur in the late stages of the syndrome and are characterized by somnolence that progresses to coma. Symptomatic hyponatremia, which occurs at serum sodium levels less than or equal to 120 mEq/L, can result in headache, seizures, coma, and signs of increased intracranial pressure and may require infusion of hypertonic saline. Rapid correction should be avoided so as not to cause central pontine myelinolysis, manifested by neurologic symptoms ranging from seizures to brain damage and death. Additionally, a search for the underlying etiology of the hyponatremia should be undertaken. Acute severe hyponatremia sometimes occurs following elective surgical procedures due to a combination of appropriate stimulation of antidiuretic hormone and injudicious administration of excess free water in the first few postoperative days. Calcium oxalate stones can subsequently develop due to excessive absorption of oxalate from the colon. Normally, fatty acids are absorbed by the terminal ileum, and calcium and oxalate combine to form an insoluble compound that is not absorbed. In the absence of the terminal ileum, unabsorbed fatty acids reach the colon, where they combine with calcium, leaving free oxalate to be absorbed. Unabsorbed fatty acids and bile acids in the colon also promote oxalate uptake by the colon. Subsequently, the excess oxalate is excreted by the kidneys, promoting calcium oxalate stone formation. Hungry bone syndrome refers to rapid remineralization of bones leading to hypocalcemia and can be seen postoperatively in patients with secondary or tertiary hyperparathyroidism. Pseudohyperparathyroidism refers to hypercalcemia associated with the production of parathyroidrelated peptide. When oliguria occurs postoperatively, it is important to differentiate between low output caused by the physiologic response to intravascular hypovolemia and that caused by acute tubular necrosis. Values above this suggest a tubular injury such that Na cannot be appropriately reclaimed. The neuromuscular effects resemble those of calcium deficiency-namely, paresthesia, hyperreflexia, muscle spasm, and, ultimately, tetany. Many hospital patients with refractory hypocalcemia will be found to be magnesium deficient. Often this deficiency becomes manifest during the response to parenteral nutrition when normal cellular ionic gradients are restored. The serum calcium in this patient is normal when adjusted for the low albumin (add 0. Hypomagnesemia causes functional hypoparathyroidism, which can lower serum calcium and thus result in a combined defect. Additionally, most textbooks recommend use of an oral, nonabsorbable antibiotic regimen effective against aerobes and anaerobes in combination with a mechanical bowel preparation before elective colon resections. There is no evidence to support the continuation of antibiotics for more than 24 hours after an elective operation has been completed, and this practice should be avoided to prevent increasing microbial drug resistance. Broad-spectrum antibiotic coverage, including against anaerobic organisms, is required only in cases where such flora are anticipated, such as during colon resections. The development of a clinically significant metabolic alkalosis is secondary not only to the loss of acid or addition of alkali but also to renal responses that maintain the alkalosis (paradoxical aciduria). The normal kidney can tremendously augment its excretion of acid or alkali in response to changes in ingested load. However, in the presence of significant volume depletion and consequent excessive salt and water retention, the tubular maximum for bicarbonate reabsorption is increased. Correction of volume depletion alone is usually sufficient to correct the alkalosis, since the kidney will then excrete the excess bicarbonate.