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PubMed1996

Hemostasis: a practical review of conservative and operative care.

Progress in the treatment of persons with hemophilia has improved quality of life and made surgical intervention in these patients possible. Optimum management should include a facility equipped with a special coagulation laboratory, a hematologist proficient in the management of coagulation disorders, a surgeon with experience operating on persons with a clotting disorder, and a blood bank with experienced personnel. Persons with inhibitors should undergo elective procedures only after consultation between surgeon and hematologist. Replacement of deficient factor protein by the intravenous infusion of factor concentrates allows normal hemostasis. The manufacture of factor concentrates includes purification and viral attenuation procedures to limit exposure to other proteins and decrease the risk of transmission of viral infection. These concentrates may be delivered by bolus intravenous infusion or as a continuous intravenous infusion which allows for less total units of factor to be administered. In patients with mild hemophilia A, intravenous or intranasal desmopressin acetate may be used to increase the Factor VIII: coagulant level and eliminate exposure to blood products. With careful perioperative management, patients with hemophilia may undergo surgery safely without excessive bleeding. In the future because of prophylactic therapy, the need for orthopaedic procedures may be decreased substantially.

Blood Coagulation Factors↗
PubMed1987

Biliary tract obstruction secondary to cancer: management guidelines and selected literature review.

Malignant biliary tract obstruction (MBTO) due to either primary biliary tract cancer or metastasis to the porta hepatis is a common clinical problem. The most common metastatic tumors causing MBTO in order of frequency are gastric, colon, breast, and lung cancers. Radiographic diagnostic procedures should proceed in a cost-effective sequence from ultrasonography, computerized tomography (CT), percutaneous transhepatic cholangiography (PTHC), and endoscopic retrograde pancreatography with the goal of establishing the site of the biliary tract obstruction. The identification of the site of obstruction could be established by ultrasound 70% to 80%, CT scan 80% to 90%, PTHC 100%, and endoscopic retrograde cholangiography (ERCP) 85%. Therapeutic intervention by radiographic decompression (PTHC or endoscopic prosthesis), surgical bypass, or radiation therapy with or without chemotherapy may be selectively used based on (1) the site of obstruction; (2) the type of primary tumor; and (3) the presence of specific symptoms related to the obstruction. ("Prophylactic" biliary tract decompression to prevent ascending cholangitis is not supported by the literature in that the frequency of sepsis in the face of malignant obstruction is small (in contrast to sepsis associated with stone disease). Furthermore, PTHC with drainage as a long-term procedure is associated with a substantial frequency of sepsis and is unnecessary and possibly problematic as a preoperative procedure simply to reduce the bilirubin level. The use of radiation therapy in conjunction with chemotherapy for patients not deemed suitable for a surgical bypass because of the presence of proximal obstruction is an important alternative to PTHC.

Algorithms↗
PubMed1992

Abdominal wound closure using a running, looped monofilament polybutester suture: comparison to Smead-Jones closure in historic controls.

OBJECTIVE: To determine whether abdominal wound closure with a running, looped monofilament polybutester suture was as effective, inexpensive, and rapid as Smead-Jones closure using the same material. METHODS: Between April 19, 1990 and August 29, 1991, 154 patients undergoing major gynecologic surgery had wound closure using a running, looped monofilament polybutester suture. Controls were 154 patients undergoing similar surgical procedures in the 15 months immediately preceding the study period (January 5, 1989 to April 18, 1990) whose wounds were closed with 0 polybutester using the Smead-Jones technique. All patients received prophylactic cephalosporin antibiotic therapy and external pneumatic leg compression perioperatively. The subcutaneous tissues were not sutured after fascial closure, and the skin was closed with stainless-steel staples. There was no difference between the groups when compared by mean weight, mean ponderal index, number of previous abdominal operations, operative blood loss, or the use of chemotherapy or radiotherapy in the pre- or postoperative period. Both groups had similar rates of complicating medical conditions including insulin-dependent and non-insulin-dependent diabetes mellitus, hypertension, obstructive pulmonary disease, atherosclerotic coronary disease, or peripheral vascular disease. RESULTS: The use of a running closure with looped monofilament polybutester suture in the study patients resulted in a reduction in operating time when compared with controls. The rates of superficial separation and wound infection were similar in both groups. In the study group, there was one minor fascial separation and one wound dehiscence, which occurred when the running suture was inadvertently snipped during debridement of a superficial infection. CONCLUSION: Running closure with looped polybutester is an acceptable, inexpensive, and expeditious method of abdominal wound closure.

Abdomen↗
PubMed1982

Carotid occlusive disease as a risk factor in major cardiovascular surgery.

Carotid occlusive disease in patients undergoing major cardiovascular surgery raises the question of the perioperative risk factor of stroke. We evaluated 234 cardiovascular patients preoperatively by oculoplethysmography (OPG) to detect hemodynamically severe carotid occlusive disease. The perioperative stroke risk without flow-reducing carotid occlusive disease was 1%, in contrast to a 17% incidence of stroke when OPG studies indicated internal carotid artery stenosis of more than 60%. Oculoplethysmography is a reliable indicator of hemodynamically severe carotid occlusive disease with an associated high risk of stroke that warrants prophylactic carotid endarterectomy before major cardiovascular surgery.

Aged↗
PubMed2005

Conservative, non-surgical management of patients presenting with impacted lower third molars: a 5-year study.

Our aim was to find out what happened over a period of 5 years to fully or partially impacted mandibular third molars that were left alone. The change in emphasis towards non-intervention in patients with asymptomatic impacted wisdom teeth over the past few years was accompanied by considerable debate as to the eventual outcome of such teeth. Examination of a number of factors including smoking, extent of eruption, depth of periodontal pocket, and history of pericoronitis failed to show any predictive factors that would indicate which teeth would subsequently require removal. However, about one-third of the teeth in this series had to be removed within the 5-year period. Although this does not allow a 'lifetime extrapolation', it blurs the edges of our current thinking about asymptomatic wisdom teeth and certainly suggests that further (possibly longer term) studies need to be completed. It does, however, provide little support for the reintroduction of prophylactic removal of wisdom teeth.

Adolescent↗
PubMed2001

Impact of antiemetic selection on postoperative nausea and vomiting and patient satisfaction.

STUDY OBJECTIVE: To determine the impact of antiemetic selection on postoperative nausea and vomiting (PONV) and patient satisfaction after ambulatory surgery. DESIGN: Prospective, observational study. SETTING: Ambulatory surgery center in an academic medical center. PATIENTS: Five hundred fifty-four consecutive patients undergoing ambulatory surgical procedures of any kind. INTERVENTION: Data on antiemetic utilization, occurrence of PONV, and patient satisfaction were collected perioperatively. Multiple regression analyses for antiemetic choice were performed. MEASUREMENTS AND MAIN RESULTS: Prophylactic antiemetic therapy was administered to 292 (52.7%) patients, most often with droperidol (200 patients), metoclopramide (134), or dexamethasone (55). Forty-one (7.4%) patients had an episode of emesis in the postanesthesia care unit. Choice of antiemetic was not a significant predictor of PONV. Patient satisfaction for all patients was 9.5 on a 10-point scale, with no agent more or less successful than any other. CONCLUSION: As choice of antiemetic drug given for prophylaxis had little impact on clinical outcome or patient satisfaction, traditional agents should form the core of antiemetics used for PONV prophylaxis in ambulatory surgery patients.

Adolescent↗
PubMedDate not supplied

Epidemiology of gallbladder cancer.

Gallbladder cancer, although rare in most Caucasian populations, is among the most frequently observed cancers in native populations of North and South America, and in the Maori population of New Zealand. In all populations, there is a strong correlation between gallstones and gallbladder cancer: the risk of gallbladder cancer is approximately 4-5 times higher in patients with gallstones, than in patients without gallstones. In those populations where the onset of gallstone disease occurs in the first few decades, the risk is much higher. Obesity, which is also a risk factor for gallstones, increases the risk of gallbladder cancer, as does the consumption of diets high in fats and calories. Other risk factors, such as increased parity, also increase the frequency of gallbladder cancer, most probably explained by the association between gallstones and parity. Prophylactic cholecystectomy for asymptomatic gallstones cannot be justified for the control of gallbladder cancer, but the increasing frequency of this procedure in many countries, secondary to the widespread use of laparoscopic surgical techniques, will clearly lower the incidence and mortality rates for this lethal disease.

Adult↗
PubMed1992

[Infection of methicillin resistant Staphylococcus aureus (MRSA) in patients with cardiovascular operations: four years' clinical analysis of the effect of strategy of prophylactic and treatment].

To evaluate the effect of strategy to reduce the rate and outcome of MRSA infection, 940 patients with cardiovascular operations from 1988 to 1991 were analyzed in aspect of the infection rate and outcome per year. Prophylactics and treatments which have been done during recent four years were) to use the inhalation of vancomycin for MRSA carriers, to quit the intravenous administration of prophylactic antibiotics on third postoperative day, to limit medical staffs to treat the patient with MRSA infection, to choose the most susceptible combination of two antibiotics for MRSA in each patients by periodical checking of bacterial cultures. The percentages of patients with infection to all patients detected with MRSA per year were decreased from 80% in 1988, to 66% in 1989, 31% in 1990, and 30% in 1991. The numbers of patients who died from MRSA infection were 4 in 1988 and only one in 1989 and 1991. MRSA infection in cardiovascular surgery could be reduced by sophisticated methods of prophylactics and treatments.

Anti-Bacterial Agents↗
PubMed1986

Comparative study of cefamandole versus cephalothin as antibiotic prophylaxis for open heart surgery.

Cefamandole nafate and cephalothin sodium were administered as prophylaxis in a randomized, prospective study to 80 consecutive patients undergoing open heart surgery. The two groups matched well in age, sex, and type of operation. Postoperative infection developed in 2 of 40 patients (5%) in the cefamandole-treated group and in 11 of 40 patients (27.5%) in the cephalothin-treated group (p less than 0.01). The two patients in the former group had respiratory tract infections. There were no instance of endocarditis, mediastinitis or bacteraemia in any of the two groups. Both antibiotics were well tolerated with no adverse reactions. Cefamandole appears to be an effective and preferable prophylactic antibiotic for use during cardiac surgery.

Adolescent↗
PubMedDate not supplied

Vestibular ototoxicity of prophylactic aminoglycoside antibiotics in head and neck cancer patients.

The effect of prophylactic aminoglycoside antibiotics upon vestibular function was studied using a double-blind protocol in a group of head and neck cancer patients scheduled for contaminated (skin-to-mucosa) surgical procedures. The amplitude (gain) of vestibular responses to rotation temporarily declined in 12 of 25 patients postoperatively. There was no correlation between temporary decline in vestibular response and administration of gentamicin, clindamycin, and cefazolin. After a recovery period of one to three months, none of the patients showed evidence of vestibular aminoglycoside ototoxicity. The transient reduction in vestibular responses to rotary stimuli was possibly related to the use of analgesics, anesthetic agents, or radical neck dissection procedures. The importance of repeat measures and proper timing of vestibular ototoxic monitoring procedures in a surgical patient population was demonstrated by this study. Results of this study may also impact interpretation of findings from certain surgical procedures performed for control of vertigo.

Aminoglycosides↗
PubMed1994

The use of surgical antibiotic prophylaxis in seven Malaysian hospitals.

A survey on the use of antibiotics in surgical prophylaxis was carried out in seven Malaysian hospitals. Details of antibiotic prescriptions were obtained through questionnaires completed by the prescriber. A total of 430 such prescriptions was analysed. A large number of different antibiotic regimens were used for a variety of surgical procedures. The majority of prescriptions (70%) were issued for procedures where such prophylaxis was probably not necessary. Antibiotics were also often prescribed for durations that were longer than necessary. There is an urgent need to educate surgeons and standardize surgical prophylactic regimens in order to reduce cost and combat the emergence of antibiotic resistance.

Anti-Bacterial Agents↗
PubMed1992

The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection.

BACKGROUND: Randomized, controlled trials have shown that prophylactic antibiotics are effective in preventing surgical-wound infections. However, it is uncertain how the timing of antibiotic administration affects the risk of surgical-wound infection in actual clinical practice. METHODS: We prospectively monitored the timing of antibiotic prophylaxis and studied the occurrence of surgical-wound infections in 2847 patients undergoing elective clean or "clean-contaminated" surgical procedures at a large community hospital. The administration of antibiotics 2 to 24 hours before the surgical incision was defined as early; that during the 2 hours before the incision, as preoperative; that during the 3 hours after the incision, as perioperative; and that more than 3 but less than 24 hours after the incision, as postoperative. RESULTS: Of the 1708 patients who received the prophylactic antibiotics preoperatively, 10 (0.6 percent) subsequently had surgical-wound infections. Of the 282 patients who received the antibiotics perioperatively, 4 (1.4 percent) had such infections (P = 0.12; relative risk as compared with the preoperatively treated group, 2.4; 95 percent confidence interval, 0.9 to 7.9). Of 488 patients who received the antibiotics postoperatively, 16 (3.3 percent) had wound infections (P less than 0.0001; relative risk, 5.8; 95 percent confidence interval, 2.6 to 12.3). Finally, of 369 patients who had antibiotics administered early, 14 (3.8 percent) had wound infections (P less than 0.0001; relative risk, 6.7; 95 percent confidence interval, 2.9 to 14.7). Stepwise logistic-regression analysis confirmed that the administration of antibiotics in the preoperative period was associated with the lowest risk of surgical-wound infection. CONCLUSIONS: We conclude that in surgical practice there is considerable variation in the timing of prophylactic administration of antibiotics and that administration in the two hours before surgery reduces the risk of wound infection.

Adult↗
PubMed2003

Lack of effect of prophylactic N-acetylcysteine on postoperative organ dysfunction following major abdominal tumour surgery: a randomized, placebo-controlled, double-blinded clinical trial.

Sepsis and respiratory dysfunction leading to multiple system organ failure remains the leading cause of postoperative morbidity and mortality following major surgical procedures. It has been suggested the oxygen free radicals might play a pivotal role in this process. The aim of this study was to investigate whether short-term infusion of N-acetylcysteine (N-acetylcysteine), a potent antioxidant, administered before and during extensive abdominal surgery, could ameliorate the progression of early postoperative organ dysfunction and improve oxygenation. Out of the 93 patients, 47 received N-acetylcysteine and 46 were given placebo in a randomized, controlled, double-blinded fashion. Patients received N-acetylcysteine (150 mg.kg-1 bolus followed by a continuous infusion of 12 mg.kg-1.h-1) or the same volume of placebo (5% dextrose) during surgery. Treatment effect on organ function was assessed by organ dysfunction scores according to physiological parameters of six main organ systems: respiratory, cardiovascular, renal, hepatic, haematological and central nervous system. The scores were obtained on admission, then daily during the first three postoperative days. For statistical analysis Mann-Whitney U and Chi-squared tests were used. There was no significant difference between the two groups in any of the six organ dysfunction parameters, length of intensive care stay, days of mechanical ventilation and mortality. Our results do not support the routine use of N-acetylcysteine as a prophylactic measure during surgery, and reinforce previous evidence which challenges the indication of N-acetylcysteine in the critically ill.

Abdominal Neoplasms↗
PubMed2001

When data conflict with practice: rethinking the use of prophylactic antibiotics before dental treatment.

Concern is growing about the overuse of antibiotics and the subsequent rise in antibiotic-resistant bacteria. Antibiotics are commonly used to prevent heart valve infections in susceptible patients undergoing dental or other surgical procedures. Although this practice has been standard for nearly 50 years, little evidence exists that it works. This Issue Brief summarizes a population-based study that challenges the link between dental procedures and heart valve infections, and illustrates the difficulty in incorporating new evidence into existing guidelines and longstanding practices.

American Heart Association↗