Surgery
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Comparative Study Clinical Trial
Thoracic versus lumbar epidural anesthesia's effect on pain control and ileus resolution after restorative proctocolectomy.
Epidural anesthesia as a perioperative adjunct has been shown to provide superior pain control and has been implicated in more rapid ileus resolution after major abdominal surgery, possibly through a sympatholytic mechanism. Studies suggest that the vertebral level of epidural administration influences these parameters. ⋯ Thoracic epidural analgesia has distinct advantages over both lumbar epidural or traditional patient-controlled analgesia in shortening parameters measuring postoperative ileus and in reducing surgical pain. The procedure is safe and associated with low morbidity. Thoracic epidural anesthesia is also economically justifiable and may prove to impact significantly on future postoperative management by reducing length of hospitalization. Our data and those of others are most striking in these regards for patients with thoracic catheters, indicating the importance of vertebral level in epidural drug administration.
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One of the most difficult problems in blunt trauma is evaluation for potential intraabdominal injury. Admission for serial abdominal exams remains the standard of care after intraabdominal injury has been initially excluded. We hypothesized a normal abdominal computed tomography (CT) scan in a subgroup of minimally injured patients would obviate admission for serial abdominal examinations, allowing safe discharge from the emergency department (ED). ⋯ Abdominal CT scan is a safe and cost-effective screening tool in patients with blunt trauma. A normal CT scan in minimally injured patients allows safe discharge from the ED.
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Although early extubation after coronary bypass surgery has been shown to reduce length of stay, a systematic cost analysis of its economic benefit has not been reported, and previous studies have used hospital charges that are typically confused with actual costs. ⋯ Early extubation after coronary bypass surgery is an effective strategy of reducing length of stay and does not appear to impact on either morbidity or mortality. An additional benefit is significant cost savings realized through accelerated recovery and control of resource use.
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Preservation of neurological function with a low incidence of restenosis is a measure of the long-term durability of carotid endarterectomy. Routine and selective patch angioplasty of the internal carotid artery have both been used to reduce the incidence of restenosis. The European literature has had many reports of lower restenosis rates in patients undergoing eversion carotid endarterectomy. We evaluated our experience with the eversion carotid endarterectomy procedure over a 2-year period to identify any advantage of this technique. ⋯ These data demonstrate that eversion carotid endarterectomy can be performed with low stroke and mortality rates in the treatment of extracranial carotid occlusive disease. The incidence of restenosis was lower and approached significance in eversion endarterectomy when compared to standard carotid endarterectomy in the short-term follow-up in this series.
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Blood cultures are commonly obtained to delineate an infectious process in the ill surgical patient with fever, leukocytosis, or other septic parameters. We studied how often bacteremia was diagnosed, whether a positive blood culture changed therapy, and the cost analysis of this practice. ⋯ Routine ordering of blood cultures is not cost-effective, rarely alters or provides therapeutic direction, and appears not to affect mortality. Obtaining clinically indicated blood cultures as a secondary rather than a primary diagnostic measure is suggested.