Surgery
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Achieving and maintaining hemostasis in neurosurgical procedures is critical to the outcome. After trauma to the brain, a cascade of events initiated by tissue factor (TF) or thromboplastin results in a coagulation process that develops into an exaggerated fibrinolytic response, called disseminated intravascular coagulation (DIC). ⋯ Recombinant factor VIIa (rFVIIa) also is discussed, including its mechanism of action and use in neurosurgery. The ultra-early administration of rFVIIa also is covered, in both the military and the civilian settings.
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Anticoagulant therapy is challenging to modern surgical practice because it complicates risks of bleeding and the need for allogeneic blood transfusions. In an aging population, there is extensive use of antiplatelet agents, and patients present for operations receiving these agents. Hemostatic inhibitors are reviewed here, including anticoagulants, platelet inhibitors (clopidogrel), low-molecular-weight heparins, pentasaccharide (fondaparinux), and other factor Xa inhibitors. Agents used to manage bleeding, including aprotinin, lysine analogs, desmopressin, and recombinant factor VIIa, are discussed.
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The bariatric patient is among the most complex in general surgery. Morbid obesity and associated comorbidities create a higher likelihood for intensive care unit (ICU) services. Obstructive sleep apnea (OSA) is often unrecognized and may contribute to increased respiratory events and ICU admissions. Identifying and treating occult OSA may decrease the need for ICU utilization. This retrospective review attempts to evaluate this hypothesis. ⋯ Multiple variables lead to a decrease in ICU stay. Our study suggests that recognizing and treating occult sleep apnea may further improve this quality metric. In our center, mandatory OSA screening and aggressive preoperative treatment have eliminated the need for respiratory-related ICU stays after bariatric surgery.
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Major bile duct injuries remain a potentially devastating complication after laparoscopic cholecystectomy. A retrospective review was conducted of patients who underwent a biliary-enteric reconstruction of a biliary injury to assess their long-term outcome. ⋯ Bile duct injuries that require a biliary-enteric repair are commonly associated with long-term complications. Level of injury and likely timing of repair predict risk of postoperative stricture.
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The National Surgical Quality Improvement Program (NSQIP) has reduced complications for surgery patients in the Department of Veterans Affairs Healthcare System. The American College of Surgeons Committee on Trauma maintains the National Trauma Data Bank (NTDB) to track injured patient comorbidities, complications, and mortality. We sought to apply the NSQIP methodology to collect comorbidity and outcome data for trauma patients. Data were compared to the NTDB to determine the benefit and validity of using the NSQIP methodology for trauma. ⋯ Complications occurred more frequently in trauma patients than general surgery patients. The UM NSQIP Trauma patients had higher rates of complications than reported in the NTDB. The NTDB data potentially underreport important comorbidity and outcome data. Application of the NSQIP methodology to trauma may present an improved means of effectively tracking and reducing adverse outcomes in a risk-adjusted manner.