American journal of surgery
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Comparative Study
Tomographic findings are not always predictive of failed nonoperative management in blunt hepatic injury.
Nonoperative management (NOM) has become the standard treatment of blunt hepatic injury (BHI) for stable patients. Contrast extravasation (CE) on computed tomography (CT) scan had been reported as a sign that is associated with NOM failure. The goal of this study was to further investigate the risk factors of NOM failure in patients with CE on CT scan. ⋯ Higher injury severity score, more blood transfusion, and higher grade of liver injury are factors that correlate with NOM failure in patients with BHI. Contrast leakage into the peritoneum is not always a definite sign of NOM failure in BHI. Early and aggressive angioembolization is an effective adjunct of NOM in BHI patients, even with contrast leakage into peritoneum.
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Changes in surgical training have decreased opportunities for experiential learning in the operating room (OR). With this decrease, a commensurate increase in debriefing-dependent simulation-based activities has occurred. Effective debriefing could optimize learning from both simulated and real clinical encounters. ⋯ A need exists to enhance surgical training through regular structured debriefing. Identifying the key components of an effective debrief is a first step toward improving practice and embedding a debriefing culture within the OR.
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Comparative Study
Tale of two sites: capillary versus arterial blood glucose testing in the operating room.
Pre- and intraoperative glycemic control has been identified as a putative target to improve outcomes of surgical patients. Glycemic control requires frequent monitoring of blood glucose levels with appropriate adjustments. However, monitoring standards have been called into question, especially in cases in which capillary samples are used. Point-of-care testing (POCT) using capillary samples and glucometers has been noted to give relatively accurate results for critically ill patients. However, the package inserts of most glucometers warn that they should not be used for patients in shock. This has led clinicians to doubt their accuracy in the operating room. The accuracy of capillary samples when tested in patients undergoing surgical procedures has not been proven. This study aims to determine the accuracy of intraoperative blood glucose values using capillary samples relative to arterial samples. ⋯ Capillary samples collected intraoperatively are strongly correlated with arterial samples. Glucose monitoring in the operating room can be safely performed by collecting capillary samples for POCT. However, clinicians should still be cautious when interpreting glucose levels that are high, either by repeating the blood glucose test or by having samples sent to the laboratory.
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Comparative Study
An evaluation of the routine use of contrast radiography as a screening test for cervical anastomotic integrity after esophagectomy.
The use of contrast radiography as a screening test for anastomotic integrity after esophagectomy is unclear. ⋯ Most leaks (56.3%) were diagnosed without contrast esophagography. Contrast studies changed clinical management correctly in only 2 of 132 patients, while failing to diagnose 4 of 7 possible leaks. This study suggests that its routine use after THE or PLE is not indicated.
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Comparative Study
Utilization of a cognitive task analysis for laparoscopic appendectomy to identify differentiated intraoperative teaching objectives.
Experts become automated when performing surgery, making it difficult to teach complex procedures to trainees. Cognitive task analysis (CTA) enables experts to articulate operative steps and cognitive decisions in complex procedures such as laparoscopic appendectomy, which can then be used to identify central teaching points. ⋯ CTA can deconstruct the essential operative steps and decision points associated with performing a laparoscopic appendectomy. These results provide a framework to identify key teaching principles to guide intraoperative instruction. These learning objectives could be used to guide resident level-appropriate teaching of an essential general surgery procedure.