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Resumenes de la semana del 13 al 19 de Junio,2002-06-12 The Prevention of Emesis in Plastic Surgery: A Randomized, Prospective Study Jeffrey R. Marcus, M.D.; Julius W. Few, M.D.; Jerome D. Chao, M.D.; Neil A. Fine, M.D.; Thomas A. Mustoe, M.D. Chicago, Ill. From the Division of Plastic and Reconstructive Surgery, Northwestern University Medical School. Presented at the 45th Annual Meeting of the Plastic Surgery Research Council, in Seattle, Washington, in May of 2000; and at the 69th Annual Meeting of the American Society of Plastic Surgeons, in Los Angeles, California, October 14 through 18, 2000. PLASTIC AND RECONSTRUCTIVE SURGERY 2002;109:2487-2494 Perhaps the most unpleasant experience following outpatient plastic surgery procedures is postoperative nausea and vomiting. Postoperative nausea and vomiting often results in delayed recovery time and unintended admission, and it can be a contributing factor to the formation of hematoma following rhytidectomy. Ondansetron (Zofran) has proven benefit in preventing postoperative nausea and vomiting if given before general anesthesia in a variety of surgical procedures. Its utility in cases performed under conscious sedation has not been determined. The purpose of this study was (1) to test the ability of prophylactic ondansetron to prevent postoperative nausea and vomiting in plastic surgery cases performed under conscious sedation, and (2) to determine relative risk factors for postoperative nausea and vomiting and a selection policy for the administration of antiemetic prophylaxis. This was a prospective, randomized, double-blind study. One hundred twenty patients were enrolled after giving informed consent. Patients received a single dose of either placebo or ondansetron (4 mg intravenously) before administration of sedation. Sedation administration followed a standardized institutional protocol, using midazolam and fentanyl. Data were recorded from a series of three questionnaires: preoperatively, immediately postoperatively, and at the time of the first office return. Data were confirmed by means of telephone interview, chart analysis, and nursing documentation. Multivariate analysis was conducted. Nausea and emesis occurred with an overall frequency of 33 percent and 22 percent, respectively. Postoperative nausea and vomiting was associated with statistically longer recovery periods. The incidence of emesis was statistically higher among women, among those undergoing facial rejuvenation, and among those with a history of opioid-induced emesis or postoperative nausea and vomiting following a previous operation (p < 0.05). The incidence of postoperative nausea and vomiting paralleled increases in case duration; the incidence of emesis was zero in cases less than 90 minutes in duration. Ondansetron significantly reduced the incidence of emesis overall (placebo, 30 percent; ondansetron, 13 percent; p < 0.05). Postoperative perception of nausea was significantly lower among those who had received ondansetron (p < 0.05). These results confirm the efficacy of ondansetron for the prevention of postoperative nausea and vomiting in plastic surgery cases under conscious sedation. In those who are at increased risk, prophylaxis should be considered. Such risks include female gender, facial rejuvenation procedures, and a patient history of opioid-induced emesis or postoperative nausea and vomiting following a prior operation. The zero incidence of emesis in cases less than 90 minutes does not support the routine use of prophylaxis in such cases. Patient satisfaction in plastic surgery is derived from the overall subjective experience of the event as much as by the final result. By remaining attentive to patient concerns and optimizing perioperative care, we can improve the subjective experience for our patients. Perioperative risk factors for posterior ischemic optic neuropathy 1 Stephan Dunker a, Hugo Y. Hsu a, Jerry Sebag a and Alfredo A. Sadun aA Los Angeles, CA 90033 USA[a]Doheny Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA USA A Correspondence address: Alfredo A Sadun, MD, PhD, Doheny Eye Institute, 1450 San Pablo St, Manuscript received 1 November 2001 Revised 29 January 2002 Accepted 30 January 2002; Journal of the American College of Surgeons Volume 194Issue6 (June 2002)Pages705-710 Background: Infarction of the optic nerve posterior to the lamina cribrosa, called posterior ischemic optic neuropathy (PION), is a condition that can result in profound bilateral blindness. Cases of PION treated at this institution and those described in the literature were analyzed to identify clinical features that profile those individuals at risk of PION in an attempt to identify major contributing factors that could be addressed prophylactically to enable effective prevention. Study Design: Salient clinical features in seven cases of PION diagnosed at the Doheny Eye Institute between 1989 and 1998 are compared with 46 cases of PION reported in the literature. Results: In the Doheny series there were six men and one woman aged 12 to 66 years (mean, 47 years). Five patients were status-post spine surgery, one was status-post knee surgery, and one had a bleeding stomach ulcer. Vision loss was simultaneously bilateral in six of seven patients (85.7%) and was apparent immediately after surgery. There were no abnormal retinal or choroidal findings including diabetic retinopathy, in any of the patients. Notable contributing factors were blood loss in all seven patients, ranging from 2,000 to 16,000 mL, with a drop in hematocrit of 9.5% to 19% (mean, 14%), and intraoperative systemic hypotension in all patients. Facial edema was a factor in three of six spine surgery patients (50%). Patients reported in the literature had a mean age of 50 years and were also predominantly men (34 of 46, 74%) who underwent spine surgery (30 of 46, 65.2%). Conclusions: Middle-aged men undergoing spine surgery with prolonged intraoperative hypotension and postoperative anemia and facial swelling are at risk of developing PION from hypovolemic hypotension. Avoiding or immediately correcting these contributory factors can reduce the incidence of PION. Predictors of mortality in adult trauma patients: the Physiologic Trauma Score is equivalent to the Trauma and Injury Severity Score 1 Abstract presented at the American College of Surgeons 86th Annual Clinical Congress, Surgical Forum, Chicago, IL, October 2000. Deborah A. Kuhls a, Debra L. Malone a,b a,b, Robert J. McCarter d and Lena M. Napolitano b,c b,cA Baltimore, MD 21201 USA[a]Department of Surgery, University of Nevada School of Medicine, Las Vegas, Nevada (Kuhls) USA[b]The R Adams Cowley Shock Trauma Center (Malone, Napolitano), University of Maryland School of Medicine, Baltimore, MD USA[c]Department of Surgery (Malone, Napolitano), University of Maryland School of Medicine, Baltimore, MD USA[d]Department of Epidemiology (McCarter), University of Maryland School of Medicine, Baltimore, MD USA A Correspondence address: Lena M Napolitano, MD, Department of Surgery, University of Maryland School of Medicine, 10 North Greene St, Manuscript received 8 March 2001 Revised 14 December 2001 Accepted 12 February 2002; Journal of the American College of Surgeons 194Issue6 (June 2002 ) Pages 695-704 Background: Several statistical models (Trauma and Injury Severity Score [TRISS], New Injury Severity Score [NISS], and the International Classification of Disease, Ninth Revision-based Injury Severity Score [ICISS]) have been developed over the recent decades in an attempt to accurately predict outcomes in trauma patients. The anatomic portion of these models makes them difficult to use when performing a rapid initial trauma assessment. We sought to determine if a Physiologic Trauma Score, using the systemic inflammatory response syndrome (SIRS) score in combination with other commonly used indices, could accurately predict mortality in trauma. Study Design: Prospective data were analyzed in 9,539 trauma patients evaluated at a Level I Trauma Center over a 30month period (January 1997 to July 1999). A SIRS score (1 to 4) was calculated on admission (1 point for each: temperature >38°C or <36°C, heart rate >90 beats per minute, respiratory rate >20 breaths per minute, neutrophil count > 12,000 or < 4,000. SIRS score, Injury Severity Score (ISS), Revised Trauma Score (RTS), TRISS, Glasgow Coma Score, age, gender, and race were used in logistic regression models to predict trauma patients' risk of death. The area under the receiver-operating characteristic curves of sensitivity versus 1-specificity was used to assess the predictive ability of the models. Results: The study cohort of 9,539 trauma patients (of which 7,602 patients had complete data for trauma score calculations) had a mean ISS of 9 ± 9 (SD) and mean age of 37 ± 17 years. SIRS (SIRS score 2) was present in 2,165 of 7,602 patients (28.5%). In single-variable models, TRISS and ISS were most predictive of outcomes. A multiple-variable model, Physiologic Trauma Score combining SIRS score with Glasgow Coma Score and age (Hosmer-Lemenshow CHI-SQUARE = 4.74) was similar to TRISS and superior to ISS in predicting mortality. The addition of ISS to this model did not significantly improve its predictive ability. Conclusions: A new statistical model (Physiologic Trauma Score), including only physiologic variables (admission SIRS score combined with Glasgow Coma Score and age) and easily calculated at the patient bedside, accurately predicts mortality in trauma patients. The predictive ability of this model is comparable to other complex models that use both anatomic and physiologic data (TRISS, ISS, and ICISS). Der Anaesthesist Volume 51 Issue 6 (2002) pp 457-462 Does intraoperative hyperventilation improve neurological functions of older patients after general anaesthesia? U. Linstedt (1), O. Meyer (1), A. Berkau (2), P. Kropp (3), M. Zenz (1), C. Maier (4) (1) Klinik für Anästhesiologie, Intensiv- und Schmerztherapie, BG Kliniken Bergmannsheil, Ruhr-Universität Bochum (2) Klinik für Anästhesiologie und Intensivmedizin, Christian-Albrechts-Universität zu Kiel (3) Institut für Medizinische Psychologie, Christian-Albrechts-Universität zu Kiel (4) Abteilung für Schmerztherapie, BG Kliniken Bergmannsheil, Ruhr-Universität Bochum Summary. The purpose of the study was to investigate the effect of intraoperative hyperventilation on postoperative cognitive functions. Methods. A total of 120 patients (60 older and 60 younger than 65 years old) were allocated randomly to group I "hyperventilation" (petCO2=30 mmHg) or group II "normoventilation" (petCO2 =45 mmHg). Before the operation and on days 1, 3 and 6 after the operation, a battery of neuropsychological tests was performed (concentration endurance test d2, number connection test, digit symbol test). A decline of 20% in at least one test was regarded as postoperative cognitive deficit (POCD). Anaesthesia was maintained with isoflurane in nitrous oxide/oxygen supplemented with fentanyl. Results. In all patients pooled, POCD was present in 26 patients (22%). In patients older than 65 years, POCD was present in 3 cases after hyperventilation and 13 cases after normoventilation (p <0.01). In younger subjects, 5 cases of POCD were diagnosed in each ventilation group. Furthermore, POCD was more severely pronounced in older patients after normoventilation. Conclusion. In older patients, POCD occurred more frequently after intraoperative normoventilation. We assume that a reduced amount of noxious substances reach the brain after hyperventilation, because hyperventilation reduces the cerebral blood flow. Keywords Intraoperative hyperventilation · Older patients · POCD · Postoperative cognitive deficit BMJ 2002;324:1386-1389 ( 8 June ) Education and debate Quality improvement report Effect of a scoring system and protocol for sedation on duration of patients' need for ventilator support in a surgical intensive care unit Guttorm Brattebø, consultant anaesthetist a, Dag Hofoss, professor b, Hans Flaatten, consultant anaesthetist a , Anne Kristine Muri, registered nurse a, Stig Gjerde, consultant anaesthetist a, Paul E Plsek, consultant c. a Department of Anaesthesia and Intensive Care, Haukeland University Hospital, N-5021 Bergen, Norway, b HELTEF, Foundation for Health Services Research, PO Box 55, N-1474 Nordbyhagen, Norway, c Paul E Plsek & Associates, 1005 Allenbrook Lane, Roswell, GA 30075, USA Correspondence to: G Brattebø [email protected] Abstract Problem: Need for improved sedation strategy for adults receiving ventilator support. Design: Observational study of effect of introduction of guidelines to improve the doctors' and nurses' performance. The project was a prospective improvement and was part of a national quality improvement collaborative. Background and setting: A general mixed surgical intensive care unit in a university hospital; all doctors and nurses in the unit; all adult patients (>18 years) treated by intermittent positive pressure ventilation for more than 24 hours. Key measures for improvement: Reduction in patients' mean time on a ventilator and length of stay in intensive care over a period of 11 months; anonymous reporting of critical incidents; staff perceptions of ease and of consequences of changes. Strategies for change: Multiple measures (protocol development, educational presentations, written guidelines, posters, flyers, emails, personal discussions, and continuous feedback) were tested, rapidly assessed, and adopted if beneficial. Effects of change: Mean ventilator time decreased by 2.1 days (95% confidence interval 0.7 to 3.6 days) from 7.4 days before intervention to 5.3 days after. Mean stay decreased by 1.0 day (-0.9 to 2.9 days) from 9.3 days to 8.3 days. No accidental extubations or other incidents were identified. Lessons learnt: Relatively simple changes in sedation practice had significant effects on length of ventilator support. The change process was well received by the staff and increased their interest in identifying other areas for improvement. Acta Anaesthesiologica Scandinavica Volume 46 Issue 6 Page 625 - July 2002 Small-volume resuscitation: from experimental evidence to clinical routine. Advantages and disadvantages of hypertonic solutionsU. Kreimeier1,2 and K. Messmer2 Background: The concept of small-volume resuscitatioin (SVR) using hypertonic solutions encompasses the rapid infusion of a small dose (4 ml per kg body weight, i.e. approximately 250 ml in an adult patient) of 7.2-7.5% NaCl/colloid solution. Originally, SVR was aimed for initial therapy of severe hypovolemia and shock associated with trauma. Methods: The present review focusses on the findings concerning the working mechanisms responsible for the rapid onset of the circulatory effect, the impact of the colloid component on microcirculatory resuscitation, and describes the indications for its application in the preclinical scenario as well as perioperatively and in intensive care medicine. Results: With respect to the actual data base of clinical trials SVR seems to be superior to conventional volume therapy with regard to faster normalization of microvascular perfusion during shock phases and early resumption of organ function. Particularly patients with head trauma in association with systemic hypotension appear to benefit. Besides, potential indications for this concept include cardiac and cardiovascular surgery (attenuation of reperfusion injury during declamping phase) and burn injury. The review also describes disadvantaages and potential adverse effects of SVR: Conclusion: Small-volume resuscitation by means of hypertonic NaCl/colloid solutions stands for one of the most innovative concepts for primary resuscitation from trauma and shock established in the past decade. Today the spectrum of potential indications envolves not only prehospital trauma care, but also perioperative and intensive care therapy. Acta Anaesthesiologica Scandinavica Volume 46 Issue 6 Page 674 - July 2002 Improved long-lasting postoperative analgesia, recovery function and patient satisfaction after inguinal hernia repair with inguinal field block compared with general anesthesiaV. Aasbø1, A. Thuen2 and J. Ræder3 Background: Inguinal hernia repair is a common surgical procedure, and different types of anesthetic techniques are in use. We wanted to test if preoperative inguinal field block (IFB) with ropivacaine would provide benefits in the postoperative period compared with general anesthesia and wound infiltration. Methods: Sixty patients scheduled for inguinal hernia repair were randomized to receive general anesthesia with wound infiltration postoperatively, or inguinal field block (IFB) before surgery, with no or only light sedation intraoperatively. General anesthesia was induced with midazolam, fentanyl and propofol, maintained with propofol and alfentanil, and supplemented with nitrous oxide in oxygen through a laryngeal mask. The IFB was performed by an anesthesiologist, with 50-60ml ropivacaine and 5mg/ml with a dedicated technique. Results: All significant differences were in favor of the IFB group: less pain (visual analog scale, verbal pain score) postoperatively and until day 7, faster mobilization with less pain, lower analgesic consumption, and higher patient satisfaction. Conclusion: Preoperative inguinal field block for hernia repair provides benefits for patients in terms of faster recovery, less pain, better mobilization and higher satisfaction throughout the whole first postoperative week. Paediatric Anaesthesia Volume 12 Issue 5 Page 411 - June 2002 Airway management in spontaneously breathing anaesthetized children: comparison of the Laryngeal Mask Airway with the cuffed oropharyngeal airwayBIRUTA MAMAYA Background: The efficacy and safety of the smallest size of the cuffed oropharyngeal airway (COPA) for school age, spontaneously breathing children was investigated and compared with the Laryngeal Mask Airway (LMA ). Methods:Seventy children of school age (7-16years) were divided into two groups: the COPA (n=35) and the LMA (n =35). Induction was with propofol i.v. or halothane, nitrous oxide, oxygen and fentanyl. After depression of laryngopharyngeal reflexes, a COPA size 8 cm or an LMA was inserted. Ventilation was manually assisted until spontaneous breathing was established. For maintenance, propofol i.v. and fentanyl or halothane with nitrous oxide were used. Local anaesthesia or peripheral blocks were also used. Results: Both extratracheal airways had a highly successful insertion rate, but more positional manoeuvres to achieve a satisfactory airway were required with the COPA, 28.6 versus LMA 2.9 . The need to change the method of airway management was higher (8.6 ) in the COPA group. After induction, the need for assisted ventilation was higher in the LMA group 54.3 versus 20 in the COPA group. Airway reaction to cuff inflation was higher in the LMA group 14.3 versus COPA 5.7 . Problems during surgery were similar, except continuous chin support to establish an effective airway was more frequent (11.4 ) in the COPA group. In the postoperative period, blood on the device and incidence of sore throat were detected less in the COPA group. Conclusions: The COPA is a good extratracheal airway that provides new possibilities for airway management in school age children with an adequate and well sealed airway, during spontaneous breathing or during short-term assisted manual ventilation. Paediatric Anaesthesia Volume 12 Issue 5 Page 438 - June 2002 The reliability of endtidal CO2 in spontaneously breathing children during anaesthesia with Laryngeal Mask AirwayTM, low flow, sevoflurane and caudal epiduralPer AASHEIM MD, SIGURD FASTING MD, Ulf MOSTAD MD & PETTER AADAHL MD, PhD Background: Noninvasive devices for monitoring endtidal CO2 (PECO2 ) are in common use in paediatric anaesthesia. Questions have been raised concerning the reliability of these devices in spontaneous breathing children during surgery. Our anaesthetic technique for elective infraumbilical surgery consists of spontaneous breathing through a Laryngeal Mask Airway (LMATM), low fresh gas flow, sevoflurane and a caudal epidural. We wanted to compare PECO2 and arterial CO2 (PaCO2) during surgery. Methods: Twenty children, aged 1-6years, scheduled for infraumbilical surgery, were studied and one arterial sample was taken 45min after induction of anaesthesia. PECO2, inspiratory PCO2 , oxygen saturation, heart rate, respiratory rate, mean arterial blood pressure and expiratory sevoflurane concentration were measured every 5min. The respiratory and circulatory parameters were stable during surgery. Results: The mean PaCO2 -PECO2 difference was 0.15 (0.16)kPa [1.1 (1.2mmHg)]. Conclusions: PECO2 is a good indicator of PaCO2 in our anaesthetic setting. Successful determination of lower inflection point and maximal compliance in a population of patients with acute respiratory distress syndrome* Nicholas S. Ward, MD ; Dennis Y. Lin, MD; David L. Nelson, BA; Jeane Houtchens, MS; William A. Schwartz, BA, RRT; James R. Klinger, MD; Nicholas S. Hill, MD; Mitchell M. Levy, MD From Brown University School of Medicine, Division of Pulmonary and Critical Care Medicine, Rhode Island Hospital, Providence, RI. CRITICAL CARE MEDICINE 2002;30:963-968 Objective: To compare the ease and efficacy of two commonly used methods for choosing optimal positive endexpiratory pressure (PEEP) in patients with acute respiratory distress syndrome: a static pressure-volume curve to determine the lower inflection point (Pflex) and the “best PEEP” (PEEPbest) as determined by the maximal compliance curve. Design: Prospective study. Setting: Medical and respiratory intensive care units of university-associated tertiary care hospital. Patients: Twenty-eight patients on mechanical ventilation with acute respiratory distress syndrome. Interventions: A critical care attending physician or fellow and an experienced respiratory therapist attempted to obtain both static pressure-volume curves and maximal compliance curves on 28 patients with acute respiratory distress syndrome by using established methods that were practical to everyday use. The curves then were used to determine both Pflex and PEEPbest, and the results were compared. Measurement and Main results: Our results showed at least one value for optimal PEEP was obtained in 26 of 28 patients (93%). Pflex was determined in 19 (68%), a PEEPbest in 24 (86%), and both values in 17 (61%). In patients who had both Pflex and PEEPbest determined, there was a close concordance (±3 cm H2O) in 60%. When the values of Pflex and PEEPbest were interpreted by two additional investigators, there was unanimous agreement on the Pflex (±3) only 64% of the time. There was agreement on the value of PEEPbest 93% of the time. Conclusions: Our data show that optimal PEEP, as determined by a pressure-volume curve and a maximal compliance curve, are sometimes unobtainable by practical means but, when obtained, often correspond. A maximal compliance is more often identified, has less interobserver variability, and poses less risk to the patient. We conclude that determining optimal PEEP by maximal static compliance may be easier to measure and more frequently obtained at the bedside than by using a static pressure-volume curve. Key Words: positive end-expiratory pressure; acute respiratory distress syndrome; mechanical ventilation; pressure-volume curves; optimal positive end-expiratory pressure; lower inflection point; static compliance