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PubMed1993

Convective warming therapy does not increase the risk of wound contamination in the operating room.

Although convective warming therapy is effective in preventing hypothermia in anesthetized patients, little is known concerning the potential risks of its use. Hence, this balanced cross-over study was designed to determine if the use of convective warming therapy increased the risk of wound contamination. For 4 h, eight healthy male volunteers (aged 20-25 yr) lay supine on an operating room table with their lower bodies and legs covered with a warming cover and sterile surgical drape. The convective warming therapy was administered for 2 h. The other 2 h served as the control. In each session, culture plates were placed directly on the subject's abdomen through an opening in the drape. Tympanic membrane and leg skin temperatures were significantly higher with active warming. No significant differences in the number of bacterial colonies were observed between the two study periods. It was concluded that convective warming therapy, when appropriately applied, does not increase the risk for airborne bacterial wound contamination in the operating room.

Adult↗
PubMed2004

Spring-mediated cranial reshaping for craniosynostosis.

The evolution of modern craniofacial surgery has come full circle from the early strip craniectomies to the complete calvarial remodeling and now back to attempts at minimally invasive surgical interventions. The goal of the craniofacial surgeon has always been the correction of form and function with minimization of associated morbidity and mortality. Particularly problematic has been the ability to maintain the anatomical correction beyond the result seen on the operating room table secondary to changes with growth. The ability to improve the clinical result in a growing and developing child has been the impetus for dynamic treatment modalities. Dr Claes Lauritzen's pioneering work in this area has been particularly successful using internal springs to correct craniofacial deformities. The purpose of this study is to assess this treatment modality clinically in terms of safety and efficacy and to develop a methodology for the spring formation that would be easily reproducible. This is an institutional review board-approved prospective study of 15 children (11 male, 4 female) with non-syndromic sagittal suture synostosis. All patients were treated with a sagittal strip craniectomy and placement of 2 omega-shaped stainless steel springs at a mean age of 3.9 months. Patients were followed clinically and with cephalograms; after reossification of the intervening bone, the springs were removed at a mean age of 8.2 months. The mean force applied at initial placement of the springs was 6.9 N, and the mean spring deflection at formation was 6.87 cm. All patients completed the study protocol without any significant morbidity or any mortality. Perioperative variables, including blood loss, transfusion rate, operative time, intensive care unit stay, hospital stay, and hospital charges, were all significantly less (P < 0.05) in this study group compared with children with the same diagnosis treated with cranial vault reshaping during the same period. Furthermore, the preoperative mean cephalic index of 64.3 corrected to 77.6 after surgery and was maintained over time. Spring-mediated cranial reshaping is efficacious and safe for the treatment of sagittal synostosis. Long-term study of cranial development and clinical morphology are ongoing to validate further the effectiveness of this treatment modality.

Cephalometry↗
PubMed1981

Microfibrillar collagen hemostatic pledgets.

The use of topical microfibrillar collagen hemostatic agents is increasing in many areas of clinical surgery. We have developed a method of preparing the hemostatic agent by which a pledget is formed in a syringe. This gives it a firm consistency and allows easier handling and application and can be done at the operating room table.

Collagen↗
PubMed1980

Air conditioning systems.

There are some basic requirements for air conditioning systems in operating theatres. 1. Obviously the regulation of temperature and humidity is necessary, but cleaning of fresh air and circulating air is much more important. 2. Concerning cleaning, a high standard of filtration of air is demanded to avoid contamination of wounds. 3. So far only HEPA-filters, a technical description, give security and safety. They filter particles down to under 1 micrometer and have a filtration rate of more than 99.9%. 4. The ventilation rate is directly related to the germ concentration in the air. The higher the ventilation rate the cleaner the air during working. 5. To avoid turbulences unidirectional or uniform flow is necessary. This technique has become popular as the laminar flow technique. To get such a flow an air flow velocity of 0 45 +/- 0.1 m/s is necessary. 6. The arrangement of the different working places in an operating theatre is very important. Instrument tables and the operation field itself have to be in the zone of first air. 7. One of the commonest germ dispersion sources is the human body. Proper dressing and behaviour have to be observed. The airflow behind a person (in laminar cross flow) or under a person (in laminar down flow for instance when the neurosurgeon bends his head over the operating field) has to be regarded as contaminated. 8. Hygienic controls must be made in the operation theatre when unused and also under working conditions, in a sophisticated manner. If all these points are respected a real clean room technique is possible with considerable lowering of the risk of infection for the patient. Obviously all the other rules of hygiene, i.e., asepsis and antisepsis, elaborated since the days of Lister, have to be strictly respected.

Air Conditioning↗
PubMed1998

[Cranial development after corrective skull surgery in craniosynostosis].

Craniofacial development may be potentially implicated after vault corrections in cases of craniosynostosis. The aim of this prospective study was the investigation of the surgical effect on calvaria growth, correlating the percentiles of a group of patients before and after craniosynostosis correction in relation to the normal percentiles of growth. The patient population consisted of 71 children; the postoperative follow-up time in 57 patients was more than 12 months. Of the children followed up, 36 were male and 21 female. Thirty-six cases involved untreated non-syndromic craniosynostosis; the remaining 21 were syndrome cases. The patient ages ranged from 16 to 27 months. In 11 cases correction of an occipital craniosynostosis was carried out. The fronto-occipital circumference was registered in accordance with Prader's percentile table. The operative method included a fronto-parietal craniotomy, the temporary removal and shaping of the fronto-orbital band and a vault cranioplasty. During follow-up 13 patients treated with fronto-orbital advancement in cases of isolated craniosynostosis remained in the registered percentile curve. In 13 patients a change to a lower percentile curve was confirmed; 1 patient changed to a higher curve. In cases of syndromic craniosynostosis 10 patients remained in the post-operatively registered percentile curve; 8 patients changed to a lower and 1 patient to a higher percentile curve. No growth restriction of the reshaped calvaria after surgical correction of craniosynostosis was observed. No significant difference was found in the potential calvaria growth between syndromic and isolated craniosynostosis.

Child, Preschool↗
PubMed2006

[The minimally invasive anterior approach to hip arthroplasty].

A modified anterior approach to the hip developed by the senior author has been utilized in performing over 7000 hip replacement operations at this joint replacement center in the past three decades. It can be readily applied to both primary and revision surgery, and involves muscle splitting and sparing of the major hip muscles, innervation, and function. Since the late 1970s, Yale orthopaedic residents have been taught this minimally invasive anterior approach using one, two, or three mini-incisions without fluoroscopy, special operating room tables, or special retractors. The authors' overall experience has documented a very low incidence of dislocation and minimal perioperative complications. While a smaller skin incision is desirable by patients for cosmetic reasons and decreased healing time, what goes on beneath the skin is far more important. A well-placed total hip replacement should never be compromised. While many of these patients can ambulate the same or first postoperative day quite well, the authors do not advocate outpatient total hip arthroplasty as some proponents have. Bone is still cut, tissues bleed, clots can form, and the traditional complications of arthroplasty, while reduced, can still occur.

Adult↗
PubMed2004

Knife wound to the posterior fossa in a child.

BACKGROUND: Knife wounds to the posterior fossa are a rare occurrence, especially in children. We report an 8-year-old girl who sustained a penetrating knife injury through the occipital bone into the posterior fossa. On presentation, the large knife blade was firmly embedded in her head. METHODS: Radiographic evaluation was limited to plain X-rays because of the large size and sharpness of the embedded blade. Innovative positioning was used during intubation and then the patient was positioned semi-prone on the operating room table. The blade was surgically removed and the dura was closed. CONCLUSIONS: Atypical penetrating cranial injuries in children may require the treatment team to take a creative approach to the evaluation and repair of the lesion in order to maximize patient safety and minimize the risk of neurological injury.

Child↗
PubMed2004

The practice of bariatric surgery at academic medical centers.

The growing demand for laparoscopic bariatric surgery has led to an increase in the development of new bariatric surgical practices. Proper hospital facilities and an experienced bariatric surgical team are necessary to ensure optimal patient results. We surveyed academic centers participating in the University HealthSystem Consortium to examine the current practice of bariatric surgery. The survey questioned (1) availability of resources and equipment designed for the morbidly obese, (2) accidents, equipment problems, and workers' compensation relating to the care of bariatric surgical patients, (3) credentialing of bariatric surgeons, and (4) suggestions for improvements in the bariatric surgery program. Twenty-five institutions that perform bariatric surgery responded. Although the majority of institutions noted that they had basic bariatric equipment, some organizations did not have facility resources such as high-weight operating room tables and computed tomography scanners or transfer devices. Twenty-eight percent of institutions reported having accidents or equipment problems and 40% of institutions had workers' compensation claims relating to the care of bariatric patients. With regard to credentialing, 60% of institutions required the surgeons to have performed a minimum number of procedures prior to granting privileges. Suggested improvements included the need for more specialized bariatric equipment, enhancement of the education of all members of the bariatric surgical team, and designation of a bariatric physician who would coordinate care. This survey of bariatric surgery practices at academic medical centers demonstrates that the practice of bariatric surgery could be improved with regard to availability of bariatric equipment and resources and credentialing of surgeons.

Academic Medical Centers↗
PubMed1998

The fetal inflammatory response syndrome.

OBJECTIVE: The objective of this study was to determine the frequency and clinical significance of a systemic inflammatory response as defined by an elevated plasma interleukin-6 concentration in fetuses with preterm labor or preterm premature rupture of membranes. STUDY DESIGN: Amniocenteses and cordocenteses were performed in 157 patients with preterm labor and preterm premature rupture of membranes. Written informed consent and multi-institutional review board approvals were obtained. Amniotic fluid was cultured for aerobic and anaerobic bacteria, as well as mycoplasmas. Amniotic fluid and fetal plasma interleukin-6 concentrations were measured with a sensitive and specific immunoassay. Statistical analyses included contingency tables, receiver operating characteristic curve analysis, and multiple logistic regression. RESULTS: One hundred five patients with preterm labor and 52 patients with preterm premature rupture of membranes were included in this study. The overall prevalence of severe neonatal morbidity (defined as the presence of respiratory distress syndrome, suspected or proved neonatal sepsis, pneumonia, bronchopulmonary dysplasia. intraventricular hemorrhage, periventricular leukomalacia, or necrotizing enterocolitis) among survivors was 34.8% (54/155). Neonates in whom severe neonatal morbidity developed had higher concentrations of fetal plasma interleukin-6 than fetuses without development of severe neonatal morbidity (median 14.0 pg/mL, range 0.5 to 900 vs median 5.2 pg/mL, range 0.3 to 900, respectively; P < .005). Multivariate analysis was performed to explore the relationship between the presence of a systemic fetal inflammatory response and subsequent neonatal outcome. To preserve a meaningful temporal relationship between the results of fetal plasma interleukin-6 concentrations and the occurrence of severe neonatal morbidity, the analysis was restricted to 73 fetuses delivered within 7 days of cordocentesis who survived. The prevalence of severe neonatal morbidity in this subset of patients was 53.4% (39/73). A fetal plasma interleukin-6 cutoff value of 11 pg/mL was used to define the presence of a systemic inflammatory response. The prevalence of a fetal plasma interleukin-6 level > 11 pg/mL was 49.3% (36/73). Fetuses with fetal plasma interleukin-6 concentrations > 11 pg/mL had a higher rate of severe neonatal morbidity than did those with fetal plasma interleukin-6 levels < or = 11 pg/mL (77.8% [28/36] vs 29.7% [11/37], respectively; P < .001). Stepwise logistic regression analysis demonstrated that the fetal plasma interleukin-6 concentration was an independent predictor of the occurrence of severe neonatal morbidity (odds ratio 4.3, 95% confidence interval 1 to 18.5) when adjusted for gestational age at delivery, the cause of preterm delivery (preterm labor or preterm premature rupture of membranes), clinical chorioamnionitis, the cordocentesis-to-delivery interval, amniotic fluid culture, and amniotic fluid interleukin-6 results. CONCLUSION: A systemic fetal inflammatory response, as determined by an elevated fetal plasma interleukin-6 value, is an independent risk factor for the occurrence of severe neonatal morbidity.

Acute-Phase Reaction↗
PubMed1998

Coronary artery bypass grafting without cardiopulmonary bypass using the octopus method: results in the first one hundred patients.

OBJECTIVE: Cardiopulmonary bypass and global cardiac arrest enable safe coronary artery bypass grafting but have adverse effects. In off-pump coronary bypass grafting, invasiveness is reduced, but anastomosis suturing is jeopardized by cardiac motion. Therefore the key to successful off-pump coronary bypass grafting is effective local cardiac wall stabilization. METHODS: We prospectively assessed the safety and efficacy of the Octopus tissue stabilizer (Medtronic, Inc., Minneapolis, Minn.) in the first 100 patients selected for off-pump coronary bypass via full or limited surgical access. To immobilize and expose the coronary artery, two suction paddles (-400 mm Hg), fixed to the operating table-rail by an articulating arm, stabilized the anastomosis site. RESULTS: One hundred forty-one grafts (96% arterial) were used to create 172 anastomoses (17% side-to-side), up to 4 per patient, on average 23 in the full access group (46 patients) and 1.2 in the limited access group (54 patients). Complications included conversion to cardiopulmonary bypass (2%), conversion from limited to full access (3%), myocardial infarction (4%), predischarge coronary reintervention (2%), and late coronary reintervention (1%). Median postoperative length of hospital stay was 4 days (limited access) or 5 days (full access). Rapid recovery allowed 96% of patients to resume social activities within 1 month. At the 6-month angiographic follow-up, 95% of anastomoses was patent. At the 2- to 22-month follow-up (mean, 13 months), 98 patients were in Canadian Cardiovascular Society class I and 2 patients were in class II. CONCLUSION: These results suggest that off-pump coronary artery bypass grafting with the Octopus tissue stabilizer is safe. Early clinical outcome and patency rates warrant a randomized study comparing this methods with conventional coronary bypass grafting.

Cardiopulmonary Bypass↗
PubMed1996

Phacoemulsification performed in a modified waiting room chair.

Patients unable to fully recline represent challenging cases for the cataract surgeon. Various diseases of the heart, lungs, and spine may prevent certain patients from assuming a supine position, complicating the surgical approach and increasing the risk of intraoperative complications. We altered a common waiting room chair to allow these patients to remain in an upright seated position while their heads maintain the usual supine position commonly obtained with patients positioned on an operating room table.

Equipment Design↗
PubMed1997

Less invasive off-pump CABG using a suction device for immobilization: the 'Octopus' method.

OBJECTIVE: Target site immobilization is essential to enable meticulous anastomosis suturing during coronary artery bypass grafting on the beating heart. A novel device ('Octopus') was developed for local heart muscle immobilization by suction. The purpose of this study was to investigate the efficacy of the method through a limited access. METHODS: The suction device, placed on either side of the recipient coronary artery and fixed to the operating table-rail through an arm construction, restrains anastomosis site motion to 1 x 1 mm. A total of 27 patients underwent off-pump arterial bypass grafting using this method. Preoperatively, all patients had angina class III (NYHA) and were failed or unsuitable candidates for balloon angioplasty. Surgical access was via a 10-cm anterior thoracotomy (n = 26) or 10-cm subxiphoid incision (n = 1). RESULTS: Harvesting of the graft required 48 +/- 12 min (mean +/- S.D.). Immobilization with the 'Octopus' was effective and facilitated precise anastomosis suturing of 20 single and 7 sequential grafts. Immobilization did not change cardiac index and mean arterial blood pressure. During coronary surgery, however, inotropic drug support was used in 5 of 27 (18%) of patients. There was no myocardial infarction. Only minor transient complications were met. There were electro-cardiographical signs of pericarditis in 6 patients. The postoperative hospital stay ranged from 2 to 6 days, mean 4.0 +/- 1.2 days. The mean follow-up is 6.5 +/- 4 months (range, 1-12 months). All patients except one were in functional class I without angina. Social activities were resumed within 4 weeks. At 6 months angiography was performed in 15 out of 27 patients. The patency rate of 19 out of 20 anastomoses was 95%. All distal grafts were patent. One side to side anastomosis was occluded. CONCLUSIONS: The 'Octopus' immobilization method is safe and effective. It facilitates less invasive CABG in selected patients and gives way to fast recovery by reducing invasiveness.

Adult↗
PubMed2002

Allogeneic and autologous transplantation for haematological diseases, solid tumours and immune disorders: definitions and current practice in Europe.

The Accreditation Sub-Committee of the EBMT regularly publishes special reports on current practice of haemopoietic stem cell transplantation for haematological diseases, solid tumours and immune disorders. Major changes have occurred since the last report in 1998. Haemopoietic stem cell transplantation today includes allogeneic and autologous stem cells derived from bone marrow, peripheral blood and cord blood. With reduced intensity conditioning regimens in allogeneic transplantation, the age limit has increased, permitting the inclusion of older patients. New indications have emerged, such as autoimmune disorders and AL amyloidosis for autologous, and solid tumours for allogeneic transplants. Other indications, such as autologous transplantation for breast cancer have been challenged. An updated report with revised tables and operating definitions is presented here.

Adult↗
PubMed2006

Allogeneic and autologous transplantation for haematological diseases, solid tumours and immune disorders: definitions and current practice in Europe.

The Accreditation Subcommittee of the EBMT regularly publishes special reports on current practice of haemopoietic stem cell transplantation for haematological diseases, solid tumours and immune disorders in Europe. Major changes have occurred since the first report was published in 1996. Haemopoietic stem cell transplantation today includes grafting with allogeneic and autologous stem cells derived from bone marrow, peripheral blood and cord blood. With reduced intensity conditioning regimens in allogeneic transplantation, the age limit has increased, permitting the inclusion of older patients. New indications have emerged such as autoimmune disorders and AL amyloidosis for autologous, and solid tumours for allogeneic transplants. The introduction of alternative therapies has challenged well-established indications such as imatinib for chronic myeloid leukaemia. An updated report with revised tables and operating definitions is presented here.

Europe↗
PubMed2002

Popularity of complementary and alternative medicine in Japan: a telephone survey.

OBJECTIVE: To obtain information on the use of complementary and alternative medicine (CAM) in Japan. DESIGN: Nationwide, random-sampled and population-weighted telephone survey. METHODS: The survey was conducted by a telephone survey company in April 2001. The sample size of respondents was 1000. Using a region-, gender- and age-weighted sampling table, professional operators called respondents with random-digit dialling. Respondents were asked questions about their use of CAM in the past 12 months, out-of-pocket expenditures on CAM and orthodox Western medicine, reasons for the use of CAM and so on, as well as general socio-demographics. RESULTS: The percentage of respondents who had used at least one CAM therapy in the past 12 months was greater than those who had used orthodox Western medicine (76.0% (95% CI: 73.4-78.6) vs 65.6% (95% CI: 62.7-68.5). The percentage of use for each CAM therapy was as follows: nutritional and tonic drinks (43.1%), dietary supplements (43.1%), health-related appliances (21.5%), herbs or over-the-counter Kampo (17.2%), massage or acupressure (14.8%), ethical Kampo (Kampo prescribed by medical doctors) (10.0%), aromatherapy (9.3%), chiropractic or osteopathy (7.1%), acupuncture and moxibustion (6.7%), homeopathy (0.3%), and other therapies (6.5%). Regarding the reasons for the use of CAM, 60.4% responded that 'the condition was not serious enough to warrant orthodox Western medicine', and 49.3% were 'expecting health promotion or disease prevention'. Average annual out-of-pocket expenditures of all the 1000 respondents for CAM were half as much as those for orthodox Western medicine (19,080 yen (95% CI: 15,824-22,336) vs 38,360 yen (95% CI: 30,439-46,280)). CONCLUSIONS: CAM is very popular in Japan and the expenditures for them are not negligible, although there is still an overwhelming dominance of orthodox Western medicine with regard to cost, variety of indications, and severity of conditions.

Adult↗
PubMed2002

Small-dose selective spinal anesthesia for short-duration outpatient laparoscopy: recovery characteristics compared with desflurane anesthesia.

UNLABELLED: We conducted a randomized controlled trial to compare the recovery characteristics of selective spinal anesthesia (SSA) and desflurane anesthesia (DES) in outpatient gynecological laparoscopy. Twenty ASA physical status I patients undergoing gynecological laparoscopy were randomized to receive either SSA with lidocaine 10 mg + sufentanil 10 microg or general anesthesia with DES and N(2)O. Intraoperative conditions, recovery times, postanesthesia recovery scores, and postoperative outcomes were recorded. Intraoperative conditions were comparable in both groups. All patients in the SSA group were awake and oriented at the end of surgery, whereas patients in the DES group required 7 +/- 2 min for extubation and orientation. SSA patients had a significantly shorter time to straight leg raising (3 +/- 1 min versus 9 +/- 4 min; P < 0.0001) and to ambulation (3 +/- 0.9 min versus 59 +/- 16 min; P < 0.0001) compared with the DES group. SSA patients had significantly less postoperative pain than DES patients (P < 0.05). We concluded that SSA was an effective alternative to DES for outpatient gynecological laparoscopy. IMPLICATIONS: This study compared the use of a desflurane general anesthetic to a small-dose spinal anesthetic in ambulatory gynecological laparoscopy. Using the spinal technique, patients can walk from the operating room table to a stretcher on completion of surgery. Their recovery time was similar to that of the desflurane group.

Adjuvants, Anesthesia↗
PubMed2003

Traditional versus new needle retractable i.v. catheters in children: are they really safer, and whom are they protecting?

Retractable needle IV catheters are designed to reduce needle-stick injuries; their use is mandated by federal regulations. We undertook a prospective data collection with the "traditional" IV catheters (JELCO) versus the "new" (Angiocath Autoguard). Assignment of catheter type was randomized by week. Data collected included assessment of the difficulty of i.v. access; number of catheters used; and splatters or spills of blood on skin, linen, floor, clothing, and operating room table. There were 473 attempted insertions in 330 patients over 20 days. No needle-stick injuries occurred. Seventy-seven blood spills or splatters occurred in 42 patients. The number of splatters or spills was four times more with the new compared with the traditional catheters. There were significantly more total splatters or spills and patients who experienced splatters or spills with new catheters when they were placed by attendings but not when placed by trainees. Our study suggests that use of this technology by more experienced anesthesiologists may increase the risk of exposure of health care providers to blood-borne pathogens. Practitioners should choose the i.v. system that allows the most efficient venous access with the least potential for blood contamination. Hospitals should allow the choice to be made by the individuals using the devices.

Catheterization, Peripheral↗