Prophylactic Maneuvers Research Articles

An Update on Subciliary Lower Eyelid Blepharoplasty.

The subciliary lower eyelid blepharoplasty has evolved considerably to create a more harmonious natural appearance with a fuller and unoperated look and also to minimize the complications. While lower eyelid malposition was very common in the past, now this complication is significantly reduced by attention to preoperative evaluation, meticulous surgical planning, precise surgical technique, and postoperative care. Various prophylactic maneuvers maintaining/strengthening lower lid support can be utilized to prevent lower lid malposition including preservation of the pretarsal orbicularis oculi muscle, conservative resection of skin and muscle, and suspension of the orbicularis oculi muscle and/or tarsus to the periosteum of the lateral orbital rim. The release of the orbicularis retaining ligament and surgical transposition of orbital fat over the rim rather than excision allows for smoothing of the lid-cheek junction, filling the tear trough deformity, and reducing the appearance of bulging fat in the lower eyelid. In this article the reader will find a comprehensive approach for achieving a smooth contour with gradual blending at the lower eyelid-cheek junction while maintaining/restoring normal lower lid support. A descriptive outline of postoperative care is also provided to help in optimal healing for the patient.

Preoperative measures to prevent/minimize risk of surgical site infection in spinal surgery.

Background:Multiple measures prior to spine surgery may reduce the risks of postoperative surgical site infections (SSIs).Methods:The incidence of SSI following spinal surgery (including reoperations and readmissions) may be markedly reduced by performing less extensive procedures and avoiding fusion where feasible. Preoperative testing up to 3 weeks postoperatively should include other studies to limit the perioperative SSI risk; cardiac stress tests (e.g., older patients/cardiac comorbidities), starting tamsulosin in males over 60 (e.g. avoid urinary retention due to benign prostatic hypertrophy), albumin/prealbumin levels (e.g., low levels increase SSI risk), and HBA1C levels to identify new/treat known diabetics (normalize/reduce preoperative levels).Results:Other measures include the timely administration of preoperative antibiotics (e.g., cefazolin 2 g nonpenicillin allergic), one dose of gentamicin (adjusted dose/weight), nasal cultures for methicillin-resistant Staphylococcus aureus (patients/health-care workers), and bathing 2 weeks preoperatively with chlorhexidine gluconate 4% (not just night before/morning of surgery). Additionally, prior to surgery, the following medications that increase the bleeding risk should be stopped (e.g. for varying periods); anticoagulants, antiplatelet therapies (e.g., aspirin for at least 7–10 days), nonsteroidal anti-inflammatories (NSAIDS: timing depends on the drug), vitamin E, and herbal supplements. Additionally, avoiding elective spinal surgery in morbidly obese patients and recognizing other major medical contraindications to spinal surgery should help reduce infection, morbidity, and mortality rates.Conclusions:Appropriate preoperative and intraoperative prophylactic maneuvers may reduce the risk of postoperative spinal SSI. Specific attention to these details may avoid infections and improve outcomes.

Revision Rhinoplasty: Retrospective Chart Review Analysis of Deformities and Surgical Maneuvers in Patients with Nasal Airway Obstruction-Five Years of Experience.

Nasal airway obstruction is one of the most frequent causes of revision rhinoplasty in patients after previous rhinoplasty procedure. Purpose of this study is to present the deformities and the surgical maneuvers conducted in revision rhinoplasty patients with functional complaint, anatomical sites at risk, and potential prophylactic maneuvers. This study is a retrospective chart review analysis of 46 consecutive revision rhinoplasty procedures in patients with nasal airway obstruction. Inclusion criteria were at least one previous rhinoplasty and nasal airway obstruction as the epicenter of patients' complaint. Thorough clinical examination to certify the obstruction was performed. Deformities noted were separated in three categories according to functional, cosmetic, and combination of functional and cosmetic implications. Surgical maneuvers conducted were reviewed. Deformities found were checked for statistically significant coexistences. The average patient age was 34.9 years. The mean number of previous septorhinoplasties was 1.33. Nasal ventilation obstruction mainly caused either by septum deviation or nasal valve dysfunction was identified in 91.3% of our patients. Surgical maneuvers conducted included placement of grafts in 89.1% of all cases, septoplasty in 76.1%, lateral wall support in 47.8%, and placement of spreader grafts in 39.1% of patients. The average preoperative Nasal Obstruction Symptom Evaluation (NOSE) score was 61 ± 15 and it improved substantially, even from month 1, postoperatively. Owing to high prevalence of nasal airway obstruction after primary or secondary rhinoplasty, we conducted the first retrospective chart review study to identify the most common deformities in revision rhinoplasty patients with nasal airway obstruction and the appropriate surgical maneuvers to address them. Septum deviation and nasal valve dysfunction were the two pillars of nasal airway obstruction in those patients.

Composite prevention strategy for shoulder dystocia: meta-analysis

To investigate the composite prevention strategy for shoulder dystocia. The published articles of randomized controlled trial (RCT) of comparison about the prevention of shoulder dystocia were searched in PubMed, EMBASE, EBSCO databases and Cochrane Library, and these studies were screened under inclusion and exclusion criteria. The quality of included studies were evaluated. And the Meta-analysis using statistic software RevMan 5.1 was completed. Totally 16 articles, all English published with no one Chinese article being searched out, were included in this analysis, published from 1993 to 2009. ( 1)To the gestational diabetes mellitus (GDM) patients, reviewed from 2 articles, it was found that the incidence of shoulder dystocia was reduced significantly by prenatal intervention versus usual care (OR = 0.40, 95% CI:0.21- 0.75, P = 0.004). (2)To the GDM patients with intensive prenatal intervention, reviewed form 5 articles, it was found that the incidence of shoulder dystocia was reduced significantly by intensive intervention(diet control combined with insulin if necessary)versus less intensive intervention (only diet control), OR = 0.29 (95%CI:0.11-0.73, P = 0.009). (3) To the non-GDM patients with suspected macrosomia, reviewed from 4 articles, it was found that the incidence of shoulder dystocia was not reduced by early artificial induction of parturition (OR = 0.85, 95%CI:0.41-1.75, P = 0.660). (4)To the GDM patients, reviewed form 2 articles, it was found that the incidence of shoulder dystocia was reduced marginal significantly by artificial induction of parturition in 38-39 gestational weeks compared with all spontaneous parturition patients (OR = 0.18, 95%CI:0.03-0.97, P = 0.050) and significantly reduced when compared with those spontaneous parturition patients after 40 gestational weeks (OR = 0.13, 95%CI: 0.02-0.75, P = 0.020). (5)To the GDM patients with suspected macrosomia, reviewed from only one article, it was found that the incidence of shoulder dystocia was reduced marginal significantly by early artificial induction of parturition (OR = 0.34, 95%CI:0.12-0.99, P = 0.050). (6)Reviewed from 2 articles, it was found that the incidence of shoulder dystocia was not significantly reduced by the intrapartum prophylactic maneuvers (OR = 0.44, 95% CI:0.16-1.18, P = 0.100). Some varieties of intervention for the high risk patients could reduced the occurrence of shoulder dystocia.

Post-endoscopic retrograde cholangiopancreatography complications: How can they be avoided?

Endoscopic retrograde cholangiopancreatography (ERCP) has a significant complication rate which can be lowered by adopting technical variations of proven beneficial effect and prophylactic maneuvers such as pancreatic stenting during ERCP or periprocedural non-steroidal anti-inflammatory drug administration. However, adoption of these prophylactic maneuvers by endoscopists is not uniform. In this editorial we discuss the beneficial effects of the aforementioned maneuvers.

Female Patients Undergoing TEVAR May Have an Increased Risk of Postoperative Spinal Cord Ischemia

There is a paucity of literature regarding thoracic endovascular aneurysm repair (TEVAR) in women. We report our institutional experience with TEVAR. Retrospective chart review was performed from 2004 to 2008. TEVAR was performed in 59 patients; 29 (49%) were female. Mean age was 73.5 years. Mean thoracic aortic aneurysm (TAA) diameter was larger for women (5.9 cm vs 4.7 cm). A trend toward an increase in paraplegia was noted in women, 10.3% vs 4.8%. This may be related to increase in length of aortic coverage in women, 18.2 cm vs 15.2 cm (P < .05). TEVAR in women is safe and effective. The length of aortic coverage is greater in women, which may be related to larger aneurysms and more diffuse disease. This may be associated with a concerning increase in postoperative paraplegia. Women undergoing TEVAR should be considered for prophylactic maneuvers to prevent spinal cord ischemia (SCI), including minimizing length of coverage.

Colonoscopic polypectomy and associated techniques

Polypectomy of colonic polyps has been shown to reduce the risk of colon cancer development and is considered a fundamental skill for all endoscopists who perform colonoscopy. A variety of polypectomy techniques and devices are available, and their use can vary greatly based on local availability and preferences. In general, cold forceps and cold snare have been the polypectomy methods of choice for smaller polyps, and hot snare has been the method of choice for larger polyps. The use of hot forceps has mostly fallen out of favor. Polypectomy for difficult to remove polyps may require the use of special devices and advanced techniques and has continued to evolve. As a result, the vast majority of polyps today can be removed endoscopically. Since electrocautery is frequently used for polypectomy, endoscopists should be thoroughly familiar with the basic principles of electrosurgery as it pertains to polypectomy. Tattooing of a polypectomy site is an important adjunct to polypectomy and can greatly facilitate future surgery or endoscopic surveillance. The two most common post-polypectomy complications are bleeding and perforation. Their incidence can be decreased with the use of meticulous polypectomy techniques and the application of some prophylactic maneuvers. This review will examine the technique of polypectomy and its complications from the perspective of the practicing gastroenterologist.

Clinical and Epidemiological Aspects of Clostridium difficile

Clostridium difficile-associated disease (CDAD) has increased in frequency and severity throughout North America and Europe over the last 5 years, largely due to the emergence of the NAP1 epidemic strain. This transformation of a formerly mild disease into one that can cause severe morbidity and mortality within a few days has challenged our entire approach to this serious infection. Institutions require accurate and rapid diagnostics for early detection of cases and possible outbreaks in order to initiate specific therapy and implement effective infection control. The optimal hand hygiene techniques, barrier methods and environmental cleaning practices that would diminish transmission remain uncertain. Clinicians need reliable research that can pinpoint the most important factors determining severity of disease and relapse. Epidemiologic and molecular analyses are vital in order to understand the local and international transmission of this disease, as well as its recent change in pathogenicity. As well, further examination of this infection is crucial in order to find effective prophylactic maneuvers and optimal therapies. This review discusses the changing epidemiology of CDAD across North America and internationally, as well as the common diagnostic methods and molecular typing tools for this pathogen. Finally, the current evidence supporting conventional, novel, and non-antimicrobial preventative and therapeutic options is examined.

Avoiding Trouble Down the Line: The Management and Prevention of Hemodialysis Catheter-Related Infections

Over the last 2 decades, hemodialysis catheter use has increased. Annually, approximately 30% of patients using a central venous catheter (CVC) experience a septic or bacteremic episode and are subsequently at risk of its associated long-term complications and mortality. Because of the serious clinical and financial impact of hemodialysis catheter-related bacteremias (HCRIs), standardized, validated definitions based on the hemodialysis patient population are necessary in order to better diagnose, monitor, and report HCRI for patient quality assurance and research purposes. The pathophysiology of HCRI involves a complex interaction between a triad that consists of the host patient, the infecting microorganism, and the vehicle catheter. Although the microorganism contribution in the pathogenesis of HCRI is likely most important, certain patient and catheter-related characteristics may be more amenable to manipulation. The key to managing HCRI is on prophylaxis against the initial microorganism catheter adherence and subsequent biofilm development. General and specific prophylactic maneuvers directed at both an intravascular and extraluminal route of microorganism entry are discussed including antibiotic- and silver-impregnated catheters and dressings, subcutaneous access devices, and topical prophylaxis at the exit site. In addition to systemic antibiotic use, the 3 methods of HRCI treatment using catheter salvage, guidewire exchange, and concurrent antibiotic lock are compared. The outcome and complications of HCRI may be serious and highlight the importance of careful, continual infection surveillance. Although the use of a multidisciplinary hemodialysis infection control team is desirable, staffing education and physician feedback have been shown to improve adherence to infection control guidelines and reduce HCRI.

Intentional coverage of the left subclavian artery during endovascular stent graft repair for thoracic aortic disease

Surgical revascularization of the left subclavian artery (LSA) has been performed to warrant arm perfusion and to prevent paraplegia during thoracic stent graft (SG) procedures. We retrospectively investigated the outcome after intentional occlusion of the left subclavian artery during SG repair for thoracic aortic diseases. From December 2000 to June 2005, 11 patients (mean age, 57 +/- 19 years) with a short (<1 cm) proximal aspect of a thoracic aortic lesion underwent intentional LSA coverage to expand the proximal landing zone for SG fixation. Three patients were treated in the emergency setting. We did not perform a prophylactic revascularization of the LSA prior to SG implantation. A preliminary balloon occlusion test of the LSA was not performed in this series. The SG was positioned so that its covering was immediately distal to the left common carotid artery. SG implantation was technically successful in all patients. Intraoperative mortality was not observed; no patient suffered any impairment of left carotid artery flow. Aortography after SG implantation showed no direct flow in the LSA and refilling of the LSA via the ipsilateral vertebral artery. After the intervention, mean systolic pressure in the left arm decreased by 38 +/- 17 mmHg. The stented length of the aorta was 171 +/- 73 (median, 150). During hospitalization, no patient showed any signs of left arm malperfusion. Paraplegia was not observed. One patient developed transient ischemic attack. During a mean follow-up of 19 +/- 8 months (range, 3-36), all patients were completely asymptomatic and had no functional deficit or temperature differential between arms. No leakage was detected. Intentional LSA occlusion seems to be well tolerated. Prophylactic surgical maneuvers may be relegated to an elective measure after an endovascular aortic intervention when intolerable signs or symptoms of ischemia occur.

EVALUATION OF INTRA-ABDOMINAL PRESSURES AND GAS EMBOLISM DURING LAPAROSCOPIC PARTIAL NEPHRECTOMY IN A PORCINE MODEL

Gas embolization is a well documented complication of laparoscopic surgery. We evaluated the association of gas embolization with increased intra-abdominal pressure (IAP) in the porcine model during laparoscopic partial nephrectomy with real-time transesophageal echocardiography. Eight domestic pigs weighing 143 to 162 pounds underwent unilateral transperitoneal laparoscopic heminephrectomy with renal artery clamping with varied IAPs. The renal vein was not clamped, allowing the exposure of venous tributaries to the pneumoperitoneum. IAP was increased in 5 mm Hg increments in 4 pigs each by 1) insufflation pressure adjustment to a maximum of 30 mm Hg and 2) intermittent application of an argon beam coagulator (ABC) to the cut kidney surface. Transesophageal echocardiography was used to monitor embolism. None of the 4 animals subjected to increased CO2 insufflation pressure (maximum 30 mm Hg) demonstrated gas embolization during partial nephrectomy. The ABC caused gas embolization during partial nephrectomy at an IAP of 30 to 50 mm Hg in 4 animals. The volume of embolized gas was 4 to 20 ml. None of the animals showed intraoperative hemodynamic compromise. Gas embolization was not seen during laparoscopic partial nephrectomy with typical insufflation pressures. The ABC can rapidly increase IAP and cause argon embolization at IAPs greater than 30 mm Hg. Prophylactic maneuvers to prevent gas embolization, such as intra-abdominal venting or renal vein clamping, should be considered when applying the ABC.

Matched-unrelated-donor bone marrow transplantation for children with leukemia.

This report describes the results of matched-unrelated-donor transplant for leukemia or myelodysplasia in the first 23 recipient children at a single medical center in Taiwan. Between August 1994 and February 2003, 23 consecutive children with leukemia or myelodysplasia underwent matched-unrelated-donor bone marrow transplantation (BMT). The preparative regimen consisted of fractionated total body irradiation and cyclophosphamide in 6 patients; busulfan in combination with etoposide and cyclophosphamide in 4 patients who received cranial irradiation before transplantation; and busulfan and cyclophosphamide in 13 patients. Engraftment was achieved in 91.3% of cases. Acute graft-versus-host disease (GVHD) occurred in 18 of 21 patients who engrafted (85.7%). Event-free survival for all patients was 24.46 +/- 9.24%. The 12 children with standard-risk disease had better event-free survival than the 11 children with high-risk disease (46.88 +/- 15.03% vs 0%, p < or = 0.001). The major obstacles to successful matched-unrelated-donor BMT are acute GVHD, relapse and infection. Early transplantation and patient selection, prophylactic and therapeutic maneuvers for GVHD, as well as appropriate donor selection and virus prophylaxis may improve the results.

Pre-, Intra-, and Post-Procedure Risk Factors for Post-ERCP Pancreatitis

BACKGROUND: Objective means for estimating the risk for post-ERCP pancreatitis (PEP) during the PRE-procedure, INTRA-procedure, and POST-procedure phases would allow optimal application of prophylactic maneuvers, based upon the evolving risk profile for a given pt. Our aim is to prospectively identify these risk factors (RF) and to construct predictive models for these phases. METHODS: Pts. scheduled for elective outpatient ERCP at the Mayo Clinic consented to data-collection and laboratory studies. Data pertaining to potential RF were collected. Blood was collected 4 hours after ERCP; serum amylase & lipase were then determined for pts. admitted with PEP and for a contemporaneous control pt. scheduled on the same day. Logistic regression was used to estimate the odds (OR) for PEP and 95% confidence intervals. RESULTS: 664 unselected ERCP pts. (ages 18-93, mean 55 yrs; 53% female) were evaluated. Pancreatitis developed in 37 (5.6%). Age and a prior hx of acute pancreatitis were associated with an increased risk of PEP (p=0.04 and 0.03). When adjusting for age & hx of pancreatitis no additional PRE-RF were associated with PEP. Adjusted INTRA-RF included: PD or dual duct injection (OR 2.7(1.2-6.0)*), > 1 PD injection (3.9(1.5-9.9)**), filling of the entire PD (5.1(1.7-15.6)**) or the side branches (4.7(1.5-14.8)**), and performance of needle-knife sphincterotomy (NK-ES) (2.6(1.2-5.9)*), pancreatic ES (18.2(6.4-51.6)**), or PD manometry (5.5(1.6-19.3)**). Adjusted POST-RF included: abdominal pain (5.6(2.4-13.1)**), nausea or vomiting (3.2(1.4-7.0)**), use of analgesics (8.9(4.1-19.2)**), or antiemetics (3.3(1.4-7.8)**), and post-ERCP amylase > 255 (17.4(4.7-63.6)**) (* p<0.05, ** p<0.01). No association was detected for gender, pre-procedure amylase, number of cannulation attempts, subjective assessment of cannulation difficulty, acinarization, biliary manometry, biliary sphincterotomy, or failed ERCP. CONCLUSIONS: 1) Pre-procedure RF for PEP include younger age and past history of pancreatitis. 2) Procedural RF for PEP include needle-knife sphincterotomy and pancreatic manipulations, but not those interventions limited solely to the biliary tree. 3) Post-procedure RF include presence of abdominal pain or nausea/vomiting in recovery, the need to medicate for either of these complaints, and serum amylase values > 255 U/L. 4) These data should allow development of predictive models for post-ERCP pancreatitis during the PRE, INTRA, and POST phases.

A Randomized Controlled Trial of Prophylactic Maneuvers to Reduce Head-to-Body Delivery Time in Patients at Risk for Shoulder Dystocia

Beall, Marie H. MD; Ross, Michael G. MD, MPH; Spong, Catherine Y. MD Author Information

A Randomized Controlled Trial of Prophylactic Maneuvers to Reduce Head-to-Body Delivery Time in Patients at Risk for Shoulder Dystocia

A Randomized Controlled Trial of Prophylactic Maneuvers to Reduce Head-to-Body Delivery Time in Patients at Risk for Shoulder Dystocia

A Randomized Controlled Trial of Prophylactic Maneuvers to Reduce Head-to-Body Delivery Time in Patients at Risk for Shoulder Dystocia

In Brief OBJECTIVE To assess whether prophylactic use of the McRoberts maneuver and suprapubic pressure decreased the head-to-body time, as a proxy for shoulder dystocia, in at-risk patients. METHODS Patients with estimated fetal weights over 3800 g were randomized to undergo the McRoberts maneuver and suprapubic pressure before delivery of the fetal head (prophylactic maneuvers) or to undergo maneuvers only after delivery of the head, if necessary (controls). A total of 185 patients were enrolled in the study. After exclusions (eg, abdominal delivery), there were 128 evaluable vaginal deliveries. The study had the power to detect a 30% difference in head-to-body time between groups. RESULTS Head-to-body delivery times did not differ between the prophylactic and control patients (24 ± 18 seconds versus 27 ± 20 seconds, P = .38). In addition, the two groups did not differ in rates of admission of the infant to the special care nursery or in birth injuries. There was a significant increase in the risk of delivering by cesarean for patients randomized to the use of prophylactic maneuvers. CONCLUSION This study does not support the hypothesis that prophylactic use of the McRoberts maneuver and suprapubic pressure speeds delivery in a population of patients at increased risk for shoulder dystocia. Prophylactic use of the McRoberts maneuver and suprapubic pressure did not speed head-to-body delivery time in patients expected to deliver a large infant.