Protection of Renal Function During Surgery of the Abdominal Aorta

The operative and postoperative urinary output of 55 patients who underwent surgery for ruptured abdominal aortic aneurysms, unruptured abdominal aortic aneurysms, and aorto-iliac occlusive disease was recorded. There were five cases of postoperative anuria among 28 patients who received no free fluid in the immediate preoperative period. No case of anuria occurred in 27 patients who received either: (1) a water load of 5% dextrose in water or (2) 20% mannitol solution. The patients who received mannitol had a markedly greater operative and postoperative urinary output.Intravenous infusion of mannitol is recommended during the preoperative and operative period in patients with ruptured aneurysms of the abdominal aorta.     

Cardiac rhythm abnormalities in patients presenting with transient non-focal neurological symptoms: a diagnostic grey area?

Eighty-nine patients attending neurology clinics with transient non-focal neurological symptoms were studied by routine electrocardiography and 24-hour monitoring of the electrocardiography and 24-hour monitoring of the electrocardiogram. In comparison with 109 control subjects there was no significant overall excess of arrhythmias (age-adjusted odds ratio 1.7, kappa2 = 2.67) except in the subgroup of patients under the age of 30 (odds ratio 11.6, p less than 0.05). Bradyarrhythmias, but not tachyarrhythmias, were significantly more common in the patients (odds ratio 7.4, p less than 0.001),. Since patients can rarely be studied while they are having symptoms a working diagnosis must be based on a balance of probabilities: arrhythmias in young patients, or bradyarrhythmias in any patient, are likely to be clinically relevant. Ambulatory electrocardiographic monitoring contributed to the diagnosis in at least 25 of the patients, Nevertheless, the extent to which further investigations are pursued, and the form of treatment ultimately adopted, must also be influenced by the frequency and severity of the patients'' symptoms.     

DIAGNOSIS OF HEMORRHAGIC DISEASES—Evaluation of Procedures—Part II Preoperative Tests

Routine preoperative tests such as the determination of bleeding time and coagulation time are unnecessary and are not recommended. Rulings which require routine preoperative tests result in the adoption of inferior and unreliable time-saving methods in the laboratory. If the clinical staff insists that laboratory procedures to predict hemorrhage be performed on every patient scheduled for operation, approved methods of performing the tests should be employed.Preoperative procedures should include a personal and a family history, a careful and complete physical examination and screening laboratory tests such as urinalysis, hematocrit, leukocyte count and smear examination, including estimation of the number of thrombocytes.Special hemorrhagic studies are indicated on selected patients. These selected patients include those who have a history of abnormal bleeding, those who consider themselves “easy bleeders” or who have apprehension concerning hemorrhage at the time of operation, and those who have physical signs of hemorrhage. Special hemorrhagic studies should also be performed on patients who have diseases that are known to be associated with vascular and coagulation abnormalities, infants who have not been subjected to tests of trauma and on patients from whom a reliable history cannot be obtained.Extra precaution should be taken if operation is to be performed in hospitals or clinics that do not have adequate blood banking facilities and if the operation to be performed is one in which difficulty in hemostasis is anticipated.The preoperative tests that are indicated on selected patients should include as a minimum: The thrombocyte count, determination of the bleeding time by the Ivy method, determination of the coagulation time by the multiple tube method and the observation of the clot. Where facilities are available, the hemorrhagic study should also include the plasma and serum prothrombin activity tests.     

Preventive health care, 1999 update: 2. Echocardiography for the detection of a cardiac source of embolus in patients with stroke

OBJECTIVE: To develop guidelines for the use of echocardiography in the investigation of patients with stroke. OPTIONS: (1) Routine transthoracic echocardiography (TTE); (2) routine transesophageal echocardiography (TEE); (3) routine TTE followed by TEE if the TTE findings are noncontributory; (4) selective TTE or TEE in patients with cardiac disease who would not otherwise receive anticoagulant therapy. OUTCOMES: This article reviews the available evidence on the yield of TTE and TEE in detecting cardiac sources of cerebral emboli in patients with stroke, the effectiveness of treatment for cardiac sources of emboli and the effectiveness of screening echocardiography for secondary stroke prevention. EVIDENCE: MEDLINE was searched for relevant articles published from January 1966 to April 1998; also reviewed were additional articles identified from the bibliographies and citations obtained from experts. BENEFITS, HARMS AND COSTS: Echocardiography can detect intracardiac masses (thrombus, vegetation or tumour) in about 4% (with TTE) to 11% (with TEE) of stroke patients. The yield is lower among patients without clinical evidence of cardiac disease by history, physical examination, electrocardiography or chest radiography (less than 2%) than among patients with clinical evidence of cardiac disease (less than 19%). The risks of echocardiography to patients are small. TTE has virtually no risks, and TEE is associated with cardiac, pulmonary and bleeding complications in 0.18%. Patients with an identified intracardiac thrombus are at increased risk for embolic events (absolute risk uncertain, range 0%-38%), and this appears to be reduced with anticoagulant therapy (absolute risk reduction uncertain). Anticoagulant therapy carries a risk of major hemorrhage of 1% to 3% per year. The overall effectiveness of echocardiography in the prevention of recurrent stroke is unknown. VALUES: The strength of evidence was evaluated using the methods of the Canadian Task Force on Preventive Health Care. RECOMMENDATIONS: There is fair evidence to recommend echocardiography in patients with stroke and clinical evidence of cardiac disease by history, physical examination, electrocardiography or chest radiography (grade B recommendation). There is insufficient evidence to recommend for or against TEE in patients with normal results of TTE (grade C recommendation). There is insufficient evidence to recommend for or against routine echocardiography in patients (including young patients) without clinical cardiac disease (grade C recommendation). Routine echocardiography is not recommended for patients with clinical cardiac disease who have independent indications for or contraindications to anticoagulant therapy (grade D recommendation). There is fair evidence to recommend anticoagulant therapy in patients with stroke and intracardiac thrombus (grade B recommendation). There is insufficient (no) evidence to recommend for or against any specific therapy for patent foramen ovale (grade C recommendation). VALIDATION: The findings of this analysis were reviewed through an iterative process by the members of the Canadian Task Force on Preventive Health Care.     

Criteria of fitness for anaesthesia in patients with chronic obstructive lung disease.

Twelve patients with severe chronic obstructive lung disease undergoing 15 operations were assessed with preoperative lung function tests and blood gas estimations. Their operative and postoperative course was followed. There were no deaths or serious complications. Patients fell into three groups: those with low respiratory capacity but normal blood gases, who required no special respiratory treatment apart from physiotherapy and antibiotics; those with hypoxaemia but normal arterial carbon dioxide pressure, who needed more prolonged oxygen treatment after operation; and those with hypoxaemia and hypercapnia, who needed postoperative ventilatory support. While forced expiratory volume in one second (FEV) is a good screening test in preoperative assessment it should be supplemented by arterial blood gas estimations in patients with an FEV of less than 1 litre.     

The aetiology of myocardial injury after non-cardiac surgery

Recognition of myocardial injury after non-cardiac surgery is difficult, since strong analgesics (e.g. opioids) can mask anginal symptoms, and ECG abnormalities are subtle or transient. Thorough knowledge of the pathophysiological mechanisms is therefore essential. These mechanisms can be subdivided into four groups: type I myocardial infraction (MI), type II MI, non-ischaemic cardiac pathology, and non-cardiac pathology. The incidence of type I MI in patients with a clinical suspicion of perioperative acute coronary syndrome (ACS) is 45–57 %. This percentage is higher in patients with a high likelihood of MI such as patients with ST-elevation ACS. Of note, the generalisability of this statement is limited due to significant study limitations. Non-ischaemic cardiac pathology and non-cardiac pathology should not be overlooked as a cause of perioperative myocardial injury (PMI). Especially pulmonary embolism and dysrhythmias are a common phenomenon, and may convey important prognostic value. Implementation of routine postoperative troponin assessment and accessible use of minimally invasive imaging should be considered to provide adequate individualised therapy. Also, addition of preoperative imaging may improve the stratification of high-risk patients who may benefit from preoperative or perioperative interventions.     

Hepatocerebral dysfunction

Routine preoperative tests such as the determination of bleeding time and coagulation time are unnecessary and are not recommended. Rulings which require routine preoperative tests result in the adoption of inferior and unreliable time-saving methods in the laboratory. If the clinical staff insists that laboratory procedures to predict hemorrhage be performed on every patient scheduled for operation, approved methods of performing the tests should be employed. Preoperative procedures should include a personal and a family history, a careful and complete physical examination and screening laboratory tests such as urinalysis, hematocrit, leukocyte count and smear examination, including estimation of the number of thrombocytes. Special hemorrhagic studies are indicated on selected patients. These selected patients include those who have a history of abnormal bleeding, those who consider themselves "easy bleeders" or who have apprehension concerning hemorrhage at the time of operation, and those who have physical signs of hemorrhage. Special hemorrhagic studies should also be performed on patients who have diseases that are known to be associated with vascular and coagulation abnormalities, infants who have not been subjected to tests of trauma and on patients from whom a reliable history cannot be obtained. Extra precaution should be taken if operation is to be performed in hospitals or clinics that do not have adequate blood banking facilities and if the operation to be performed is one in which difficulty in hemostasis is anticipated. THE PREOPERATIVE TESTS THAT ARE INDICATED ON SELECTED PATIENTS SHOULD INCLUDE AS A MINIMUM: The thrombocyte count, determination of the bleeding time by the Ivy method, determination of the coagulation time by the multiple tube method and the observation of the clot. Where facilities are available, the hemorrhagic study should also include the plasma and serum prothrombin activity tests.     

The Activated Coagulation Time of Whole Blood as a Routine Pre-Operative Screening Test

Patients with disorders of hemostasis who undergo surgical procedures are in danger of hemorrhage. While the careful medical history remains the most sensitive test of a bleeding tendency, some such patients can give no suggestive history. In three patients with coagulopathy—one with mild classical hemophilia, one with Christmas disease, and one with warfarin toxicity—the abnormality was missed by routine preoperative history but promptly detected by the routine preoperative use of the activated coagulation time (act). Either this test or the activated partial thromboplastin time should be included in the routine preoperative work-up, along with appropriate additional tests of the hemostatic mechanism.     

Cardiac asystole secondary to carotid sinus compression in the face-lift operation.

We present 3 cases of carotid sinus compression with cardiac asystole which occurred in healthy patients undergoing routine rhytidectomies. The mechanism is discussed and suggestions are made regarding preoperative evaluation and operative management.     

手术室术前访视应用ipad对访视效果影响的研究

目的：探讨术前访视应用ipad在术前访视中对手术患者心理状态的影响。方法：将300例择期手术患者随机分为对照组（150例）和实验组（150例）,对照组采用常规术前访视方案;实验组在此基础上结合ipad展示围术期相关信息,采用焦虑自量表评估两组病人入院时和入手术室时的焦虑状况及血压、心率等指标,并且进行术后并发症和满意度的调查。结果：改良术前访视后焦虑评分、收缩压、舒张压、心率实验组明显低于对照组。结论：术前访视应用ipad可明显减轻手术病人术前的焦虑。     

Popularity of less frequent follow up for breast cancer in randomised study: initial findings from the hotline study.

OBJECTIVE: To compare the experiences of patients with breast cancer who were conventionally monitored with those in whom routine follow up was restricted to the time of mammography. DESIGN: Randomisation to conventional schedule of clinic visits or to visits only after mammography. Both cohorts received identical mammography and were invited to telephone for immediate appointments if they detected symptoms. SETTING: Combined breast clinic, Chelsea and Westminster Hospital. SUBJECTS: 211 eligible outpatients with a history of breast cancer. MAIN OUTCOME MEASURES: Acceptability of randomisation, interim use of telephone and general practitioner, satisfaction with allocation to follow up. RESULTS: Of 211 eligible patients, 196 (93%) opted for randomisation in the study. Of these, 55 were under 50 years, 78 were diagnosed fewer than five years before, 90 had stage T2-4 tumours, and 71 had involved axillary nodes. Patients who did not participate were more likely to be under 50 years, to be two to five years after diagnosis, and to have had aggressive primary disease. Twice as many patients in both groups expressed a preference for reducing rather than increasing follow up. No increased use of local practitioner services or telephone triage was apparent in the cohort randomised to less frequent follow up by specialists. CONCLUSIONS: Reducing the frequency of routine follow up has so far proved popular among patients with breast cancer at standard risk in this cohort. A multicentre study is needed to determine the effectiveness and cost-effectiveness of routine follow up with respect to disease outcomes.     

Reliability of cardiotocography in predicting baby's condition at birth.

A prospective study of 6825 labours was undertaken to determine the relation between the Apgar scores of the babies at one minute and the cardiotocograph tracing in labour. The sensitivity of an abnormal tracing was 35.2% for babies who needed intermittent positive pressure ventilation and 20.0% for babies who did not but who had Apgar scores of less than 7. The sensitivity of an abnormal tracing for all babies with an Apgar score of less than 7 was 23.2%. The positive predictive value of an abnormal tracing was 8.7% for babies who needed intermittent positive pressure ventilation and 18.7% for babies who did not but who had an Apgar score of less than 7. The positive predictive value of an abnormal tracing was 27.4% for all babies with an Apgar score of less than 7. The specificity of the tracing was 93.4% for babies with an Apgar score of 7 or over. The relatively high incidence of false positive predictions might be explained on the grounds that abnormalities in the cardiotocograph tracing are a more sensitive indicator of hypoxia than the Apgar score. False negative predictions might have been due to adverse factors other than hypoxia--for example, fetal trauma, compression of the head, infection, and analgesia in labour. These findings suggest that the current overdependence on fetal monitoring by cardiotocography alone should be examined and that other reliable indicators for non-hypoxic fetal distress should be sought.     

Mandibular distraction osteogenesis in Pierre Robin sequence: application of a new internal single-stage resorbable device

Pierre Robin sequence may result in physiologically significant obstructive apnea in the neonatal and infant period. This may be life threatening and is most often treated by tracheostomy. To avoid tracheostomy or allow for early decannulation in severely affected infants and children, the authors have developed a new class of neonatal and infant mandibular bone distraction devices. These devices require a single operative procedure for placement and no operative removal is necessary. Fifteen infants (aged 7 days to 11 months; mean age, 3 months) and five children (aged 2 to 8 years; mean age, 5.5 years), 10 boys and 10 girls, with severe obstructive apnea and Pierre Robin sequence were treated with the mandibular infant devices over a 24-month period. Tracheostomy was avoided in 14 patients, whereas five of six patients who had previous tracheostomy were decannulated after mandibular distraction. The final tracheostomy status in one patient will be determined after surgery for gastroesophageal reflux. There were no major complications and no structural device failures.     

Intensive care unit admission parameters improve the accuracy of operative mortality predictive models in cardiac surgery

Background

Operative mortality risk in cardiac surgery is usually assessed using preoperative risk models. However, intraoperative factors may change the risk profile of the patients, and parameters at the admission in the intensive care unit may be relevant in determining the operative mortality. This study investigates the association between a number of parameters at the admission in the intensive care unit and the operative mortality, and verifies the hypothesis that including these parameters into the preoperative risk models may increase the accuracy of prediction of the operative mortality.

Methodology

929 adult patients who underwent cardiac surgery were admitted to the study. The preoperative risk profile was assessed using the logistic EuroSCORE and the ACEF score. A number of parameters recorded at the admission in the intensive care unit were explored for univariate and multivariable association with the operative mortality.

Principal Findings

A heart rate higher than 120 beats per minute and a blood lactate value higher than 4 mmol/L at the admission in the intensive care unit were independent predictors of operative mortality, with odds ratio of 6.7 and 13.4 respectively. Including these parameters into the logistic EuroSCORE and the ACEF score increased their accuracy (area under the curve 0.85 to 0.88 for the logistic EuroSCORE and 0.81 to 0.86 for the ACEF score).

Conclusions

A double-stage assessment of operative mortality risk provides a higher accuracy of the prediction. Elevated blood lactates and tachycardia reflect a condition of inadequate cardiac output. Their inclusion in the assessment of the severity of the clinical conditions after cardiac surgery may offer a useful tool to introduce more sophisticated hemodynamic monitoring techniques. Comparison between the predicted operative mortality risk before and after the operation may offer an assessment of the operative performance.     

UNILATERAL RENAL DISEASE AND HYPERTENSION

Cure is obtained in about 20 per cent of patients with unilateral renal disease and hypertension who have nephrectomy primarily for relief of hypertension. Carrying out urologic studies on a larger number of hypertensive patients might result in tracing the condition to renal disease in more cases. Renal angiography more accurately indicates renal origin of hypertension than any other diagnostic study. When it can reasonably be established that hypertension is of renal origin, nephrectomy should be performed unless there is some general contraindication to an operative procedure.     

Large-volume liposuction: a review of 631 consecutive cases over 12 years.

Since the advent of epinephrine-containing wetting solutions and sophisticated fluid management techniques, increasingly larger and larger volumes of liposuction aspirations have been reported. Unfortunately, with these larger volumes of liposuction being routinely performed, greater rates of complications have also been reported, with the worst of these resulting in deaths. In a response to the increasing concerns over the safety of large-volume liposuction, a critical review of the senior author's own series has been performed to evaluate risks and benefits and to recommend guidelines for safe and effective large-volume liposuction. A retrospective chart review was performed on 631 consecutive patients who underwent liposuction procedures of at least 3000 cc total aspirate. All procedures were performed by the same senior surgeon between January of 1986 and March of 1998. Before September of 1996, traditional liposuction techniques were used. After September of 1996, ultrasound-assisted liposuction was performed. The superwet technique of fluid management was employed for all procedures performed after 1991. The particulars of the surgical and anesthetic techniques used are reviewed in the article. Data collection included preoperative patient demographics, preoperative and postoperative weights and measurements, and preoperative and postoperative photographs. Total aspirate volumes, fluid intakes, and fluid outputs were measured, and all complications were tallied. Average follow-up was 1 year.Results showed the majority of patients to be women, aged 17 to 74 years old. Of the preoperative weights, 98.7 percent were within 50 pounds of ideal chart weight. Total aspirate volumes ranged from 3 to 17 liters, with 94.5 percent of these under 10 liters. Fluid balance measurements showed an average of 120 cc/kg positive fluid balance at the end of the procedure, with none of these patients experiencing any significant fluid balance abnormalities. Cosmetic results were good, with a 2- to 6-inch drop from preoperative measurements, depending on the area treated. Ten percent of patients experienced minor skin contour irregularities, with most of these patients not requiring any additional surgical procedures. One year after surgery, 80 percent of patients maintained stable postoperative weights. No serious complications were experienced in this series. The majority of the complications consisted of minor skin injuries and burns, allergic reactions to garments, and postoperative seromas. The more serious complications included four patients who developed mild pulmonary edema and one patient who developed pneumonia postoperatively. These patients were treated appropriately and went on to have uneventful recoveries. The results show that large-volume liposuction can be a safe and effective procedure when patients are carefully selected and when anesthetic and surgical techniques are properly performed. Meticulous fluid balance calculations are necessary to avoid volume abnormalities, and experience is mandatory when performing the largest aspirations. Cosmetic benefits are excellent, and overall complication rates are low.     

Dural ectasia is a common feature of the Marfan syndrome.

Widening of the lumbosacral spinal canal was found in 63% of 57 patients with the Marfan syndrome and in none of 57 age- and sex-matched non-Marfan control patients, who underwent CT scanning for routine clinical indications. The bony abnormalities in mild cases consisted of thinning of the pedicles and taminae and erosion of the neural foraminae and were generally limited to L5 and S1. More severe changes were present in 13 patients, two of whom had associated neurologic signs, and included meningoceles or near total erosion of a pedicle. Presence and severity of vertebral abnormalities were associated with neither any other clinical feature nor overall phenotypic severity. Dural ectasia can be added to the list of pleiotropic manifestations of the Marfan syndrome.     

Comparison of Operative and Non-Operative Treatment of Acute Undisplaced or Minimally-Displaced Scaphoid Fractures: A Meta-Analysis of Randomized Controlled Trials

Background

Traditionally, acute undisplaced or minimally-displaced scaphoid fractures are treated by casting in short- or long-arm casts. Although reports have shown that operative treatment is safe, effective and produces satisfactory results, outcomes from current studies comparing these two methods are questionable. The aim of this meta-analysis was to evaluate the effects of operative versus non-operative treatment for acute undisplaced or minimally-displaced scaphoid fractures in adults.

Methods

Computerized searches were performed without language restrictions and all randomized controlled studies providing information on the effects of operative versus non-operative treatment on the outcomes of acute undisplaced or minimally-displaced scaphoid fractures were included. The weighted and standard mean difference (WMD and SMD) or the relative risk (RR) were calculated for continuous or dichotomous data respectively.

Results

A total of six studies reported in seven publications were included, representing data on 340 fractures. Meta-analysis indicated that operative treatment resulted in significantly better functional outcomes in the short term when compared with non-operative treatment. Consistently, patients who accepted surgery had a more rapid return to work. Further, surgery was advantageous in preventing delayed union of the fractures, a finding supported by the results of analysis of the time to fracture union. A number-needed-to-treat analysis revealed that more than 20 patients would have to undergo operative treatment to prevent one delayed union.

Conclusion

Acute undisplaced or minimally-displaced scaphoid fractures demonstrate faster recovery with operative treatment; however, the current meta-analysis does not provide evidence supporting the routine use of operative treatment for all acute undisplaced or minimally-displaced scaphoid fractures.     

Influence of Prior Coronary Stenting on the Immediate and Mid-term Outcome of Isolated Coronary Artery Bypass Surgery

BACKGROUND:: There has been little emphasis on the possible consequences of prior stent placement on the outcome of coronary bypass surgery (CABG). We compared the results of isolated CABG patients who had prior stents with those who had not with respect to preoperative status, operative procedure, and postoperative immediate and long-term outcome. METHODS:: Records of 1471 patients undergoing isolated CABG at our institution between January 1, 2000, and March 31, 2005, were reviewed. Patients were divided into three groups. Group I had no stents (n = 1317). Group II had one to three stents (n = 137). Group III had more than three stents (n = 17). Groups were compared with respect to preoperative risk factors, operative procedures, and postoperative results. Long-term survival data were obtained on 97.6% of patients with a mean follow-up, 4.1 ± 2.3 years. RESULTS:: Stented patients were younger (66.1 ± 10.8 vs. 69.1 ± 10.8 years, P = 0.006), had more unstable angina (68.2% vs. 58.9%, P = 0.02), hypercholesterolemia (83.8% vs. 61.2%, P = 0.00), chronic obstructive pulmonary disease (13.6% vs. 8.4%, P = 0.03), peripheral vascular disease (15.2% vs. 8.4%, P = 0.00), and previous CABG (10.1% vs. 4.2%, P = 0.00), fewer low ejection fractions (1.3% vs. 5.2%, P = 0.02), left main disease (25.3% vs. 32.6%, P = 0.04), diabetes (31.2% vs. 40.8%, P = 0.01), or diffuse disease (19.5 ± 10.5 vs. 22.5 ± 10.9, P = 0.00), had more off pump procedures (53.2% vs. 45.3%, P = 0.03), fewer internal thoracic artery grafts (80.5% vs. 86.6%, P = 0.03), fewer grafts placed (>3: 52.6% vs. 61.8%, P = 0.02), more complications (76.5% vs. 42.6%, P = 0.005), atrial fibrillation (47.1% vs. 19.7%, P = 0.011), longer hospital stays (12.2 vs. 8.3 days, P = 0.019). Percentage survival for groups I, II, and III at 60 months was 82.1%, 84.7%, and 72.6%, respectively. CONCLUSIONS:: Stents placed before surgery in isolated CABG patients may be associated with higher preoperative risk, altered operative procedures, more postoperative complications, longer hospitalizations, and more readmissions. Overall, stented patients experienced more preoperative hospitalizations, catheterizations, and percutaneous coronary interventions (PCIs) than nonstented patients. Survival for those with more than three stents may be diminished.     

Histology of the postoperative stomach before and after diversion of bile.

Gastric biopsy specimens were taken in 33 patients before and after procedures to divert bile (construction of Roux loop in 19, closure of gastrojejunostomy in 14). Each biopsy specimen was assessed for dysplasia, intestinal metaplasia, atrophy, and gastritis, each variable being given a score ranging from 0 to 6. Patients were given preoperative and postoperative scores for each of these variables based on the average score of all preoperative or postoperative specimens. Comparison between preoperative and postoperative histology showed that there was no difference for gastritis, atrophy, or intestinal metaplasia. Patients who underwent closure of a gastrojejunostomy showed improvement in dysplasia that was not statistically significant. There was, however, a significant improvement in dysplasia in patients in whom a Roux loop was fashioned (p = 0.006) and in all patients taken together (p = 0.002). It was concluded that procedures that divert bile improve dysplasia but not other histological abnormalities in the stomach postoperatively.