Postsurgical Patient Research Articles

Chronic pain with beneficial response to electroconvulsive therapy and regional cerebral blood flow changes assessed by single photon emission computed tomography

Background: Recent neuroimaging studies suggested that chronic neuropathic pain may be largely sustained by a complex neuronal network involving the thalamus. Although recent studies have demonstrated the efficacy of electroconvulsive therapy (ECT) in the treatment of a variety of types of chronic neuropathic pain, the effects of ECT on regional cerebral blood flow (rCBF) have not been studied. Objectives and Methods: We present a 50-year-old female postsurgical chronic pain patient whose pain had failed to respond to standard pain treatment, but was resolved by ECT. To investigate the potential role of rCBF in ECT's analgesic effect, we measured significant changes in the rCBF in the thalamus before and after a course of bilateral ECT using technetium-99m ethyl cysteinate dimer (99mTc-ECD) single photon emission computed tomography (SPECT). Results: 99mTc-ECD SPECT showed a significant bilateral decrease in the thalamus on the side of the pain, and this decreased rCBF in the thalamus increased after ECT. Conclusions: The results from the SPECT suggest that ECT increases abnormally decreased thalamus activity in chronic neuropathic pain. Reg Anesth Pain Med 2002;27:211-213.

Surgery of the Avian Reproductive and Gastrointestinal Systems

Surgery of the female reproductive system is the most commonly indicated intra-abdominal surgery of avian patients. Surgery of the male reproductive system and avian gastrointestinal tract are less commonly indicated but are occasionally necessary. Indications for surgery of the female reproductive tract include egg-laying-related disorders, dystocia, egg binding, damage or trauma to the oviduct, oviductal torsion and volvulus, abnormal egg production, biopsy or culture of the oviduct, internal laying, egg related coelomitis, oviductal impaction, oviductal or ovarian neoplasia, ovarian cysts, or as a sterilization procedure to stop egg laying. Indications for surgery of the male reproductive tract include castration (most often as a treatment of behavioral problems) and treatment of testicular neoplasia. Indications for gastrointestinal tract surgery include repair of traumatic injury, foreign-body retrieval, obstructive disease, as a treatment for neoplasia, and as a diagnostic tool to retrieve tissue for biopsy. Avian reproductive anatomy and physiology are reviewed. Presurgical and postsurgical patient care ensures successful recovery. Lateral, horizontal, and midline approaches may be preferred based on indication or concurrent disease. Approaches are described in detail. Indications and descriptions of surgery conclude this article.

Ogilvie’s Syndrome After Cesarean Delivery

Ogilvie's syndrome is a rare postsurgical complication that can be associated with cesarean delivery. It is characterized by massive dilation of the colon, much like that which occurs with an obstruction but in the absence of a mechanical obstruction. Early detection and intervention are necessary to avoid serious morbidity and/or mortality. Conservative treatment is effective in many cases, but surgical intervention may be required. Nursing assessment of the gastrointestinal system in the postsurgical patient is reviewed using a case report of a patient who developed Ogilvie's syndrome after a cesarean delivery.

Complications of nosocomial pneumonia in the surgical patient

Nosocomial pneumonia is a leading cause of morbidity and mortality in the surgical and trauma patient. Inadequate treatment can lead to the complications of acute respiratory distress syndrome (ARDS), empyema, and lung abscess. The prevention and treatment of these complications revolve around several key principles. Complete treatment of pneumonia requires appropriate antimicrobial therapy, as well as mechanical pulmonary hygiene and proper airway management. Despite advances in treatment of pneumonia, complications arise necessitating treatment. This article reviews the treatment of ARDS, empyema, and lung abscesses. In particular, the many options for treatment of empyema are discussed in detail. Additionally, the treatment of pulmonary contusion and hemopneumothorax in the trauma patient is discussed. The understanding of sound treatment principles in the critically ill postsurgical patient helps prevent complicated or recurrent pneumonia and allows the surgeon to intervene effectively when such complications occur.

Student-patient communication during physiotherapy treatment

Some communication skills adopted by 30 Australian and 27 Hong Kong final year physiotherapy students were observed by their clinical supervisor, while delivering treatment to an acute post-surgical patient in their country of origin. In each case, patient and student were racially similar and verbal communication was in their first language. The results showed that Australian students used more explanation, eye contact, verbal reinforcement, facial expression, variation of tone and response with interest, compared with Hong Kong students. Female students from both cultures used more verbal skills, such as information finding and response with interest, compared with male students; Australian female students responded with interest more frequently with female patients. When treating male patients, Hong Kong male students applied more non-therapeutic touch but less response with interest, compared with Australian male students. This study suggests that, regardless of the cultural setting, more physiotherapy student teaching resources should be channelled towards development of communication skills during undergraduate training, with particular emphasis given to verbal communication skills for male students.

Practice of ambulatory anesthesia in honduras: The central American experience

H ONDURAS IS A developing country, with scarcely 5 million inhabitants and 112,000 km 2 of territorial extension. The entire country has only 52 anesthesiologists, all of whom completed residency training abroad because it is not available in the educational programs of the local medical schools. What occurs is that the anesthe~ sia specialists train paramedical personnel to be anesthetic technicians who will be working at the public hospitals under the anesthesiologist's supervision. This allows them to meet the needs of the people in the field. Even though Honduras has not suffered the deleterious effects of war, it endures other problems, such as the two clearly separate socioeconomic poles of the miserable poverty (in the largest percentage) and the ostentatious richness, with a very small middle class. The world crisis is more visible in this type of society, which has generated excessive violence, thievery, and misery. Nevertheless, there are some advantages in this ongoing smuggle. Necessity is the mother of invention, and although anesthesiologists in Honduras do not have international fame, they have been obligated to improvise with materials and equipment in their dally practice (adhesive tape has become our number 1 auxiliary). The adoption of a saving policy to face the precarious situation has helped to overcome the necessities. The upper class might not be accustomed to these medical behaviors, but the resources must be well spent and waste avoided i f it is possible. New inventions from the medical engineering field have given us accurate devices to obtain better measurement, precise evaluation, and prompt treatment of the patient. The great activity of pharmaceutical laboratory chemists have launched many new products to the medicine market that make the practice of anesthesiology easier, safer, and more efficient. In developed countries this reality has made a real change because of the lower costs for medical care due to the ability to have patients hospitalized for a shorter period of time. It is economically attractive for the administration of hospitals or health care facilities to treat several patients per day with a short postoperative time rather than to have beds perpetually occupied. The profits are larger with the new methods. In Third World Countries, many things regarding medical service are done backwards (day surgeIaj is no exception) because of the difficulty to obtain expensive modern drugs and devices. There are arguments among the administrations because they would rather give affordable (or inexpensive) health care, believing this is the best solution to the crisis that the health care system faces, without making an effort to understand and compare the cost per day for inpatient care versus the technology investment and the acquisition of new drags that will allow a short hospital stay, which is what makes this kind of practice profitable. What occurs in private practice regarding this matter? Hospital permanency of the postsurgical patient is extended as much as possible because of the profits obtained by them; therefore, we believe that the ambulatory surgery programs are not attractive to these kinds of nonspecific day surgery centers. In the late i940s some ideas of day surgery programs took shape in Latin America, but it was not until 1970 that Honduras began those programs when some procedures were done in long-stay medical centers under ambulatory surgery criteria. In those early days the operations performed were mostly adenotonsillectomy, circumcision, inguinal herniorrhaphy, cystocele correction, hand surgery, and more, but percent-

Adjuvant treatment of colon and rectal cancer: impact of chemotherapy, radiotherapy, and immunotherapy on routine postsurgical patient management. Forschungsgruppe Onkologie Gastrointestinaler Tumoren (FOGT).

Colon cancer patients with UICC stage III or T4 N0 M0 stage II should receive postoperative adjuvant therapy, since relapse rates are high and surgical outcome has been improved by adjuvant treatment. The standard treatment is 5-fluourouracil plus levamisole; an alternative option is the combination of 5-fluourouracil and folinic acid. Stage II (T3 N0 M0) colon cancer patients should not receive adjuvant treatment outside of studies. Rectal cancer patients of stage II or III should receive postoperative radiochemotherapy with 45-54.4 Gy and 5-fluourouracil as standard treatment. Patients not eligible for radiotherapy may receive adjuvant chemotherapy only. Studies need to be conducted to improve adjuvant therapy in colorectal cancer. All qualified patients should be treated within these studies requiring sufficient patient numbers, as well as comparable surgical procedures, proper patient selection and stratification criteria, drug and dose intensities. Intraportal infusion may be as effective as systemic adjuvant treatment; the tumor type and stage for which benefit from this kind of treatment is consistently significant needs to be defined, since intraportal infusion of all resectable colorectal cancers is overtreatment. Both surgery and histopathological staging may be improved in some centers, and these require standardization and quality control.

Influence of diets containing eicosapentaenoic or docosahexaenoic acid on growth and metastasis of breast cancer cells in nude mice.

Diets rich in omega-6 polyunsaturated fatty acids (e.g., corn oil and other fats containing linoleic acid) stimulate the growth and metastasis of human breast cancer cells in athymic nude mice. On the other hand, diets containing fish oil, which is rich in omega-3 fatty acids (e.g., eicosapentaenoic and docosahexaenoic acids), exert suppressive effects. Our objective was twofold: 1) to compare the effects of diets containing linoleic acid with those of diets containing eicosapentaenoic acid and docosahexaenoic acid on the growth and metastasis of MDA-MB-435 human breast cancer cells in the nude mouse model and 2) to determine how such effects relate to observed changes in the chemical content of tumor fatty acids and eicosanoid production. Groups of 30 female athymic nude mice were fed 20% (wt/wt) fat diets containing either linoleic acid (8%) alone, linoleic acid (8%) plus eicosapentaenoic acid (4%) or docosahexaenoic acid (4%), or linoleic acid (4%) plus eicosapentaenoic acid (8%) or docosahexaenoic acid (8%) for 7 days before one million MDA-MB-435 cells were injected into a thoracic mammary fat pad. Diets were continued for 12 more weeks. Primary tumors were measured weekly. The mice were then killed and necropsied, and tumor tissues preserved. Cell membrane phospholipid fatty acid analyses and eicosanoid assays were performed. All P values represent two-tailed tests of statistical significance. The growth of the primary tumors was retarded in mice fed the diets supplemented with eicosapentaenoic or docosahexaenoic acid compared with the growth of primary tumors in mice fed the 8% linoleic acid diet. Growth inhibition was statistically significant (P < .05) and most effective in association with the diets containing 8% of either omega-3 fatty acid, where tumors were smaller than those in the group fed the diet containing 8% linoleic acid alone at all time points after the 2nd week. The occurrence and severity of lung metastases were reduced in the groups fed omega-3 fatty acid (P < .05). In groups of mice fed eicosapentaenoic or docosahexaenoic acid, the representation of these acids in tumor phospholipids increased, with a statistically significant reduction in the concentrations of arachidonic acid (all groups), tumor 12- and 15-hydroxyeicosatetraenoic acid, and prostaglandin E. Levels of 5-hydroxyeicosatetraenoic acid and leukotriene B4 were unaffected by the omega-3 fatty acids. The inhibitory effects of dietary fish oil on human breast cancer cell growth and metastasis in this model system are ascribable to its high eicosapentaenoic acid and docosahexaenoic acid content; the mechanism very likely involves suppression of tumor eicosanoid biosynthesis. Future dietary intervention trials designed to reduce the risk of recurrence in the postsurgical breast cancer patient should include the evaluation of eicosapentaenoic acid and docosahexaenoic acid supplementation.

Validation of unit-based infection control instituted by staff nursing to identify nosocomial infections in the post surgical patient: J. Hargreaves, DO, C. Mann, RN, CIC, S. Hansen, MT.∗ United Hospital, Grand Forks Clinic, Grand Forks, ND

Validation of unit-based infection control instituted by staff nursing to identify nosocomial infections in the post surgical patient: J. Hargreaves, DO, C. Mann, RN, CIC, S. Hansen, MT.∗ United Hospital, Grand Forks Clinic, Grand Forks, ND

Cosmetics in the Postsurgical Patient

The application of colored facial cosmetics is an important part of patient postsurgical rehabilitation. Careful cosmetic selection can avoid surgical complications while providing necessary camouflaging until healing is complete. Dermatologic surgeons should provide guidelines to their patients on postsurgical cosmetic use.

A new, simplified posterior culdoplasty and vaginal vault suspension during abdominal hysterectomy

Objective: A new surgical technique of creating a prophylactic, reconstructive posterior culdoplasty and vaginal vault suspension during abdominal hysterectomy is described. The procedure restores the pelvic topography and gross and functional anatomy after removal of the uterus. A systematic order of the operation, its safety and effectiveness are presented and illustrated. Methods: This surgical technique has been studied for 10 years, from 1983 to 1993, in a group of 250 patients with ages ranging from 19 to 76 years, average age 43 years (Caucasian, n = 178; black, n = 61; and Asian, n = 11). The following new elements were introduced to achieve post-hysterectomy restoration of the posterior cul-de-sac and vaginal vault suspension: the deep layer of the uterosacral ligaments and pararectal-paravaginal fascia are incorporated for reconstructive posterior culdoplasty; the cardinal ligaments and the deep and superficial layers of the uterosacral ligaments are used for anatomical vaginal vault suspension from the latero-posterior aspect of the vaginal wall. Results: This study has documented a good outcome and effectiveness of the operation as well as good postsurgical patient satisfaction, with no symptomatology or signs of dysfunctional vagina, vaginal prolapse or enterocele formation. Conclusion: This new prophylactic procedure is effective, safe, simple to learn, easy to carry out, and adds very little on to the overall surgical time. Restoration of the pelvic topography, functional anatomy, prevention of dysfunctional vagina, vaginal prolapse and pelvic hernia (enterocele) formation can be achieved by following this technique. Post-hysterectomy dysfunctional vagina, vaginal prolapse and pelvic hernia formation are preventable occurrences when a surgical operation is appropriately selected and properly executed.

Does disorder of gastrointestinal motility affect food intake in the post-surgical patient?

In summary, POI is a predictable event with actual return of bowel function preceding clinically detectable signs of function by at least 24 h. All parts of the gastrointestinal tract are affected, but small-intestinal function returns first, probably as early as 4-8 h after surgery in many cases. The timing of restarting feeding could be earlier than current practice would suggest, and because of the more rapid recovery of small-intestinal function it could be argued that post-pyloric feeding, at least in the first 24-48 h, may be preferable. While a policy of refeeding only when bowel function is clinically detectable is acceptable for many patients, there are certainly some who would benefit from feeding at an earlier stage. Parenteral feeding is expensive and a greater knowledge of the mechanisms underlying POI may lead clinicians to different and perhaps more appropriate methods of management.

Determinants of subsequent home health care nursing service use by hospitalized patients with cancer.

The authors examined the extent to which specific patient characteristics and length of hospital stay were capable of independently explaining the use of home health care nursing services by hospitalized patients with cancer after discharge. The current study represents a secondary analysis of a data set originally gathered to identify the home health care needs of patients with cancer. The sample involved 87 patients with cancer who received home health care after hospitalization and 43 patients who did not receive such services. A logistic regression analysis indicated that home health care use was related to patient age, length of hospital stay, and level of symptom distress. Specifically, the likelihood of home health care use was found to increase among subjects older than 50 years of age, subjects with hospital stays of more than 7 days (apparently related to surgery), and those who experienced moderate to high levels of symptom distress. The results indicate a need for home health care nurses to be skilled in the management of cancer symptoms and in the complex problems commonly experienced by the postsurgical patient with cancer.

Coil embolization of aortopulmonary collateral arteries as an emergency in infants and children

SummaryEmbolization of major aortopulmonary collateral arteries by coils introduced via catheterization is a well-established procedure for the control of excessively high pulmonary blood flow in patients with tetralogy of Fallot and pulmonary stenosis or atresia. Under special circumstances, this procedure can be life-saving. Between October 1987 and February 1992, four patients with tetralogy of Fallot and pulmonary atresia and one patient with pulmonary stenosis rather than atresia underwent transcatheter embolization of major aortopulmonary collateral arteries as an emergency. Their ages ranged from 41 days to 13 years, with a mean of 45 months. Two patients had recently undergone surgical repair of tetralogy of Fallot while one had been palliated by enlarging the right ventricular outflow tract without closing the ventricular septal defect. All three had been dependent on mechanical ventilation in the postoperative period with signs of pulmonary congestion or intraparenchymal hemorrhage. Eight embolizations were attempted with 0.025 or 0.038 inch coils; seven collateral arteries were completely occluded and one was partially occluded. Thirteen coils were used in total. The systemic saturation rose in one postsurgical patient, with radiological evidence of decreased pulmonary congestion and regression of hemorrhage. In the other cases, the systemic saturation was unchanged. Peak pulmonary arterial pressures dropped in two patients but remained unchanged in three. Our experience suggests that embolization of major aortopulmonary collateral arteries can be beneficial in critical patients, thus avoiding the risks of surgical reexploration.

The Anatomic Data Sheet in Plastic Surgery

A graphic and written anatomic data sheet (ADS) for facial aesthetic surgery and body contour surgery is presented as a tool for: (1) analyzing surgical maneuvers and their effect on final outcome; (2) recording individual anatomic variations; (3) communicating data between office personnel and colleagues; (4) aiding in the treatment of the postsurgical patient; (5) use as a worksheet for the surgeon; and (6) standardizing, evaluating, and comparing surgical techniques. The ADS takes account of the common aesthetic facial and body contour procedures performed in plastic surgery. A supplemental rubber stamp for use on the office chart, with graphics identical to those of the ADS, identifies areas of treatment concern before and after surgery.

Arterial thromboembolic complications of inflammatory bowel disease

Extraintestinal manifestations of inflammatory bowel disease are legion and are demonstrated in one-third of those afflicted. In general, they do not mandate surgery. Three patients with active pancolonic ulcerative colitis developed arterial thromboembolic complications prior to surgical treatment. Thromboembolic complications are not fully understood, as is evidenced by the paucity of information in the literature, and only sporadic cases of arterial thromboemboli are found. These have been described primarily in the postsurgical patient. To ascertain whether others have encountered similar cases, a survey form was distributed to members of The American Society of Colon and Rectal Surgeons, yielding an additional 54 patients with thromboembolic complications. Approximately two-thirds were deep venous thromboses and/or pulmonary emboli. Ten patients had cerebrovascular accidents, and eight had arterial emboli. Eleven patients, over 21 percent, suffered multiple events. There were four resultant mortalities. An arterial thromboembolic event in a patient with ulcerative colitis is usually associated with pancolonic disease, has a poor long-term prognosis, and is an indication for colectomy.

Microbial Growth and Endotoxin Production in the Intravenous Anesthetic Propofol

In this study, we measured microbial growth and endotoxin production in the intravenous anesthetic propofol using 10 different microbial strains; 6 isolated from outbreak cases and 4 from laboratory stock cultures. In each trial, endotoxin-free glass tubes containing 10 ml propofol were inoculated with 10(0)-10(3) CFU/ml of the test organism and incubated at 30 degrees C for 72 hours. In May and June 1990, the Centers for Disease Control received reports of 5 outbreaks in 5 states of postsurgical patient infections and/or pyrogenic reactions. Epidemiologic and laboratory investigations implicated extrinsic contamination of an intravenous anesthetic, propofol, as the probable source of these outbreaks. After 24 hours, 9 of the 10 cultures increased in viable counts by 3 to 6 logs. At least 1 ng/ml of endotoxin was produced within 24 hours by Escherichia coli, Enterobacter cloacae, and Acinetobacter calcoaceticus subspecies anitratus. Propofol can support rapid microbial growth and endotoxin production. To avoid infectious complications, scrupulous aseptic technique should be used when preparing or administering this anesthetic.

Microbial Growth and Endotoxin Production in the Intravenous Anesthetic Propofol

OBJECTIVE In this study, we measured microbial growth and endotoxin production in the intravenous anesthetic propofol using 10 different microbial strains; 6 isolated from outbreak cases and 4 from laboratory stock cultures. DESIGN In each trial, endotoxin-free glass tubes containing 10 ml propofol were inoculated with 10(0)-10(3) CFU/ml of the test organism and incubated at 30 degrees C for 72 hours. SETTING In May and June 1990, the Centers for Disease Control received reports of 5 outbreaks in 5 states of postsurgical patient infections and/or pyrogenic reactions. Epidemiologic and laboratory investigations implicated extrinsic contamination of an intravenous anesthetic, propofol, as the probable source of these outbreaks. RESULTS After 24 hours, 9 of the 10 cultures increased in viable counts by 3 to 6 logs. At least 1 ng/ml of endotoxin was produced within 24 hours by Escherichia coli, Enterobacter cloacae, and Acinetobacter calcoaceticus subspecies anitratus. CONCLUSIONS Propofol can support rapid microbial growth and endotoxin production. To avoid infectious complications, scrupulous aseptic technique should be used when preparing or administering this anesthetic.

Meningitis in the Neurosurgical Patient

In the patient with a basilar skull fracture and CSF leak, the risk of meningitis is greatly increased. The diagnosis of both leak and infection can be obscured by the patient's other injuries, and requires aggressive investigation of symptoms that suggest infection. Although the diagnosis is made with CSF cultures, when clinically suspected, treatment should begin after appropriate cultures have been obtained. Treatment should be directed against the most likely organisms, Streptococcus pneumoniae, Haemophilus influenzae, and the other organisms common to the upper respiratory tract. There are no good indications for prophylactic antibiotic usage in patients with known CSF leaks. The patient with a shunt or other CNS prosthetic device may have various manifestations of infection, depending on the type of device and its termination. Frank meningitis or ventriculitis is not always present. Diagnosis requires direct culturing of the shunt milieu, with the most frequent isolates being staphylococcal species and gram-negative enteric bacilli. The most effective therapy, for both eradication of the infection and minimization of the duration and morbidity of therapy, involves removal of the infected shunt, external drainage during parenteral antibiotic therapy, and complete replacement of hardware at the time of internalization. The postsurgical patient will not develop meningitis very frequently, but like the posttrauma patient, concurrent factors can make the diagnosis difficult. Differentiating infectious from chemical meningitis must often be initially based on CSF cell counts and chemistries alone. Treatment to cover the most likely organism, staphylococcal species and respiratory flora, should be started before the culture results are finalized.(ABSTRACT TRUNCATED AT 250 WORDS)

Combination High Dose Amrinone and Dopamine in the Management of Moribund Cardiogenic Shock After Open Heart Surgery

Two patients who suffered severe cardiogenic shock after open-heart surgery were successfully resuscitated with high doses of amrinone and dopamine. Both patients had required cardiopulmonary resuscitation and neither was responsive to more conventional mechanical and pharmacologic intervention. Neither patient suffered any serious side effects and both were eventually discharged from the hospital in good condition. These two case reports suggest the potential for using higher than previously reported doses of amrinone in combination with dopamine for the successful treatment of moribund cardiogenic shock in the post open-heart surgical patient. Further studies are needed to assess whether this high-dose drug combination will be successful in patients who present with severe cardiogenic shock unrelated to the post open-heart surgical setting.