American journal of surgery
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Most liver injuries lend themselves to satisfactory hemostasis and drainage, with or without resectional debridement. A small number of injuries will necessitate massive blood transfusion with clinically significant coagulopathy developing in about half of these patients despite prophylactic infusion of fresh frozen plasma and platelet concentrates. ⋯ Packs should be removed early (within 24 to 48 hours postoperatively), and surgery performed as indicated by the injury. No intraabdominal abscesses have been encountered among our 12 patients who underwent temporary packing of their liver injuries.
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Complications from attempts to block the intercostal nerves intraneurally before closure of a thoracotomy have resulted in hypotension with or without spinal block. Placement of a chest tube has resulted in transection of the intercostal nerve. The first of these complications can be avoided by not attempting intraneural block of the nerves intrathoracically. Avoidance of the latter requires careful dissection of the intercostal spaces and identification of the intercostal nerve, as opposed to stab insertion of a chest tube.
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We asked whether surgical process and outcome differ for physicians in postgraduate training supervised by attending surgeons compared with attending surgeons alone. All appendectomies performed during a 2 year period in a 320 bed voluntary hospital where either the admitting diagnosis or the preoperative diagnosis suggested acute appendicitis were included in the study. Data were abstracted from medical records and pathology reports. ⋯ The average length of stay was 8.8 days for attending surgeons' cases and 7.1 days for residents' cases (t = 1.09, p = 0.29). The postoperative complication rates were 24 percent for attendings' cases and 12 percent for residents' cases (chi-square = 2.31, p = 0.16). We conclude that there is no appreciable difference in either the process or the outcome of care for patients undergoing appendectomy whether the operation is performed by an attending physician or a resident physician supervised by an attending physician.