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PubMed1998

Diagnostic and management procedures for compensable back injuries without serious associated injuries. Modeling of the 1991 injury cohort from a major Michigan compensation insurer.

STUDY DESIGN: A retrospective cohort of 2425 workers with compensated back conditions was created from the 1991 compensated cohort of the largest compensation insurer in Michigan by linking computerized information on social and demographic factors, diagnostic and management procedures, and cumulative missed worktime. OBJECTIVE: To describe medical care use from date of injury in 1991 to mid-1993 by type of back condition, to identify factors affecting this use, to determine the effect of alternative model selection strategies on identifying such factors, to investigate the timing of surgery and the use of diagnostic studies in patients with displaced or herniated discs with and without surgery, and to compare the use of medical care in the study group with that recommended by national expert panels. SUMMARY OF BACKGROUND DATA: Despite the enormous costs involved in medical care for patients with work-related back injuries, almost no information on the use of medical care is available for compensated back injuries by diagnostic and procedure code. METHODS: Use of medical care was grouped into 18 categories for tabulation. Factors affecting use of medical care were identified by logistic regression, supplemented by Cox analysis for time to first procedure. The Hosmer-Lemeshow chi-square statistic was compared with the Bayes Information Criterion for evaluating model fit. Overall model utility was evaluated by comparing receiver operating characteristic curves generated by the model. For patients with displaced or herniated discs, algorithms were used to identify the diagnostic procedures performed before and after the first surgery and the amount of time that passed before each procedure was performed. RESULTS: In patients with diagnoses of disc displacement or herniation or vertebrogenic neuritis, approximately 80% underwent radiography to obtain plain views of the spine, 75% underwent diagnostic imaging, 45% underwent electrodiagnostic procedures, and 24% underwent spinal surgery (29.3% had surgical procedures among those with disc conditions). In patients with diagnoses of back sprain or other symptomatic diagnoses, the percentages for the first three procedures are approximately 70%, 12%, and 12%, respectively. Diagnostic category, age, gender, and cumulative missed worktime predicted the receipt of diagnostic and treatment procedures. Women were 30% less likely to undergo computed axial tomography or magnetic resonance imaging and 50% less likely to undergo spinal surgery. Median time to spinal surgery was twice as long in the group that underwent diagnostic imaging and electrodiagnostic testing before surgery (134.5 days). Of the 622 patients with disc displacement/herniation, 510 (approximately 80%) had initial diagnostic imaging studies, and, of the 510, 162 (approximately 30%) had surgery. Thirteen (8%) were reoperated. Of the 162 patients who had surgery, 46 (approximately 30%) had follow-up diagnostic imaging, and, of the 46, nine (approximately 20%) were reoperated. Of the 348 managed conservatively, 96 (approximately 30%) had follow-up diagnostic imaging. CONCLUSIONS: The data suggest only modest differences in the use of medical care between this study group and noncompensated study populations from previous reports. The authors of this study estimate that 27% of diagnostic imaging studies and 43% of plain radiography of the spine could have been avoided if then available Canadian recommendations or current American, guidelines had been followed. The gender effect remains unexplained and needs to be investigated in additional studies. There was an increase of 6% in the use of surgery in compensated patients compared with the use of surgery in a recent American series involving traditional health insurance, but this may be associated with greater work disability in the compensated group. The results of the current study suggest that the use and reporting of model selection strategies and the use of receiver operati

Adolescent↗

PubMed2000

On-line vectorcardiography during elective coronary angioplasty indicates procedure-related myocardial infarction.

BACKGROUND: Increased creatine kinase concentrations after elective percutaneous transluminal coronary angioplasty (PTCA) have been shown to be associated with increased late cardiac mortality. OBJECTIVE: To evaluate the potential of continuous on-line vectorcardiography during elective PTCA to identify procedure-related myocardial infarction. METHODS: Patients (n = 192, ages 58 +/- 10 years), treated with elective and initially successful PTCA, were studied using vectorcardiogram (VCG) recordings. VCG monitoring was started 5 min before start of the PTCA and was carried out during the entire procedure, for at least 30 min after the first balloon inflation. ST-segment vector magnitude (ST-VM) and ST-segment change vector magnitude (STC-VM) were monitored. RESULTS: Fifteen (7.8%) procedure-related myocardial infarctions occurred. Indicators of procedure-related myocardial infarction were maximum value of ST-VM (P < 0.001) and STC-VM (P < 0.001), total ischemic time of all ST-VM episodes (P < 0.001) and STC-VM episodes (P < 0.001). The variable most closely related to a procedure-related myocardial infarction was the maximum STC-VM value during the procedure. With an optimized cutoff value, maximum STC-VM predicts a procedure-related myocardial infarction with a sensitivity of 93%, a specificity of 59% and a negative predictive value of 99%. Patients who had a stent implanted had significantly greater VCG values (P < 0.05-P < 0.001) than the group without a stent. There was a trend (P < 0.06) to a relation between increased creatine kinase concentration and stent implantation. In patients both with and without an implanted stent, greater STC-VM values were associated with procedure-related myocardial infarction (P < 0.01). CONCLUSION: Continuous VCG monitoring during elective PTCA is a promising method for immediate detection of patients at increased risk of procedure-related myocardial infarction.

Adult↗

PubMed2003

Procedural coding of spinal surgeries (CPT-4 versus ICD-9-CM) and decisions regarding standards: a multicenter study.

STUDY DESIGN: A comparison of procedural coding systems ( [ICD-9-CM] [CPT-4]) applied to lumbar spine surgery patients from six teaching institutions. OBJECTIVE: To compare the detail reflected by coding systems used to describe spinal procedures. SUMMARY OF BACKGROUND DATA: Administrative databases contain ICD-9-CM procedural codes, which are derived from hospital discharge abstracts. These databases are used, in part, to establish health care utilization patterns and set health care policy. Previous studies have demonstrated inaccuracies in ICD diagnosis coding. However, the literature is void of information regarding the accuracy of ICD procedural coding of spine procedures. METHODS: Data were complete in 143 of 150 lumbar spine surgery patients (aged 17-84 years). Surgeons assigned CPT-4 procedural codes. These codes were compared with ICD procedure codes assigned by hospital medical records staff. RESULTS: On average, in four of six hospitals, there were more CPT codes assigned to patient records by the surgeon than ICD codes assigned by hospital medical records staff. Overall, CPT codes reflected a greater level of detail than ICD codes. CONCLUSIONS: These findings illustrate the increased detail of CPT coding over ICD coding in the spinal surgery cases reviewed. The ICD procedural codes contained in administrative databases tend to underrepresent the complexity of the surgical procedures actually performed.

Adolescent↗

PubMed2006

Laparoscopic Burch colposuspension and the tension-free vaginal tape procedure.

PURPOSE OF REVIEW: Minimally invasive procedures for urinary incontinence and pelvic organ prolapse have gained increasing popularity in the past decade. The advantages of minimal access through laparoscopic and vaginal routes include smaller incisions, shortened hospital stay, decreased analgesia, rapid recovery and rapid return to work. The laparoscopic Burch colposuspension and the tension-free vaginal tape procedure were at the forefront of minimal access antiincontinence procedures. The most recent and significant publications regarding laparoscopic Burch colposuspension and tension-free vaginal tape procedure are highlighted in this article. RECENT FINDINGS: The laparoscopic Burch is time-consuming and requires a steep learning curve in laparoscopic suturing, thwarting its adoption and staying power. The advantages and success of the retropubic midurethral sling procedures such as tension-free vaginal tape have largely replaced all other antiincontinence procedures and have ignited the development and adoption of transobturator midurethral sling procedures and vaginal 'kit' procedures for pelvic organ prolapse. SUMMARY: Clinical trials show that laparoscopic Burch cure rates are equal or inferior to tension-free vaginal tape cure rates. Publications regarding laparoscopic Burch colposuspension have tapered significantly in the past year, which may represent the ebb of its utilization. Tension-free vaginal tape and other midurethral sling procedures may become the new 'gold standard' antiincontinence therapy.

Female↗

PubMed2005

Propofol versus midazolam/ketamine for procedural sedation in pediatric oncology.

Different pharmacologic agents have been used for sedation in children undergoing invasive procedures. The authors prospectively compared the efficacy, the occurrence of adverse effects, cardiovascular parameters, oxygen saturation and induction, and recovery time in propofol with or without morphine versus midazolam/ketamine sedation for procedural sedation in children with malignancies and hematologic disorders. Fifty children received either propofol with or without morphine or ketamine/midazolam sedation for invasive procedures. Intravenous sedation consisted of 0.1 mg midazolam/kg and 1.0 mg ketamine/kg or 2 mg propofol/kg with or without 0.1 mg morphine/kg. Incremental dosages of ketamine or propofol were given, if necessary, to achieve or to maintain adequate sedation levels. Systolic and diastolic blood pressure, heart rate, oxygen saturation, time to induce sedation, recovery time, and adverse effects were recorded. All invasive procedures were successfully completed, with satisfactory sedation levels in all 25 patients in the propofol group and 23 of the 25 patients in the ketamine group. In 14 of the 25 procedures in the propofol group and 4 of the 25 procedures in the ketamine group, sedation was associated with side effects, the most common being oxygen desaturation. There was a significant increase in diastolic blood pressure after ketamine medication and a significant decrease in systolic and diastolic blood pressure and heart rate in the propofol group. Induction and recovery times in the propofol group were significantly shorter. Both regimens for procedural sedation are efficacious in achieving satisfactory sedation levels for invasive procedures. Propofol offers a quicker onset of sedation and a faster, smoother recovery but is associated with a higher rate of side effects. Considering the substantial rate of adverse effects, these procedural sedations should be performed only by physicians trained in advanced airway management and life support.

Adolescent↗

PubMed2005

Selection criteria for patients undergoing transjugular intrahepatic portosystemic shunt procedures: current status.

The transjugular intrahepatic portosystemic shunt (TIPS) procedure has a well-established role in the management of patients with complications of portal hypertension such as variceal bleeding or refractory ascites. Several clinical variables have been described to be associated with a poor prognosis after a TIPS procedure, including the presence of uncontrollable ascites, the number of sclerotherapy sessions to control a bleeding episode, the use of drugs for hemodynamic support, the use of balloon tamponade to control bleeding, the need for an emergency TIPS procedure, the need for mechanical ventilation, prothrombin time, increased serum creatinine, increased serum bilirubin, encephalopathy, and sepsis. In addition, several scoring systems have been developed and applied to patients undergoing TIPS procedures in an attempt to improve patient selection criteria for this invasive procedure. This article reviews the most important scoring systems that have been developed and applied to patients undergoing emergency or elective TIPS procedures, with particular emphasis on the prognostic index designed for patients undergoing emergency TIPS procedures and the Model for End-stage Liver Disease score designed for patients undergoing elective TIPS procedures. The most practical application of these scoring systems is probably that, with the information provided, the operator is able to discuss with referring physicians, patients, and family members the expected outcomes of this challenging procedure.

Ascites↗

PubMed2006

Operative mortality and procedure volume as predictors of subsequent hospital performance.

CONTEXT: Despite growing interest in evidence-based hospital referral for selected surgical procedures, there remains considerable debate about which measures should be used to identify high-quality providers. OBJECTIVES: To assess the usefulness of historical mortality rates and procedure volume as predictors of subsequent hospital performance with different procedures. DESIGN, SETTING, AND PARTICIPANTS: Using data from the national Medicare population, we identified all U.S. hospitals performing one of 4 high-risk procedures between 1994 and 1997. Hospitals were ranked and grouped into quintiles according to 1) operative mortality (adjusted for patient characteristics) and 2) procedure volume. MAIN OUTCOME MEASURES: Risk-adjusted operative mortality in 1998 to 1999. RESULTS: Although historical mortality and volume both predicted subsequent hospital performance, the predictive value of each varied by procedure. For coronary artery bypass graft surgery, mortality rates in 1998 to 1999 differed by 3.3% across quintiles of historical mortality (3.6% to 6.9%, best to worst quintile, respectively), but only by 1.0% across volume quintiles (4.8% to 5.8%). In contrast, for esophagectomy, mortality rates in 1998 to 1999 differed by 12.5% across volume quintiles (7.5% to 20.0%, best to worst quintile, respectively), but only by 1.5% across quintiles of historical mortality (11.4% to 12.9%). Historical mortality and procedure volume had comparable value as predictors of subsequent performance for pancreatic resection and elective abdominal aortic aneurysm repair. Our findings were similar when we repeated the analysis using data from later years. CONCLUSIONS: Historical measures of operative mortality or procedure volume identify hospitals likely to have better outcomes in the future. The optimal measure for selecting high-quality providers depends on the procedure.

Aged↗

PubMed2003

Parental presence during invasive procedures in children: what is the physician's perspective?

INTRODUCTION: Invasive procedures may be frightening and painful experiences for children and their parents. Many parents prefer to be present when procedures are performed in their children. Allowing parents to be present during procedures decreases procedure-related anxiety. Few if any studies have addressed the physician's perspective on this issue. We conducted a simple observation survey to examine this question. METHODS: We sent three-part questionnaires to the directors of 80 emergency departments with pediatric and/or emergency medicine (EM) residencies or pediatric EM fellowship training programs. The questionnaires asked whether physicians allowed parents to be present during medical procedures, as well as their opinions regarding parental presence and the effect it had on them as physicians. RESULTS: The response rate was 77% (n = 62). More than 87% of physicians stated that they allow parents to be present during simple procedures (eg, venipuncture), but they indicated that they are more reluctant to do so during more invasive procedures (eg, major resuscitation scenario; 22%). Physicians' training also may influence their level of comfort and their decision making in such situations. CONCLUSION: Most physicians stated that they allow parental presence during simple procedures. Physicians were more reluctant to allow parents to be present during complex procedures. EM and pediatric emergency medical training increased the physicians' level of comfort.

Age Factors↗

PubMedDate not supplied

Partial maze procedure is effective treatment for chronic atrial fibrillation associated with valve disease.

The maze procedure may be performed in combination with valve operations to treat chronic atrial fibrillation associated with valve dysfunction. Although we initially used the modified Cox maze III procedure, a more limited partial maze procedure is now preferred because the left atrium might be considered as the electrical impetues for atrial fibrillation. In this study we compared the results of 30 patients (group I) who underwent the full biatrial modified Cox maze III and 20 (group II) patients the partial maze procedure. While the rates of restored sinus rhythm were the same in both groups at 6-month follow-up (I: 83.3%, vs II: 80%), the following advantages were noted in the patients undergoing the partial maze procedure: shorter operative times, lesser elevations of creatine phosphokinase, lower rate of blood transfusion, lower rate of junctional rhythm soon after the operation, and a higher P wave in those patients with restored sinus rhythm. The effectiveness of the partial maze procedure seems equal to that of the biatrial modified Cox maze III procedure for atrial fibrillation associated with valve disease. The partial maze procedure is simple and less invasive, and thus might be applied more frequently as an additional procedure to valve operations without additional risk.

Aged↗

PubMed2001

Efficacy and safety of nitrous oxide in alleviating pain and anxiety during painful procedures.

AIMS: To evaluate the efficacy and safety of nitrous oxide for children undergoing painful procedures. METHODS: Ninety children requiring repeated painful procedures (lumbar puncture, bone marrow aspirate, venous cannulation, or dressing changes) were given nitrous oxide at a variable concentration of 50-70%. Procedure related distress was evaluated using the Observational Scale of Behavioral Distress-Revised (OSBD-R). OSBD-R scores were obtained for each of the following phases of the procedure: phase 1a, waiting period; phase lb, during induction with nitrous oxide; phase 2, during positioning and cleaning of the skin; phase 3, during the painful procedure; and phase 4, immediately following the procedure and withdrawal of nitrous oxide. Side effects were monitored and recorded by a second observer. RESULTS: OSBD scores reached a maximum during the induction phase with lower scores during subsequent phases. Children over the age of 6 showed a lower level of distress during nitrous oxide administration and the painful procedure. Eighty six per cent of patients had no side effects. The incidence of vomiting, excitement, and dysphoria was 7.8%, 4.4%, and 2% respectively. Eight patients developed oxygen desaturation (SaO(2) < 95%), but none developed hypoxia, airway obstruction, or aspiration. Ninety three per cent of patients fulfilled the criteria for conscious sedation, and 65% had no recollection of the procedure. Mean recovery time was three minutes. CONCLUSIONS: Inhalation of nitrous oxide is effective in alleviating distress during painful procedures, with minimal side effects and short recovery time.

Analgesics, Non-Narcotic↗

PubMed2006

Transcatheter closure of ventriculopulmonary artery communications in staged Fontan procedures.

BACKGROUND: Ventricle-pulmonary artery connections in patients after the Fontan procedure lead to ineffective volume loading and can cause long term problems. In patients with a cavopulmonary shunt anterograde pulmonary blood flow is frequently maintained, but can cause significant volume loading of the heart or complicate the subsequent Fontan procedure. OBJECTIVE: To evaluate the use of transcatheter closure of a ventricle-pulmonary artery communication in the setting of a cavopulmonary shunt or after the Fontan procedure. PATIENTS AND METHODS: Retrospective study at a tertiary referral centre. Eight patients (age 1.5-18 years, mean 7.8 years). INDICATIONS: cardiac failure or persistent pleural effusions after cavopulmonary shunt (n = 2) or after Fontan (n = 3) and abolishing the volume load of the single ventricle prior to Fontan completion (n = 3). RESULTS: Devices used: Rashkind Umbrella (n = 1), Amplatzer PDA (n = 7) and Amplatzer ASD (n = 1). One patient required two devices. There were no procedural complications. All 3 patients with prolonged pleural effusions (1 post CP shunt and 2 post Fontan) showed complete resolution between 4 and 10 days after catheter closure. Two patients underwent transcatheter occlusion for progressive ventricular dilatation and cardiac failure. The first patient was post Fontan and showed gradual improvement in ventricular function. The second patient (post CP shunt) was in end stage cardiac failure due to severe AV valve regurgitation. The patient died 48 hours after an uncomplicated procedure due to ventricular failure and electromechanical dissociation (non-procedure-related cardiac death). Three patients underwent catheter closure to off-load the systemic ventricle prior to the Fontan procedure. The device had to be removed prior to release in one patient, due to unsatisfactory position. CONCLUSIONS: Transcatheter closure of ventricle-pulmonary artery communication is a safe and effective technique in the treatment of selected patients after cavopulmonary shunt or Fontan procedure with early or late complications due to inappropriate pulmonary blood flow. This intervention should also be considered in the preparation for the Fontan procedure in selected patients with ventricular overload.

Adolescent↗

PubMedDate not supplied

Safety and cost savings of endovascular procedures: are outpatient interventions feasible when combined with open surgery?

As increasing experience and comfort with endovascular interventions performed in an outpatient setting has occurred, the safety and cost effectiveness of performing these procedures without an overnight stay were analyzed, especially when endovascular procedures were combined with open vascular operations requiring an arteriotomy and surgical closure. Ninety patients underwent endovascular procedures alone or concomitantly with open, minor vascular operations to salvage a failing graft between February 1994 and June 1999. Patients undergoing endovascular interventions during primary lower extremity bypass or other major surgical procedures were not included in this review because they were not candidates for outpatient procedures. Balloon angioplasty alone (79) or angioplasty with stent placement (11) was performed to treat stenoses in 50 failing grafts, 16 iliac, 14 femoral, 5 tibial, and 5 axilla/subclavian arteries. A significant increase in outpatient procedures was accomplished as more experience was garnered with these techniques: 19% (8/42) between 1994 and 1996 vs 57% (28/48) between 1997 and 1999 (p = 0.001). Age and comorbidity did not play a role in determining the need for admission because there were no significant differences in patients with diabetes mellitus, hypertension, smoking, or hyperlipidemia and those admitted or discharged the same day (p > 0.05). Patients admitted for overnight observation tended to have longer mean operative times and more complex revascularizations than outpatients (110 vs 69 min, respectively; p < 0.0001). Twenty-seven patients underwent surgical exposure of the access vessel: 63% (17) were admitted and 37% (10) were discharged the same day. Sixty-three patients underwent a percutaneous procedure: 42% (27) were admitted and 58% (37) were discharged the same day. Outpatients were more likely to receive only local anesthesia (83%; 30/35) compared to patients admitted overnight (67%; 36/53); the remaining patients received spinal or epidural anesthesia. Complications included graft thrombosis within 30 days in 6% (5/90) of patients and arterial graft infection in 2% (2). No patient required surgery for bleeding. The average charges for outpatient interventions were $1980 compared to $10,026 for patients who stayed overnight (p < 0.0001). As vascular surgeons become more experienced and comfortable with outpatient endovascular procedures, especially when performed in combination with open minor vascular surgery, significant cost savings can be realized without sacrificing patient safety. Even when open surgical exposure is planned, patients should be instructed preoperatively to anticipate discharge the day of their procedure to minimize resistance to this strategy.

Aged↗

PubMed2006

Procedural sedation in the community emergency department: initial results of the ProSCED registry.

OBJECTIVES: Procedural sedation and analgesia (PSA) has been well profiled in experimental studies in university emergency departments. Extrapolation of these practices into the community hospital setting is not well established. This report describes community hospital practices and outcomes in a multicenter PSA registry. METHODS: The Procedural Sedation in the Community Emergency Department (ProSCED) registry is a prospective observational database composed of consecutive emergency physician-directed procedural sedation cases in community hospitals. Registered procedures described by 15 categorical data fields are collected at the time of the patient encounter and entered into a secure Internet-housed database. RESULTS: A total of 1,028 procedural sedations were performed on 980 patients at 14 study sites. The most common specified procedures performed included shoulder relocation (392), hip relocation (102), elbow relocation (70), upper extremity fracture care (69), lower extremity fracture care (66), and facial laceration repair (67). Complications of any description occurred in 42 cases (4.1%), with no patient's disposition changed secondary to a complication. Patients' ages ranged from 1 month to 95 years, with a median age of 31 years. Of procedures attempted, 982 (95.5%) were successfully completed, 21 cases (2.0%) were adequately sedated but unable to have their procedure completed, and 21 cases (2.0%) were believed to be inadequately sedated. Medication use included midazolam in 423 cases (41.1%), propofol in 253 (24.6%), fentanyl in 253 (24.6%), etomidate in 241 (23.4%), and ketamine in 145 (14.1%), as well as several others. Cases using either ketamine or propofol exhibited the fewest complications, while those using fentanyl, hydromorphone, or midazolam demonstrated the highest complication rates. CONCLUSIONS: Community emergency physicians deliver safe and effective PSA over a wide variety of ages and procedures while using a broad selection of agents.

Adolescent↗

PubMed1997

Efficacy and safety of intravenous midazolam and ketamine as sedation for therapeutic and diagnostic procedures in children.

OBJECTIVE: We have used the combination of midazolam, a short-acting benzodiazepine, and ketamine, a "dissociative anesthetic," to provide conscious sedation for invasive or lengthy procedures. METHODS: A total of 350 procedures (74 lumbar punctures, 97 bone marrow aspirations or biopsies, 84 radiotherapy sessions, and 95 imaging studies) were performed on 68 children, 4 months to 17 years of age, in both inpatient and ambulatory settings. All patients had an intravenous line in place and were monitored for heart rate and O2 saturation by pulse oximetry for the duration of the procedure and recovery time. Blood pressure was monitored periodically (every 5 to 30 minutes). Oxygen and suction equipment was available during the procedure. In addition to the individual performing the procedure, a second staff member trained in airway management (eg, physician, nurse practitioner, or registered nurse) was present to monitor vital signs and respiratory status. Patients were sedated initially with midazolam (0.05 to 0.1 mg/kg intravenously; maximum single dose of 2 mg, maximum total dose of 4 mg), followed by ketamine (1 to 2 mg/kg intravenously). During lengthy procedures, additional doses of ketamine (0.5 to 1 mg/kg) were given as necessary. Effectiveness of the sedation, recovery time, and adverse events associated with the sedative regimen were documented. RESULTS: All patients were effectively sedated with this regimen. Four patients experienced transient decrease in O2 saturation (<85%) requiring temporary interruption of the procedure and oxygen by blow-by; the procedure was subsequently completed without incident in each case. Two patients experienced significant agitation during recovery from sedation. This side effect resolved spontaneously after 5 to 10 minutes in one patient and was effectively treated with diphenhydramine hydrochloride in the other. Twenty-four lumbar punctures were associated with transient decrease in O2 saturation (88% to 92%), which improved by relief of neck flexion and/or blow-by oxygen. No hypotension, bradycardia, or respiratory depression requiring respiratory support or reversal of sedation was noted. Anesthesia recovery time ranged from <15 minutes to 120 minutes with >70% of patients recovering within 30 minutes. Most patients demonstrated an increase in oral secretions requiring occasional suctioning. Transient sleep disturbances were reported in only two patients. CONCLUSIONS: This sedative regimen of intravenous midazolam and ketamine was found to be safe and effective. Its use has greatly reduced patient and parent anxiety for diagnostic and therapeutic procedures.

Adolescent↗

PubMed1997

Efficacy of ketamine hydrochloride sedation in children for interventional radiologic procedures.

OBJECTIVE: The purpose of this study was to evaluate the efficacy of ketamine hydrochloride sedation in children younger than 11 years old who underwent short interventional radiologic procedures. SUBJECTS AND METHODS: Two hundred eleven children, 3 days to 10 years old, were given Ketalar (ketamine hydrochloride; Parke-Davis, Morris Plains, NJ), either 2 mg/kg i.v. (114 patients) or 3 mg/kg intramuscularly (i.m.) (97 patients). Atropine sulfate (Fujisawa USA, Deerfield, IL) (0.01 mg/kg i.v. or 0.02 mg/kg i.m.) was added in all patients to control secretions. Patients were monitored with continuous pulse oximetry and with automatic blood pressure cuffs. Respiratory rate and heart rate were recorded every 5 min. Adequacy of sedation was graded by the radiologist. Induction time, procedure time, recovery time, and adverse effects were recorded. RESULTS: Sedation was considered excellent and the procedures were completed in 191 patients (91%). The sedation was considered light but the procedures were completed in the remaining 20 patients (9%). No sedation failures were observed. Average induction time was 45 sec for the i.v. procedure and 4 min for the i.m. procedure. Average recovery time was 18 min for the i.v. procedure and 25 min for the i.m. procedure. Average procedure time for both methods was 25 min. Hemoglobin saturation remained at or greater than 95% in 200 patients (94%). Transient desaturation below 95% occurred in 11 patients (5%). The airway was manipulated to improve ventilation (head, neck, and jaw lifts) and supplemental oxygen was given via nasal cannula or mask. The episodes lasted only a few seconds and oxygen saturation promptly returned to a level greater than 95%. A 7-week-old male infant who had been born prematurely at 32 weeks' gestation experienced apnea. Ventilation was assisted for several breaths and the patient promptly recovered. We observed only minor cardiovascular changes in all patients. CONCLUSION: Ketamine hydrochloride provides excellent sedation and analgesia in young children. The short induction time, rapid recovery, and minimal respiratory depression are features that make this sedative ideal for interventional radiology.

Child↗

PubMed2001

The Batista procedure. Theoretical analysis and clinical implications.

BACKGROUND: The Batista procedure leads to dramatic early improvement in left ventricular function in some patients and a worsening in function in others. The theoretical and actual clinical effects of the procedure on early postoperative left ventricular function remain controversial. The purpose of this study is to utilize an appropriate mathematical model to determine the effects of the Batista procedure on stroke volume and myocardial wall stress. Our hypothesis is that the preoperative end-systolic stress (ses) is an important predictor of early postoperative myocardial function after this procedure. A corollary is that an index related to ses may be useful in selecting patients for this procedure. METHODS: An analysis of the Batista procedure is developed, based upon a spherical membrane model of the ventricle. This model shows how ventricular dilatation distorts the systolic and diastolic pressure-volume relations. RESULTS: Dilatation initially improves ventricular performance; but further dilatation, beyond a critical value, produces an unstable state with sharply falling performance. For a ventricle operating significantly beyond the point of critical dilatation, our theoretical results suggest that the Batista procedure not only reduces myocardial stress but may improve stroke volume. The end-systolic stress, ses is an indicator of how close a ventricle is to the critical dilatation point. CONCLUSIONS: There is a theoretical basis for the Batista procedure. Resection of myocardium not only decreases wall stress but may improve stroke volume for sufficiently dilated and depressed ventricles. Patients with markedly elevated end-systolic stress may benefit most from the Batista procedure.

Cardiac Surgical Procedures↗

PubMed1996

The role of office-based procedures in family practice residency training.

BACKGROUND: Fifteen years ago, the American Board of Family Practice determined the need for a procedural "core" list requirement for residency training. Program directors at that time could not reach a consensus about a specific list of procedures. This study examined the current attitudes of residency directors about a core list of office-based procedures required for residency training. METHODS: A questionnaire was designed to elicit general information about attitudes toward establishing a core requirement of office-based procedures. The program directors were asked to select from a list of 35 office-based procedures those they felt should be required. The questionnaire was mailed to all 421 US family practice residency directors. RESULTS: The response rate was 78%. Of responding directors, 68% favored a core list requirement. Eleven out of 35 procedures received at least 80% consensus by those directors favoring a core list requirement. Programs situated in rural areas were more likely to oppose the core list requirement. Geographic region of the residency program impacted on the number of core procedures respondents felt residents should master in their training. CONCLUSIONS: The majority of residency directors who responded believe that the potential advantages of a core list requirement outweigh the potential disadvantages. The directors approximated consensus (80% agreement) on seven procedures across all geographic regions. With this evidence in mind, it would seem appropriate for the governing bodies of family practice to reexamine the core procedure issue.

Ambulatory Surgical Procedures↗

PubMed1998

Variation profiles of common surgical procedures.

BACKGROUND: Rates of many surgical procedures vary widely across both large and small geographic regions. Although variation in health care use has long been described, few studies have systematically compared variation profiles across surgical procedures. The goal of this study was to examine current patterns of regional variation in the rates of common surgical procedures. METHODS: The study population consisted of patients enrolled in Medicare in 1995, excluding those enrolled in risk-bearing health maintenance organizations. Patients ranged in age from 65 to 99 years. Using data from hospital discharge abstracts, we calculated rates of 11 common inpatient procedures for each of 306 US hospital referral regions (HRRs). To assess the relative variability of each procedure, we determined the number of low and high outlier regions (HRRs with rates < 50% or > 150% the national average) and the ratio of highest to lowest HRR rates. RESULTS: Procedures differed markedly in their variability. Rates of hip fracture repair, resection for colorectal cancer, and cholecystectomy varied only 1.9- to 2.9-fold across HRRs (0, 0, and 4 outlier regions, respectively). Coronary artery bypass grafting, transurethral prostatectomy, mastectomy, and total hip replacement had intermediate variation profiles, varying 3.5- to 4.7-fold across regions (8, 10, 16, and 17 outlier regions, respectively). Lower extremity revascularization, carotid endarterectomy, back surgery, and radical prostatectomy had the highest variation profiles, varying 6.5- to 10.1-fold across HRRs (25, 32, 39, and 56 outlier regions, respectively). CONCLUSIONS: Although the use of many surgical procedures varies widely across geographic areas, rates of "discretionary" procedures are most variable. To avoid potential overuse or underuse, efforts to increase consensus in clinical decision making should focus on these high variation procedures.

Aged↗