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PubMed2004

Bispectral index monitoring quantifies depth of sedation during emergency department procedural sedation and analgesia in children.

STUDY OBJECTIVE: The bispectral index monitor uses processed electroencephalogram signals to measure sedation depth on a unitless scale from 0 to 100 (0, coma; 40 to 60, general anesthesia; 60 to 90, sedated; 100, awake). It has been validated in the operating room as an objective measure of sedation depth with nondissociative general anesthesia; however, its usefulness in the pediatric emergency department (ED) for procedural sedation and analgesia has not been established. We determine the ability of the bispectral index to monitor depth of nondissociative procedural sedation and analgesia in children. METHODS: This was an observational study conducted in a children's hospital ED. Procedural sedation and analgesia was performed in the standard manner, with the addition of bispectral index monitoring and simultaneous clinical sedation scoring (modified Ramsay Sedation Scale [range 1 to 8; 1=alert, 8=unresponsive]). Paired bispectral index and Ramsay Sedation Scale scores were assigned every 5 minutes during the sedation. Ramsay Sedation Scale scores were assigned by a single study investigator blinded to the bispectral index score. An emergency physician independently administered all medications for procedural sedation and analgesia. The correlation between the paired bispectral index/Ramsay Sedation Scale scores was determined by using a repeated-measures regression analysis. Receiver operator characteristic (ROC) curves were constructed to determine the ability of the bispectral index to discriminate various thresholds of sedation depth. RESULTS: A convenience sample of 20 patients was enrolled, providing 217 paired bispectral index/Ramsay Sedation Scale measurements. Median age was 4.6 years (range 0.4 to 16.7 years). Fourteen patients received midazolam with fentanyl; the remainder received pentobarbital. Bispectral index scores ranged from 40 to 98 (mean 81.6+/-16.1). Ramsay Sedation Scale scores ranged from 1 to 8 (median 3; interquartile range 2 to 4). The simple Pearson correlation between paired bispectral index and Ramsay Sedation Scale scores was -0.78 (95% confidence interval [CI] -0.83 to -0.72; P<.001). After adjustment for the nonindependence of intrapatient data with bivariate repeated-measures analysis, the correlation was -0.67 (95% CI -0.90 to -0.43; P<.001). The linear regression coefficient between bispectral index and Ramsay Sedation Scale scores was estimated to be between -5.7 and -12.7. ROC curve analysis demonstrated moderate to high discriminatory power of bispectral index scores in predicting level of sedation throughout the sedation continuum, with areas under the curve at least 0.87 for all Ramsay Sedation Scale score thresholds. Bispectral index scores between 60 and 90 predicted with moderate accuracy traditional clinical levels of sedation typically encountered during procedural sedation and analgesia in the pediatric ED. CONCLUSION: Bispectral index monitoring correlated with clinical sedation scores and may serve as a useful, objective adjunct in quantifying depth of nondissociative procedural sedation and analgesia in children.

Adolescent↗

PubMed2002

The efficacy and safety of the tension-free vaginal tape procedure do not depend on the method of analgesia.

OBJECTIVE: The original tension-free vaginal tape (TVT) method, described by Ulmsten et al., routinely uses local anaesthesia during the procedure. Since the anaesthetic effect after local application of lidocaine hydrochloride was not always satisfactory we decided to introduce the spinal anaesthesia during this operation. The aim of the present study was to compare local and spinal anaesthesia with respect to their efficacy and safety in the TVT procedure. METHODS: 103 women, with objectively confirmed stress urinary incontinence, were randomised into the study. Sixty-seven women were anaesthetised locally and 36 patients spinally. All TVT procedures were performed as originally described. Objective assessment of the influence of anaesthesia on intra-abdominal pressure at rest and during the cough test was done using a rectal catheter and a central venous pressure manometer. The efficacy of the TVT procedure was based on a gynaecological examination with a cough test and a three-degree subjective scale: complete cure, improvement or failure. RESULTS: The success of the TVT procedure performed under local anaesthesia is comparable with that achieved under spinal analgesia (p=0.42). The number of complications that occurred in the two groups does not differ significantly (p=0.57). CONCLUSIONS: Spinal anaesthesia impairs the ability to cough effectively during the TVT procedure. However, the efficacy and safety of the operations performed under this type of anaesthesia are comparable with the efficacy and safety of operations done under local anaesthesia.

Adult↗

PubMed1996

Risks and benefits of combined maze procedure for atrial fibrillation associated with organic heart disease.

OBJECTIVES: This study sought to identify the risks and benefits of adding the maze procedure in patients with atrial fibrillation (AF) undergoing operation for underlying organic cardiac disorders. BACKGROUND: Persistent AF often leaves patients symptomatic even after otherwise successful cardiac surgery. METHODS: Fifty-one patients undergoing valvular operation and the maze procedure (n = 43) or repair of congenital anomalies (n = 8) combined with the maze procedure were compared with 51 patients (control group) matched for underlying diseases and procedures except for the maze operation. Each group, including 31 patients with a concomitant tricuspid annuloplasty and 12 undergoing reoperation, were similar in age, duration of arrhythmia, degree of cardiomegaly and New York Heart Association functional class. RESULTS: Patients undergoing the maze procedure had longer cardiopulmonary bypass time (213 vs. 144 min, p < 0.0001), longer cardiac arrest (134 vs. 93 min, p < 0.0001) and greater blood loss with longer respiratory care (39 vs. 18 h p = 0.021) and intensive care unit stay but no mortality. No significant differences were found in catecholamine or transfusion requirements immediately after operation. Sustained AF was much less frequent in the maze group (12% at 1 year) than the control group (86%, p < 0.0001), with an average follow-up period of 32 months (range 25 to 42). Atrial contraction was documented in 41 (80%) and 40 (78%) patients for right and left ventricular filling, respectively, after the maze procedure, resulting in a significantly smaller cardiac size and improved functional capacity. Medication was discontinued in seven patients in the maze group compared with two in the control group. CONCLUSIONS: Improved restoration of atrial rhythm and contraction with combined maze operation appeared to justify the increased operative time and complexity and postoperative care.

Atrial Fibrillation↗

PubMedDate not supplied

Procedural sedation and analgesia in the emergency department. Canadian Consensus Guidelines.

Procedural sedation and analgesia are core skills in emergency medicine. Various specialty societies have developed guidelines for procedural sedation, each reflecting the perspective of the specialty group. Emergency practitioners are most likely to embrace guidelines developed by people who understand emergency department (ED) skills, procedures, conditions, and case mix. Recognizing this, the Canadian Association of Emergency Physicians (CAEP) determined the need to establish guidelines for procedural sedation in the ED. In March, 1996, a national emergency medicine (EM) working committee, representing adult and pediatric emergency physicians, was established. This committee teleconferenced with representatives of the Canadian Anesthetic Society (CAS) to identify problems, perspectives, and controversial issues, and to define a process for guideline development. The EM committee subsequently reviewed existing literature, determined levels of evidence, and developed the document, which evolved based on feedback from the CAS and CAEP Standards Committees. The final version was approved by the CAEP Standards Committee and the CAEP Board of Directors, then submitted for peer review. These guidelines discuss the goals, definitions, and principles of ED sedation, and make recommendations for pre-sedation preparation, patient fasting, physician skills, equipment and monitoring requirements, and post-sedation care. The guidelines are aimed at non-anesthesiologists practicing part-time or full-time emergency medicine. They are applicable to ED patients receiving parenteral analgesia or sedation for painful or anxiety-provoking procedures. They are intended to increase the safety of procedural sedation in the ED.

Adult↗

PubMed1998

Cost-identification analysis of revascularization procedures on patients with peripheral arterial occlusive disease.

OBJECTIVE: To determine average total in-hospital costs of various revascularization procedures for peripheral arterial occlusive disease; to examine the effect of procedure-related complications and patient characteristics on these costs; and to examine whether costs have changed over time. METHODS: We collected cost data on all admissions involving one revascularization procedure for peripheral arterial occlusive disease at the Brigham and Women's hospital from 1990 through 1995 (n = 583). The main outcome measures were total costs per admission in 1995 US dollars and length of stay in days. RESULTS: For each of 12 different procedures identified, total costs per admission varied considerably. Multiple linear regression analysis was performed to determine the effect of local and systemic complications and of patient characteristics on total in-hospital costs per admission. The additional cost incurred for fatal systemic complications was $11,675 (P = .004) and for nonfatal systemic complications was $9345 (P < .001). The results demonstrated significant additional costs with management of critical ischemia versus intermittent claudication ($4478, P < .001), presence of coronary artery disease ($1287, P = .05), female sex ($1461, P = .03), and advanced age ($1345, P = .02). No statistically significant changes over time were demonstrated. CONCLUSION: Total in-hospital costs per admission for peripheral revascularization procedures are highly variable and significantly increased by procedure-related complications, advanced age, female sex, management of critical ischemia, and presence of coronary artery disease.

Adult↗

PubMed2000

Extracardiac conduit fontan procedure: early and intermediate results.

OBJECTIVE: The extracardiac Fontan procedure, as compared with classic atriopulmonary connections, may have the potential for optimizing ventricular and pulmonary vascular function by maximizing the laminar flow principle, by the avoidance of intra-atrial suture lines and cardiac manipulation, and by minimizing cardiopulmonary bypass time. In this study the clinical results of this procedure are assessed. METHODS: From January 1990 until January 1997, 45 patients (33 males and 12 females) with a median age of 4.0 years (range 2.7-38 years) underwent an extracardiac Fontan procedure for univentricular physiology. The underlying diagnoses included tricuspid atresia (n=19), double-inlet left ventricle (n=11), and complex anomalies (n=15). Forty patients (89%) were in sinus rhythm. The median ventricular ejection fraction was 60%. In 37 patients (82%) the procedure was staged. RESULTS: Median cardiopulmonary bypass time was 72 min, with a decrease to a median time of 24 min in the last ten patients. Aortic cross-clamping was avoided in 33 patients (73%). The intraoperative Fontan pressure and transpulmonary gradient were low: 13.6+/-3.2 and 8.5+/-3.9 mmHg, respectively. Transient supraventricular tachyarrhythmias were observed in six patients (13%). There was no early or late mortality. At a median follow-up of 64 months (range 26-105 months), 39 patients (87%) were in NYHA class I, four (9%) were in NYHA class II, and two (4%) were in class III. Forty patients (89%) remained in sinus rhythm. The median ventricular ejection fraction was 59%. The median arterial oxygen saturation raised from 82% preoperatively to 97%. Functional class (P=0.02), maintenance of sinus rhythm (P=0.04), and preservation of ventricular function (P=0.05) was superior in patients who were appropriately staged. None of the patients had atrial thrombus, chronic pleural effusions, or protein losing enteropathy. CONCLUSIONS: In the majority of patients, the extracardiac Fontan procedure, when performed as a staged procedure, provides excellent early and midterm results in terms of quality of life, maintenance of sinus rhythm, and preservation of ventricular function.

Adolescent↗

PubMed2000

Medium-term results after the modified Cox/Maze procedure combined with other cardiac surgery.

OBJECTIVE: Long-term results after the modified Cox/Maze III procedure combined with other cardiac procedure for the treatment of organic heart disease and chronic atrial fibrillation (AF) has not been clarified. This report describes our medium-term results after such operation. METHODS: Between March 1993 and August 1995, 104 consecutive patients with chronic AF underwent the modified Cox/Maze III procedure combined with other cardiac procedure. There were 100 long-term survivors. There were 45 men and 55 women, with ages ranging from 21 to 77 years (mean 59.7). Patients were followed up and changes in rhythm, need for pacemaker implantation, and the incidence of CNS (central nervous system) complications were retrospectively studied. RESULTS: The follow-up was complete in 103 patients and 99 long-term survivors (99%). The mean follow-up period was 44.6 +/- 1.1 months. In the immediate postoperative period, 73 patients regained sinus rhythm (SR group), 21 patients were in AF (AF group), and six patients underwent pacemaker implantation because of sick sinus syndrome (SSS). During the follow-up period, eight patients died. One- and 5-year survival rates (Kaplan-Meier) after surgery was 95.1 +/- 2.3 and 87.8 +/- 3.4% for the entire group. Preoperative NYHA class was 2.5 +/- 0.7 and medium-term NYHA class was 1.5 +/- 0.5. (P < 0.001) Changes in rhythm for the SR group were followed. Fifty-two patients of the SR group stayed in SR (72%), 16 patients converted back to AF (22%), and four patients had newly-developed SSS (6%) at follow-up period. Probability in SR maintenance for SR group at 1 year was 88.8 +/- 3.7% and at 5 years was 64.8 +/- 7.5%. Five patients experienced the CNS complication during the follow-up period. Two of the AF group and two of the SR group patients developed cerebral/cerebellar infarction. One of the SR group patients experienced small cerebral bleeding. CONCLUSIONS: The medium-term results after the modified Cox/Maze III procedure concomitant with other cardiac procedure are good with improved functional status and good survival rate. However, there seems to be gradual but constant attrition in the rate of SR maintenance in SR group.

Adult↗

PubMed2000

The Maze procedure: the LDS Hospital experience.

At our center we have encouraged consideration of the Maze procedure over noncurative therapies for atrial fibrillation, particularly in patients who have other indications for cardiac surgical intervention. As a result, 78 of the 99 Maze procedures we have performed since 1993 have involved combined procedures. These combined operations included procedures on 1 or more valves in 69 of 78 patients (88%). The unmodified "cut-and-sew" Maze-III technique was used in all patients. There has been no operative mortality, and the median postoperative stay has been 7 days. Cure of atrial fibrillation has been observed in 97% of patients, and pacemaker implantation was required for sick sinus syndrome in 6%. Our results favor broader use of the Maze procedure for symptomatic atrial fibrillation and support use of the original Maze-III technique as the procedure of choice.

Atrial Fibrillation↗

PubMedDate not supplied

Hospital procedure volume and teaching status do not influence treatment and outcome measures of rectal cancer surgery in a large general population.

A clear benefit of increased hospital procedure volume or teaching hospital status on outcomes of rectal cancer surgery has yet to be shown. Few have examined treatment differences that may lead to varying outcomes. This study assessed the impact of hospital procedure volume and teaching status on both treatment and outcome measures of rectal cancer surgery in a large general population. Data were obtained for 1072 incident cases of rectal adenocarcinoma diagnosed in 1990 from Ontario, Canada, and treated with a major resection. Hospitals were classified by teaching status and procedure volume. Pathology reports were examined for 418 procedures. Abdominoperineal resections accounted for 31.0% of all procedures. There were no clinically significant differences in treatment measures, operative mortality, and long-term survival among the hospital groups according to both univariate and multivariate analyses. In conclusion, the absence of a hospital volume or teaching status effect on treatment and outcome measures suggests that for rectal cancer surgery in Ontario, centralization of procedures into high-volume or teaching centers is unlikely to improve surgical quality.

Adenocarcinoma↗

PubMedDate not supplied

Laparoscopic cholecystectomy as a "true" outpatient procedure: initial experience in 130 consecutive patients.

Laparoscopic cholecystectomy has received nearly universal acceptance and is currently considered the "gold standard" for the treatment of cholelithiasis. Many centers have employed "short-stay" units or "23-hour admissions" for postoperative observation following laparoscopic cholecystectomy. The practice of early discharge as "true" outpatients following this procedure has not been well defined. A retrospective analysis of 130 consecutive patients undergoing laparoscopic cholecystectomy in an outpatient surgery unit was performed. A follow-up telephone survey was carried out of patients who successfully completed the procedure as outpatients. One hundred thirty patients underwent outpatient laparoscopic cholecystectomy. The patient population consisted of 78% women, with an age range of 17 to 76 years (mean age 47.1 years). Symptomatic gallstone disease was the indication for laparoscopic cholecystectomy in 92% of the patients. All patients underwent successful completion of laparoscopic cholecystectomy with no conversions to an open procedure. The mean length of operation was 75 +/- 23 minutes (range 25 to 147 minutes). The mean length of stay in the postanesthesia care unit (PACU) ranged from 95 to 460 minutes with a mean length of stay of 200 +/- 79 minutes. A total of eight patients (6.2%) were admitted to the hospital directly from the PACU in the immediate postoperative period. Six of these eight patients were discharged on the first postoperative day. Following discharge from the PACU, an additional six patients (4.6%) required hospital admission. Three of these six patients were discharged after a single day of hospitalization. Ninety-eight of 116 eligible patients were available for follow-up telephone evaluation. The outpatient experience was rated as good by 75.5% of the patients, fair by 22.5%, and poor by 2%. In retrospect, 20.4% of the patients stated that they would have preferred an inpatient to an outpatient procedure. Laparoscopic cholecystectomy can be performed as a true outpatient procedure with patients discharged to home within hours of completion of the procedure. Less than 10% of patients will fail this protocol and another 5% of the patients may require hospitalization after returning to their homes.

Adolescent↗

PubMed2004

The Warden procedure for partially anomalous pulmonary venous connection to the superior caval vein.

PURPOSE: When there is partially anomalous pulmonary venous connection to the superior caval vein, intracardiac repair alone can result in obstruction. Although the Warden procedure involving translocation of the superior caval vein is commonly performed as an alternative to atriocavoplasty, follow-up of a larger number of patients in the modern era is lacking. We report and discuss the experience of a single institution with the Warden procedure for correction of partially anomalous pulmonary venous connection to the superior caval vein. METHODS: Since 1995, all 16 patients presenting with partially anomalous pulmonary venous connection to the superior caval vein underwent the Warden procedure at a mean age of 7.1 +/- 4.2 years, with a range from 0.2 to 14.3 years, and a mean weight of 24.7 +/- 14.0 kg, with a range from 4.1 to 52.9 kg. There were 9 males and 7 females. In 8 patients, we performed 10 concomitant procedures, including closure of an atrial or ventricular septal defect in 7, and advancement of the aortic arch in the other. RESULTS: There were no deaths, and only one episode of postoperative sinus bradycardia with intermittent junctional rhythm, which resolved spontaneously during temporary atrial pacing. All patients were discharged home in normal sinus rhythm at an average of 4.1 +/- 2.2 days after the procedure, with a range from 2 to 10 days. All are currently in the first grade of the New York Heart Association up to 5.6 years postoperatively. There is currently no evidence of sinus nodal dysfunction, nor obstruction of the superior caval vein, in any patient. CONCLUSION: The Warden procedure for partially anomalous pulmonary venous connection to the superior caval vein produces excellent results, preserves the function of the sinus node, and should be routinely considered for the repair of this lesion.

Adolescent↗

PubMed2003

The use of general anesthesia for the tension-free vaginal tape procedure and concomitant surgery.

BACKGROUND: To study the efficacy of performing the TVT procedure and concomitant surgery under general anesthesia in the management of urinary stress incontinent patients. METHODS: Eighty-six women with genuine stress incontinence without pelvic relaxation syndrome were surgically managed. TVT procedures were performed using vigorous manual pressure against the abdominal wall to position and adjust the vaginal tape and ensuring no lifting of the urethra by intraoperative introital ultrasonography. Concurrent gynecologic procedures were performed, if indicated. The urodynamic studies, 1-h pad-tests and introital ultrasonography were performed preoperative and 1 year after surgery. RESULT: Six women were excluded for various reasons. Among 80 patients, 74 (92.5%) were cured, five improved and one failed. No major intra-or postoperative complications occurred. After surgery, urine leakage observed on the pad-tests was significantly reduced from a mean of 24 to 1.3 g. The operating time for the TVT procedure was 23 min, and postoperative hospital stay was 2.8 days. The position and mobility of the bladder neck showed no significant difference before and after surgery. De nova detrusor instability was observed in one patient. Spontaneous voiding with adequate volume of post-void residual urine was noted for all patients by the fourth day postoperatively. Urodynamic parameters related to the voiding dysfunction showed no significant difference pre- and postoperatively. CONCLUSION: With modifications of the technique and the aid of intraoperative ultrasonography, the TVT procedure can be performed under general anesthesia. The procedure is safe, effective, minimally invasive, and has an additional benefit of correcting various coexisting gynecologic disorders in a single operation.

Adult↗

PubMed2003

Tension-free vaginal tape procedure on genuine stress incontinent women with coexisting genital prolapse.

OBJECTIVE: To study the efficacy of performing the tension-free vaginal tape (TVT) procedure concurrently with vaginal pelvic relaxation surgeries in the management of genuine stress incontinence with genital prolapse. MATERIALS AND METHODS: Fifty-eight women were surgically managed. Various vaginal pelvic reconstructive surgeries for prolapses were completed before the TVT procedure. Pre-operative and postoperative urodynamic studies, 1-h pad tests and symptom analysis were evaluated 1 year postoperatively. Surgical procedures and patient outcomes are discussed. RESULTS: Objective data available for 55 patients. Fifty (91%) were dry 1 year postoperatively. The concurrent pelvic surgeries included vaginal total hysterectomies, anterior colporrhaphies, posterior colporrhaphies and sacrospinous ligament fixations. No major surgical complications occurred. The average blood loss was 134 ml, the average operating time for the TVT procedure was 21 min, and the average postoperative hospital stay was 3.4 days. All patients voided spontaneously with adequate volumes of postvoid residual urine before being discharged. Two patients had a recurrent prolapse. Urodynamic parameters showed no significant differences before and after the surgery, except that the parameters related to voiding dysfunction were improved in the patients with severe cystocele. De nova detrusor instability was observed in one patient. CONCLUSIONS: The tension-free vaginal tape procedure performed with concurrent vaginal pelvic relaxation surgery is safe and effective for genuine stress incontinence and pelvic prolapse. Concomitant procedures also appear to relieve bladder outlet obstructions caused by severe prolapse.

Adult↗

PubMed2002

Comparison of cost and outcome of endovascular and neurosurgical procedures in the treatment of ruptured intracranial aneurysms.

Endovascular techniques for the treatment of intracranial aneurysms have gained rapid acceptance in some countries as an alternative to conventional neurosurgical treatment. The International Subarachnoid Aneurysm Trial (ISAT) is the first multicentre prospective randomized trial comparing neurosurgery with endovascular coil (Guglielmi detachable coil) treatment of acute subarachnoid haemorrhage. The cost and outcome of endovascular procedures was compared with neurosurgical procedures in the treatment of ruptured intracranial aneurysms within the context of the ISAT. Two groups of patients (Endovascular group with 10 patients and the Neurosurgical group with 12 patients) were drawn from admissions to Royal Perth Hospital and Sir Charles Gairdner Hospital, Perth, Western Australia, as detailed in the ISAT trial protocol. Data were collected in the following categories: patient, procedure, hospitalization, morbidity and mortality. While the endovascular procedure tended to be the more expensive in terms of the cost of consumables, this expense was more than compensated by savings in staffing costs, and the period and cost of hospitalization. Following an endovascular procedure, patients tended to return to normal activity or paid employment sooner and have a favourable functional outcome compared with patients following a neurosurgical procedure.

Aneurysm, Ruptured↗

PubMed1998

A questionnaire-based outcome analysis of the Stamey bladder neck suspension procedure for the treatment of urinary stress incontinence: the Hannover experience.

OBJECTIVES: To evaluate the long-term continence rate, including subjective satisfaction and therapy-associated morbidity, of patients undergoing Stamey bladder neck suspension. PATIENTS AND METHODS: Eighty-five women (median age 55 years, range 30-85) with urinary stress incontinence treated by Stamey bladder neck suspension at our institution between 1987 and 1995 were evaluated using an anonymous questionnaire over a mean (range) follow-up of 61 (13-93) months. RESULTS: Of the 85 patients, 44 (52%) reported an improvement in clinical symptoms at the evaluation and 29 (34%) were completely continent after the Stamey procedure. However, 53 (62%) patients reported subjective satisfaction with the result, because they had a durable improvement in continence for a mean (range) of 44 (10-79) months. There was no correlation between the number of previous urogynaecological operations undergone by the patients and the success of the Stamey procedure. However, the frequency of complications other than urinary retention was significant during and after surgery, at 27%, and in accord with the complication rate reported in earlier studies. CONCLUSIONS: Compared with other bladder neck suspension procedures, e.g. Burch colposuspension, the Stamey procedure appears to be associated with a higher frequency of postoperative recurrent urinary stress incontinence. Therefore, the Stamey procedure should only be used if the patient demands a minimally invasive surgical procedure for bladder neck suspension. Although approximately equal to 60% of patients were satisfied with the durable improvement in clinical symptoms, it is appropriate to inform patients before surgery of the high recurrence rate after Stamey bladder neck suspension.

Adult↗

PubMed2002

Ethics of practicing medical procedures on newly dead and nearly dead patients.

OBJECTIVE: To examine the ethical issues raised by physicians performing, for skill development, medically nonindicated invasive medical procedures on newly dead and dying patients. DESIGN: Literature review; issue analysis employing current normative ethical obligations, and evaluation against moral rules and utilitarian assessments manifest in other common perimortem practices. RESULTS: Practicing medical procedures for training purposes is not uncommon among physicians in training. However, empiric information is limited or absent evaluating the effects of this practice on physician competence and ethics, assessing public attitudes toward practicing medical procedures and requirements for consent, and discerning the effects of a consent requirement on physicians' clinical competence. Despite these informational gaps, there is an obligation to secure consent for training activities on newly and nearly dead patients based on contemporary norms for informed consent and family respect. Paradigms of consent-dependent societal benefits elsewhere in health care support our determination that the benefits from physicians practicing procedures does not justify setting aside the informed consent requirement. CONCLUSION: Current ethical norms do not support the practice of using newly and nearly dead patients for training in invasive medical procedures absent prior consent by the patient or contemporaneous surrogate consent. Performing an appropriately consented training procedure is ethically acceptable when done under competent supervision and with appropriate professional decorum. The ethics of training on the newly and nearly dead remains an insufficiently examined area of medical training.

Attitude to Death↗

PubMedDate not supplied

Partial left ventriculectomy (Batista's Procedure) case report: 40 months follow-up.

OBJECTIVE: Partial left ventriculectomy (PLV) (also known as Batista's Procedure) is a surgical procedure for treatment of dilated cardiomyopathy when cardiac transplant is contraindicated. Mitral valve replacement is needed because of mitral regurgitation as a consequence of annulus enlargement and papillary muscle resection. Bleeding and arrythmias are the main complications. METHODS: We considered for this operation a 60-year-old male patient. He suffered from valvular dilating cardiomyopathy as a consequence of mitral and aortic valve regurgitation. Furthermore, a severe peripheral vascular disease treated with aortic-bifemoral prosthesis contraindicated heart transplantation. He needed frequent hospital admissions for pulmonary edema and his quality of life was very poor. Batista's procedure was performed in March 1998, successfully. Mitral and aortic valves were replaced by use of mechanical prosthesis. The postoperative period was characterized by early weaning from ventilator and drugs; atrial fibrillation, reversed by Amiodaron; a little bilateral pleural effusion; and pacemaker implantation following advanced heart conduction block. No bleeding episodes were observed. In March 2001 the progression of the vascular disease forced the patient to undergo to a femoro-femoral bypass and endoarterectomy of the right branch of the vascular prothesis. The patient tolerated the procedure very well. He had no complications during the postoperative period with early weaning from ventilator and drugs. RESULTS: At the end of the procedure ejection fraction raised from 15% to 30%. Echocardiographic data demonstrated a slow but progressive improvement of the cardiac diameters and volumes with a preserved left ventricular function. CONCLUSION: Even if a larger number of cases and longer follow-up are necessary, our report demonstrated that Batista's procedure should be considered as a surgical alternative to heart transplantation, in well-selected patients with absolute contraindication to heart transplantation and left ventricular assist device implantation.

Cardiac Surgical Procedures↗

PubMed2005

Anesthetic care during modified fontan procedure without cardiopulmonary bypass.

OBJECTIVE: The purpose of this study was to report the anesthetic care of patients during performance of a Fontan procedure without cardiopulmonary bypass (CPB). DESIGN: Retrospective chart review. SETTING: Operating room of a university hospital. PARTICIPANTS: Seven pediatric-patients undergoing inferior vena cava (IVC)-to-pulmonary artery (PA) anastomosis for completion of the Fontan procedure. INTERVENTIONS: Charts were reviewed for anesthetic technique, hemodynamic and ventilatory changes occurring during the procedure, and anesthetic interventions that were provided. MEASUREMENTS AND MAIN RESULTS: The off-bypass Fontan procedure was attempted in 7 patients (age: 26 months-7 years, weight: 13 to 28 kg). Exposure of the PA was not feasible in 1 patient because of a markedly enlarged right atrium. In the remaining 6 patients, before cross-clamping of the PA to allow for the proximal anastomosis between the PA and the conduit, alkalosis (pH > or =7.5) was maintained by the administration of sodium bicarbonate. After PA cross-clamping, fluid administration was necessary in 5 patients and dopamine (3-7 microg/kg/min) was necessary in 4 patients. The minute ventilation was increased by 18 +/- 7% to maintain baseline PaCO2 values. Before the placement of the PA cross-clamp, the end-tidal PaCO2 difference was 7 +/- 4 mmHg and the transcutaneous (TC)-PaCO2 difference was 3 +/- 2 mmHg. The end-tidal PaCO2 difference increased to 14 +/- 6 mmHg during cross-clamping of the PA, whereas no change was noted in the TC-PaCO2 difference. Once the proximal anastomosis was completed, a bridge was placed to redirect blood from the IVC to the right atrium while the IVC was clamped and attached to the distal end of the conduit. After placement of the distal end of the bridge into the IVC, fluid administration to maintain the blood pressure was necessary in 3 patients. In 1 patient, 20 minutes after placement of the bridge, the authors noted a progressive increase in the central venous pressure reading measured from the left femoral vein and the need for the administration of volume to maintain the mean arterial pressure. Examination of the bridge revealed occlusion with thrombus despite an activated coagulation time value of 250 to 300 seconds. The tracheas of 3 of the 6 patients were extubated in the operating room, whereas the other 3 were extubated in the pediatric intensive care unit within 4 hours of completion of the procedure. The 1 patient who required the use of CPB required reintubation and had a protracted intensive care unit course. The other 6 patients were discharged home on postoperative days 7 to 12. CONCLUSIONS: With alteration of the anesthetic technique, the Fontan procedure can be performed in selected patients without the need for CPB.

Anesthetics↗