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PubMed2006

Obstacles and solutions to maintenance of advanced procedural skills for rural and remote medical practitioners in Australia.

INTRODUCTION: Most rural communities are too small and remote to sustain specialist services, and therefore some rural and remote doctors in Australia practice advanced procedural skills as part of their comprehensive care to underserved rural communities. The declining number of rural and remote procedural non-specialist doctors poses a problem in Australia. There is, at present, no comprehensive delineation of the obstacles Australian rural doctors face in trying to maintain their skills in the procedural areas of obstetrics, anaesthetics and surgery, nor of the solutions that may overcome the problems. This literature review addresses these two needs. METHODS: We interrogated the MEDLINE database to find articles about rural and remote medical education, with a specific focus on procedural skills. Other sources, including Google Scholar, were used to find relevant project and conference reports. RESULTS: The barriers to the maintenance of advanced procedural skills for rural and remote medical practitioners include: lack of opportunity; expense associated with remaining skilled in advanced procedural areas; lack of access to locum relief to attend educational sessions; lack of flexible options for education; lack of access to advanced procedural training; time constraints; multiple credentialing requirements from state health departments and joint consultative committees; family obstacles; and perceived medico-legal problems. Retention of rural doctors and the difficulties faced by them in maintaining advanced procedural skills are related. There is evidence that both these problems can be addressed, at least in part, by increased support for flexible continuing medical education and professional development such as specific skills rural training programs, the availability of group practice opportunities, improved hospital facilities, reasonable workloads, financial incentives, locum assistance, improved housing quality, and better educational support for families. We also noted a positive association between dedicated rural training programs and the recruitment of rural doctors. Factors associated with these successful training programs include: rural fellowships, explicit rural mission, rural location, rural program directors, and procedural orientation. CONCLUSION: The authors investigated the obstacles rural and remote doctors currently face in obtaining and remaining skilled in procedural medicine. The article describes the main barriers and presents some solutions from the literature. It also highlights the areas where work is being done and highlights the need for more quality research in this area.

Australia↗
PubMed1985

Vertebral body resection for epidural compression by malignant tumors. Results of forty-seven consecutive operative procedures.

We are presenting our experience with vertebral body resection in forty-seven operative procedures in forty patients with a malignant epidural tumor. The indication for surgery was neural relapse after previous radiotherapy in eighteen procedures, the need for a tissue diagnosis in sixteen, a radioresistant tumor in seven, neural deterioration while receiving radiotherapy in five, and a pathological fracture-dislocation in one. In thirty-three procedures (70 per cent) the level of compression was in the thoracic spine. Replacement of the resected vertebral bodies was achieved by anterior instrumentation and the use of methylmethacrylate in twenty-one procedures (45 per cent), while bone-grafting, cement, and instrumentation in various combinations were used in the remainder. Before surgery all of the patients had some neural deficit. The patient was still able to walk prior to twelve (26 per cent) of the procedures, was paraparetic prior to twenty-three (49 per cent), and was paraplegic prior to twelve (26 per cent). Bowel and bladder dysfunction was present before twenty-five (53 per cent). The outcome of only forty-four procedures could be evaluated because three patients died postoperatively. The patient was able to walk following thirty-five (80 per cent) of the procedures, was paraparetic after eight (18 per cent), and was still paraplegic after one. The patient regained normal sphincter control after forty-one (93 per cent) of the procedures. Three (6 per cent) of the procedures were followed by the death of the patient, and complications occurred after five (11 per cent) of the procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

Bone Transplantation↗
PubMed1980

How to set up a policy and procedures manual.

This three-part article describes the process followed by Northwestern General Hospital in establishing policy and procedures manuals. It also shares the discoveries made during this process which might benefit other hospitals attempting either to rewrite or create manuals of their own. Much of the available literature either deals with the need for policies and procedures, differentiates between policy and procedure, or gives sample policies or procedures for different hospital areas. These topics have been pointedly avoided here in favor of the practical aspects of policy and procedures manual development. The first part, 'Establishing the Basics", describes the brief and informal study of some existing hospital policy and procedure manuals and outlines the basic principles adopted as a result of this study. The second part, "Policy and Procedures Manual Preliminaries", reviews the considerations and decisions which were made by Northwestern General Hospital before work on policies and procedures could actually get underway. The third part, "Procedure Writing Skills", is more didactic and offers suggestions for improving the quality of procedure writing.

Hospital Administration↗
PubMed1994

New treatment for rectal impaction in children: an efficacy, comfort, and safety trial of the pulsed-irrigation enhanced-evacuation procedure.

To determine the efficacy, comfort, and safety of the pulsed-irrigation enhanced-evacuation (PIEE) procedure in children, we evaluated 27 procedures performed on 24 consecutive children, 16 boys and 8 girls, 4-15 years old (mean, 8.7), with chronic constipation, encopresis, and rectal impaction. Children with known heart, lung, and/or neurologic diseases were excluded. Temperature, pulse, respiratory rate, and blood pressure were obtained prior to, during, and immediately after the procedure. Abdominal radiographs were obtained before and after the procedure, and the degree of disimpaction was estimated by a single radiologist. Patients graded the discomfort of the procedure at the time of speculum insertion and every 15 min from 1 to 5: 1, painless; 2, mild discomfort; 3, moderate discomfort; 4, severe discomfort; 5, extremely painful. Serum sodium, potassium, chloride, and bicarbonate values were obtained before, immediately after, and 90 min after the procedure and compared by paired Student t analysis. A digital rectal examination confirmed rectal impaction prior to insertion of the speculum. One course of pulsed irrigations was performed, typically lasting 25-30 min. No significant changes in vital signs were found during or after the procedure. In 18 of 23 (78%) procedures, there was at least a 50% emptying of feces from the colon immediately after the procedure. Patients continued to empty their colon up to 12 h later; thus, the procedure effectively disimpacted all patients. In terms of comfort, patients graded the PIEE a 2.6 +/- 0.75 (range, 1-5). Speculum insertion was the most uncomfortable factor and received a 2.7. No child had any indication of water intoxication.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1996

Parents and procedures: a randomized controlled trial.

INTRODUCTION: Previous work has shown that parents prefer to be present when their children undergo common invasive procedures, although physicians are ambivalent about parental presence. PURPOSE: To determine the effect of a parent-focused intervention on the pain and performance of the procedure, anxiety of parents and clinicians, and parental satisfaction with care. POPULATION: Children younger than 3 years old undergoing venipuncture, intravenous cannulation, or uretheral catheterization. SETTING: Pediatric emergency department of Boston City Hospital. DESIGN: Randomized controlled trial with three groups; parents present and given instructions on how to help their children; parents present, but no instructions given; and parents not present. INTERVENTION: The parents were instructed to touch, talk to, and maintain eye contact during the procedure. RESULTS: A total of 431 parents was randomized to the intervention (N = 153), present (N = 147), and not present (N = 131) groups. The groups were equivalent with respect to measured sociodemographic variables and parents' previous experience in the pediatric emergency department. No differences emerged with respect to pain (3-point scale measured by parent and clinician, and analysis of cry); performance of the procedure (number of attempts, completion of procedure by first clinician, time); clinician anxiety; or parental satisfaction with care. Parents who were present were more likely to rate the pain of the children as extreme/severe (52%) in comparison to clinicians (15%, kappa .07, poor agreement) and were significantly less anxious than parents who were not present. CONCLUSION: Overall, the intervention was not effective in reducing the pain of routine procedures. Parental presence did not negatively affect performance of the procedure or increase clinician anxiety. Parents who were present were less anxious than those who were not present. CLINICAL IMPLICATION: In general, parents have indicated that they want to be present when their children undergo procedures. The results of this study challenge the traditional belief that parental presence negatively affects our ability to successfully complete procedures. We should encourage parents who want to be present to stay during procedures.

Adult↗
PubMedDate not supplied

Potentially unintended discontinuation of long-term medication use after elective surgical procedures.

BACKGROUND: Transitions between health care settings represent vulnerable periods for medical error. Discontinuation of long-term medication use may occur during discharge from the hospital to the community. METHODS: We performed a population-based, cohort study using administrative records from Ontario, Canada, between April 1, 1997, and September 30, 2002. We studied all residents 66 years and older with continuous use of warfarin, 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins), or beta-blocker ophthalmic drops for 1 or more years. Those who had an overnight hospitalization for selected elective surgical procedures were compared with 2 control groups: one that had an ambulatory procedure and one that had no procedures. All groups were assessed for the outcome of failure to renew the prescription within 6 months. RESULTS: Rates of drug treatment discontinuation after overnight hospitalizations, after ambulatory procedures, and after no procedures were 11.4%, 7.5%, and 4.8%, respectively, in the warfarin group; 4.0%, 3.9%, and 3.9%, respectively, in the statin group; and 8.4%, 8.9%, and 7.9%, respectively, in the ophthalmic drops group. The adjusted odds ratio (OR) was 2.6 (95% confidence interval [CI], 2.0-3.4) for discontinuation of warfarin therapy after overnight hospitalizations and 1.6 (95% CI, 1.4-1.7) after ambulatory procedures. In contrast, there was no increased risk of discontinuing treatment with either statins (OR for overnight hospitalization, 1.0 [95% CI, 0.9-1.2]; OR for ambulatory procedure, 1.0 [95% CI 1.0-1.1]) or ophthalmic drops (OR for overnight hospitalization, 1.0 [95% CI, 0.8-1.5]; OR for ambulatory procedure, 1.1 [95% CI, 1.0-1.2]). CONCLUSIONS: Patients prescribed long-term therapy with warfarin were at risk for potentially unintended medication discontinuation after elective procedures. Patients prescribed statins or beta-blocker ophthalmic drops were not at increased risk.

Aged↗
PubMed2000

Current status of the Maze procedure for the treatment of atrial fibrillation.

Since the first patient underwent the Maze procedure on September 25, 1987, 346 patients have undergone this operation for the treatment of atrial fibrillation. The procedure was designed as an open-heart operation performed through a median sternotomy. It underwent 2 major modifications relatively early in the series, evolving into the so-called Maze-III procedure, which has been used exclusively since April 16, 1992. Since that time, the Maze-III procedure has been adapted to allow it to be done by minimally invasive techniques. In addition, we recently performed the entire procedure in 2 patients without the use of cardiopulmonary bypass. The operative mortality rate has remained at 2% to 3%. This includes patients undergoing concomitant high-risk cardiac surgical procedures and all re-do cases. The overall success rate in curing atrial fibrillation has been 99%. The procedure itself has been shown to cause no permanent damage to the sinus node. The left atrium has been documented to function long-term postoperatively in 93% of patients and the right atrium functions in 99% of patients. The Maze-III procedure remains the surgical procedure of choice for the treatment of medically refractory atrial fibrillation.

Atrial Fibrillation↗
PubMed2002

Development of an appropriate list of surgical procedures of a specified maximum anesthetic complexity to be performed at a new ambulatory surgery facility.

UNLABELLED: A common but difficult task for a hospital when it decides to open a freestanding ambulatory surgery facility is how to decide which surgical procedures should be done at the new facility. This is necessary in order to determine how many operating rooms to plan for the new facility and which ancillary services are needed on-site. In this case study, we describe a novel methodology that we used to develop a comprehensive list of procedures to be done at a new ambulatory facility. The level of anesthetic complexity of a procedure was defined by its number of ASA Relative Value Guide basic units. Broad categories of procedures (e.g., eye surgery) were defined according to the International Classification of Diseases, Ninth Revision, Clinical Modification. We identified 22 categories that are of a type that every procedure in the category has no more than seven basic units. In addition, by analyzing all procedures that the hospital being studied actually performed on an ambulatory basis, we identified six other categories of procedures that were of a type that all procedures eligible for surgery at the new facility had seven or fewer basic units. IMPLICATIONS: We describe a novel method to develop a comprehensive list of procedures that have a prespecified maximum level of anesthetic complexity to be performed at a new ambulatory surgery facility.

Adolescent↗
PubMed1997

The incidence, morbidity, and mortality of surgical procedures after orthotopic heart transplantation.

OBJECTIVE: The authors present their experience with patients having undergone orthotopic heart transplantation (OHT) in whom surgical conditions subsequently developed that required operative intervention. The incidence, morbidity, and mortality of these procedures are reported. SUMMARY BACKGROUND DATA: Several studies have evaluated the management options of biliary tract disease after OHT. Multiple reports of patients having undergone OHT who subsequently underwent peripheral vascular reconstructions, plastic reconstructive, and thoracic procedures also have been published. METHODS: A chart review of 349 patients who underwent OHT between 1985 and 1996 was conducted to identify surgical procedures that were required in the post-transplant period. Their outcomes are reported. RESULTS: Of 349 patients who underwent OHT, conditions requiring 94 surgical procedures developed in 54 patients (15%). Biliary tract disease developed in 17 patients (5%) who required cholecystectomy, 2 of the 5 patients with acute cholecystitis died. Eight patients (2%) underwent orthopedic procedures with no operative mortality. Flap advancements for sternal wound infections were performed in five patients and four deaths occurred. Seventeen thoracic procedures were performed in 11 patients with an overall mortality of 45%. Twenty-one vascular procedures were performed on 17 patients with 1 delayed death due to a malignancy. Seven patients underwent procedures of the colon and rectum with no mortality. Seven patients underwent repair of inguinal or incisional hernias with no mortality. Various infections occurred with one resultant death after operative intervention. Six procedures were performed for diseases of the small intestine with no resultant mortalities. CONCLUSIONS: Patients having undergone OHT and chronic immunosuppression are at increased risk of having complications develop from infection. Acute cholecystitis and sternal wound infection caused an inordinate risk of complications and death. Malignancies developed in four patients who required surgical intervention. A heightened awareness of coexisting peripheral vascular disease in patients transplanted for ischemic cardiomyopathy should exist. Close screening before surgery and surveillance after surgery to identify risk factors for infection and vascular disease and to screen for malignancies are essential.

Adult↗
PubMed2006

The modified Bristow procedure for anterior shoulder instability: 26-year outcomes in Naval Academy midshipmen.

BACKGROUND: Many procedures have been proposed for the correction of anterior shoulder instability. Some of these procedures address the problem anatomically, such as the Bankart procedure, and some prevent instability nonanatomically, such as the Bristow-Latarjet procedure. A modified Bristow procedure was the procedure of choice for anterior shoulder instability among midshipmen at the United States Naval Academy from 1975 to 1979. HYPOTHESIS: The modified Bristow procedure for anterior shoulder instability provides good shoulder function and stability in the long term. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: There were 52 shoulders in 49 patients reviewed at a mean follow-up of 26.4 years. The Rowe score, Single Assessment Numeric Evaluation, and Western Ontario Shoulder Instability Index were used to assess outcomes. RESULTS: The mean Rowe score was 81.8 (range, 5-100), and the mean Single Assessment Numeric Evaluation score was 82.9 (range, 30-100), with an overall Single Assessment Numeric Evaluation of 71.2% (37 of 52 shoulders) rated as good and excellent. The mean Western Ontario Shoulder Instability Index was 376 of 2100 (range, 0-1560). Overall, recurrent instability occurred in 8 of 52 shoulders (15.4%), with recurrent dislocation in 5 shoulders (9.6%) and recurrent subluxation in 3 shoulders (5.8%). The mean time to recurrent dislocation was 7.0 years. CONCLUSION: This study represents the longest follow-up in the literature of the modified Bristow procedure. The authors have shown nearly 70% good and excellent results and recurrent instability comparable with other long-term follow-up studies of open instability procedures.

Adolescent↗
PubMedDate not supplied

Cosmetic surgery procedures as luxury goods: measuring price and demand in facial plastic surgery.

OBJECTIVES: To evaluate the relationship between cosmetic facial plastic surgery procedure price and demand, and to test the hypothesis that these procedures function as luxury goods in the marketplace, with an upward-sloping demand curve. METHODS: Data were derived from a survey that was sent to every (N = 1727) active fellow, member, or associate of the American Academy of Facial Plastic and Reconstructive Surgery, assessing the costs and frequency of 4 common cosmetic facial plastic surgery procedures (face-lift, brow-lift, blepharoplasty, and rhinoplasty) for 1999 and 1989. An economic analysis was performed to assess the relationship of price and demand for these procedures. RESULTS: A significant association was found between increasing surgeons' fees and total charges for cosmetic facial plastic surgery procedures and increasing demand for these procedures, as measured by their annual frequency (P</=.003). After a multiple regression analysis correcting for confounding variables, this association of increased price with increased demand holds for each of the 4 procedures studied, across all US regions, and for both periods surveyed. CONCLUSIONS: Cosmetic facial plastic surgery procedures do appear to function as luxury goods in the marketplace, with an upward-sloping demand curve. This stands in contrast to other, traditional, goods for which demand typically declines as price increases. It appears that economic methods can be used to evaluate cosmetic procedure trends; however, these methods must be founded on the appropriate economic theory.

Attitude to Health↗
PubMed2003

Safe and efficacious use of procedural sedation and analgesia by nonanesthesiologists in a pediatric emergency department.

BACKGROUND: Children often require relief of pain and anxiety when undergoing diagnostic or therapeutic procedures in the emergency department (ED). Procedural sedation and analgesia (PSA) has become standard practice in the outpatient setting for such procedures. Few studies have looked at the overall success and incidence of complications of PSA as performed by nonanesthesiologists. OBJECTIVES: To prospectively describe PSA as performed in a pediatric ED and to report the success of sedation and incidence of complications. DESIGN: Prospective descriptive study. Setting and Population Subjects aged 0 to 21 years presenting to the ED of an urban, tertiary care, children's hospital between May 1, 1997, and April 30, 1999, requiring PSA for a diagnostic or therapeutic procedure. METHODS: A PSA form was designed and used by ED personnel to record pertinent clinical and demographic characteristics of patients, information related to the procedure, vital signs, and occurrence of complications. Success of sedation was defined a priori as successful completion of the procedure in a minimally responsive subject. Complications were defined as apnea, hypoxia (sustained pulse oximetry, <93%), seizure, arrhythmia, laryngospasm, stridor, hypotension, rash, vomiting, disinhibition, or aspiration. Follow-up telephone calls were made to families within 24 to 48 hours of discharge from the ED to document further complications. MAIN OUTCOME MEASURES: Rate of success of sedation and incidence of complications. RESULTS: Procedural sedation and analgesia was performed 1244 times in 1215 patients during the study. The median age of the patients was 5.9 years (mean age, 6.9 years; range, 2 months to 19.4 years). There were 791 boys (65.1%) and 424 girls (34.9%). A little more than half of the patients (643 or 52.9%) required PSA for fracture reduction and 396 (32.6%) for laceration repair. Intravenous (IV) fentanyl citrate and midazolam hydrochloride was provided in 734 sedation events (59.0%); IV ketamine hydrochloride, midazolam, and atropine sulfate in 293 (23.6%); and intramuscular ketamine, midazolam, and atropine in 82 (6.6%). Procedural sedation and analgesia was successfully provided in 1177 (98.6%) of 1194 sedation events. Complications occurred in 207 (17.8%) of 1161 events. The most common complication was hypoxia (79.1% of patients), followed by vomiting (6.2% of patients). No patient required intubation. One patient had an oral airway placed, 3 patients received flumazenil, 3 patients received naloxone hydrochloride, and 1 patient received naloxone and bag-valve-mask ventilation. Seventy (9.8%) of 717 patients, following discharge from the ED, reported minor complications related to PSA. The most common complication was vomiting (76.7% of patients), followed by persistent dizziness (6.8% of patients). Patients who received IV fentanyl and midazolam were significantly more likely to experience a complication during PSA (P<.001), while patients sedated using IV ketamine, midazolam, and atropine (P =.006) or IV midazolam alone (P =.005) were less likely. No difference in success of sedation or incidence of complications at follow-up was found between the types of PSA provided. CONCLUSIONS: Complications related to PSA occurred in 17.9% of patients, but most commonly consisted of hypoxia that was easily treated. Sedation was successful in 98.6% of patients. Procedural sedation and analgesia can be safely and effectively provided by nonanesthesiologists in a pediatric ED.

Adolescent↗
PubMed2001

Pressure distribution in the humeroradial joint and force transmission to the capitellum during rotation of the forearm: effects of the Sauvé-Kapandji procedure and incision of the interosseous membrane.

A biomechanical study was undertaken, using four fresh cadaveric arms, to evaluate the changes in pressure distribution in the humeroradial joint (H-R joint) during rotation of the forearm before and after the Sauvé-Kapandji procedure (S-K procedure) and also after incision of the interosseous membrane (IOM) following the S-K procedure. The pressure distribution was measured with a pressure-sensitive conductive rubber sensor while the forearm was rotated. Force transmitted to the capitellum was calculated from the measured pressure. In the intact specimens, pressure was concentrated on the medial side of the capitellum in pronation and on the posterolateral side in supination. The pattern of change after the S-K procedure and that after incision of the IOM following the S-K procedure were almost the same as that in the intact forearm. Although the force transmitted to the capitellum increased after the S-K procedure, there were no significant differences between the forces before and after the S-K procedure. However, the force increased significantly after incision of the IOM following the S-K procedure when the forearm was supinated more than 35 degrees, and it was concentrated on the posterior side of the capitellum. The IOM seemed to have an important axial load-bearing function in the forearm position supinated more than 35 degrees. The S-K procedure in patients suffering from distal radioulnar joint disorders with IOM injury is likely to induce H-R joint osteoarthritis, so it should be avoided in these patients.

Analysis of Variance↗
PubMed1993

Loop electrosurgical excision procedures for cervical dysplasia: experience in a community hospital.

OBJECTIVE: The study was undertaken to evaluate the use of the loop electrosurgical excision procedure as an outpatient hospital or surgicenter procedure. STUDY DESIGN: The records of 358 patients treated for cervical intraepithelial neoplasia at a large community hospital over a 1-year period were reviewed. RESULTS: The specimens obtained by loop electrosurgical excision procedure and laser cone excision were comparable in size but smaller than those by means of cold-knife conization. Seventy-two percent of loop electrosurgical excision procedure specimens consisted of two to eight tissue fragments (mean 3.4). In addition, 48% of the loop electrosurgical excision procedure specimens and 38% of laser cones had moderate or severe thermal artifacts. Fragmentation and cautery damage precluded orientation of tissue and evaluation of margins in 19% of the cases. CONCLUSIONS: The advent of the loop electrosurgical excision procedure has shifted the management of cervical intraepithelial neoplasia from the office to the outpatient surgery centers. This negates and, in fact, reverses the advantage of loop electrosurgical excision procedure over other methods in regard to cost and convenience through evaluating and treating a patient with cervical intraepithelial neoplasia in one office visit. Loop electrosurgical excision procedures provide specimens that are inferior compared with cold-knife cones; therefore the role of loop electrosurgical excision procedure for the management of cervical intraepithelial neoplasia outside the office appears limited.

Adolescent↗
PubMed1986

Sugiura procedure outside Japan. The Mexican experience.

In the last 10 years, we operated on 231 patients with hemorrhagic portal hypertension. Most of these patients had some form of liver disease. We performed various surgical procedures: 47 conventional shunts with H grafts and terminolateral portacaval shunts with arterialization of the portal stump, 139 selective Warren shunts, and in those patients in whom a selective portasystemic shunt could not be performed for technical reasons, esophagogastric devascularization in the form of the Sugiura procedure. Forty-five patients were treated with the Sugiura procedure as a one stage or two stage procedure. A total of 68 emergency and elective operations were performed. The operative mortality rate for the emergency thoracic operation was 41 percent and for the abdominal operation, 42 percent. The overall operative mortality rate in the emergency group was 41 percent. The incidence of recurrent variceal bleeding and encephalopathy was 0 in the surviving patients. The survival rate at 3 year follow-up was 40 percent. The elective group was made up of 24 patients. Eighteen patients had a two stage procedure and 6 patients had a one stage procedure. The operative mortality rate for the abdominal operation was 11 percent, whereas that for the thoracic operation was 7 percent. The operative mortality rate for the one stage procedure was 16 percent. The overall operative mortality rate in the elective group was 10.8 percent. None of these patients had recurrent variceal bleeding and encephalopathy developed in only one (5 percent). The encephalopathy was easily controlled with medical treatment. The 3 year survival rate was 83 percent. We conclude that the Sugiura procedure is an effective procedure to treat hemorrhagic portal hypertension when a selective shunt cannot be performed.

Adolescent↗
PubMed1994

Predictors of postoperative outcome after general surgical procedures in patients with congenital heart disease.

This study was undertaken to evaluate factors predictive of postoperative outcome after general surgical (GS) procedures in patients with congenital heart disease (CHD). All patients with a diagnosis of CHD who underwent a GS procedure under general anesthesia during a consecutive 10-year period were considered eligible for the study The congenital heart defect was classified as either simple (ASD, VSD, PDA) or complex (endocardial cushion defects, transposition of the great vessels, tetralogy of Fallot), and the GS procedure as either major (intraperitoneal, intrathoracic, or vascular reconstructive) or minor (inguinal herniorrhaphy, vascular access). The overall mortality rate for the patient population was 12% (27 deaths among 226 procedures), minor procedures being associated with a 3% mortality rate (2 of 70 procedures), and major procedures with a 16% mortality rate (25 of 156 procedures). Incremental risk factors for mortality included a preoperative American Society of Anesthesiologists' (ASA) physical status class of IV or higher (P = .0003), a preoperative in-hospital stay of 10 or more days (P = .004), birth at a tertiary care center (P = .04), and emergency operations (P = .05). In the subgroup of patients less than 6 months old, weight of less than 2.4 kg at the time of surgery and a 1-minute Apgar score of less than 4 were additional independent risk factors (P = .04 and .01, respectively). By logistic analysis, previous corrective cardiac procedures, whether complete or palliative, did not significantly alter the postoperative outcome. The authors conclude that physiologically well-compensated patients with CHD can undergo elective operations at a low operative risk; however, poorly compensated patients undergoing urgent or emergent operations are at high risk.(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthesia, General↗
PubMed1995

Average blood loss and the risk of requiring perioperative blood transfusion in 506 orthognathic surgical procedures.

PURPOSE: This study quantifies the estimated blood loss in seven groups of orthognathic surgical procedures and the risk of requiring perioperative blood transfusion, and identifies the factors relating to blood loss and need for transfusion. PATIENTS AND METHODS: The records of 506 consecutive patients who underwent various orthognathic surgical procedures under hypotensive anesthesia from 1987 to 1990 were analyzed retrospectively. All procedures were performed by the authors in the same hospital setting. Patients were placed in seven groups based on the operation(s) performed, including single-jaw and double-jaw procedures. Estimated blood loss was calculated for each group and was correlated with patients' sex, age, and year of surgery, and whether they autodonated blood. The volume of intravenous (IV) fluids given was also recorded. RESULTS: Average estimated blood loss for all groups was 273.23 mL. Double-jaw procedures resulted in more blood loss than single-jaw procedures. Men and boys had a higher average blood loss than women and girls, but average blood loss was not affected significantly by patients' age or year of surgery. Only four patients (0.8%) received blood transfusions, and their average estimated blood loss was 975 mL. The percentage of patients autodonating increased from 10.4% in 1987 to 54.9% in 1990. There was no significant difference in the percentage of autodonators by surgical procedure. CONCLUSIONS: The need for blood transfusion in this study was extremely low. Factors contributing to this are believed to be use of hypotensive anesthesia; a single surgical team; and a constant surgical setting. Patients having double-jaw surgery are at greater risk for blood loss than those having single-jaw procedures, and should be so advised, along with the risks of blood transfusion. The authors believe that under the conditions of this study the use of autodonation is not necessary, with the possible exception of complex double-jaw procedures involving small patients.

Adolescent↗
PubMed2006

A prospective evaluation of "ketofol" (ketamine/propofol combination) for procedural sedation and analgesia in the emergency department.

STUDY OBJECTIVE: We evaluate the effectiveness and consider the safety of intravenous ketamine/propofol combination ("ketofol") in the same syringe for procedural sedation and analgesia in the emergency department (ED). METHODS: A prospective case series of consecutive ketofol procedural sedation and analgesia events in the ED of a trauma-receiving community teaching hospital from July 2005 to February 2006 was studied. Patients of all ages, with any comorbid conditions, were included. Ketofol (1:1 mixture of ketamine 10 mg/mL and propofol 10 mg/mL) was administered intravenously at the discretion of the treating physician by using titrated aliquots. The presence or absence of adverse events was documented, as were procedural success, recovery time, and physician, nurse, and patient satisfaction. Physiologic data were recorded with established hospital procedural sedation and analgesia guidelines. RESULTS: One hundred fourteen procedural sedation and analgesia events using ketofol were performed for primarily orthopedic procedures. The median dose of medication administered was ketamine at 0.75 mg/kg and propofol at 0.75 mg/kg (range 0.2 to 2.05 mg/kg each of propofol and ketamine; interquartile range [IQR] 0.6 to 1.0 mg/kg). Procedures were successfully performed without adjunctive sedatives in 110 (96.5%) patients. Three patients (2.6%; 95% confidence interval [CI] 0.6% to 7.5%) had transient hypoxia; of these, 1 (0.9%; 95% CI 0.02% to 4.8%) required bag-valve-mask ventilation. Four patients (3.5%; 95% CI 1.0% to 8.7%) required repositioning for airway malalignment, 4 patients (3.5%; 95% CI 1.0% to 8.7%) required adjunctive medication for sedation, and 3 patients (2.6%; 95% CI 0.6% to 7.5%) had mild unpleasant emergence, of whom 1 (0.9%; 95% CI 0.02% to 4.8%) received midazolam. No patient had hypotension or vomiting or received endotracheal intubation. Median recovery time was 15 minutes (range 5 to 45 minutes; IQR 12 to 19 minutes). Median physician, nurse, and patient satisfaction scores were 10 on a 1-to-10 scale. CONCLUSION: Ketofol procedural sedation and analgesia is effective and appears to be safe for painful procedures in the ED. Few adverse events occurred and were either self-limited or responded to minimal interventions. Recoveries were rapid, and staff and patients were highly satisfied.

Adult↗