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PubMed1995

Procedures associated with infective endocarditis in adults. A case control study.

OBJECT: To assess the relative risk of infective endocarditis associated with various procedures and the protective efficacy of antibiotic prophylaxis by a case-control study. BACKGROUND: Recommendations for the prevention of infective endocarditis are based on the hypothesis of a relationship between procedures and infective endocarditis which is supported by anecdotal reports and data from experimental models. METHODS: Cases met the Von Reyn's diagnostic criteria modified with echocardiographic and macroscopic findings Controls were recruited from cardiology or medicinal wards. Cases (n = 171) and controls were matched as regards sex, age and underlying cardiac condition. They were requested to indicate all the medical, surgical or dental procedures within the previous 3 months. Among potential confounding factors, infectious episodes and skin wounds in the previous 3 months were reported. Antibiotic prophylaxis administration was documented for type, dosage, duration and administration schedule. RESULTS: Cases significantly more frequently than controls had undergone at least one procedure (matched odds ratio, 1.6; 95% confidence interval, 1.01 to 2.53). Dental procedures considered as a whole were not associated with an increased risk, although scaling and root canal treatment showed a trend towards a higher risk of infective endocarditis (P = 0.065). Among non-dental procedures, only surgery appeared to be at risk (matched odds ratio, 4.7; 95% confidence interval, 1.02 to 22). Considering all procedures, the risk of infective endocarditis increased significantly with the number of procedures. While general co-morbid conditions did not differ between the two groups, cases significantly more frequently than controls had experienced an infectious episode or a skin wound. In multivariate analysis, only infectious episodes and skin wounds significantly increased the risk of infective endocarditis. Scaling was the only independent risk factor for viridans streptococcal infective endocarditis. The 46% protective efficacy of antibiotic prophylaxis was not significant. CONCLUSIONS: Procedures do increase the risk of infective endocarditis. The interpretation of the apparent low risk associated with dental procedures may be as a result of the current practice of antibiotic prophylaxis. Our data suggest that surgery should be more clearly mentioned in future guidelines, and reemphasize that a rigorous treatment of any focal infection in cardiac patients is mandatory. From the efficacy rate of antibiotic prophylaxis,it can be estimated that the overall incidence of infective endocarditis might be reduced by 5 to 10% in France by appropriate use of antibiotic prophylaxis in cardiac patients.

Adult↗

PubMed2005

Patient and staff doses in interventional X-ray procedures in Sweden.

UNLABELLED: Interventional procedures in radiology are of concern because of irradiation doses to the patients and also to the staff. A questionnaire sent to all radiology departments in Sweden showed that 11,350 procedures were performed annually 1996-1997. In a follow-up study, data from patient procedures were recorded. Type of procedure, dose-area product (DAP) values, fluoroscopy times, number of radiography series and patient data were recorded. For some procedures, staff doses were measured. Skin doses to the patients were also calculated where possible. RESULTS: A total of 380 interventional procedures were described. The procedures were grouped into cranial, neck and thorax, intestine and abdominal, uro/genital and pelvis and extremities. DAP and fluoroscopy times (mean values) were 200 Gy cm2 for 57 min, 57 Gy cm2 for 16 min, 270 Gy cm2 for 35 min, 212 Gy cm2 for 37 min, 67 Gy cm2 for 21 min, respectively, for the named procedures. Maximum patient skin doses exceeded threshold values for erythema (2 Gy) in cranial, neck/thorax and intestine/abdominal procedures. Effective doses to the patients could be high, 200 mSv. CONCLUSION: It was found that patient doses could exceed threshold values for skin erythema (2 Gy) and temporary epilation (3 Gy). Hence, the procedures require immediate improvement.

Adult↗

PubMed2002

Antimicrobial prophylaxis for gastrointestinal procedures: current practices in North American academic pediatric programs.

BACKGROUND: Guidelines for the use of antibiotic prophylaxis in children are based on a small number of studies that assess the risk of infection associated with performing endoscopic procedures. The American Heart Association (AHA) and the American Society of Gastroenterological Endoscopy (ASGE) have established guidelines that identify conditions and procedures that place a child at greater risk for infectious complications. Because data on bacteremia and sepsis associated with endoscopy in children are very limited, we reviewed the practices of 15 large academic pediatric gastroenterology services to see if patterns of practice and safety could be determined. METHODS: A questionnaire was sent to 15 academic gastroenterology centers in the United States and Canada asking about antibiotic prophylaxis for endoscopic procedures for children with six conditions. These included three conditions related to congenital heart disease based on negligible, moderate, and high risk for endocarditis; immune compromise; the presence of a central venous line; and the presence of a ventriculo-peritoneal shunt. Six procedures were evaluated, including esophagogastroduodenoscopy with biopsy, flexible sigmoidoscopy or colonoscopy with biopsy, endoscopic retrograde cholangiopancreatography, esophageal sclerotherapy, esophageal dilation, and percutaneous endoscopic gastrostomy (PEG) tube placement. RESULTS: The patterns of reported practice generally conform to the AHA and ASGE guidelines. The six conditions and six procedures yielded 36 response categories for the participating centers. The majority of centers reported routine use of antibiotic prophylaxis in about half (17) of the response categories, which represented three distinct situations. These included children with congenital heart disease having moderate or high risk for bacterial endocarditis for almost all procedure categories and children undergoing PEG tube placement regardless of underlying condition. In all other combinations of underlying conditions and procedures, the majority of centers did not use routine prophylaxis. The majority of centers did not use antibiotic prophylaxis for cardiac conditions with a negligible risk of infectious complication or for children with immunocompromise, central venous lines, or ventriculo-peritoneal shunts for any procedure except PEG placement. CONCLUSIONS: These results indicate that the routine use of antibiotic prophylaxis is limited in pediatric academic centers to a few very specific conditions and procedures. The results also provide indirect evidence that the risk of infectious complications associated with endoscopic procedures appears to be exceedingly low.

Antibiotic Prophylaxis↗

PubMedDate not supplied

Intravenous anesthesia with propofol for painful procedures in children with cancer.

OBJECTIVE: To study the safety and efficacy of propofol-based intravenous anesthesia in children with cancer undergoing painful procedures. METHODS: This study is a retrospective analysis of data collected from 52 consecutive children who underwent 335 procedures using propofol anesthesia. These data were routinely collected in all patients: time to induction, duration of the procedure, time to recover, and the doses of the drugs used. Monitoring with electrocardiography and pulse oximetry was continuous during the procedure; blood pressures were recorded before and after the procedure and every 5 to 10 minutes during the procedure. The patients received one of these four propofol-based intravenous regimens according to the anesthesiologist's preference: propofol only; propofol plus fentanyl; propofol plus midazolam; or propofol, fentanyl, and midazolam. The efficacy of sedation was rated by this scoring system: 3 = no movement during procedure; 2 = minimal movement that did not interfere with the procedure; 1 = moderate movement requiring physical restraint to complete the procedure. RESULTS: There were six episodes of mild hypoxia (oxygen saturation 85%-94%) and one episode of laryngospasm. None required intubation. Two patients had agitation and one patient had emesis during the postrecovery phase. There was no difference in the efficacy of sedation between the four regimens. Patients receiving the combination of propofol, fentanyl, and midazolam received the least amount of propofol and required the least time to recover. There were no life-threatening complications. CONCLUSIONS: Propofol-based anesthesia, when administered by an anesthesiologist in a controlled setting, is safe and effective for performing painful procedures in children with cancer.

Ambulatory Care↗

PubMed1997

Procedures in complex systems: the airline cockpit.

In complex human-machine systems, successful operations depend on an elaborate set of procedures which are specified by the operational management of the organization. These procedures indicate to the human operator (in this case the pilot) the manner in which operational management intends to have various tasks done. The intent is to provide guidance to the pilots and to ensure a safe, logical, efficient, and predictable (standardized) means of carrying out the objectives of the job. However, procedures can become a hodge-podge. Inconsistent or illogical procedures may lead to noncompliance by operators. Based on a field study with three major airlines, the authors propose a model for procedure development called the "Four P's": philosophy, policies, procedures, and practices. Using this model as a framework, the authors discuss the intricate issue of designing flight-deck procedures, and propose a conceptual approach for designing any set of procedures. The various factors, both external and internal to the cockpit, that must be considered for procedure design are presented. In particular, the paper addresses the development of procedures for automated cockpits--a decade-long, and highly controversial issue in commercial aviation. Although this paper is based on airline operations, we assume that the principles discussed here are also applicable to other high-risk supervisory control systems, such as space flight, manufacturing process control, nuclear power production, and military operations.

Accidents, Aviation↗

PubMed1993

Improving the quality and ease of tracking invasive procedures.

Documentation of the decision-making process leading up to an outcome of procedures is essential for assessing quality of patient care, supporting reimbursement, determination of appropriate utilization, and discernment of practitioner competence. Currently, doctors document interventions conducted outside the operating room in narratives within the daily progress notes. The free-form narrative typically includes the practitioner directly involved, procedure performed, technique used and outcomes. While hospitals encourage conformity to these documentation standards, the quality and content of the narratives vary greatly by practitioner, frequently leaving significant information missing. Therefore, to improve both quality of documentation in procedure notes and ease of monitoring non-operating room procedures, we developed a multicopy standardized procedure note. The form contains lines for recording the type, location, indication, anaesthesia, findings, and complications of the procedure, plus the persons performing, supervising and undergoing the procedure. Practitioners complete the multicopy note instead of the usual narrative note. We encode all the information from the standardized note into a data base that accumulates information on all procedures done throughout the hospital. The data base is used to generate summary reports to provide feedback to residents, residency directors and practitioners on procedural proficiency. The major advantage of this system is that it simultaneously improves the quality of documentation and ease of tracking non-operating room procedures at our hospitals. In addition, the system collects the information needed for reimbursement coding, hospital quality assurance and utilization review, and practitioner and resident credentialling purposes.

Clinical Competence↗

PubMed2002

Procedure-related abdominal discomfort in patients undergoing colorectal cancer screening: a comparison of colonoscopy and flexible sigmoidoscopy.

OBJECTIVES: The aims of this study were to determine if there was a difference in procedure-related abdominal discomfort or willingness to return for subsequent screening examinations between patients undergoing colonoscopy and those undergoing flexible sigmoidoscopy. METHODS: Two groups were compared: patients referred for screening flexible sigmoidoscopy and patients referred for screening colonoscopy. All patients were asymptomatic for colorectal cancer. Four university-based gastroenterologists performed all procedures. Patients received conscious sedation for colonoscopy but not for flexible sigmoidoscopy. A research nurse blinded to the procedure performed and the study purpose administered a standardized telephone questionnaire assessing and quantifying peri-procedural discomfort. RESULTS: A cohort of 466 patients underwent screening examinations, and 87% were contacted subsequent to their examination. Procedure-related discomfort, postprocedural discomfort, or discomfort at either of these two times ("peri-procedural discomfort") occurred in 28% (68/243), 14% (34/243), and 36% (88/243) of patients undergoing colonoscopy, respectively. Procedure-related discomfort, postprocedural discomfort, or discomfort at either of these two times occurred in 58% (94/162), 16% (26/162), and 62% (100/162) of patients undergoing flexible sigmoidoscopy, respectively. Peri-procedural discomfort was significantly more common in patients undergoing flexible sigmoidoscopy than with colonoscopy (p < 0.0005). Patients undergoing screening colonoscopy were more willing to undergo the procedure again than those undergoing screening flexible sigmoidoscopy (p < 0.0005). CONCLUSIONS: Patients undergoing screening colonoscopy with conscious sedation are less likely to experience peri-procedural discomfort than those undergoing screening flexible sigmoidoscopy. Although most patients are willing to undergo subsequent screening examinations, patients undergoing screening colonoscopy are significantly more willing to undergo a subsequent examination than those undergoing screening flexible sigmoidoscopy.

Abdominal Pain↗

PubMed2006

A comparison of adaptive procedures for rapid and reliable threshold assessment and training in naive listeners.

In psychoacoustic studies there is often a need to assess performance indices quickly and reliably. The aim of this study was to establish a quick and reliable procedure for evaluating thresholds in backward masking and frequency discrimination tasks. Based on simulations, four procedures likely to produce the best results were selected, and data collected from 20 naive adult listeners on each. Each procedure used one of two adaptive methods (staircase or maximum-likelihood estimation, each targeting the 79% correct point on the psychometric function) and two response paradigms (3-interval, 2-alternative forced-choice AXB or 3-interval; 3-alternative forced-choice oddball). All procedures yielded statistically equivalent threshold estimates in both backward masking and frequency discrimination, with a trend to lower thresholds for oddball procedures in frequency discrimination. Oddball procedures were both more efficient and more reliable (test-retest) in backward masking, but all four procedures were equally efficient and reliable in frequency discrimination. Fitted psychometric functions yielded similar thresholds to averaging over reversals in staircase procedures. Learning was observed across threshold-assessment blocks and experimental sessions. In four additional groups, each of ten listeners, trained on the different procedures, no differences in performance improvement or rate of learning were observed, suggesting that learning is independent of procedure.

Adult↗

PubMed1995

Procedural skills of practicing pulmonologists. A national survey of 1,000 members of the American College of Physicians.

We surveyed pulmonologists to determine which procedures they do in practice, where they learned the procedures, and how much training they recommend to attain and maintain clinical competence in each. We mailed a survey to a random sample of 1,000 members of the American College of Physicians who were identified as practicing pulmonologists; 755 (75%) responded. Respondents performed a variety of pulmonary procedures, an average of 17 of the 29 listed. Pulmonologists who were more recent graduates, who worked longer hours, and who were involved in critical care did a greater variety of procedures. Only 26% of practicing pulmonologists currently do all the procedures required for board certification in pulmonary medicine. For each of 13 specific procedures, the number reported done in the past year was generally unrelated to practice factors. Many respondents who learned procedures in practice did so without formal training or supervision. Respondents' recommendations regarding numbers of procedures required to attain or maintain competence did not vary greatly. Pulmonologists vary considerably in the types of procedures they do. Their opinions about the training needed for competence help to better define requirements for training programs. More attention should be focused on training and certifying practicing pulmonologists in procedures learned after formal fellowship training.

Adult↗

PubMedDate not supplied

The effect of search procedures on utility elicitations.

OBJECTIVE: Elicited preferences for health states vary among scaling methods, manners of describing health states, and other features of the elicitation process. The authors examined the effects of changing the search procedure for a subject's utility on mean utility values. METHODS: A randomized controlled trial of two search procedures (titration and "ping-pong") using two otherwise identical computer programs that describe health states related to Gaucher's disease, then measuring subjects' preferences. SETTING: Paid, healthy volunteers recruited from the community through advertisements. RESULTS: The mean time tradeoff (TTO) and standard gamble (SG) utility values for life with severe anemia and splenomegaly and life with chronic bone pain from Gaucher's disease were between 0.10 and 0.15 higher with the titration search procedure than with the ping-pong procedure. Effects of the search procedure were additive with variability due to scaling methods, resulting in mean differences in utility ratings for the same health state of as much as 0.28 among procedures and scaling methods. Effects of search procedures on utility values persisted on repeated testing at week 2 and week 3; there was no evidence of convergence to a single "true" utility value over time. CONCLUSIONS: The procedure used to search for subjects' utility values strongly influences the results of preference-assessment experiments. Effects of search procedures persist on repeated testing. The results suggest that utility values are heavily influenced by, if not created during, the process of elicitation. Thus, utility values elicited using different search procedures may not be directly comparable.

Adult↗

PubMedDate not supplied

Effects on preferences of violations of procedural invariance.

BACKGROUND: In studies of health preferences, utilities for hypothetical health states cannot always be successfully measured. One marker for unsuccessful measurement is violation of "procedural invariance": when the ranking of two health states varies across assessment procedures. Using preference values based on unsuccessful measurement may result in misinterpretation of patients' attitudes about health. OBJECTIVE: The authors sought to determine whether people who violated procedural invariance had different preferences than people who satisfied it. METHODS: They performed secondary analyses of three completed studies that used the same two assessment procedures, identifying participants who violated procedural invariance and comparing the mean standard gamble (SG) and visual analog scale (VAS) scores of violators and satisfiers. PARTICIPANTS: Experiment 1, 30 healthy volunteers and 30 patients with cardiac arrhythmias; experiment 2, 139 patients with depressive illness; experiment 3, 98 family members of patients with schizophrenia. RESULTS: Rates of violation of procedural invariance ranged from 16% to 32%. Violation of procedural invariance was not associated with age, education level, race, or gender. Subjects with violations of procedural invariance had, in general, less ability to discriminate among states and less reliable VAS and SG measurements, and sometimes had different mean SG and VAS values. CONCLUSIONS: Violation of procedural invariance of preferences across scaling methods may be a signal for failure of the measurement process. Researchers should test for procedural invariance and consider reporting data separately for satisfiers and violators.

Aged↗

PubMed2003

Procedure skill competence and certification in internal medicine residency training.

BACKGROUND: Procedure skill training and competency certification are an important part of internal medicine residency training. Expert guidelines exist on the minimum number of procedures recommended to attain competence, but these have not been validated. PURPOSE: To study the validity of the American Board of Internal Medicine (ABIM) recommended procedure guidelines. METHODS: We performed a retrospective review of all monthly procedure log sheets collected during residency training for the graduates of our internal medicine residency program. The number of procedure attempts and the length of time needed to be certified as competent in 13 different procedures were recorded and compared with ABIM guidelines. RESULTS: There were 69 graduates with an average of 32.7 monthly procedure log sheets per resident. There was a wide variation in the number of attempts and time needed to attain competence in the measured procedures. Overall, our residents received their competency certification for each required procedure within 1 SD of the corresponding ABIM recommendation. CONCLUSIONS: Our study suggests that the ABIM recommended guidelines on procedure skill competence may be valid on the program level

Certification↗

PubMed1998

A study of patient radiation doses in interventional radiological procedures.

Patient radiation doses received during interventional radiological procedures can be significant. To aid in the establishment of reference dose levels, a patient dose survey has been conducted of such procedures. A total of 288 non-coronary procedures (177 classified as diagnostic and 111 as therapeutic) were accrued into the study. For each procedure, the fluoroscopy screening time and the fluoroscopic and digital radiographic dose-area products were recorded in a computer database. For example, median dose-area product values (due to fluoroscopy and digital radiography combined) of 24.2, 27.9, 69.6 and 74.7 Gy cm2 were obtained for nephrostomy, biliary stent removal/insertion, cerebral angiography and percutaneous transhepatic cholangiography procedures. While the effective dose is not an accurate measure of patient risk, it is convenient for comparing the radiological risks associated with various procedures. Effective doses were estimated from the total dose-area products. The respective median estimated effective dose values for the four procedures noted above were 3.9, 4.5, 7.0 and 12.0 mSv. While an infrequently performed procedure at this institution (n = 4 during this survey), the transjugular intrahepatic portosystemic shunt (TIPS) procedure had the greatest median dose-area product and effective dose values: 347 Gy cm2 and 55.5 mSv, respectively. Excluding the extreme case of TIPS, it was found that among commonly-performed procedures, those that are categorized as therapeutic do not necessarily present a statistically significant greater radiation risk than those which are diagnostic. Comparisons between dose-area product values obtained from this study are made with data from other interventional radiology patient dose surveys and reasons for some differences noted are discussed.

Angiography↗

PubMed2001

A suspension procedure using the extensor carpi ulnaris tendon for distal radioulnar joint disorders.

Recently the Sauve-Kapandji (S-K) procedure has become popular for the treatment of various distal radioulnar joint (DRUJ) disorders. However, some complications, especially pain over the proximal stump of the ulna due to instability of the ulna have been reported in more recent follow-up studies. To prevent the occurrence of this pain, we devised a modified S-K procedure, which we called the suspension procedure, in which the extensor carpi ulnaris (ECU) tendon was used to suspend the proximal ulnar stump. We report here the surgical technique and compare clinical and radiographic results between the suspension procedure and the S-K procedure alone. We performed the S-K procedure alone on 8 patients (original group) and the suspension procedure on 5 (suspension group). Clinical results were assessed according to the clinical evaluation scoring system described by Inoue. Radiographic evaluations included the radio-ulnar distance, the gap of the ulna, and the distance between the articular surface of the wrist and the proximal ulnar stump. In the original group, 4 patients were rated as excellent, 2 as good and 2 as fair, whereas in the suspension group, 3 were rated as excellent, 2 as good and none as fair. In regard to radiographic evaluations, there were no significant differences in any of the 3 parameters between the 2 group. This suspension procedure had an advantage over the S-K procedure alone, especially in preventing the occurrence of stump pain. As there was no significant difference in radiographic findings between the two procedures regarding the site of osteotomy, the amount of bone resection, and radio-ulnar distance, stump pain may be attributed to dynamic instability rather than to static instability.

Adult↗

PubMedDate not supplied

Family member presence for procedures: the resident's perspective.

OBJECTIVE: To describe resident acceptance of and comfort with family member presence (FMP) during pediatric invasive procedures and resuscitation in a large, multicenter pediatric residency program. To determine if increased level of training impacts on opinion toward FMP for procedures. DESIGN AND METHODS: Seventy-six residents of postgraduate levels 1-4 were administered a survey about FMP for procedures. The survey consisted of 4 Likert-scale questions and 1 multiple-choice question of resident acceptance of and comfort with FMP during procedures and cardiopulmonary resuscitation (CPR). Statistical analysis was performed using the Mann-Whitney U test and one-way analysis of variance (ANOVA). RESULTS: Fifty-three residents (70%) responded. Residents were accepting of FMP during procedures, with a mean score of 3.9/5. However, residents were less accepting of FMP presence during CPR, with a mean score of 2.84/5. There was a trend toward increased comfort and acceptance of FMP with increased level of training; however, this was not statistically significant. In our study, nearly one half of residents (45%) reported that their major reservation toward FMP was that resident anxiety could result in procedure or resuscitation failure. CONCLUSION: The residents in our pediatric training program generally accept FMP for procedures. Residents were less accepting of FMP for CPR than for procedures. Residents most commonly oppose FMP for procedures because they believe this will make them anxious and lead to failure. This information provides insight into the implementation of FMP for procedures in a medical education setting.

Attitude of Health Personnel↗

PubMed1998

Evaluation of a predictive kinetic procedure for the enzymatic measurement of creatinine in serum.

We have evaluated the analytical performance of a predictive kinetic procedure for the enzymatic measurement of serum creatinine in comparison with equilibrium and kinetic fixed-time procedures. The procedure uses commercially available reagents and is based on calculating the total change in absorbance expected if the reaction were to proceed to equilibrium by fitting the initial part of the absorbance-time curve to a three-parameter function by non-linear regression. Total imprecision for different concentrations of creatinine ranges from 1.47 to 1.86% and is significantly better than that obtained for the fixed-time procedure. The results with the predictive procedure are less dependent on creatinine amidohydrolase activity in the reagent, pH of the reagent and temperature of analysis than are the results with the fixed-time procedure. All the procedures are interfered with by bilirubin and ascorbic acid to about the same extent. Recovery and linearity are quite acceptable, and the estimated accuracy is below 2.1%. However, in comparison with the equilibrium procedure, the predictive procedure tends to underestimate creatinine concentrations at values below 100 micromol/l, and the results obtained by the two procedures are not transferable. In conclusion, the predictive approach substantially improves the imprecision but not the specificity of the enzymatic assay of serum creatinine.

Artifacts↗

PubMed2006

National trends in the use of antireflux procedures for children.

OBJECTIVE: The purpose of this study was to analyze recent nationwide trends in the use of and outcomes after antireflux surgery for children. METHODS: We conducted a retrospective cohort study of children (age: <18 years) undergoing antireflux surgery by using data from 1996 to 2003 from the Nationwide Inpatient Sample. Census data were used to calculate the population-based rates of procedures stratified according to age and presence of neurologic impairment. Multivariate analyses were performed to determine factors associated with length of stay and in-hospital death. RESULTS: During the study period, 48,665 antireflux procedures were performed for children in the US. Although procedure rates were generally higher in 2003 than in 1996, no trends in rates were observed among different age groups and census regions during the study period. The highest population-based procedure rates were observed among infants (49-101 procedures per 100,000 population). There was a significant decrease in the percentages of children undergoing antireflux procedures who were neurologically impaired between 1996 and 2003 (53% vs 40%). Neurologically impaired children had longer lengths of stay and higher mortality rates than did neurologically normal children. CONCLUSIONS: Although procedure rates have not changed, the use of antireflux surgery has evolved during the laparoscopic era, with a decreasing percentage of neurologically impaired children undergoing this procedure. Antireflux procedures were performed predominantly for infants, most of whom were neurologically normal. Neurologically impaired children remain a group at high risk for death after antireflux procedures.

Adolescent↗

PubMed2004

Metformin monitoring and change in serum creatinine levels in patients undergoing radiologic procedures involving administration of intravenous contrast media.

STUDY OBJECTIVES: To evaluate the prevalence and magnitude of serum creatinine level elevations in patients receiving metformin who underwent radiologic procedures involving administration of intravenous contrast media, and to evaluate the efficacy of an electronic consultation in promoting timely evaluation of renal function after the procedure. DESIGN: Retrospective evaluation. SETTING: Veterans Affairs Medical Center. PATIENTS: Ninety-seven patients receiving metformin who underwent a radiologic procedure involving administration of intravenous contrast media over a 27-month period. MEASUREMENTS AND MAIN RESULTS: Ninety-seven patients underwent a total of 111 radiologic procedures with documented administration of intravenous contrast dye. Average time from procedure to laboratory follow-up, excluding one patient, was 2.62+/-1.56 days. Average serum creatinine levels before and after the procedure were 1.10+/-0.19 and 1.13+/-0.23 mg/dl, respectively (p>0.05). Four patients developed contrast material-associated nephropathy. An additional four patients with borderline serum creatinine levels at baseline (1.4 mg/dl) had a serum creatinine level of 1.5 mg/dl or greater after the procedure. CONCLUSION: Our results indicated that electronic consultations result in timely evaluation of serum creatinine levels in patients receiving metformin who undergo a radiologic procedure involving intravenous contrast material. Also, the study suggests that nearly 4% of patients with diabetes mellitus and normal renal function may develop contrast material-associated nephropathy [corrected] with nonionic contrast material. In addition, about 8% of patients with diabetes treated with metformin (with baseline serum creatinine levels < 1.5 mg/dl) who undergo a procedure with nonionic intravenous contrast material acquire an increased risk (serum creatinine > or = 1.5 mg/dl) of lactic acidosis. These findings support the recommendations of the Food and Drug Administration regarding metformin monitoring in patients undergoing radiologic procedures involving administration of intravenous contrast media.

Aged↗