Bedside Drainage Research Articles

"Emergency Room Incision and Drainage of Perirectal Abscess is Equivalent to Incision and Drainage in the Operating Room".

Current guidelines for management of anorectal abscesses make no recommendations for operative vs bedside incision and drainage (I&D). The purpose of this study was to determine if management in the operating room is necessary to adequately drain anorectal abscesses and prevent short-term complications for patients presenting to the emergency department (ED). Patients with perirectal abscesses were identified and divided into two groups based on intervention type: "bedside" or "operative." Demographic, laboratory, and encounter data were obtained from the medical record. Study outcomes included 30-day complications (return to the ED, reintervention, and readmission). Data were analyzed with univariate and multivariate analyses using SPSS (version 28). A total of 113 patients with anorectal abscesses were identified. Sixty-six (58%) underwent bedside I&D and 47 (42%) operative I&D. The overall complication rate was 10%. A total of 9 patients (6 bedside and 3 operative) returned to the ED. Six of these patients required reintervention (5 bedside and 1 operative), and 1 was readmitted. Two patients from the bedside group required a second I&D during their index admission. Pre-procedure SIRS (P = .02) was found to be associated with 30-day complications. Provider specialty and training level were not associated with 30-day complications. In this study, for patients presenting to the ED, bedside drainage was found to be an adequate management strategy to achieve complete drainage without a significant increase in the rate of complications when compared to operative drainage.

Middle Meningeal Artery Embolization to Treat Chronic Subdural Hematoma

Background Chronic subdural hematoma is associated with high rates of perioperative complications and recurrence. Methods The classic treatments are observation or surgical evacuation. Middle meningeal artery embolization is a recently emerging procedure that has evolved as the neuroendovascular community has gained collective experience. This review summarizes the pathophysiology of chronic subdural hematoma, reviews the classic treatment strategies, discusses the advent and use of middle meningeal artery embolization, and describes the contemporary technical approach to middle meningeal artery embolization. Results Embolization has the advantages of targeting the vascular supply of the neomembranes implicated in chronic subdural hematoma pathophysiology and avoiding surgical or bedside drainage in a population associated with significant comorbidities. Conclusions Middle meningeal artery embolization is increasingly used both as an adjunct treatment to surgical evacuation and as a stand‐alone method for managing this challenging entity.

1470 Consenting for a Bedside Procedure: A Prospective Observational Analysis of Consenting Practice in the Surgical Emergency Admissions Unit of a District General Hospital

Abstract Aim Consent is necessary to enable patient autonomy, and it is vital that it is voluntary, informed and, where possible, the patient has valid mental capacity to give consent. Recent case law has grown around consent and practice guidance has evolved. This was a prospective observational study investigating the quality of consenting practice for incision and drainage procedures performed within the surgical emergency admissions unit (SEAU) at a district general hospital. Method A prospective study was conducted on consent documentation for a study period from August to September 2020, for patients undergoing bedside incision and drainage (I&D) procedures within the SEAU. Documentation was reviewed and data collected for quality of consent. Further data into the quality of this documentation was also collected; including legibility, risk and benefit discussions, local anaesthetic used, operation note documentation and discussion of the procedure. This was compared against GMC standards. Results Of 20 cases (n = 20), 1 case had written consent and 15 cases had verbal consent documented. 4 cases had no documentation of consent. No cases had benefit documentation, and 4 out of the 20 cases had risks documented. 4 cases had documentation of procedure discussion. 13 cases had an operation note included. Conclusions This study highlights a deviation from recommended practice, and results have been communicated at a departmental level. Recommendations have been offered in an attempt to improve compliance, including the display of posters in the SEAU. We shall re-audit practice within the coming months after these changes have been implemented.

Propensity-Matched Case-Control Analysis of Operative versus Bedside Drainage of Chronic SDH

Mohan, Arvind BS; Kubilis, Paul; Lucke-Wold, Brandon MD, PhD; Malnik, Sam; Hoh, Brian L MD Author Information

A simple and effective modified technique of twist drill craniostomy for bedside drainage and irrigation of chronic subdural hematoma: Technical and clinical study

ObjectiveChronic subdural hematoma (CSDH) is an important health problem observed mostly in elderly population. Here, we aimed to describe and validate a simple modified technique of twist-drill craniostomy (TDC) using easily accessible tools for effective and safe bedside CSDH drainage. MethodsA detailed description of the new modified TDC technique which allows for sequential drainage and irrigation under physiological conditions is provided. Clinical and radiological characteristics as well as surgical results of the patients undergoing this procedure are also presented. ResultsA total of 55 patients (30 M, 25 F) underwent this modified TDC. Mean age was 61.7 ± 12.3 years. Medical comorbidities were common (76.4 %). Subdural hematoma was mostly unilateral (83.6 %). Maximum width of hematoma was 21 ± 4 mm on average (range: 9−38 mm). In total, patients underwent 1.6 ± 0.9 subdural tappings on average (median: 1, range: 1−5). Repeat tappings were performed in 43.6 % of the patients. No mortality, serious morbidity or infectious complications were noted. Pneumocephalus was either absent or minimal in most cases (96.4 %). Mean length of hospital stay was 4.9 ± 4.0 days (median: 3; range: 2−20 days). The clinical outcomes were favorable in 92.7 % of the patients (no craniotomy required and no symptomatic recurrence detected). ConclusionThis modified technique of TDC utilizes easily available tools, yields satisfactory radiological and clinical results, allows repeated tappings even in outpatient settings and can thus be readily applied in every neurosurgical unit across the world. It can be an effective alternative to existing procedures for patients with multiple co-morbidities and/or high anesthesia risk, in emergency conditions and busy neurosurgical centers.

Subdural Drain versus Subdural Evacuating Port System for the Treatment of Nonacute Subdural Hematomas: A Single-Center Retrospective Cohort Study

Subdural drain (SDD) and Subdural Evacuating Port System (SEPS) are bedside options for management of nonacute subdural hematomas (SDHs). These interventions have not been compared with each other. Our objective is to compare the need for second bedside procedure, need for craniotomy, complication rate, and other outcomes related to bedside drainage of SDH with SDD or SEPS. We hypothesized that SDD would be associated with superior outcomes to SEPS. Database queries and direct patient chart reviews were used to gather patient data. t-Tests, Fisher exact tests, and proportional odds models were performed. Of 41 SDDs and 25 SEPS, baseline characteristics were similar except more isodense SDHs were present in SDD (P= 0.0312). SEPS was associated with significant risk of requiring a second bedside procedure (odds ratio, 3.2381; 99% confidence interval, 1.0345-10.1355) relative to SDD. Need for craniotomy did not differ between groups (12.1% SDD vs. 16% SEPS; P= 0.721). The complication rate was similar between groups (2.4% SDD vs. 12% SEPS; P= 0.1484). Symptom resolution, condition at latest follow-up, and posthospital disposition were similar between groups, but SEPS was associated with longer intensive care unit and total hospital length of stay (P= 0.02 and 0.04, respectively). SEPS was associated with higher risk for need of second bedside procedure and longer intensive care unit and hospital length of stay than SDD, although not increased need for craniotomy. Additional studies are needed to confirm our findings and determine if SDD may be more effective than SEPS for the treatment of nonacute SDH.

MASSIVE LUNG ABSCESS DUE TO STREPTOCOCCUS INTERMIDIUS IN AN IMMUNOCOMPETENT PATIENT

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Streptococcus intermidius (SI) is a gram positive bacterium which is a part of the oral, respiratory, urogenital as well as gastrointestinal flora. We present a case of a massive lung abscess with severe acute respiratory distress syndrome (ARDS) requiring veno-venous extracorporeal membrane oxygenation (V-v ECMO) in an immunocompetent patient. CASE PRESENTATION: A 54-year-old male patient with past history of diabetes mellitus presented with shortness of breath and fever. The patient was found to have tachycardia, tachypnea and low blood pressure. A Chest radiograph showed a large dense appearing mass like lesion in the right lung (Figure 1)and a CT scan was performed. The scan showed a 14 cm lung abscess with dense necrotic material (Figure 2&3). The patient decompensated and required emergent intubation with a bedside drainage of the lung abscess and placement of a chest tube. Cultures on the aspirated material grew Streptococcus Intermidius. The patient was started on antibiotics Cefepime and Metronidazole. The patient developed severe ARDS and required the V-v ECMO. The V-v ECMO was explanted after 6 days. Over the course of his stay, the chest tube continued to drain purulent material with a continued air leak. The patient underwent a right lung decortication by a video assisted thoracoscopic surgery (VATS). Due to the prolonged intubation and a likelihood of failure of weaning a tracheostomy was performed. The patient was discharged to a rehabilitation facility with a month long course of Cefepime and Metronidazole. On a 12 month follow up the patient was doing well and the tracheostomy had been successfully decanulated. DISCUSSION: Streptococcus intermidius is a gram positive bacterium that belongs to the Streptococcus Millieri group (SMG). Streptococcus intermidius is usually associated with infections of the head, neck and respiratory tract and have a tendency to cause abscesses (1). Infections with SI a commoner in individuals with uncontrolled or undiagnosed diabetes, malignancy or intravenous drug use. Individuals with poor oral hygiene and dental caries are also at risk for getting SI infections (2). Multiple sites for infections are reported in literature including brain, lung, liver and head /neck region abscesses. A multiplex polymerase chain reaction (PCR) may aid in early detection of SI, while cultures can take over a week to grow. A study of the antibiotic sensitivities of SMG showed excellent susceptibility to Penicillin, Ampicillin and Ceftriaxone (3). However, penetration of the drugs into the abscess and necrotic material remains poor and surgical drainage and decortication is usually required. CONCLUSIONS: Streptococcus Intermidius is an important cause of empyema, early diagnosis and treatment is imperative to limit significant morbidity and mortality. Reference #1: Reddy S, Singh K, Hughes S. Liver Abscesses Caused by Streptococcus intermedius in an Immunocompromised Patient. Cureus. 2018;10(1):e2107. Published 2018 Jan 24. https://doi.org/10.7759/cureus.2107 Reference #2: Ramhmdani S, Bydon A. Streptococcus intermedius: an unusual cause of spinal epidural abscess. J Spine Surg. 2017;3(2):243-249. Reference #3: Tracy M, Wanahita A, Shuhatovich Y, Goldsmith EA, Clarridge JE, Musher DM. Antibiotic susceptibilities of genetically characterized Streptococcus milleri group strains. Antimicrob Agents Chemother. 2001;45(5):1511-4. DISCLOSURES: No relevant relationships by Yizhak Kupfer, source=Web Response No relevant relationships by Ravikaran Patti, source=Web Response No relevant relationships by Vignesh Ponnusamy, source=Web Response No relevant relationships by Chanaka Seneviratne, source=Web Response No relevant relationships by Ankur Sinha, source=Web Response No relevant relationships by Parita Soni, source=Web Response No relevant relationships by Taek Sang Yoon, source=Web Response

Peritoneal drainage versus laparotomy in necrotizing enterocolitis

Introduction Necrotizing enterocolitis (NEC) is a severe surgical problem affecting mainly premature neonates (low birth weight and short gestational age neonates). Because of the severe deterioration in their general condition, some babies are subjected to formal laparotomy as a definitive treatment whereas others cannot tolerate this operative decision and may die if operated. Therefore, these poor babies may be subjected to bedside drainage with local anesthesia or sedation. Surprisingly, some of these neonates who undergo primary peritoneal drainage survive. This led us to compare both methods to identify a definitive management of this serious problem. Patients and methods Fifty-six cases who presented with surgical NEC were studied during the period from March 2013 to March 2016. They were subdivided into two groups. Group A included cases treated by peritoneal drainage. Group B included cases treated by laparotomy. All cases had plain erect abdomen, abdominopelvic ultrasound, complete blood count, C-reactive protein, blood culture, and arterial blood gases. We inserted a central venous catheter in all cases and total parenteral nutrition was planned. Results The mean age of the babies at presentation was10 days. The mean gestational age in group A was 31.9 weeks, whereas in group B it was 31.8 weeks. The mean body weight was 1.7 and 1.6 kg in groups A and B, respectively. Six babies in group A died during the study, whereas seven babies died in group B. Conclusion Primary peritoneal drainage may be areasonable line of treatment in neonates with NEC with good general condition, taking into consideration the possibility of traditional laparotomy if needed. Keywords : drainage, enterocolitis, laparotomy, necroteizing

Spontaneous Nasal Septal Abscess Presenting as a Soft Tissue Mass in a Child

BackgroundNasal septal abscess (NSA) is a rare condition most commonly seen as a complication of nasal trauma. The diagnosis of NSA requires emergent treatment, because delayed management can result in significant morbidity. Typically, NSA presents as a purulent collection that can be managed with drainage, either surgically or at bedside. Case ReportWe report an unusual presentation of a spontaneous NSA in a 7-year-old boy as a solid nasal mass eroding the nasal septum. The solid, tumor-like nature of the mass necessitated intervention beyond drainage and was ultimately excised. Imaging initiated in the emergency department revealed a partially cystic mass and erosion of the septum, which was key to the diagnosis. Why Should an Emergency Physician be Aware of This?Given the ease with which a diagnosis of NSA may be missed and the need for urgent management upon diagnosis of a NSA, we aim to highlight the clinical, radiologic, and histopathologic aspects that aid in diagnosis of NSA. Imaging, obtaining culture results, and initiation of antibiotics are paramount in management. In addition, NSAs may also necessitate bedside drainage given their emergent nature.

Abstract: Locoregional Microbiology Differs by Mechanism, Location, Type, and First Intervention at Initial Evaluation: Novel Findings in Hand Infection Epidemiology

INTRODUCTION: Hand infections confer significant functional morbidity due to prolonged recovery, loss of time at work, and diminished ability with activities of daily living. Prior investigations have focused exclusively on patients who were operated on. Delineating the locoregional microbiology of hand infections, including patients drained non-operatively who may have a different pathologic microbiome, can lead to a superior understanding of infection epidemiology and optimize initial antibiotic regimen. MATERIALS AND METHODS: A prospective registry enrolled surgical hand infection patients. Infections were categorized by mechanism, location, and type. Patients were stratified by first intervention at initial evaluation. Chi-squared analysis compared microbiology by covariate. RESULTS: 177 patients presented with a total of N = 238 culture results. Mechanisms were as follows: 5% burn, 4% fight bite, 34% trauma, 17% IVDA, 10% animal bite, 1% cancer-related, 2% dermatologic lesion, 1% sepsis, 1% foreign body, and 44% idiopathic. Locations occurred as follows: 10% thumb, 50% digit, 22% hand, 23% wrist, 20% forearm. Type was as follows: 9% paronychia, 5% felon, 57% abscess, 4% tenosynovitis, 5% osteomyelitis, 2% fasciitis, 18% joint. At initial evaluation, 23% were discharged after bedside drainage, 11% were admitted without drainage, 26% were admitted after bedside drainage, while 40% went to the OR. From cultures, 71% grew Gram-positive microorganisms, 13% Gram-negative, 1% fungal, 5% few mixed, and 11% showed no growth. The overall prevalence of Staph aureus was 41%, with 19% MRSA. The prevalence of Staph aureus was significantly different in patients with mechanisms that were traumatic (51%, p=0.03), IVDA (18%, p<0.01), animal bites (21%, p<0.03), and idiopathic (62%, p<0.01), in locations in the digits (51%, p<0.01), wrist (23%, p=0.05), and forearm (20%, p<0.01), in infection types that were felon (69%, p<0.04) and joint (28%, p=0.05), and in patients who went to the OR at initial evaluation (30%, p<0.01). CONCLUSIONS: These findings suggest that our locoregional infection microbiology varies significantly by mechanism, location, type, and in patients initially triaged for operative drainage. Coupled with sensitivity data, these findings can develop a risk-stratified, optimized algorithm for initial empiric antibiotic choice at presentation as a function of mechanism, location, type, and triage, which could potentially reduce inpatient length-of-stay and hasten recovery to normal functional status in this patient population. DISCLOSURE/FINANCIAL SUPPORT:None

Risk factors for wound morbidity after open retromuscular (sublay) hernia repair

Retrorectus repairs (RR) of abdominal wall hernias are growing in popularity, yet wound morbidity and predictors in this context have been characterized poorly. Models aimed at predicting wound morbidity typically do not control for technique and/or location of mesh. Our aim was to describe wound morbidity and risk factors specifically in the context of RR hernia repair. Our hypothesis was that the incidence of wound morbidity with mesh sublay would be less than predicted by a model that does not control for mesh position. Consecutive RR hernia repairs with at least a 90-day follow-up were identified in our prospective database and analyzed. The primary outcome measures were the incidence of surgical-site occurrence (SSO) and surgical-site infection (SSI) via modern, standardized definitions. For predictors of SSO, statistical analysis was performed with univariate analysis, χ(2), and logistic regression as well as multivariate regression. A total of 306 patients met the inclusion criteria. Eighty-four SSOs identified in 72 (23.5%) patients included 48 (15.7%) SSIs, 14 (4.6%) instances of wound cellulitis, 12 (3.9%) skin dehiscences, 6 (2.0%) seromas, and 4 (1.3%) hematomas but no instances of mesh excision or fistula formation. Treatment entailed antibiotics alone in 30 patients, 14 bedside drainage procedures, 9 radiographically assisted drainage procedures, and 10 returns to the operating room for debridement. After multivariate analysis, diabetes (OR 2.41), hernia width >20 cm (OR 2.49), and use of biologic mesh (OR 2.93) were statistically associated with the development of a SSO (P < .05). Notably, the mere presence of contamination was not independently associated with wound morbidity (OR 1.83, P = .11). SSO and SSI rates anticipated by a recent risk prediction model were 50-80% and 17-83%, respectively, compared with our actual rates of 20-46% and 7-32%. Based on a large cohort of patients, we identified factors contributing to SSOs specifically for RR hernia repairs. Paradoxically, biologic mesh was an independent predictor of wound morbidity. The development of clinically important mesh complications and rates of wound morbidity less than anticipated by recent predictive models suggest that the retromuscular (sublay) mesh position may be more advantageous.

MP64-11 PROPHYLACTIC MESH PLACEMENT AT RADICAL CYSTECTOMY TO PREVENT PARASTOMAL HERNIAS: TECHNIQUE AND EARLY COMPLICATIONS

You have accessJournal of UrologyBladder Cancer: Natural History and Pathophysiology1 Apr 2015MP64-11 PROPHYLACTIC MESH PLACEMENT AT RADICAL CYSTECTOMY TO PREVENT PARASTOMAL HERNIAS: TECHNIQUE AND EARLY COMPLICATIONS Timothy Donahue, Eugene K. Cha, Hebert A. Vargas-Alvarez, Guido Dalbagni, and Bernard H. Bochner Timothy DonahueTimothy Donahue More articles by this author , Eugene K. ChaEugene K. Cha More articles by this author , Hebert A. Vargas-AlvarezHebert A. Vargas-Alvarez More articles by this author , Guido DalbagniGuido Dalbagni More articles by this author , and Bernard H. BochnerBernard H. Bochner More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2322AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Parastomal hernia (PH) is a frequent complication of ileal conduit (IC) formation after radical cystectomy (RC) with up to 48% of patients having radiographic evidence of PH and 35% experiencing adverse clinical symptoms by 2 years. Placement of mesh at the time of IC may reduce the incidence of PH. We describe the technique and early complications of prophylactic mesh placed at RC. METHODS Patients at high risk for PH development (female gender or males with BMI>30) had partially absorbable mesh placed dorsal to the rectus muscle and anterior to the posterior rectus sheath at RC. The IC was brought through a 2.5cm – 3.0cm circle cut in the center of the mesh with overlap of mesh in all directions extending 3-5 cm beyond the conduit. The mesh was anchored to the posterior rectus sheath with absorbable sutures placed in the lateral corners. The anterior peritoneum/posterior rectus fascia along the medial aspect of dissection was re-approximated to completely exclude mesh from the abdominal contents. Standard perioperative antibiotics were administered. Complication rates for patients with > 90 days follow up are reported. RESULTS Of 29 patients having prophylactic mesh placed, 22 had >90 days follow up (Median=271 days, IQR 192, 351). Median age of the 12 men and 10 women was 70.9 years. Median BMI was 32 (IQR 30.1, 35.4) and median preoperative albumin level was 4.3 (IQR 4.1, 4.4). 32% had neoadjuvant chemotherapy prior to RC, 23% had prior radiation therapy, and 41% had prior abdominal surgery. Both Turnbull (n=11) and end-stoma (n=11) techniques were used for IC formation. Placement of mesh added on average 10:03 minutes of surgical time. There were no mesh infections, fistula formation, or conduit strictures identified. Wound complications, including seroma (n=4) and superficial wound infections (n=6), were the most frequent, followed by GI (n=5), Infectious (n=5), GU (n=4), Bleeding (n=4), and Cardiac, Pulmonary, Thromboembolic, and Neurologic (n=1 each). All wound related complications were managed with bedside drainage and local wound care. No patient had a mesh-related complication and there was no need for mesh removal. CONCLUSIONS The placement of prophylactic, partially absorbable mesh in patients at high risk for PH formation appears feasible and safe. Wound-related complications were the most frequently seen and were successfully managed with bedside drainage and local wound care. Over a short period of follow up, no fistulas, strictures, or mesh-related complications were identified. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e801-e802 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Timothy Donahue More articles by this author Eugene K. Cha More articles by this author Hebert A. Vargas-Alvarez More articles by this author Guido Dalbagni More articles by this author Bernard H. Bochner More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Chronic Subdural Hematoma Management

To compare the efficacy and safety of multiple treatment modalities for the management of chronic subdural hematoma (CSDH) patients. Current management strategies of CSDHs remain widely controversial. Treatment options vary from medical therapy and bedside procedures to major operative techniques. We searched MEDLINE (PubMed and Ovid), EMBASE, CINAHL, Google scholar, and the Cochrane library from January 1970 through February 2013 for randomized and observational studies reporting one or more outcome following the management of symptomatic patients with CSDH. Independent reviewers evaluated the quality of studies and abstracted the data on the safety and efficacy of percutaneous bedside twist-drill drainage, single or multiple operating room burr holes, craniotomy, corticosteroids as a main or adjuvant therapy, use of drains, irrigation of the hematoma cavity, bed rest, and treatment of recurrences following CSDH management. Mortality, morbidity, cure, and recurrence rates were examined for each management option. Randomized, prospective, retrospective, and overall observational studies were analyzed separately. Pooled estimates, confidence intervals (CIs), and relative risks (RRs) were calculated for all outcomes using a random-effects model. A total of 34,829 patients from 250 studies met our eligibility criteria. Sixteen trials were randomized, and the remaining 234 were observational. We included our unpublished single center series of 834 patients. When comparing percutaneous bedside drainage to operating room burr hole evacuation, there was no significant difference in mortality (RR, 0.69; 95% CI, 0.46-1.05; P = 0.09), morbidity (RR, 0.45; 95% CI, 0.2-1.01; P = 0.05), cure (RR, 1.05; 95% CI, 0.98-1.11; P = 0.15), and recurrence rates (RR, 1; 95% CI, 0.66-1.52; P = 0.99). Higher morbidity was associated with the adjuvant use of corticosteroids (RR, 1.97; 95% CI, 1.54-2.45; P = 0.005), with no significant improvement in recurrence and cure rates. The use of drains following CSDH drainage resulted in a significant decrease in recurrences (RR, 0.46; 95% CI, 0.27-0.76; P = 0.002). Craniotomy was associated with higher complication rates if considered initially (RR, 1.39; 95% CI, 1.04-1.74; P = 0.01); however, craniotomy was superior to minimally invasive procedures in the management of recurrences (RR, 0.22; 95% CI, 0.05-0.85; P = 0.003). Percutaneous bedside twist-drill drainage is a relatively safe and effective first-line management option. These findings may result in potential health cost savings and eliminate perioperative risks related to general anesthetic.

Symptomatic Floor-of-Mouth Swelling with Neck Extension in a 14-Year-Old Girl

A plunging ranula is a soft-tissue mass stemming from a mucous extravasation cyst of the sublingual gland which can herniate through the mylohyoid muscle. We describe a case in which a 14-year-old girl presented with a rapidly expanding mass on the floor of her mouth affecting her ability to swallow and speak and causing tracheal compression. The patient was initially managed conservatively with antibiotics and steroids; however, the mass continued to expand necessitating emergent bedside incision and drainage and subsequent surgical intervention. The pathophysiology and management options for ranulas are also discussed herein.

The Usefulness of Intensivist-Performed Bedside Drainage of Pleural Effusion via Ultrasound-Guided Pigtail Catheter

Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Myongji Hospital, Goyang; * Department of Radiology, Chungnam National University College of Medicine, Daejeon; † Emergency Intensive Units, Daejeon Regional Emergency Center, Chungnam National University College of Medicine, Daejeon; ‡ Department of Anesthesiology and Pain Medicine, Chungnam National University College of Medicine, Daejeon; § Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea

The infusion drain: An Approach to Treatment of Intranasal Abscesses

INTRODUCTION Nasal septal abscesses are associated with a high level of morbidity from cartilage loss and may even be life threatening due to intracranial spread of the infection. It is generally agreed upon in the literature that treatment of these abscesses should not be delayed. Standard treatment involves incision and drainage of the abscess, with or without drain placement, and culture-directed antibiotic treatment. Previous reports favor treatment of intranasal abscesses either in the operating room or under moderate sedation with local anesthetic. Here, we describe a novel method for bedside drainage and treatment of nasal septal abscesses without the need for sedation or general anesthetic. The technique presented has been used across all age groups at our institution to effectively treat several nasal and septal abscesses as well as an intranasal hematoma.

Percutaneous Catheter Decompression in the Treatment of Elevated Intraabdominal Pressure

Intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS) traditionally have been treated surgically through emergent laparotomy. Intensivist-performed bedside drainage of free intraperitoneal fluid or blood (percutaneous catheter decompression [PCD]) has been advocated as a less-invasive alternative to open abdominal decompression (OAD). A single-center disease and severity of illness-matched case-control comparison of 62 patients with IAH/ACS treated with PCD vs traditional OAD was performed. The relative efficacy of each treatment in reducing elevated intraabdominal pressure (IAP) and improving organ dysfunction was assessed. Physiologic and demographic predictors of successful PCD therapy were determined. PCD and OAD both were effective in significantly decreasing IAP and peak inspiratory pressure as well as in increasing abdominal perfusion pressure. PCD potentially avoided the need for subsequent OAD in 25 of 31 patients (81%) treated. Successful PCD therapy was associated with fluid drainage of > 1,000 mL or a decrease in IAP of > 9 mm Hg in the first 4 h postdecompression. Intensivist-performed PCD is an effective and less-invasive technique for treating patients with IAH/ACS where free intraperitoneal fluid or blood is present as determined by bedside ultrasonography. Failure to drain at least 1,000 mL of fluid and decrease IAP by at least 9 mm Hg in the first 4 h postdecompression is associated with PCD failure and should prompt urgent OAD.

The Role of Reconstruction for Transoral Robotic Pharyngectomy and Concomitant Neck Dissection

To evaluate the impact of primary reconstruction of postablative defects following transoral robotic surgery on function and the risk of orocutaneous fistula. Prospective nonrandomized clinical trial. Tertiary academic medical center. Thirty-one patients treated with transoral robotic pharyngectomy for malignant disease. Each case was analyzed for patient age, sex, primary site of the tumor, pathologic characteristics, stage of disease, complications, fistula rate, and functional outcomes. Functional outcomes were assessed using the Performance Status Scale for Head and Neck Cancer Patients and the Functional Oral Intake Scale. In 25 patients, the primary treatment was with transoral robotic pharyngectomy, and 6 cases were salvage procedures performed for recurrent disease following radiation (3 patients) or chemoradiation (3 patients). Twenty-six patients underwent a concomitant unilateral selective neck dissection, and 3 patients underwent concomitant bilateral selective neck dissections; 2 patients did not require a neck dissection for treatment of the primary malignant tumor. Complication rate, fistula rate, and oral function. Primary intraoral reconstruction was performed in all 31 patients. Musculomucosal advancement flap pharyngoplasty was performed in 25 patients with a concomitant velopharyngopasty (6 patients), and radial forearm free flap reconstruction was performed in 6 patients. There were no intraoperative complications; however, postoperatively, 1 patient developed a neck hematoma that was treated with bedside drainage and 4 patients sustained minor musculomucosal flap necrosis of the superior aspect of the flap. None of the patients developed a neck infection of salivary fistula. Endoscopic evaluation of swallowing demonstrated that none of the patients experienced aspiration or velopharyngeal reflux, and the performance Status Scale for Head and Neck Cancer Patients and the Functional Oral Intake Scale at 2 weeks, 2 months, 6 months, 9 months, and 1 year demonstrated a progressive improvement in diet, swallowing, and oral function. Primary transoral robotic reconstruction may provide a benefit by decreasing the fistula rate in patients undergoing concomitant neck dissection. Patients regain excellent function following surgery and adjuvant therapy.

Invited Commentary

This study by Pham and colleagues [1Pham T.H. Perry K.A. Enestvedt K. et al.Decreased conduit perfusion measured by spectroscopy is associated with anastomotic complications.Ann Thorac Surg. 2011; 91: 380-386Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar] describes an intraoperative method to assess gastric conduit perfusion during minimally invasive esophagectomy. The technique, intraoperative optical fiber spectroscopy (OFS), works in a fashion similar to the familiar oxygen saturation probe to determine the oxygenation of the blood within the stomach graft. Although used during minimally invasive esophagectomy in this study, OFS could be used during open esophagectomy as well. The authors found that decreased gastric conduit perfusion, as measured by OFS, was associated with increased anastomotic complication rates (leak, 26%; strictures, 13%). They hypothesize that steps could be taken in patients at risk to prevent gastric conduit ischemia and, therefore, anastomotic complications. In 4 patients in their series, the stomach graft was mobilized in advance to ischemic condition it. A nonsignificant trend towards improved graft oxygenation was noted and no leaks in this small set of patients.Since the beginning of esophageal resective operations, preventing anastomotic leaks and their potentially deadly consequences has been the holy grail of the esophageal surgeon. New technologies are developing that may resolve this issue once and for all. However, over the years, it has been the widespread adoption of the gastric conduit, refinement in anastomotic techniques (both hand sewn and stapled), and placement of the anastomosis in the neck, that have made the greatest impact on reducing both the incidence and consequences of leaks. Now, esophageal anastomotic leak rates of 1% to 2% or less are reported in large series. Many consider a leak rate of zero to be the attainable target. Furthermore, a cervical anastomotic leak can be managed by bedside drainage and dressings. The addition of an adjuvant jejunostomy even permits home enteral feeding until the leak spontaneously closes. I believe these methods remain the gold standard for reducing anastomotic complications. This study by Pham and colleagues [1Pham T.H. Perry K.A. Enestvedt K. et al.Decreased conduit perfusion measured by spectroscopy is associated with anastomotic complications.Ann Thorac Surg. 2011; 91: 380-386Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar] describes an intraoperative method to assess gastric conduit perfusion during minimally invasive esophagectomy. The technique, intraoperative optical fiber spectroscopy (OFS), works in a fashion similar to the familiar oxygen saturation probe to determine the oxygenation of the blood within the stomach graft. Although used during minimally invasive esophagectomy in this study, OFS could be used during open esophagectomy as well. The authors found that decreased gastric conduit perfusion, as measured by OFS, was associated with increased anastomotic complication rates (leak, 26%; strictures, 13%). They hypothesize that steps could be taken in patients at risk to prevent gastric conduit ischemia and, therefore, anastomotic complications. In 4 patients in their series, the stomach graft was mobilized in advance to ischemic condition it. A nonsignificant trend towards improved graft oxygenation was noted and no leaks in this small set of patients. Since the beginning of esophageal resective operations, preventing anastomotic leaks and their potentially deadly consequences has been the holy grail of the esophageal surgeon. New technologies are developing that may resolve this issue once and for all. However, over the years, it has been the widespread adoption of the gastric conduit, refinement in anastomotic techniques (both hand sewn and stapled), and placement of the anastomosis in the neck, that have made the greatest impact on reducing both the incidence and consequences of leaks. Now, esophageal anastomotic leak rates of 1% to 2% or less are reported in large series. Many consider a leak rate of zero to be the attainable target. Furthermore, a cervical anastomotic leak can be managed by bedside drainage and dressings. The addition of an adjuvant jejunostomy even permits home enteral feeding until the leak spontaneously closes. I believe these methods remain the gold standard for reducing anastomotic complications. Decreased Conduit Perfusion Measured by Spectroscopy Is Associated With Anastomotic ComplicationsThe Annals of Thoracic SurgeryVol. 91Issue 2PreviewGastric conduit ischemia during esophagectomy likely contributes to high anastomotic complication rates, yet we lack a reliable method to assess gastric conduit perfusion. We hypothesize that optical fiber spectroscopy (OFS) can reliably assess conduit perfusion and that the degree of intraoperative gastric ischemia is associated with subsequent anastomotic complications. Full-Text PDF

Unintentional Needlestick Injuries in Livestock Production: A Case Series and Review

ABSTRACT Livestock producers and their employees sometimes experience unintentional needlestick injury (NSI) while vaccinating or injecting medications into animals. There is little published regarding the medical complications that can develop from this occupational exposure. The objectives of this study were to (1) perform a retrospective review of animal-related NSIs treated at a tertiary medical center of a rural state; and (2) review the risks of NSI and measures to decrease their occurrence. Medical records of patients with NSI related to animal injection were identified from the University of Iowa Hospitals and Clinics database from 2002 to 2008 and reviewed. Nine patients received medical care for NSI that occurred while vaccinating farm animals. Most common NSI site was the nondominant hand and most occurred while attempting to inject the animal. Soft tissue infection was common and all nine received oral and/or intravenous antibiotics. Two thirds required hospital admission. Three required surgery and one had a bedside incision and drainage procedure. One patient had a serious inflammatory reaction with necrosis in the leg due to the oil adjuvant in the animal vaccine. Another case had a probable mycetoma with osteomyelitis and soft tissue infection due to the bacteria Streptomyces, which is a NSI complication not previously reported. Although medical complications from farm-related NSIs do not appear to be common, this case series illustrates how these injuries can be debilitating, costly, and lead to loss of work time and productivity. Producers and employees who inject livestock need to be aware of the risks and utilize measures to decrease unintentional NSI.