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Surgical and economic advantages of polyglycolic-acid suture material in skin closure.
A prospective, randomised trial compared polygycolic-acid subcuticular skin closure with interrupted silk skin closure in 152 patients. There was no significant difference in the incidence of wound infection. The use of polyglycolic acid was associated with economic advantages.
Surgical prophylaxis--the emerging picture.
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Review of antibiotic drug use in a surgical ICU: management with a patient data management system for additional outcome analysis in patients staying more than 24 hours.
BACKGROUND: A number of developments have been made in computerized patient data management systems (PDMSs), making them of interest to medical and nursing staff as a means of improving patient care. OBJECTIVES: The aim of this study was to assess the capability of a PDMS to record and provide drug-administration data and to investigate whether the PDMS may be used as a means of support for clinical audits and quality control. Furthermore, we assessed whether antibiotic therapy as a surrogate for infections correlates with hospital mortality in patients staying >24 hours in a surgical intensive care unit (SICU). METHODS: Because of its medical and economic importance in ICU treatment, we chose to use the field of antibiotic therapy as an example. A PDMS was used in a 14-bed SICU (Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Giessen, Giessen, Germany) to record relevant patient data, including therapeutic, diagnostic, and nursing actions. During a 15-month period (April 1, 2000 to June 30, 2001), antibiotic drug therapy was electronically analyzed and presented using the anatomic therapeutic chemical (ATC) category for antibacterials (ATC group, J01) with daily defined doses. Furthermore, the correlation of antibiotic therapy with patient outcome (hospital mortality) was tested using logistic regression analysis. RESULTS: A total of 2053 patients were treated in the SICU. Of these, 58.0% (1190 patients) received antibiotics (4479 treatment days; 13,145 single doses). Cephalosporins (ATC category, J01DA) were used most frequently (1785 treatment days [39.9% of treatment days]), followed by combinations of penicillins with beta-lactam inhibitors (ATC category, J01CR; 1478 treatment days [33.0%]) and imidazole derivatives (ATC category, J01XD; 667 treatment days [14.9%]). The antibiotic therapy lasted <3 days in 65.6% of cases. In 13.8% of cases, the treatment lasted >1 week. A total of 36.7% of cases were treated with only 1 antibiotic agent, 14.1% were given a combination of 2, and 7.2% were given a combination of > or =3 antibiotic agents. Seven hundred twenty-six patients remained in the SICU for >24 hours; 143 (19.7%) died during their hospital stay; 110 (15.2%) in the SICU. The duration of antibiotic therapy (odds ratio [OR], 1.46) and number of different antibiotic drugs used (OR, 2.15) significantly correlated with hospital mortality. CONCLUSIONS: Antibiotic therapy in a SICU can be assessed and analyzed in detail using a PDMS. Furthermore, in this study, the duration of antibiotic therapy and the number of antibiotic agents used correlated with hospital mortality. In further developing PDMSs, it is important for quality-assurance purposes to document the reasons for giving antibiotics and for changing prescriptions. It would also be helpful to integrate certain therapy standards and reminder functions for the duration of therapy in the PDMS.
Healing of the surgical wound. I. Basic considerations.
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Healing of the surgical wound. II. Factors influencing repair and regeneration.
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A simple system for intraoperative antiseptic wound ventilation.
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Hospital-acquired infections among surgical patients in a Brazilian hospital.
A historical cohort study was conducted among surgical patients in a large general hospital in Porto Alegre, Brazil between March 1992 and May 1993. Data were collected by means of a retrospective chart review, which followed a standardized method based on the systematic review of all clinical and laboratory information available in the hospital records. The criteria for diagnosis of all hospital-acquired infections (HAIs) were based on those from the Centers for Disease Control, Atlanta. In total, 890 HAIs were detected among the 4199 patients included in the cohort. The incidence rate of HAIs for all sites combined was 21.20%. Incidence rates ranged from 2.95% for bloodstream infections to 8.65% for surgical wound infections. The overall incidence density was 16.32 HAIs per 1000 patient-days. Incidence densities ranged from 2.03 for bloodstream infections to 7.46 per 1000 patient-days for surgical wound infections. The median incubation period for surgical wound infections was seven days, and 29.4% of these infections were detected at post-discharge. Gram-negative bacteria were the most common organisms implicated in HAIs.
Nosocomial infection, indices of intrinsic infection risk, and in-hospital mortality in general surgery.
The objectives of this paper are to assess whether two indices of intrinsic infection risk (the SENIC and the NNIS index) predict in-hospital mortality and the attributable in-hospital mortality due to nosocomial infection in surgical patients. A prospective study on 4714 patients admitted to three hospitals has been carried out. The relative risk and its 95% confidence interval (CI) were estimated. Multiple-risk factors adjusted for odds ratios (OR) were yielded by logistic regression analysis. Overall, 119 patients (2.5%) died before hospital discharge. Both the SENIC and the NNIS indices were related to in-hospital mortality in crude data. After controlling for several variables (age, sex, ASA score, cancer, renal failure, diabetes mellitus, stay at the ICU), the SENIC index did not show any significant trend with mortality (P = 0.252), whereas the trend was significant for the NNIS index (P < 0.001). Risk of death in patients with one nosocomial infection was 7.5%, and in patients developing more than one nosocomial infection was 17.1%. After adjusting for several confounding variables, the development of an organ/space surgical site infection was significantly related to mortality (OR = 4.5, 95% CI 1.5-15.6) as was blood infection (OR = 17.3, 95% CI 3.5-87.0). The association of a surgical site infection and either a respiratory tract infection or a blood infection also increased significantly the risk of in-hospital mortality (OR = 3.3, 95% CI 1.2-8.7). In conclusion, the NNIS index is a good predictor of in-hospital mortality. Patients developing an organ/space surgical site infection and/or a blood infection have an increased risk of in-hospital mortality.
Chest wall resection for local recurrence of breast cancer. Presented at the 99th Meeting of the Royal Belgium Society of Obstetrics and Gynecology, Brussels May 9th 1998, Belgium.
We present three cases of chest wall resection for locally recurrent breast cancer and a Medline review of the current literature. In selected cases full thickness resection of the chest wall may be used as a salvage procedure to improve the quality of life and prolong the survival at low morbidity and mortality.
Failure of thrombolytic therapy to improve long-term vascular patency.
PURPOSE: Few data are available on long-term follow-up of arterial segments subjected to thrombolysis. We reviewed all cases of vascular occlusion treated with urokinase to identify early success and determine the influence of postlysis intervention and the nature of the thrombosed segment (i.e., artery vs graft) on long-term patency. METHODS: Data on 134 cases (58 arteries, 76 grafts) treated with high-dose urokinase infusion in the lower limbs over a 7-year period were analyzed. Limbs were divided into five groups on the basis of therapy after lytic infusion to determine long-term efficacy: group I, success with no additional therapy; group II, percutaneous angioplasty alone; group III, limited surgical procedure (operative angioplasty, jump graft); group IV, extensive procedure (new bypass); and group V, revascularization after lytic failure. Long-term results were assessed by life-table analysis and groups compared by log-rank test (Mantel-Haenszel). RESULTS: Initial patency was established in 87 (64.9%) of 134 cases with 5 deaths (3.7%), 11 amputations (8.2%), and 16 complications (11.9%). Follow-up was available in 68.6% of cases for a mean of 10.9 months. No difference was seen between grafts and native arteries. Patency was analyzed at 6, 12, 18, and 24 months. The 24-month patency rate after lysis alone (group I-25.9%) was inferior (p < 0.05) to results after lysis and any subsequent intervention (groups II, III, and IV). The type of intervention did not influence subsequent patency. Twenty-four-month patency of procedures performed after failed thrombolysis (group V, 41.4%) was not different from those after successful lysis (groups I to IV). Twenty-four-month patency in groups II and III (minor interventions, 62.9%) was not significantly different from that of groups IV and V (major interventions, 53.2%) (p > 0.25). CONCLUSIONS: Operative intervention is required to produce long-term arterial patency, even after successful thrombolysis. No statistically significant benefit of thrombolysis on vascular patency was seen in our series.
[Perioperative antibiotic prophylaxis practice of French anesthesiologists and resuscitators: results of a national survey].
Antibiotics are the most prescribed drugs in French hospitals in one third of cases they are used for antiobiotic prophylaxis in surgery. In spite of the guidelines for antibioprophylaxis produced in the last years, their prescription patterns remain still often inappropriate. This survey aimed to assess whether the prescription of antibiotics for prophylaxis by French anaesthetits complied with the French recommendations for antibioprophylaxis in surgery. It focused on the recommended agents, the time of the first injection, the duration of treatment. A sample of 1,473 anaesthetists participated in the survey. In 93% of cases, the first injection of the antibiotic took place at anaesthesia induction, as specified by the recommendations. Cephalosporins of the first and second generation were often administered, as well as the association amoxicillin-clavulanic acid. In contradiction with the recommendations, the cephalosporins of the third generation were widely prescribed in digestive and urological surgery, and the quinolones in urology and ophtalmology. The duration of treatment was restricted to 48 hours by 94% of anaesthetists. However there was a strong tendency to prolonge it in immunodepressed patients and in case of major surgery. This survey showed disparities between the French recommendations for antibioprophylaxis in surgery and the prescription patterns of anaesthetists. The lack of compliance occurred mainly for recent cephalosporins and treatment duration of over 48 hours. It is concluded that a stronger adherence to the principles of antibioprophylaxis is required in surgical patients.
The surgical correction of fronto-ethmoidal meningo-encephaloceles.
One-stage correction of fronto-ethmoidal meningo-encephaloceles and related stigmata, via an orbito-cranial approach, is recommended. A bifrontal craniotomy is only required when simultaneous correction of hypertelorism is to be undertaken. A combined intra- and extracranial approach is essential. The possibility of a high relapse rate for repaired fronto-ethmoidal meningo-encephaloceles, together with the possibility of prolonged postsurgical cerebrospinal fluid leakage, meningitis and other complications is invited when either a transcranial bifrontal craniotomy surgical approach, or an extracranial approach via the facial lesion, is undertaken alone. Modification of existing craniofacial surgical approaches in order to avoid a frontal craniotomy, allowed for good repair of the encephalocele together with significant benefits in terms of simplification of the surgical procedure, operating time, blood loss, frontal lobe retraction and complications.
Mechanisms of ischemic preconditioning and clinical implications for multiorgan ischemic-reperfusion injury.
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[Comparison of 2 therapeutic strategies in severe endometriosis, in young women consulting for sterility or pain. II. In the case of infertility, value of ovarian stimulation with intrauterine insemination after surgery].
AIM OF THE STUDY: Define the best medico surgical strategy in infertile women with stage III-IV endometriosis. MATERIAL AND METHODS: Two groups, A (N26) and B (N 37), treated for infertility associated or not with pelvic pain, due to stage AFS III or IV endometriosis, were compared. They had similar surgical procedure: operative laparoscopy including resection of endometriotic lesions, more particularly endometriomas and rectovaginal septum nodules. Associated medical strategy was different: group A, operative laparoscopy without preoperative treatment and in 40% a second laparoscopy taking place after 2-3 months of LHRH analogues; no post operative treatment; group B, operative laparoscopy taking place after ovarian blockage with 3-6 weeks of Diane (Androcur + ethinyl estradiol), then 2-3 months of analogue postoperative treatment immediately followed by ovarian stimulation (OS) + intrauterine insemination (IUI) in women more than 30 years old with operative tubes (N 22), no treatment for six months in similar cases less than 30 (N 5), and IVF in women with damaged tubes (N 5) or after OS + IUI failure (N 4). One patient refused two patients with high FSH level had oocyte donation. RESULTS: Two years evolutive pregnancy rate was significantly higher (p < 0.01) in group B (59%) versus group A (23%) and was higher after OS + IUI (68%) than after IVF (55%) or without any treatment in women < 30 (43%). The difference is equally significant by age (p < 0.05), for endometriomas (p < 0.01) and for recurrences (p < 0.01). CONCLUSION: Similar results obtained for pelvic pain (see chapter I) suggest that both strategies are similarly successful in treating endometriosis. These results confirm the interest of an ART after surgery for stage III-IV endometriosis and show that OS + IUI, a less costly than IVF technique, can be used successfully in selected cases with operative tubes.
Consequences of inadvertent perioperative hypothermia.
Perioperative hypothermia triples the incidence of adverse myocardial outcomes in high-risk patients. Mild hypothermia significantly increases blood loss and augments allogeneic transfusion requirement, but the molecular pathophysiology of this effect remains to be elucidated. Only 1.9 degrees C core hypothermia triples the incidence of surgical wound infection following colon resection and increases the duration of hospitalization by 20%. Hypothermia adversely affects antibody- and cell-mediated immune defences, as well as the oxygen availability in the peripheral wound tissues. Mild perioperative hypothermia changes the kinetics and action of various anaesthetic and paralysing agents, increases thermal discomfort, and is associated with delayed post-anaesthetic recovery. Finally, mild core hypothermia influences pulse oximetry monitoring and various electrophysiological indices of the nervous system, with questionable clinical significance, as yet.