Superficial Procedures Research Articles

Critical care innovations: navigating pain relief in intensive care: the role of regional anesthesia.

The purpose of this article is to provide an update of regional anesthesia and its applications in the critical care patient population. Regional anesthesia including blocks of the abdomen and thorax, head and neck, as well as upper and lower extremities can be used to alleviate pain and assist in managing life-threatening conditions such as cerebral vasospasm and ventricular storm in the ICU population. There have been many advances in these techniques including ultrasound-guidance with innovative approaches that allow for more superficial procedures that are safer for critically ill patients. Regional anesthesia can decrease hospital length of stay (LOS), prevent ICU admission, shorten ICU LOS, and increase ventilator free days and may have mortality benefits. Pain management in the ICU is an important and sometimes challenging aspect of patient care. Regional anesthetic techniques have more indications and are safe, versatile tools that should be incorporated into care of critically ill patients.

Enhancing the Microneurosurgical Training: Development of the Folded Placenta Model for Simulation of the Deep Operative Field Challenges of Cranial Procedures

Neurosurgery relies heavily on advanced manual skills, necessitating effective training models for skill development. While various models have been utilized, the human placenta has emerged as a promising candidate for microneurosurgical training due to its anatomical similarities with cerebral vasculature. However, existing placenta models have primarily focused on simulating superficial procedures, often neglecting the complexities encountered in deep operative fields during cranial surgeries. This study obtained ethical approval and implemented a modified placenta model to address the limitations of existing training models. The key modification involved folding the placenta and placing it within a rigid container, closely mimicking the structural challenges of cranial procedures. The placenta preparation followed a standardized protocol, including the use of specialized equipment for documentation. The primary feature of the modified model is the folded placenta within the rigid container, which replicates cranial anatomy. This innovative approach enables trainees to engage in a comprehensive range of microsurgical exercises, encompassing vessel dissection, aneurysm clipping, tumor resection, and more. The model successfully mirrors the complexities of real cranial procedures, providing a realistic training experience. The presented modified placenta model serves as an effective tool for simulating the conditions encountered in deep cranial surgeries. By accurately replicating the challenges of deep operative fields, the model significantly enhances the training of neurosurgical residents. It successfully prepares trainees to navigate the intricacies and difficulties inherent in real cranial surgeries, thus contributing to improved surgical skills and readiness for neurosurgical practice.

About them, without them? figures of youth in Australian policy 2014–2021

ABSTRACT This paper considers the multiple and contradictory depictions of young people in youth policy and reflects on how youth engagement is constructed in Australian Federal and State policy. In this journal, researchers have been challenged to critically reflect on ‘figures of youth' (Threadgold, 2020) and we take up this challenge and consider how and why ‘figures of youth' are deployed in Australian youth policy. Drawing on an environmental scan of youth policy documents published between 2014-2021, we analyse the ways young people's voices are positioned to legitimate policy claims about what is required to help young people in Australia across multiple domains. Despite the apparent agreement among policy-makers that youth consultation is important in the policy development process, our scan points to a wide variety of interpretations of what ‘youth voice' might look like, how young people participate, and how their contributions are actually utilised. We argue that the persistence and frequent emergence of particular ‘figures of youth’ throughout Australian youth policy reflects the endurance of adult-centric interpretations of youth, and the partial and superficial procedures that claim to engage with young people, but which ultimately privilege the interests of other agendas.

Liposuction to improve vascular access in hemodialysis patients with arteriovenous fistulas.

Arteriovenous fistulas (AVFs) are indispensable in the care of patients with end-stage renal disease requiring hemodialysis. Obesity is a common comorbidity in hemodialysis patients, often making AVF cannulation technically challenging. Liposuction can be performed for superficialization of the AVF without the need for an open superficialization procedure. The aim of the present study was to evaluate the outcomes of liposuction to improve AVF access for hemodialysis. We performed a retrospective medical record review of patients who had undergone liposuction over an AVF at our institution from January 2000 to September 2021. Data were collected on the demographics, medical comorbidities, AVF site and depth, AVF diameter and flow, operative details, surgical complications, and follow-up. A total of 19 patients had been referred by the hemodialysis clinic for liposuction. Their mean age was 55.5years, and their mean body mass index was 39.5kg/m2. Either liposuction alone or liposuction combined with minimal access direct lipectomy was performed to superficialize the AVF. All procedures were performed secondarily, after prior creation of the AVF. Of the 19 patients, 18 had had an upper AVF and 1 had had a lower extremity AVF graft. Of the 19 patients, 12 (63%) had proceeded to hemodialysis after one liposuction. The mean time to cannulation for 10 of these 12 patients was 52.1± 25.6days. Two of the 12 patients were excluded from the mean calculation to prevent skewing from their prolonged time to requiring dialysis initiation. Of the 19 patients, 2 had required additional liposuction sessions, and 1 had required AVF intervention after the first liposuction attempt before achieving successful cannulation. Four patients (21%) had had unsuccessful cannulation despite additional liposuction or AVF interventions owing to AVF stenosis or thrombosis. Overall, 15 of the 19 patients (79%) had successfully proceeded to dialysis in the same extremity. The mean access depth had decreased from 1.75cm before liposuction to 0.93cm after liposuction. The mean volume of fat removed was 92.3cm3. Of the 16 patients with prior dialysis catheters, 11 were eventually removed after surgery once the vascular site was accessible. The body mass index correlated positively with the interval to the first successful cannulation (r= 0.5881; P< .05). The surgical complications included two cases of cellulitis treated with oral antibiotics. The mean follow-up time was 38.3months. Our results have shown that liposuction can be performed safely in obese patients requiring hemodialysis and was successful in improved AVF access for 15 of the 19 patients (79%) in our cohort. Larger studies are needed to compare the outcomes of this technique with those of open superficialization.

Perceptions of telemedicine at a pediatric otolaryngology-head and neck surgery program

ObjectiveWith few studies investigating the effectiveness of telemedicine (TM) in pediatric otolaryngology (ear, nose, and throat; ENT), its role in clinical practice is unclear. The objective of this study was...

학업중단 예방 사업 운영 현황 분석

The purpose of this study is to draw implications for policy improvement by identifying the current status of school drop prevention policies and projects being operated at school sites. To achieve this objective, a survey was conducted with school teachers in charge of the nationwide school drop prevention projects. A total of 1,575 people responded to the survey. The results of analyzing the school members’ perceptions of the school drop prevention projects, the current status of business operations, difficulties, and areas for improvement were analyzed as follows. First, the designation of the school drop prevention projects and the operation of the deliberation systems are concentrated at the high school level. Considering the accumulated situations of the academic discontinuation, it is necessary to activate projects in both elementary school and high school level. Second, the operation of alternative classrooms in schools was in the order of middle school (39.8%), elementary school (6.4%), and high school (27.3%). In particular, it is necessary to understand the difficulties in operating alternative classrooms in elementary schools. In addition, it is necessary to prepare a way to overcome stigmas and prejudices, and a plan to link the curriculum of alternative classrooms in high schools. Third, the significance and necessity of the study regarding the school drop prevention projects were found in the order of providing emotional stability (4.08 points), providing time and space for rest (4.07 points), helping with school adjustment (3.94 points), and providing customized education (3.92 points). Therefore, it is necessary to provide programs and opportunities for students to solve problems according to their situation. Fourth, the difficulties of the school drop prevention project were derived from the overload of the person in charge, the lack of connection to external organizations, and formal and superficial work procedures. Therefore, it is necessary to improve policies such as assigning one or more professional counselors to schools, providing incentives for those in charge, support from the office of education for linking external instructors with local community organizations, and discovering and expanding entrusted educational institutions for alternative education with expertise.

Ultrasound-Assisted Rhytidectomy Including Sub-SMAS and Subplatysmal Dissection.

Energy-based facelifting techniques are a relatively new genre of surgery. In this approach, the energy-based device-whether laser, radiofrequency plasma, or ultrasound-can be used in the superficial plane to elevate skin flaps before performing more traditional facelift techniques involving the superficial musculoaponeurotic system (SMAS) or platysma. The initial reports of utilizing fiber lasers as surgical tools date back to approximately 2007 and initial lipolasers were used to elevate facial skin flaps. The other energy-based devices were also tested. The author has probably the largest series of energy-based facial rejuvenation procedures, having performed over 3,000 of these procedures. The advantages of laser-assisted rhytidectomy include hemostasis, facilitated dissection in areas hard to elevate conventionally such as nasolabial folds or distal neck and the remodeling and tightening of tissue that results from the activation of the wound healing cascade of neocollagenesis and wound contraction. The author currently has a preference for energy device used during rhytidectomy and it is a high frequency ultrasound energy delivered by a five-ring 2.9- and 3.7-mm probe. The use of the ultrasound dissector in both superficial and deep procedures is highlighted in this article with emphasis on its use for deep cervicoplasty and subplatysmal procedures as well as sub-SMAS elevations of the facial deep plane.

Effect of unplanned excision of soft tissue sarcomas on skin defects and reconstructive procedures

Unplanned excision (UE) is defined as a procedure wherein a surgeon operates a tumor resection without appropriate preoperative diagnostic modalities and without the intent to achieve tumor-free margins. Generally, the reconstruction rate after UE is higher than that after planned excision (PE). The present study aimed to investigate how the reconstructive procedure and size of skin defect could be influenced. We reviewed the cases of 442 patients who underwent the resection of soft tissue sarcoma. Patients were stratified into two groups (UE vs. PE). We compared the histologic grade, skin defect, reconstructive procedures, depth of the reconstruction layer. For superficial reconstructions, we also compared procedures involving skin graft-only or flap. 105 cases (23.8%) were UE. Histologic grade in PE was significantly higher (p = .024). The reconstruction rate and size of skin defect in UE was significantly higher (76.2% vs. 27.3%, p < .001) and larger (124.5 cm2 vs. 65.7 cm2, p < .001). The rate of deep layer reconstruction was significantly higher in PE (7.5% vs. 26.1%, p = .001). In superficial reconstructions, 18 (24.3%) skin graft-only procedures were performed in UE and 15 (22.1%) in PE, all other superficial reconstructive procedures involved flap, and there was no significant difference (p = .45). Skin defects were 1.9 times larger after UE than PE. UE did not affect the superficial reconstructive procedure.

Preoperative Considerations for the Prevention of Surgical Site Infection in Superficial Cutaneous Surgeries: A Systematic Review.

Background: Surgical site infections (SSIs) pose challenges to the outcome of superficial cutaneous procedures. Objective: The objective of this study was to summarize published data regarding appropriate perioperative considerations to decrease SSI, including antiseptic use, topical decolonization, antibiotic prophylaxis, and clean versus sterile technique in superficial cutaneous procedures. A literature search was performed via PubMed and Cochrane Library by using relevant keywords. A total of 37 articles met the inclusion criteria. Strength of data was assessed according to the Oxford Centre criteria and a modified Grading of Recommendations, Assessment, Development, and Evaluation approach. Results: Chlorhexidine is the antiseptic of choice in clean or outpatient superficial cutaneous procedures. Decolonization of carriers of Staphylococcus aureus with mupirocin is warranted for all superficial cutaneous procedures. Minor procedure rooms may be considered for superficial cutaneous procedures that possess an inherently low risk of SSI. Surgeons may consider nonsterile gloves instead of sterile gloves for clean or outpatient superficial cutaneous procedures. Postoperative use of topical antibiotics may be discontinued, as there are risks of adverse effects and increasing bacterial resistance without a significant reduction in SSI. Conclusion and Relevance: This systematic review provides new and updated evidence for the prevention of SSI in superficial cutaneous procedures through antiseptic use, antibiotic use, topical agents, and the surgical environment. The overall quality of evidence is good, with most articles being original research or systematic reviews. However, there is a need for dermatologic- and plastic surgery-specific studies regarding the prevention of SSI.

Liposuction used to treat deep vascular accesses for hemodialysis.

Oftentimes, obese dialysis patients develop a viable dialysis access but the access is too deep for cannulation and needs a superficialization procedure. We present our 14-patient cohort in whom we performed liposuction to superficialize viable but deep vascular accesses. Out of 14 patients, 12 had arteriovenous fistulas and 2 arteriovenous grafts. The primary end points were the ability to superficialize a completely unusable access and to remove the hemodialysis catheter (3patients), or to significantly extend the useful length of a deep access in which only a very short segment was used and to continue to use the access post-surgery without the need to place a dialysis catheter (11 patients). The study goal was met in 13 out of 14 patients. In two of three patients, the catheters were removed and their access usable length was 14 and 13 cm, respectively. The accesses could be used immediately after liposuction in all patients in which this applied-11 patients. The usable access length increased from a mean of 5 to 12.7 cm. The access mean depth decreased from 10.8 mm pre-surgery to 7 mm post-surgery and 5.3 mm 4 weeks after surgery. The mean volume of fat removed was 43.8 cc. We had only one surgical complication: bleeding that was readily controlled with manual pressure. All patients were discharged to home the same day. Postoperative pain was mild. Liposuction is effective, safe, and seems to be the least invasive technique of superficialization.

Effect of an ultrasound-guided lung recruitment manoeuvre on postoperative atelectasis in children: A randomised controlled trial.

Ultrasound-guided alveolar recruitment, regardless of the technique, could be more effective because it facilitates real-time monitoring of the expansion of collapsed alveoli. To evaluate and compare the effects of an ultrasound-guided lung recruitment manoeuvre with those of a conventional recruitment manoeuvre on the occurrence of postoperative atelectasis and clinical outcomes in children. A randomised controlled trial. Tertiary children's hospital. Children aged 6 years or less. Children scheduled for simple, superficial procedures underwent lung ultrasound after tracheal intubation (T1), at the end of surgery (T2) and before discharge from the postanaesthesia care unit (T3). Following lung ultrasound evaluation at T1 and T2, the conventional recruitment manoeuvre with a maximal airway pressure of 30 cmH2O was performed in the control group, while an ultrasound-guided recruitment manoeuvre was performed in the ultrasound group. The primary outcome was the incidence of significant atelectasis at T3. The incidences of atelectasis at T3 were 20.9 and 11.6% in the control (n = 43) and ultrasound groups (n = 43), respectively (odds ratio [OR], 2.012; 95% confidence interval [CI], 0.614 to 6.594; P = 0.249). The lung ultrasound scores were better in the ultrasound group than in the control group at T2 and T3, and the incidence of postoperative desaturation was higher in the control group than in the ultrasound group (16.3 vs. 2.3%; OR, 0.12; 95% CI 0.01 to 1.04; P = 0.05). The median airway pressure required for full lung expansion in the ultrasound group was 35 cmH2O at T1 and T2. Other postoperative outcomes were similar between groups. Ultrasound-guided lung recruitment may be more effective than the conventional procedure in terms of the prevention of intra-operative atelectasis and postoperative desaturation; however, its beneficial effects on postoperative atelectasis remain unclear. An inspiratory airway pressure of more than 30 cmH2O is required for full recruitment of alveoli in healthy children. ClinicalTrials.gov (NCT03453762).

Technical note: An alternative method for AV access superficialization.

An arteriovenous fistulae for dialysis access is only functional if superficial enough for reliable cannulation. We describe a previously unreported technique to superficialize arteriovenous fistulae too deep for reliable cannulation. The path of the fistula is marked using ultrasound, and three to four transverse incisions are made along this path. The subcutaneous tissue is separated from the dermis over this entire area. The fistula is then accessed through transverse incisions and by dividing the overlying adipose tissue. The mobilized vein is then "trapped" directly under the dermis by closing the superficial fascia and adipose tissue beneath it and using this tissue to elevate the fistula. No anastomotic revisions are necessary, and moderate straightening can be performed. We have performed this procedure on 20 patients with 100% technical success. One fistula had thrombosis within 8-10 weeks of the superficialization procedure and one patient refused access due to pain, but all other fistulas were successfully cannulated. Two patients were lost to follow-up, and one patient developed skin breakdown in the area of the flap which delayed cannulation. Our 3-month patency was 94.4% with a functional patency, defined as a clinically patent fistula successfully being used for hemodialysis, of 87.5%. The technique described allows elevation of the vein to the level of the dermis without division and re-anastomosis or re-tunneling, through several small incisions maintaining virgin skin and normal contour for easier cannulation.

History of Cardiac Anesthesia in India

Before the 19th century, the heart was considered as a "no-go" area, although minor and superficial procedures were performed in the early 1800s. It was only in the later part of the century that surgical repair of the wounds of the cardiac chambers was attempted. Cardiac surgery came to India in the mid-20th century and the operations performed were minor and extracardiac. Initially, the surgeries were performed at a select few centers located at Mumbai, Vellore, Delhi, Chennai, and Kolkata. The anesthesiologists of an earlier era in India worked with limited facilities, and with their interest and devotion contributed immensely to the growth of the specialty of cardiac anesthesia. The progress was somewhat modest until the 1980s, when it started increasing rapidly and India caught up with the Western world by the turn of century. The progress was seen not only in the clinical field, but also in technology, teaching, and academic fields. This article presents an account of the progress in the field of cardiac anesthesia in India, and highlights the contribution of some of the dedicated anesthesiologists because of whom the specialty has reached the present stature.

Topical anaesthetics for pain control during repair of dermal laceration.

Topical local anaesthetics provide effective analgesia for patients undergoing numerous superficial procedures, including repair of dermal lacerations. The need for cocaine in topical anaesthetic formulations has been questioned because of concern about adverse effects, thus novel preparations of cocaine-free anaesthetics have been developed. This review was originally published in 2011 and has been updated in 2017. To assess whether benefits of non-invasive topical anaesthetic application occur at the expense of decreased analgesic efficacy. To compare the efficacy of various single-component or multi-component topical anaesthetic agents for repair of dermal lacerations. To determine the clinical necessity for topical application of the ester anaesthetic, cocaine. For this updated review, we searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11), Cumulative Index to Nursing and Allied Health Literature (CINAHL; 2010 to December 2016), Embase (2010 to December 2016) and MEDLINE (2010 to December 2016). We did not limit this search by language or format of publication. We contacted manufacturers, international scientific societies and researchers in the field. Weemailed selected journalsand reviewed meta-registers of ongoing trials. For the previous version of this review, we searched these databases to November 2010. We included randomized controlled trials (RCTs) that evaluated the efficacy and safety of topical anaesthetics for repair of dermal laceration in adult and paediatric participants. Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information when needed. We collected adverse event information from trial reports. We assessed methodological risk of bias for each included study and employed the GRADE approach to assess the overall quality of the evidence. The present updated review included 25 RCTs involving 3278 participants. The small number of trials in each comparison group and the heterogeneity of outcome measures precluded quantitative analysis of data for all but one outcome: pain intensity. In two pooled studies, the mean self-reported visual analogue scale (VAS; 0 to 100 mm) score for topical prilocaine-phenylephrine (PP) was higher than the mean self-reported VAS (0 to 100 mm) score for topical tetracaine-epinephrine-cocaine (TAC) by 5.59 points (95% confidence interval (CI) 2.16 to 13.35). Most trials that compared infiltrated and topical anaesthetics were at high risk of bias, which is likely to have affected their results. Researchers found that several cocaine-free topical anaesthetics provided effective analgesic efficacy. However, data regarding the efficacy of each topical agent are based mostly on single comparisons in trials with unclear or high risk of bias. Mild, self-limited erythematous skin induration occurred in one of 1042 participants who had undergone application of TAC. Investigators reported no serious complications among any of the participants treated with cocaine-based or cocaine-free topical anaesthetics. The overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well-designed RCTs with low risk of bias are necessary before definitive conclusions can be reached. We have found two new studies published since the last version of this review was prepared. We have added these studies to those previously included and have conducted an updated analysis, which resulted in the same review conclusions as were presented previously.Mostly descriptive analysis indicates that topical anaesthetics may offer an efficacious, non-invasive means of providing analgesia before suturing of dermal lacerations. Use of cocaine-based topical anaesthetics might be hard to justify, given the availability of other effective topical anaesthetics without cocaine. However, the overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well-designed RCTs with low risk of bias are necessary before definitive conclusions can be reached.

AIUM Practice Parameter for the Performance of Ultrasound Vascular Mapping for Preoperative Planning of Dialysis Access

AIUM Practice Parameter for the Performance of Ultrasound Vascular Mapping for Preoperative Planning of Dialysis Access

Seizures and Methemoglobinemia After Topical Application of Eutectic Mixture of Lidocaine and Prilocaine on a 3.5‐Year‐Old Child with Molluscum Contagiosum and Atopic Dermatitis

A eutectic mixture of lidocaine and prilocaine (EMLA) is used topically to provide local anesthesia for a variety of painful superficial procedures. Although the side effects of EMLA are usually mild and transient local reactions, potentially life-threatening complications can occur. We report a case of generalized seizures and methemoglobinemia after topical application of EMLA for curettage of molluscum contagiosum lesions in a 3.5-year-old girl with atopic dermatitis.

Fast-track recovery after day case surgery.

Fast-track recovery processes are implemented for pediatric day case surgery. We conducted a prospective study to evaluate postoperative comfort and parental satisfaction of children included in this process to improve quality of care. We included all children scheduled for superficial procedures or dental treatment outside the operating room. A questionnaire was explained to parents before hospital discharge to evaluate the first night at home. Postoperative comfort evaluation included postoperative pain score (FLACC scale), incidence of postoperative nausea and vomiting, and postoperative behavior disorders. Incidence of posthospital behavior disturbance was evaluated measuring postoperative agitation at home, and disinterest with toys and games. Parental satisfaction was evaluated with a four-point Likert scale (1 = not satisfied at all, 2 = not satisfied, 3 = satisfied, 4 = very satisfied). One hundred and forty-three questionnaires were returned to hospital. Despite reduced length of stay in short-stay unit after anesthesia (28 ± 34 min), we did not report serious complications, and global parental satisfaction was good about the care process. Pain scores (FLACC >3) were higher in the group scheduled for dental procedures, but were very low for the other superficial surgery. With an odd ratio of 5.8 (95% confidence interval 2-17; P = 0.001), postoperative behavior modification (agitation or disinterest with toys or games) was the strongest variable that can predict parental dissatisfaction. Optimal pain management, better parental information about risks of postoperative behavior disturbances, and program integrating parent and child preparation should improve quality of care and global satisfaction in the fast-track recovery process.

A novel biopsy method to increase yield of subcutaneous abdominal adipose tissue.

Collection of abdominal subcutaneous adipose tissue (SAT) for research testing is traditionally performed using punch biopsy or needle aspiration techniques, yielding small amounts of very superficial SAT (100-500 mg). Although liposuction techniques can be used to obtain large amounts of SAT, these approaches can compromise the integrity of the adipose tissue. Therefore, we investigated a novel method using a 6-mm Bergström side-cutting biopsy needle to acquire suitable amounts of intact abdominal SAT for multiple complex studies such as flow cytometry, RNA extraction, ex vivo expression of molecular and post-translational protein mediators, and histology. Fifty biopsies were obtained from 29 participants using a Bergström biopsy needle, applying transient manual suction and shearing large pieces of fat within the inner-cutting trochar. Eighteen of the biopsies were performed under ultrasound guidance, whereby we successfully sampled deep SAT (dSAT) from below Scarpa's fascia. The average weight of SAT sampled was 1.5 ± 0.4 g. There was no clinically important bleeding or ecchymosis on the abdominal wall and no infection occurred with this procedure. The 6-mm Bergström biopsy needle yielded substantially more SAT than what has been obtained from superficial procedures and, for the first time, allowed sampling of dSAT by a percutaneous approach.

FDA Approves Topical Anesthetic For Superficial Derm Procedures

FDA Approves Topical Anesthetic For Superficial Derm Procedures

Regional Anesthesia and Eye Surgery

Regional Anesthesia and Eye Surgery