Arch Surg Chicago
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Randomized Controlled Trial Comparative Study Clinical Trial
Does patient-controlled analgesia achieve better control of pain and fewer adverse effects than intramuscular analgesia? A prospective randomized trial.
To compare three analgesic regimens in patients undergoing colon resection: patient-controlled morphine sulfate analgesia (PCA), intramuscular (IM) morphine, and IM ketorolac tromethamine. ⋯ While it appears that ketorolac provides a better postoperative course than either IM or PCA morphine in terms of pain control, postoperative confusion, length of stay, and duration of ileus, 18% of our patients assigned to ketorolac required additional analgesia, and there was a strong patient preference for PCA. Most patients should probably be managed with PCA narcotics, but the addition of ketorolac might reduce narcotic dose and resultant adverse effects. Those patients particularly prone to adverse effects should receive primarily ketorolac.
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To determine how other program directors use the American Board of Surgery In-Training Examination (ABSITE) scores in the resident evaluation process. ⋯ The actions taken by program directors in their use of ABSITE scores vary widely, with a noticeable difference found when comparing the methods between the university and community hospital directors. Our survey findings show that there is still no uniform standard or agreement as to how the scores should be used, even though the ABSITE has been in existence for 20 years.
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It has been reported that patients undergoing major hepatectomy tolerated 90 and 127 minutes of continuous hepatic inflow interruption with no evidence of permanent damage to the liver. We questioned the safety and feasibility of the interruption beyond 90 minutes in normothermic human beings. We also postulated that, besides injury to the liver per se, extended continuous hepatic inflow interruption would cause extrahepatic multiple-system organ damage in subjects exposed to continuous hepatic inflow interruption for 90 or 120 minutes. ⋯ Multiple-system organ failure resulting from ischemia-reperfusion injury and obstacle of portal hemodynamics in a subject subjected to an extended continuous hepatic inflow interruption is an unrecognized new disorder that may cause a high mortality rate. Our preliminary results indicated that animals subjected to continuous hepatic inflow interruption for 90 or 120 minutes developed various injuries to the liver, lung, heart, and gut. Therefore, we believe that continuous hepatic inflow interruption exceeding 90 minutes could also be hazardous in human beings.
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Nonoperative management of blunt liver and spleen injuries in hemodynamically stable, neurologically intact patients has become an accepted treatment in recent years. ⋯ Nonoperative management in patients with an altered mental status can be done safely in a monitored setting. This challenges the current criteria of excluding neurologically impaired patients with liver or spleen trauma from nonoperative management.
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Nonoperative management of blunt hepatic injury in hemodynamically stable trauma patients is now common. Recently, it has been proposed that the finding of hepatic periportal tracking (PPT) of blood on the initial computed tomographic (CT) scan is a sensitive marker of significant hepatic and subhepatic injury that might militate against nonoperative management. While CT scan is useful in diagnosing the injury, the utility of follow-up CT scans has not been elucidated. ⋯ The finding of PPT on the admission CT scan is not clinically significant and does not preclude nonoperative management of patients with blunt hepatic injury. Furthermore, routine follow-up CT scans are not indicated, as treatment is not influenced by their results. Rather, follow-up CT scans should be obtained as dictated by the patient's clinical course. Extrapolation of these findings to all patients with blunt hepatic trauma in the United States would result in considerable savings of health care dollars, without negatively affecting patient care.