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PubMedDate not supplied

Procedural training in family practice residencies: current status and impact on resident recruitment.

BACKGROUND: Although procedural training in family practice has recently received greater emphasis, the current status of this training in residency programs has not been reported. Considerable variation in procedural training among family practice residencies is allowed by the American Board of Family Practice and accreditation requirements. This study was performed to report the current status of procedural training in family practice residencies and to determine whether a correlation exists between the number of procedures taught in family practice residencies and successful resident recruitment. METHODS: A one-page questionnaire was developed to determine availability of teaching and type of instructor for 24 selected procedures. This questionnaire was mailed to all 398 family practice residency directors in the United States. Data from the survey were compared with the published residency match results in 1993 and 1994. RESULTS: Questionnaires were received from 363 programs, for a response rate of 91 percent. The current status of training in these procedures, presented by program type and geographic region, reflects considerable regional variation. Training in colposcopy and in cardiac stress testing was reported to be available in a greater percentage of programs than in previous studies. A significant positive correlation was found between the number of procedures taught by family physicians and residency match results. CONCLUSIONS: The 91 percent response rate lends credibility to this status report and indicates that family practice program directors recognize procedural training as an important issue. The trend toward greater availability of procedural training in family practice residencies is confirmed for selected procedures. Emphasis on procedural training by family physicians has a positive correlation with successful resident recruiting. The impact on medical student interest in family practice deserves further study.

Family Practice↗

PubMed1993

The dysphagia diagnostic procedure as a treatment efficacy trial.

In all of these case reports, the patient's swallow function and the effect of therapy procedures on this function could be observed and measured from the videofluoroscopic assessment. In some cases, effects could be measured using other imaging procedures. The effects of each swallow therapy procedure can be measured by examining specific physiologic elements of the swallow. Table 3 presents the various therapy procedures and appropriate efficacy measures for each. In some cases, introduction of therapy procedures into the diagnostic evaluation can immediately enable the patient to begin eating. In other cases, evaluation of the effectiveness of the therapy procedure can validate its appropriateness for use with a patient in building the neuromuscular control necessary to return to oral intake. Not all therapy procedures can be introduced into the diagnostic setting, however, since they do not all result in immediate effects. For example, range of motion exercises for the lips, tongue, and/or jaw do not have an immediate effect, but typically show an effect after 2 to 3 wks. However, the clinician can still quantify the effects of range of motion exercises by measuring the patient's structural movement at each therapy session. When a second assessment is completed, change in range of motion of the target structure can be assessed by comparing the first and second studies. Introducing treatment techniques into the diagnostic swallowing assessment requires the clinician to read the results of the radiographic study or other imaging procedure immediately and identify the physiologic dysfunction so that appropriate therapy procedures can be selected and introduced. Because videofluoroscopy involves X-ray exposure to the patient, all possible treatment techniques cannot be attempted while in X-ray. Rather, the clinician must select those techniques believed to be most appropriate for that patient's anatomy and swallow physiology. When effective techniques are identified, the videotape of the diagnostic procedure can be used as an educational tool with the patient and his or her family, nurses, physicians, and others to educate and counsel them regarding the rationale for use of particular procedures with the patient, including introduction of particular posture, diets, etc. This type of visual evidence often improves patient and family compliance with therapy recommendations.

Adult↗

PubMed1993

Brief unconscious sedation for painful pediatric oncology procedures. Intravenous methohexital with appropriate monitoring is safe and effective.

PURPOSE: We report here our experience in using intravenous methohexital (MHX), an ultrashort-acting barbiturate, for brief unconscious sedation of pediatric oncology outpatients undergoing painful, invasive procedures. METHODS: Following published monitoring guidelines for deep pediatric sedation, 1.0 mg/kg MHX was administered immediately before the procedure, 1% xylocaine was given locally, and MHX was additionally titrated to maintain minimal response to pain during the procedure. Clinical data reported here were gathered retrospectively from permanent medical records. RESULTS: Data reported here represent 132 evaluable consecutive procedures in 33 patients ranging in age from 1.6 to 20.5 years. Patients underwent an average of 4 +/- 3 procedures and received a mean total MHX dose per procedure of 5.8 +/- 2.1 mg/kg. The mean length of time from start of sedation to full arousability was 30 +/- 12 min. Twenty-three (17.4%) procedures were associated with clinically insignificant decreases in diastolic blood pressure or heart rate below resting normal ranges for age. Eight (6.1%) procedures in six patients were associated with minor complications requiring no intervention, such as transient behavioral changes, transient myoclonus, and minimal stridor. Five procedures (3.8%) in five patients required simple suctioning to manage secretions. Only two procedures (1.5%) in two patients required brief bag-mask ventilation plus suctioning for suspected laryngospasm. None required intubation. No differences in clinical features or MHX doses were noted for patients with, as compared to those without, complications. All procedures were completed with a satisfactory level of sedation. CONCLUSIONS: Our experience indicates that MHX, with appropriate monitoring as described here, is a safe and effective agent for use in pediatric oncology outpatient sedation programs.

Adolescent↗

PubMed1996

Previous intrapleural procedures do not adversely affect lung transplantation.

BACKGROUND: Initially a previous intrapleural procedure causing a partially or completely fused pleural space represented a contraindication to lung transplantation. However, as experience with transplantation increased, particularly in patients with septic lung diseases who frequently have pleural adhesions, a previous intrapleural procedure became a relative rather than an absolute contraindication. The "clam shell" incision, which allows better control of the pleural spaces than a median sternotomy, contributed to this change. METHODS: The outcome of 18 patients with a previous intrapleural procedure was compared with 18 paired controls without previous surgery involving the transplanted pleural space. RESULTS: Five study patients had a predictably fused pleural space from their previous surgery, and four had extensive adhesions (major previous intrapleural procedures). The nine patients with minor previous intrapleural procedures had undergone more limited intrapleural procedures (open lung biopsy or chest tube drainage of a pneumothorax). There was no statistically significant trend for the operating time, blood loss, transfusion requirements, time intubated, and intensive care unit stay to be greater in the study population than in the controls. However, the major previous intrapleural procedure patients were younger, required longer cardiopulmonary bypass, and had a longer intensive care unit stay. The 6- and 12-month forced expiratory volumes in 1 second from the patients with major previous intrapleural procedures were not different from those of either the patients with minor previous intrapleural procedures or the controls. CONCLUSIONS: A previous intrapleural procedure, even when resulting in a fused pleural space, did not have a significant detrimental impact on outcome. Therefore a previous intrapleural procedure should neither preclude listing a patient for transplantation nor significantly influence the choice of recipient when lungs become available for transplantation.

Adult↗

PubMed1996

Multiple test procedures for dose finding.

The problem of identifying the lowest dose level for which the mean response differs from that at the zero dose level is considered. A general framework for stepwise testing procedures that use contrasts among the dose level means is proposed. Using this framework, several new procedures are derived. These and some existing procedures, including that of Williams (1971, Biometrics 27, 103-117; 1972, Biometrics 28, 519-531), are compared analytically and by an extensive simulation study for the normal theory balanced one-way layout case. It is pointed out that the procedures based on the so-called step and basin contrasts proposed by Ruberg (1989, Journal of American Statistical Association 84, 816-822) have excessively high type I familywise error rates (FWEs) and, hence, they should not be used. Some findings of the simulation study are as follows: For monotone dose mean configurations, Williams' procedure and two step-down test procedures based on Helmert and linear contrasts offer the best performance. For nonmonotone dose mean configurations, the performance of Williams' procedure does degrade somewhat, but the other two procedures are still the best. For more complex designs, a simple step-down test procedure that uses any alpha-level tests (not necessarily t-tests) to compare each dose level with the zero dose level controls the FWE and is the only alternative available, but its power is rather low, especially under nonmonotone configurations. Step-up procedures are generally dominated by step-down procedures when the same contrasts are used although the differences are not great.

Animals↗

PubMed1997

Which procedures should be taught in family practice residency programs?

BACKGROUND: Family practice residencies lack clear guidelines defining which procedures should be included in their curricula. The American Academy of Family Physicians (AAFP) Task Force on Procedures developed a recommendation (approved by the AAFP Board of Directors) that can be used to create a set of procedures that should be taught in residencies. The task force recommendation is based on procedures taught in most family practice residencies and performed by most practicing family physicians. METHODS: The AAFP Task Force on Procedures surveyed all family practice residency programs and departments to determine which procedures they were teaching. The task force also surveyed a representative sample of practicing family physicians to find out which procedures they were performing. RESULTS: Residency programs and departments returned 397 surveys (74.1% response), and the sample of 4,400 practicing physicians returned 2,028 surveys (46.1% response). The survey data identified 69 procedures as being taught in most family practice residencies, and 30 of these procedures as being performed by most practicing family physicians. CONCLUSIONS: Many procedures can be identified as being taught in most family practice residencies or performed by most practicing family physicians. Fewer procedures are performed by practicing family physicians than are taught in residencies.

Clinical Competence↗

PubMedDate not supplied

Medium-term follow-up on use of freeze-dried, irradiated donor fascia for sacrocolpopexy and sling procedures.

The aim of this study was to document longer-term follow-up of patients in a previously reported series who underwent either sacrocolpopexy (SCP) or suburethral sling procedures utilizing freeze-dried, irradiated donor fascia. Subjects from the initial series of 67 SCPs and 35 slings were included in this retrospective chart review of postoperative follow-up where surgical follow-up longer than 3 months from the procedure was available. Subjects undergoing SCP were examined at the time of any clinical visit and their pelvic organ support evaluated utilizing the POP-Q system. The SCP procedure was considered to be unsuccessful if any anterior vaginal wall point (Aa or Ba) was at the hymen or beyond, or if the vaginal apical point (C or D) descended to a point at least halfway to the hymen from a position of perfect apical support. Subjects who did not return for clinical examination after their 3-month postoperative visit but who had been in telephone contact with the clinic stating that they had experienced symptomatic recurrence of their POP were also included as having unsuccessful SCP procedures. Those similarly in contact with the office by telephone, but not clinically examined, who indicated no subjective return of their POP, were coded as successful. The outcome of the sling procedure was primarily evaluated subjectively, with the patient indicating that stress incontinence symptoms were present or absent. Follow-up was available for 75 patients, who had undergone 54 SCP and 27 sling procedures (6 patients had undergone both SCP and sling procedures). When failure was defined according to any of the criteria listed in the methods section, 45 (83%) patients experienced SCP failure at a median of 12 months after surgery. A total of 14 (52%) sling procedures were failures, with recurrent SUI symptoms experienced from 2 weeks to 24 months (median 3 months) after the procedure. One year after surgery, 23 (43%) SCPs were known to be failures, and 11 (41%) slings were known to be failures. The remaining 13 (48%) slings were subjectively successful when last seen 7-51 months after surgery. We reoperated on 21 (40%) patients. At the time of repeat SCP (chosen by 16 patients) we found graft between the sacrum and vagina in just 3 patients (19%). The use of freeze-dried, irradiated donor fascia for both SCP and sling procedures was associated with an unacceptably high failure rate in our series.

Aged↗

PubMed2000

Office pediatric urologic procedures from a parental perspective.

OBJECTIVES: To determine the parent perception of discomfort (PPD) in children receiving local anesthesia for the lysis of labial adhesions, meatotomy, and newborn circumcision; the parents' perceived outcome of these procedures; and the overall satisfaction of parents when these procedures are performed in the office. METHODS: A confidential phone survey was given to 99 parent participants whose children had received local anesthesia for the lysis of labial adhesions (n = 14), meatotomy (n = 28), or newborn circumcision (n = 57). Parents in the labial adhesion and meatal stenosis groups were asked to rate their child's level of discomfort (PPD) during the procedure as mild (1), moderate (2), or severe (3), and those in the circumcision group were asked to use the same scale to rate their child's discomfort after the procedure. Parents were also asked whether they thought the procedure was successful and whether they were satisfied with their decision to have it done in the office using local anesthesia. RESULTS: Among the labial adhesion, meatotomy, and circumcision groups, the mean PPD +/- SD was 1.64 +/- 0.75, 1.54 +/- 0.69, and 1.21 +/- 0.53, respectively. The observed procedures, lysis of labial adhesions and meatotomy, had a significantly higher PPD score (P = 0.005) than the unobserved procedure (circumcision). Parents reported good outcomes in 94 (94.9%) of 99 children, with 4 girls experiencing recurrent labial adhesions and 1 boy experiencing recurrent meatal stenosis. Overall, 95 (96.0%) of 99 parents stated that they were satisfied with their decision to have the procedure done in the office with local anesthesia. Of the remaining 4 parents, 3 parents in the circumcision group stated they would have preferred general anesthesia, and 1 parent in the labial adhesion group was undecided. CONCLUSIONS: The PPD is greater if the parent observes their child's procedure. However, office procedures using local anesthesia for the lysis of labial adhesions, meatotomy, and newborn circumcision are well accepted among the parent population.

Ambulatory Surgical Procedures↗

PubMedDate not supplied

The Maze procedure for the treatment of atrial fibrillation: a minimally invasive approach.

OBJECTIVES: The standard Maze procedure has proven to be extremely effective in curing atrial fibrillation in thousands of patients worldwide. Until now it has required a median sternotomy and cardiopulmonary bypass. In order to simplify the standard approach, a minimally invasive technique was developed. We have recently applied this minimally invasive Maze procedure in 72 patients. METHODS: The technique is dependent on the use of cryosurgery and the total number of atriotomies has been decreased from twelve to four. In addition to performing the Maze procedure, 32% of patients have had concomitant surgery via the minimally invasive approach including mitral valve repair/replacement and tricuspid valve repair. RESULTS: Perioperative morbidity is improved following the minimally invasive approach in comparison to the standard approach with the incidence of temporary perioperative arrhythmias being decreased by 50%. The long-term recurrence of atrial fibrillation is 2.4% following the minimally invasive Maze procedure and 2.2% following the standard Maze procedure. The incidence of pacemaker requirements following the standard Maze procedure is 20% but only 6% following the minimally invasive Maze procedure. Both right atrial and left atrial transport function have been documented in 100% of patients following the minimally invasive Maze procedure. CONCLUSIONS: We believe that the minimally invasive Maze procedure is a substantial improvement over the standard approach in terms of patient morbidity while preserving the effectiveness of the Maze procedure in curing atrial fibrillation.

Adult↗

PubMed2003

Intravenous sedation vs general anesthesia for pediatric otolaryngology procedures.

OBJECTIVE: To compare efficacy, safety, and hospital charges for common pediatric otolaryngology procedures with the use of intravenous sedation (IVS) vs general anesthesia (GA). DESIGN: Retrospective chart study. SETTING: Hospital-based pediatric otolaryngology practice. PATIENTS: Patients younger than 18 years who underwent tympanostomy tube removal and/or patch myringoplasty with absorbable gelatin sponge, nasal ciliary biopsy, fine-needle aspiration, or other minor procedures between September 1, 1998, and August 31, 2001. INTERVENTIONS: Procedures performed in 2 settings: outpatient clinic with IVS or operating room with GA. MAIN OUTCOME MEASURES: Procedure completion rate, tympanic membrane perforation rate after ear procedures, complications, and hospital charges. RESULTS: Of 103 procedures, 54 were performed with IVS and 49 with GA. Within the GA group, 32 of 49 patients had additional operations performed and were excluded from analysis of safety and hospital charges. Procedure completion rate was 100% in both groups. The most common procedure was tympanostomy tube removal with patch myringoplasty (IVS, 52 ears; GA, 42 ears). The rate of persistent tympanic membrane perforation was similar between these groups (IVS, 7 [16%] of 45 ears; GA, 5 [15%] of 33; P =.96). All complications were minor and occurred at similar rates (IVS, 10 [19%] of 54 ears; GA, 3 [18%] of 17; P =.94). These events included hypoxia, airway obstruction, and bradycardia, all of which resolved spontaneously or responded to noninvasive interventions such as oxygen or repositioning. Average hospital charges were significantly higher for the GA group (IVS, $356.22; GA, $1516.55; P<.001). CONCLUSION: Various procedures can be performed safely, effectively, and with decreased hospital charges with the use of IVS administered by a pediatric sedation service.

Adolescent↗

PubMed2003

Complications and determinants of length of stay for inpatient pediatric otolaryngologic procedures.

OBJECTIVE: To identify clinical factors associated with morbidity, mortality, and length of stay (LOS) for inpatient pediatric otolaryngologic procedures. STUDY DESIGN: Retrospective cohort study. METHODS: Records of patients undergoing pediatric otolaryngologic procedures were extracted from the National Hospital Data Survey for the calendar years 1995 through 1999. These records were examined to determine demographics, morbidity, mortality, type of procedure (as defined by anatomic subsite), and LOS. The effects of morbidity and type of procedure on LOS were identified. RESULTS: A total of 4861 children underwent inpatient otolaryngologic procedures. The overall morbidity rate was 4.6%. The most common morbidity was pneumonia, occurring in 171 patients (3.5%). The presence of any morbidity was associated with a significantly increased LOS (18.4 days vs 4.6 days; P<.001). The occurrence of pneumonia was associated with an increase in LOS to 19.7 days vs 4.7 days in patients without pneumonia (P<.001). Procedures involving the larynx, trachea, or esophagus carried the longest LOS (12.3 days; P<.001) among all procedural categories. The overall mortality rate was distinctly low at 0.4%. However, the occurrence of morbidity was associated with an increased risk of death, with an odds ratio of 8.0 (P =.001). Mortality was highest (13 of 18 deaths) after procedures on the larynx, trachea, or esophagus. CONCLUSIONS: Medical complications in children undergoing inpatient otolaryngologic procedures are associated with significantly increased LOS. Despite procedural complexity, overall mortality is remarkably low. Efforts to decrease medical morbidity in this population may result in decreased LOS and improved clinical outcomes.

Adolescent↗

PubMed2003

Comparative outcomes analysis of procedures performed in physician offices and ambulatory surgery centers.

HYPOTHESIS: This study compared outcomes to determine whether patient safety is similar in Florida ambulatory surgery centers and offices. DATA SOURCES: All adverse incident reports to the Florida Board of Medicine for procedure dates April 1, 2000, to April 1, 2002 were reviewed. The numbers of office procedures performed during a 4-month period were used to estimate the total number of procedures. Ambulatory surgery death summaries, adverse incident data, and volumes of procedures for 2000 were procured from the Florida Agency for Health Care Administration. STUDY SELECTION/DATA EXTRACTION: Adverse incident reports were reviewed by multiple parties; only reports that involved an office surgical procedure and resulted in injury or death were included in the outcomes calculation. Reports were extracted independently by multiple reviewers. DATA SYNTHESIS: Adverse incidents occurred at a rate of 66 and 5.3 per 100,00 procedures in offices and ambulatory surgery centers, respectively. The death rate per 100,000 procedures performed was 9.2 in offices and 0.78 in ambulatory surgery centers. The relative risks for injuries and deaths for office procedures vs ambulatory surgery centers were 12.4 (95% confidence interval, 9.5-16.2) and 11.8 (95% confidence interval, 5.8-24.1), respectively. CONCLUSIONS: In this review of surgical procedures performed in offices and ambulatory surgery centers in Florida during a recent 2-year period, there was an approximately 10-fold increased risk of adverse incidents and death in the office setting. If all office procedures had been performed in ambulatory surgery centers, approximately 43 injuries and 6 deaths per year could have been prevented.

Ambulatory Surgical Procedures↗

PubMed2000

A staged Fontan approach in patients initially unsuitable for the primary Fontan procedure.

OBJECTIVE: To determine the efficacy of the Glenn procedure in terms of establishing the Fontan procedure. METHODS: Surgical results were investigated in 248 patients undergoing either the total or partial right heart bypass. Of these, the conventional and the bidirectional Glenn procedures were employed in 27 and 58 patients, respectively. RESULTS: Conversion to the Fontan circulation was attempted in 32 of 58 patients initially considered unsuitable for the Fontan circulation and undergoing the bidirectional Glenn procedure, with 2 operative deaths. Of the 27 undergoing the conventional Glenn procedure, 13 have undergone conversion with 2 deaths. Actuarial survival rate after the staged Fontan approach did not statistically differ from that after the primary Fontan procedure. Catheterization in 130 patients with the established Fontan circulation showed no significant differences in ejection fraction, end diastolic volume, and end diastolic pressure of the systemic ventricle, as well as in Cardiac Index, between the group of patients treated with the primary Fontan procedure and the group treated with the staged Fontan procedure. When achieving the bidirectional Glenn procedure, the size of the additional channel from the ventricles to the pulmonary arteries was correlated with the postoperative change in pulmonary arterial size, but such additional forward flow produced insufficient ventricular offloading in 9 of 16 patients with significant atrioventricular valvar regurgitation. CONCLUSION: The staged Fontan strategy has an advantage in patients with complicated circumstances. Whether the primary or the staged Fontan procedure was used, however, did not affect the Fontan circulation itself when once the Fontan circulation was established. The additional forward flow in the bidirectional Glenn physiology, if employed, should be appropriately adjusted, considering both the advantages and the disadvantages of the option.

Child, Preschool↗

PubMed2006

[Computer-assisted screw placement into the posterior pelvic ring: assessment of different navigated procedures in a cadaver trial].

OBJECTIVE: Computer-assisted procedures have recently been introduced for navigated iliosacral screw placement. Currently there are only few data available reflecting results and outcome of the different navigated procedures which may be used for this indication. We therefore evaluated the features of a new 3D image intensifier used for navigated iliosacral screw placement compared to 2D fluoroscopic and CT navigation. MATERIALS AND METHODS: Twenty fixed human cadavers were used in this trial. Cannulated cancellous screws were percutaneously implanted in the supine position in four treatment groups. An optoelectronic system was used for the navigated procedures. Screw placement was postoperatively assessed by fluoroscopic 3D scan and CT. The target parameters of this investigation were practicability, precision as well as procedure and fluoroscopic time per screw. RESULTS: All navigated procedures revealed a significant loss of time compared to non-navigated screw placement (2D: p<0.001, 3D: p>0.05, CT: p<0.001). Simultaneously a significant decrease of radiation exposure time was observed in the navigated groups (p<0.001 each). The misplacement rate was 20% in the non-navigated and the 2D fluoroscopic navigated group each. Procedures providing 3D imaging of the posterior pelvis did not produce any screw misplacement (p>0.05). However, the CT procedure was associated with time-consuming registration and high rates of failed matching procedures. CONCLUSION: Our data show a clear benefit of using C-arm navigation for iliosacral screw placement compared with the CT-based procedure. While both fluoroscopy-based navigation procedures decrease intraoperative radiation exposure times, only 3D fluoroscopic navigation seems to improve the precision compared to non-navigated screw placement.

Bone Screws↗

PubMed2006

Intraoperative MRI for interventional neurosurgical procedures and tumor resection control in children.

INTRODUCTION: Despite the introduction of neuronavigational systems, radical tumor removal is still problematic in many neurosurgical procedures. Thus, direct intraoperative imaging for tumor resection control was implemented with an intraoperative magnetic resonance imaging (ioMRI) scanner installed in the operating room. Whereas most procedures with ioMRI were carried out in adults, we summarize 7 years of experience using ioMRI in children for interventional neurosurgical procedures or for tumor resection control. METHOD: An open magnetic resonance scanner (Magnetom Open 0.2 T) was installed in the neurosurgical operating room. For tumor resection control, ioMRI was performed in 35 procedures. After the ioMRI scans were analyzed with respect to quality, the identification of residual tumor was considered by the attending neuroradiologist and neurosurgeon. If residual tumor tissue was present, a new three-dimensional (3D) dataset was acquired to update the neuronavigation; subsequently, the tumor resection was extended. In all these procedures, the results of the ioMRI were checked by an early postoperative high-field magnetic resonance imaging (MRI) study. In addition, ioMRI was carried out in ten other children to monitor interventional neurosurgical procedures. RESULTS: In all children, ioMRI was adequate both for tumor resection control and monitoring of interventional procedures. Primary radical removal of tumor was reached in 40% as confirmed by ioMRI, but in 60% of the patients, the tumor resection procedure was extended after residual tumor was detected using the new 3D dataset for navigational update. By using ioMRI, radical tumor removal improved up to 83% as confirmed by early postoperative MRI. Procedure-related complications were not seen in our series. For all MR-guided biopsies, histology findings could be confirmed, and aspiration of intracranial cysts or abscesses could be monitored online. CONCLUSION: IoMRI using the open magnetom is suitable for detecting residual tumor tissue, can compensate for the phenomenon of brain shift using a new intraopertive 3D dataset for extended tumor resection, and is capable of monitoring interventional neurosurgical procedures. By using ioMRI for tumor resection control, the degree of tumor resection could be significantly improved.

Adolescent↗

PubMed2006

Randomized clinical trial of etomidate versus propofol for procedural sedation in the emergency department.

STUDY OBJECTIVE: We compare the efficacy, adverse events, and recovery duration of etomidate and propofol for use in procedural sedation in the emergency department (ED). METHODS: This was a randomized nonblinded prospective trial of adult patients undergoing procedural sedation for painful procedures in the ED. Patients received either propofol or etomidate. Doses, vital signs, nasal end-tidal CO2 (ETCO2), pulse oximetry, and bispectral electroencephalogram analysis scores were recorded. Subclinical respiratory depression was defined as a change in ETCO2 greater than 10 mm Hg, an oxygen saturation of less than 92% at any time, or an absent ETCO2 waveform at any time. Clinical events related to respiratory depression, including an increase in supplemental oxygen, the use of a bag-valve-mask apparatus, airway repositioning, or stimulation to induce breathing, were noted during the procedure. After the procedure, patients completed visual analog scales about perceived pain during the procedure and recall of the procedure. RESULTS: Two hundred twenty patients were enrolled; 214 underwent sedation and were analyzed. One hundred five patients received etomidate and 109 received propofol. No clinically significant complications were noted. Subclinical respiratory depression was observed in 36 of 105 (34.3%) patients in the etomidate group and 46 of 109 (42.2%) in the propofol group (difference -7.9%; 95% confidence interval [CI] -20.9% to 5.1%). Myoclonus was noted in 21 of 105 (20.0%) patients in the etomidate group and 2 of 109 (1.8%) in the propofol group (difference 18.2%; 95% CI 10.1% to 26.2%). The mean difference between baseline systolic blood pressure and the nadir was 3.8% (95% CI 2.3% to 5.3%) for etomidate and 7.9% (95% CI 6.1% to 9.7%) for propofol. Clinical events related to respiratory depression included an increase in supplemental oxygen in 6.7% of etomidate patients and 5.5% of propofol patients (difference 1.2%; 95% CI -5.2% to 7.6%), the use of bag-valve-mask apparatus in 3.8% of patients in the etomidate groups and 4.6% in the propofol group (difference -0.8%; 95% CI -6.1% to 4.6%), airway repositioning in 13.3% of etomidate patients and 11.0% of propofol patients (effect size 2.3%; 95% CI -6.4% to 11.1%), and stimulation to induce breathing in 11.4% of etomidate patients and 11.9% of propofol patients (difference -0.5%; 95% CI -9.1% to 8.1%). The procedures were successful in 93 of 105 (88.6%) for etomidate and 106 of 109 (97.2%) for propofol (difference -7.4%; 95% CI -14.3% to -1.1%). CONCLUSION: Etomidate and propofol appear equally safe for ED procedural sedation; however, etomidate had a lower rate of procedural success and induced myoclonus in 20% of patients.

Adolescent↗

PubMed2005

Adjuvant procedures performed during endovascular repair of abdominal aortic aneurysm. does it influence outcome?

OBJECTIVE: The purpose of this study was to assess whether there is a difference in outcome of endovascular repair in patients with and without intraoperative adjuvant procedures. METHODS: Demographic, anatomic and operative details were assessed in patients undergoing endovascular repair using the EUROSTAR registry and correlated with morbidity and mortality rates. Three groups of adjuvant procedures: (A) endovascular, (B) surgical peripheral arterial and (C) surgical abdominal arterial were compared with a group of patients without an adjuvant procedure (D). Logistic regression and Cox proportional hazards model were used for statistical analysis. RESULTS: Of 4631 endovascular repairs, 1353 patients (29.2%) required adjuvant procedures. Additional endovascular procedures were performed in 1057 (78.1%), surgical peripheral arterial in 193 (14.3%) and surgical abdominal arterial in 103 (7.6%). The 30-day mortality rate was significantly higher in categories with peripheral arterial surgical (6.7%) and abdominal surgical procedures (7.8%) compared to patients without adjuvant procedures (1.5%, p = .001 and p = .004, respectively). Life-table-analysis demonstrated that late mortality, conversion or rupture rates were not increased in patients with an adjuvant procedure. CONCLUSION: Adjuvant surgical procedures were associated with increased 30-day mortality. Because of this higher risk, endovascular repair should be recommended with caution when surgical adjuvant procedures are anticipated.

Aged↗

PubMed2003

Morbidity with retroperitoneal procedures during endovascular abdominal aortic aneurysm repair.

PURPOSE: Retroperitoneal iliac procedures can enable successful endovascular repair of abdominal aortic aneurysm (AAA) in patients who otherwise would not be anatomically eligible. The purpose of this study was to determine perioperative outcome with adjunctive retroperitoneal procedures compared with standard bilateral femoral exposure. METHODS: Between August 1997 and November 2002, 164 patients underwent elective endovascular AAA repair at a single university medical center. Anatomic, demographic, and early postoperative outcome data gathered prospectively were analyzed. Thirty-two patients (20%) underwent 38 separate adjunctive retroperitoneal procedures. Indications included small external iliac arteries (16 of 32 patients; 50%) and concomitant iliac aneurysm that precluded fixation of the endograft limbs in the common iliac arteries (16 of 32 patients; 50%). The 38 procedures consisted of 8 iliac conduits only, 14 iliac conduits with iliofemoral bypass grafts, and 16 hypogastric revascularization procedures. Data for the study patients were compared with data for 132 patients who underwent endovascular AAA repair through femoral incisions. Primary end points were hospital length of stay, and early morbidity and mortality. RESULTS: Retroperitoneal procedures enabled an additional 14% of patients with AAA to undergo endovascular techniques. However, there was a significantly higher proportion of women and patients at high risk for anesthesia (American Society of Anesthesiologists class IV or higher) in the group who underwent retroperitoneal procedures. On average, retroperitoneal procedures were associated with 2.6-fold greater blood loss, 82% longer procedure time, 1.5 days additional hospital stay, and 1.8-fold higher rate of perioperative complications, compared with endovascular AAA repair with femoral exposure alone. In contrast, early mortality was similar in the two groups. CONCLUSION: Adjunctive retroperitoneal procedures during endovascular AAA repair are associated with increased risk for complications and longer hospital length of stay, compared with AAA repair with standard femoral exposure only. They do not, however, increase early mortality, even in patients at high risk, and enable a larger subset of patients with AAA to undergo endovascular repair.

Aged↗