The American surgeon
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The American surgeon · Oct 2012
Enhanced recovery protocol: implementation at a county institution with limited resources.
The benefits of an enhanced recovery protocol (ERP) in colorectal surgery have been well described; however, data on the implementation process is minimal, especially in a resource-limited institution. The purpose of this study was to evaluate outcomes during implementation of a physician-driven ERP at a public-funded institution. We retrospectively reviewed all elective colorectal surgery during a transition from standard care to an ERP (implemented via a standard order sheet). ⋯ Late implementation of ERP diet, analgesics, and activity were the most common process errors. Full application of the ERP reduced mean LOS by 3 days (P=0.002), and there was a trend toward decreased postoperative morbidity without an increase in readmission rate (P=0.61). Full implementation of an ERP for colorectal surgery faces many challenges in a resource-limited county institution; however, when fully applied, the ERP safely reduced overall LOS, which is important in cost containment.
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The American surgeon · Oct 2012
Closed-suction drain placement at laparotomy in isolated solid organ injury is not associated with decreased risk of deep surgical site infection.
The purpose of this study was to investigate the role of intra-abdominal closed-suction drainage after emergent trauma laparotomy for isolated solid organ injuries (iSOI) and to determine its association with deep surgical site infections (DSSI). All patients subjected to trauma laparotomy between January 2006 and December 2008 for an iSOI at two Level I urban trauma centers were identified. Patients with isolated hepatic, splenic, or renal injuries were included. ⋯ Subgroup analysis demonstrated those who sustained severe hepatic injury receiving a drain had a significantly increase risk of DSSI (P=0.02). There was no statistical difference in the rate of DSSI based on the presence or absence of an intra-abdominal drain after severe splenic injury (17 vs 18%, P=0.88). The use of intra-abdominal closed-suction drains after iSOI is not associated with decreased risk of DSSI.
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We retrospectively reviewed a series of 516 patients with motorcycle (n=353) and bicycle (n=162) injuries; 384 patients (74%) were younger than age 50 years and 132 (26%) were older. No significant differences by age group were seen in gender, helmet use, substance use, complications, or mortality. Older patients had more severe (Injury Severity Score [ISS] greater than 15) injuries (35 vs 18%; P<0.001), longer intensive care unit stay (1.8 vs 0.9 days; P=0.03), and more frequent discharge to subacute facilities (27 vs 10%; P<0.001). ⋯ We conclude that motorcycle and bicycle accidents cause major injuries in older patients with substantial use of hospital and posthospital resources. Older bicyclists are vulnerable to head injury and to greater functional decline. Helmet use among older bicyclists should be a direct target for a public health campaign.
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The American surgeon · Oct 2012
A simple algorithm for drain management after pancreaticoduodenectomy.
Pancreatic fistula (PF) continues to be the Achilles' heel of pancreaticoduodenectomy (PD) with both morbidity and mortality linked to its occurrence. The optimal drain management strategy after PD remains unclear. We evaluated drain amylase (DA) levels on postoperative Day (POD) 0 to 5 in 76 consecutive patients undergoing PD to determine the patterns associated with PF. ⋯ Overall, the temporal pattern of decreasing DA levels after PD correlates closely with the risk of PF, and only two patients (5%) developed PF after early DA levels had normalized. Based on these data, we propose an algorithm of monitoring DA daily with drain removal when the level is less than 100 U/L. In our patient group drain removal would have occurred on a mean of 1.8 days and median 1 day after surgery.
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The American surgeon · Oct 2012
The current role of magnetic resonance imaging for diagnosing cervical spine injury in blunt trauma patients with negative computed tomography scan.
Clearance of cervical spine (CS) precautions in the neurologically altered blunt trauma patient can be difficult. Physical examination is not reliable, and although computed tomography (CT) may reveal no evidence of fracture, it is generally believed to be an inferior modality for assessing ligamentous and cord injuries. However, magnetic resonance imaging (MRI) is expensive and may be risky in critically ill patients. ⋯ Although use of the single-slice scanner was significantly associated with MRI findings (odds ratio, 2.62; P=0.023), no significant clinical risk factors were identified. Patients with MRI findings were heterogeneous in terms of age, mechanism, and Injury Severity Score. We conclude that CS MRI continues play a vital role in the workup of neurologically altered patients.