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[PARIETAL PLEURECTOMY IN SURGICAL TREATMENT OF RECURRING SPONTANEOUS PNEUMOTHORAX].
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THE PROPHYLAXIS OF SURGICAL INFECTION: THE EFFECT OF PROPHYLACTIC ANTIMICROBIAL DRUGS ON THE INCIDENCE OF INFECTION FOLLOWING POTENTIALLY CONTAMINATED OPERATIONS.
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Risk factors for surgical site infection in a Tanzanian district hospital: a challenge for the traditional National Nosocomial Infections Surveillance system index.
The incidence of surgical site infections (SSIs) was 24% in a district hospital in Tanzania. Wound classification was not an independent risk factor for SSI, indicating that risk scores developed in industrialized countries may require adjustments for nonindustrialized countries. The National Nosocomial Infections Surveillance system score required adjustments to reliably predict SSI, probably to account for improper hygiene and the lack of adjustment for the duration of surgery (defined as the 75th percentile of the duration for each type of operative procedure) to reflect local circumstances. Multidrug-resistant pathogens, such as methicillin-resistant Staphylococcus aureus and gram-negative pathogens expressing broad-spectrum beta-lactamases, have already emerged.
[APROPOS OF THE HEALING OF ESOPHAGO-INTESTINAL AND ESOPHAGO-GASTRIC ANASTOMOSES PERFORMED WITH THE PKS-25 SURGICAL STAPLER IN PATIENTS OPERATED ON FOR CANCER OF THE STOMACH AND ESOPHAGUS].
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Economical saving due to prophylaxis in the prevention of surgical wound infection.
The objective was to know the principal risk factors that influence in the development of surgical would infection, and the economical saving achieved with the control of a single variable, that is, right prophylaxis. A prospective study was carried out at the Traumatology Department of La Paz Hospital. A total of 5260 patients operated during 1990-1993 are included. Active epidemiological surveillance was used to check patients; logistic regression was used in the multivariant analysis. The principal risk factors found were: immunodeficiency (OR = 8.67), incorrect healing (OR = 14.42), reoperated patient (patients who needed more than one surgical procedure while they are admitted; reoperations) (OR = 3.57), type of surgery (OR = 4.71) and wrong prophylaxis (OR = 6.36). Making constant all the variables except for prophylaxis, we calculated the percentage of infections prevented by a right prophylaxis, and the cost was calculated starting from the number of extra days of infection. The number of infections prevented during the four years was 310, saving a total of 194 million pesetas (1.5 million dollars), due to right prophylaxis. Cost-benefice ratio = 1/17. We consider of special importance to control this manipulable risk factor, in order to avoid the development of infections.
Laparoscopy for malignancy: the role of handoscopy.
In the last decade, laparoscopic surgery has revolutionized the practice of surgery to a great extent. Experienced laparoscopic surgeons have acquired proficiency for advanced procedures; however, complex laparoscopic procedures are still unpopular due to the high technical demand. Hand-assisted laparoscopic surgery or handoscopy has been developed as an adjunct to conventional laparoscopy, but its role for the management of malignancy is controversial. This technique allows the surgeon to insert a hand into the body cavities via a glovesize skin incision, while maintaining the pneumoperitoneum. The hand insertion allows tactile sensation, assists in atraumatic retraction and blunt dissection, and helps safeguard vascular control. The hand-assisted device also provides wound protection and allows intact specimen retrieval. Its applications in various oncologic procedures have demonstrated feasibility and even better recovery in some selected procedures compared with laparotomy. It may also help to reduce conversions. Handoscopic procedures allow a shorter learning curve and operative time, thereby attracting more surgeons to attempt advanced laparoscopic operations. Thus, in a selected group of complicated procedures, handoscopy provides an alternative to laparoscopy and the traditional open approach in the management of malignancy.
Reported pain after day surgery: a critical literature review.
BACKGROUND: Despite technological advancements in anaesthesia and analgesia, reported pain levels after day surgery remains high. Whilst it is unrealistic to expect no pain, the level that constitutes 'acceptable' pain remains unclear because of inconsistencies in reporting. These inconsistencies have resulted from different interpretations of what pain is and the use of different measurement tools. AIM: The aim of this paper is to report a study investigating any disparity in reported levels of pain following day surgery, within different specialties and in relation to specific operative procedures. METHOD: Nursing and health care papers published since 1983 were sought using the keywords: postoperative pain, postoperative complications, pain after day surgery, day surgery, ambulatory surgery, nursing, operation types, operative procedures, surgical procedures, descriptors of pain, pain intensity, verbal descriptor scale, numerical rating scale, visual analogue scale, validity, reliability, design, sample size, data collection methods and their various combinations. Databases searched were Medline, CINAHL, Nursing Collection, Embase, Healthstar, BMJ and several on-line Internet journals, specifically Ambulatory Surgery. The search was restricted to publications in the English language. Findings. Twenty-four papers were identified. Inconsistencies in the reported intensity of pain are highlighted, in relation to different operative procedures and specialties. Data in the papers are based on different descriptors, measurement tools and data collection methods. In many cases, sample size, and validity and reliability can also be questioned. CONCLUSIONS: There is a disparity in reported levels of pain after day surgery. It is important that a unified day surgery pain measurement strategy is established, so that patients can be informed about the intensity of pain that they are likely to experience following specific procedures.
Perioperative predictors of extubation failure and the effect on clinical outcome after cardiac surgery.
OBJECTIVES: To determine perioperative predictors of extubation failure (requirement for reintubation and mechanical ventilation after prior successful weaning from ventilator support and extubation) after cardiac surgery and the effect on clinical outcome. DESIGN: Cohort study. SETTING: A tertiary-care, 54-bed, cardiothoracic intensive care unit (ICU). PATIENTS: ICU admissions (n = 11,330) after cardiac surgery over a 42-month period. INTERVENTIONS: Collection of preoperative, operative, and ICU data from a database. MEASUREMENTS AND MAIN RESULTS: Frequency of extubation failure, total duration of mechanical ventilation, length of stay in ICU and hospital, and death. There were 748 (6.6%) patients who were weaned from mechanical ventilation after cardiac surgery and required reintubation and ventilator support. The predictors of extubation failure were: age of > or =65 yrs; inpatient hospitalization before surgery; arterial vascular disease; chronic obstructive pulmonary disease; pulmonary hypertension; severe left ventricular dysfunction; cardiac shock; hematocrit of < or =34%; blood urea nitrogen of > or =24 mg/dL; serum albumin concentration of < or =4.0 g/dL (< or =40.0 g/ L); systemic oxygen delivery of < or =320 mL/min/m2; redo operation; surgical procedures involving the thoracic aorta; transfusion of blood products of > or =10 units; and cardiopulmonary bypass time of > or =120 mins. Extubation failure prolonged the length of total mechanical ventilation, as well as ICU and hospital stay, independent of the frequency of organ dysfunction or nosocomial infections but did not increase the risk of death after cardiac surgery. CONCLUSIONS: Extubation failure after cardiac surgery is uncommon. Although extubation failure increased the utilization of ICU and hospital resources, it did not affect mortality after cardiac surgery. Protocols for early extubation and ICU discharge should be modified in the presence of certain preoperative and operative predictors of extubation failure to avoid unnecessary increase in the cost of care after cardiac surgery.
Antibiotic prophylaxis in general surgery: a comparison of single-dose intravenous and single-dose intra-incisional cephaloridine.
Four hundred and five consecutive patients undergoing emergency or elective abdominal operations were randomly allocated to receive prophylaxis against wound sepsis by means of a single dose of 1 g cephaloridine either injected intravenously at the start of, or instilled into the incision at the end of, operations. Ten patients died within two weeks without wound sepsis and in the remaining 395 patients there were no significant differences between the two groups in the rates of major (3.5% and 2.1%) or minor (12.4% and 15.5%) wound sepsis. Nutrient broth culture of visceral and parietal swabs during operations enabled a microbiological classification of abdominal operations to be made, the rates of wound sepsis being significantly different among "clean" (1.0%), "potentially contaminated" (8.1%), "lightly contaminated" (19.4%) and "heavily contaminated" (44.6%) operations. This classification by extent of operative contamination makes it possible to standardize the audit of sepsis rates both among surgeons and among hospitals.
[Hygienic study of surgical wound healing in patients operated on during 1976-1981 after the reconstruction of the First Surgical Clinic of Comenius University Medical School in Bratislava].
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Caudal analgesia in children. Influence on ventilatory efficiency during halothane anaesthesia.
The influence of caudal analgesia on pulmonary ventilation and gas exchange was studied in 26 children during halothane anaesthesia with spontaneous breathing. Two groups of children were studied with 13 patients in each group. One group received caudal analgesia. The other group had no caudal blocks. All children were subjected to lower abdominal and genital surgical procedures. Minute ventilation and respiratory rates were significantly lower in the caudal group than in the non-caudal group. Wastea minute ventilation and VD/VT ratios were increased in the non-caudal group. The end tidal carbon dioxide concentration was unchanged in both groups. The lower minute ventilation in the caudal group eliminated the same amount or even greater amounts of CO2 per minute indicating an improved gas distribution at slow respiratory rates. The improved ventilation efficiency and the excellent immediate postoperative pain relief achieved by caudal analgesia justifies its frequent use for these operative surgical procedures.
[SURGERY OF HEMORRHAGIC DIATHESIS].
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PARIETAL PLEURECTOMY FOR SPONTANEOUS PNEUMOTHORAX.
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Pediatric wound infections: a prospective multicenter study.
OBJECTIVE: Surgical wound infections remain a significant source of postoperative morbidity. This study was undertaken to determine prospectively the incidence of postoperative wound infections in children in a multi-institutional fashion and to identify the risk factors associated with the development of a wound infection in this population. SUMMARY BACKGROUND DATA: Despite a large body of literature in adults, there have been only two reports from North America concerning postoperative wound infections in children. METHODS: All infants and children undergoing operation on the pediatric surgical services of three institutions during a 17-month period were prospectively followed for 30 days after surgery for the development of a wound infection. RESULTS: A total of 846 of 1021 patients were followed for 30 days. The overall incidence of wound infection was 4.4%. Factors found to be significantly associated with a postoperative wound infection were the amount of contamination at operation (p = 0.006) and the duration of the operation (p = 0.03). Comparing children who developed a wound infection with those who did not, there were no significant differences in age, sex, American Society of Anesthesiologists (ASA) preoperative assessment score, length of preoperative hospitalization, location of operation (intensive care unit vs. operating room), presence of a coexisting disease or remote infection, or the use of perioperative antibiotics. CONCLUSIONS: Our results suggest that wound infections in children are related more to the factors at operation than to the overall physiologic status. Procedures can be performed in the intensive care unit without any increase in the incidence of wound infection.
Mitral valve operation via Port Access versus median sternotomy.
OBJECTIVE: The advantages and disadvantages of minimally invasive Port Access mitral valve operation have not been defined relative to standard median sternotomy. A study was therefore designed to delineate differences in outcome from mitral operation via Port Access versus sternotomy in comparable patients. METHODS: The records of 41 consecutive patients undergoing isolated mitral valve replacement (n = 14) or repair (n = 27) were examined. All operations were performed using cardioplegic arrest through either median sternotomy (n = 20) or a small right anterolateral thoracotomy using an endoaortic clamp and catheter system (Heartport, Redwood City, CA) to arrest and decompress the heart (Port Access, n = 21). RESULTS: Both groups were well matched for age, mitral pathology, ejection fraction, and comorbidity. except that Port Access patients were less likely to be female. Three patients had undergone previous cardiac operations. Surgical procedure time was longer for Port Access patients (384+/-80 vs. 263+/-41 min, P < 0.05). Port Access provided significantly smaller incision length (8+/-2 vs. 26+/-2 cm, P < 0.01) and similar or shorter hospital stay (6+/-4 vs. 7+/-3 days). Port Access provided excellent visualization of the mitral valve and subvalvular apparatus, generally better than sternotomy, to allow complex mitral valve repairs. The greatest advantage of Port Access mitral operation was that Port Access patients returned to normal activity more rapidly (4+/-2 vs. 9+/-1 weeks, P = 0.01) than did patients undergoing standard median sternotomy. CONCLUSIONS: By avoiding a sternotomy, Port Access mitral valve operation provided a smaller incision and a dramatically more rapid return to normal activity than did median sternotomy. Port Access cardioplegic arrest with the Heartport system allowed visualization of the mitral valve superior to median sternotomy and has become the standard approach at this institution.
The lumbar disc herniation. A computer-aided analysis of 2,504 operations.
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Techniques known to prevent post-operative wound infection.
The most important factors in controlling postsurgical sepsis are appropriate surgical judgment and technique. Efficacious prophylactic antibiotics, when indicated, also significantly reduce the postoperative infection rate. Among the other techniques often heralded as important adjunctive measures, only duration of preoperative hospitalization, preoperative bathing, use of electrocautery, preoperative hair removal, use of prophylactic drains, and duration of operation are of proven significance.