Surgical Floor Research Articles

Routine Admission to Intensive Care Unit After Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy: Not Always a Requirement.

Routine postoperative intensive care unit (ICU) observation of patients undergoing cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) is driven by historically reported morbidity and mortality data. The validity of this practice and the criteria for ICU admission have not been elucidated. A prospectively maintained database of 1146 CRS/HIPEC procedures performed from December 1991 to 2014 was retrospectively analyzed. Patients with routine postoperative ICU admission were compared with patients sent directly to the surgical floor. To test the safety of non-ICU care practice, patients with less than 48h ICU admission were compared with patients directly admitted to the floor. Demographics, primary tumor site, comorbidities, estimated blood loss (EBL), extent of CRS, Eastern Cooperative Oncology Group (ECOG) status, and overall survival were analyzed. Complete data were available for 1064 CRS/HIPEC procedures, of which 244 cases (22.93%) did not require ICU admission. Multivariate logistic regression identified age [odds ratio (OR) 1.024; p=0.02], EBL (OR 1.002; p<0.0001), number of resected organs (OR 1.308; p=0.01) and ECOG>2 (OR 6.387; p=0.003) as predictive variables of postoperative ICU admission. The cohort directly admitted to the floor demonstrated less minor grade I/II morbidity (29 vs. 47%; p<0.0001) and similar grade III/IV major morbidity (16.5 vs. 13.4%; p=0.3) than the patients admitted to the ICU for less than 48h. ICU observation is not routinely required for all patients treated with CRS/HIPEC. Selective ICU admission based on ECOG status, nutritional status, age, EBL, and CRS extent is safe, with potential implications for hospitalization cost for these complex cases.

Radiological sinus lift: a new minimally invasive CT-guided procedure for maxillary sinus floor elevation in implant dentistry.

Implant therapy has become an excellent treatment modality as its inception into the modern era of dentistry. However, when patients present with advanced atrophy of the maxillary alveolar ridge, the procedure of choice to restore the anatomic bone deficiency is surgical maxillary sinus floor elevation or sinus lift. The purpose of this study was to describe the CT guided sinus lift technique and to illustrate the minimally invasive aspect of this new radiological procedure called radiological sinus lift. For this prospective study, 17 cadaver heads which met our inclusion criteria (edentulous posterior maxillary sector and bone height less than 5 mm) were analyzed using cone beam computed tomography (CBCT) and orthopantomography (OPT). CT and sinus endoscopy was used to guide each step in the procedure. The radiological sinus lift technique consists of the following four stages: Approach. A 14.5 G OstyCut needle was inserted mesial to the canine eminence, and manual drilling was performed parallel to the sinus floor. Osteotomy. An inner obturator with a blunt tip was introduced to compress bone, to push it in close proximity to the sinus membrane and finally to create an osseous window opening into the submucosal space. Lifting. The sinus lift was performed using hydrodissection with dilute iodinated contrast medium. Filling. The submucosal space was then filled with an injection of dilute collagen. Success of the radiological sinus lift procedure was defined by the presence of a dome shape visible within the maxillary alveolar recess. All cases were imaged postoperatively using OPT and maxillary CBCT. Twelve maxillary sinuses underwent the radiological sinus floor elevation procedure. A dome shape of the Schneiderian membrane was achieved in eight maxillary sinuses (66.7%). All failures (n = 4) were caused by mucosal perforation at the time of maxillary sinus osteotomy. Mean height of membrane elevation was 12.0 mm, with a mean intervention time of 45 min. This experimental study evaluates a new minimally radiological procedure for maxillary sinus floor elevation, which provides an interventional radiological alternative to the classical surgical lateral approach and achieves an equivalent success rate to that cited in the literature for the surgical approach, a low morbidity and a shorter operating time.

Concurrent Spontaneous Sublingual and Intramural Small Bowel Hematoma due to Warfarin Use.

Introduction. We present a case of concurrent spontaneous sublingual and intramural small bowel hematoma due to warfarin anticoagulation. Case. A 71-year-old man presented to the emergency department complaining of a swollen, painful tongue. He was on warfarin therapy. Physical examination revealed sublingual hematoma. His international normalized ratio was 11.9. The computed tomography scan of the neck demonstrated sublingual hematoma. He was admitted to emergency department observation unit, monitored closely; anticoagulation was reversed with fresh frozen plasma and vitamin K. 26 hours after his arrival to the emergency department, his abdominal pain and melena started. His abdomen tomography demonstrated intestinal submucosal hemorrhage in the ileum. He was admitted to surgical floor, monitored closely, and discharged on day 4. Conclusion. Since the patient did not have airway compromise holding anticoagulant, reversing anticoagulation, close monitoring and observation were enough for management of both sublingual and spontaneous intramural small bowel hematoma.

Free Flap Reconstruction Experience and Outcomes in a Low‐Volume Setting over 20 Years

Objectives: (1) Recognize the potential efficacy of free flap reconstruction performed at a low volume program. (2) Understand how reconstructive microvascular outcomes and success change over 20 years. Methods: A retrospective chart review was performed at a tertiary care academic program on all free tissue flaps from the primary reconstructive surgeon over 20 years (1993-2013). A total of 135 procedures were obtained from operative notes, billing codes, and chart databases. Outcome variables included overall procedure success, need for surgical revision, and complications. Patients stayed in general surgical intensive care and hospital floor units. Results: Free tissue flaps were successful in 91% of all cases. In the past 13 years, 70 flaps were performed with 3 failures (96% success rate). Take-back rate was 14% of total cases with a flap recovery rate of 50%. Postoperative failure occurred after 72 hours in 70% of cases. Nearly 60% of patients experienced a complication of any type or severity. Twenty percent of successful flaps had a complication, with half due to partial dehiscence. Systemic complications affected 20% of all cases. The average hospital stay for noncomplicated patients was 13 days. There was 1 postoperative mortality. Fibula and radial forearm were the most common flaps, at 44% and 26%, respectively. Conclusions: Free flap reconstruction of the head and neck can be performed with acceptable outcomes even in low volume settings.

Automated detection of physiologic deterioration in hospitalized patients.

Develop and evaluate an automated case detection and response triggering system to monitor patients every 5 min and identify early signs of physiologic deterioration. A 2-year prospective, observational study at a large level 1 trauma center. All patients admitted to a 33-bed medical and oncology floor (A) and a 33-bed non-intensive care unit (ICU) surgical trauma floor (B) were monitored. During the intervention year, pager alerts of early physiologic deterioration were automatically sent to charge nurses along with access to a graphical point-of-care web page to facilitate patient evaluation. Nurses reported the positive predictive value of alerts was 91-100% depending on erroneous data presence. Unit A patients were significantly older and had significantly more comorbidities than unit B patients. During the intervention year, unit A patients had a significant increase in length of stay, more transfers to ICU (p = 0.23), and significantly more medical emergency team (MET) calls (p = 0.0008), and significantly fewer died (p = 0.044) compared to the pre-intervention year. No significant differences were found on unit B. We monitored patients every 5 min and provided automated pages of early physiologic deterioration. This before-after study found a significant increase in MET calls and a significant decrease in mortality only in the unit with older patients with multiple comorbidities, and thus further study is warranted to detect potential confounding. Moreover, nurses reported the graphical alerts provided information needed to quickly evaluate patients, and they felt more confident about their assessment and more comfortable requesting help.

Using the Rothman index to predict early unplanned surgical intensive care unit readmissions.

The Rothman index (RI) is a numerical score calculated hourly from 26 data points in the electronic medical record by a commercial software package. Although it is purported to serve as an indicator of change in a patient's condition, it has not been extensively evaluated in the literature. Our objective was to determine whether the RI can be used to predict early surgical intensive care unit (SICU) readmissions. This is a single-institution, retrospective 12-month period review of all patients transferred from the SICU to the surgical floor. Patients readmitted to the SICU within 48 hours were compared with patients who did not require readmission during this time (control). Demographics and continuous RI scores were collected at admission, 24 hours before SICU transfer, and for the first 48 hours on the surgical floor or until readmission to the SICU. A total of 1,152 SICU patients were transferred to the surgical floor; 27 patients were readmitted within 48 hours of transfer. Demographics were similar in both groups. The SICU length of stay was longer in the readmission group (mean [SD], 4.7 [8.1] vs. 16.5 [15.2]; p < 0.001). The RI immediately before SICU transfer was higher in the control group (70.4 [20.3] vs. 49.1 [20.9], p < 0.001) and was uniformly improved from the RI at the initial SICU admission. In comparison, readmitted patients had more variable RI trends from admission to SICU transfer (mean Δ, 6.51; range, -54.10 to 48.6), and 40.74% of readmitted patients actually had a decreased RI score on transfer. No patient with a RI score greater than 82.90 required readmission within 48 hours. An increased RI score or a score greater than 82.90 correlates with appropriateness for SICU transfer to the surgical floor. A decreased RI score is strongly associated with SICU readmission within 48 hours and should be explored as a potential quality metric. Epidemiologic/prognostic study, level III.

The Three Axial Perineal Evaluation (TAPE) score: a new scoring system for comprehensive evaluation of pelvic floor function

Abnormalities of one pelvic floor compartment are usually associated with anomalies in the other compartments. Therapies which specifically address one clinical problem may potentially adversely affect other pelvic floor activities. A new comprehensive holistic scoring system defining global pelvic function is presented. A novel scoring system with a software program is presented expressing faecal, urinary and gynaecological functions as a geometric polygon based on symptom-specific questionnaires [the three axial pelvic evaluation (TAPE) score] where differences in overall geometric area vary from normal. After validation in healthy volunteers, its clinical performance was tested on patients with obstructed defaecation, genital prolapse and urinary/faecal incontinence treated by the stapled transanal rectal resection (STARR) procedure, colpo-hysterectomy and sacral nerve modulation, respectively. The TAPE score was correlated with the Pelvic Floor Impact Questionnaire 7 quality of life score. There was good inter-observer variation and internal consistency between two observers recording the TAPE score in normal volunteers. In the STARR patients, constipation improved but the TAPE score was unchanged because of deterioration in other pelvic floor functions leading to an unchanged overall postoperative recorded quality of life. Conversely, incontinent patients treated with sacral nerve stimulation improved their function showing concomitant improvements in TAPE scores and quality of life indices. Similar correlative improvements were noted in patients undergoing hysterectomy for genital prolapse. The TAPE score defines the impact of symptom-specific treatments on the pelvic floor and may provide an opportunity for comparison of clinical data between units and in clinical trials of specific medical and surgical pelvic floor management.

Liposome bupivacaine for postsurgical pain in an obese woman with chronic pain undergoing laparoscopic gastrectomy: a case report

IntroductionTo reduce incidence and severity of postsurgical pain and minimize the effect of its clinical and economic correlates, multimodal therapy for surgical patients is recommended. In this report, we discuss the use of liposome bupivacaine, a novel multivesicular formulation of bupivacaine indicated for single-dose infiltration into the surgical site to produce postsurgical analgesia, as part of a multimodal analgesic regimen in a patient with a history of chronic pain scheduled to undergo laparoscopic sleeve gastrectomy. To the best of our knowledge, this is the first published report of liposome bupivacaine in the setting of laparoscopic sleeve gastrectomy.Case presentationA 35-year-old white woman with morbid obesity was admitted for laparoscopic sleeve gastrectomy to lose weight prior to hip replacement surgery. Because of a complicated medical history that included rheumatoid arthritis, fibromyalgia, diabetes mellitus, hypertension, and chronic pain, for which she was receiving high doses of opioid analgesics, postsurgical pain management was a concern and she was considered a candidate for multimodal analgesia. At initiation of surgery, 50mL of lidocaine and epinephrine was infiltrated around the port sites. At the conclusion, 25mL of normal sterile saline was added to a 20mL vial of liposome bupivacaine (266mg) and injected around the port sites and at the site of liver retraction. Laparoscopic sleeve gastrectomy was successfully completed. Our patient was discharged to the postanesthesia care unit for approximately four hours before discharge to the surgical floor with a pain score of 5 (11-point scale; 0 = no pain, 10 = worst possible pain). Her postoperative course was uneventful; no adverse events were recorded during surgery or during the remainder of her hospital stay. Our patient was discharged on the same opioid regimen used previously for control of her preexisting chronic pain.ConclusionsLiposome bupivacaine use in this morbidly obese patient undergoing laparoscopic sleeve gastrectomy provided analgesic efficacy and limited postsurgical opioids to a level comparable with her baseline opioid regimen for chronic pain. Given her complex medical history and previous issues with acute and chronic pain, we consider these results highly successful and continue to use liposome bupivacaine as part of a multimodal analgesic regimen in an effort to optimize postsurgical pain management.

THE FREQUENCY OF PERITONEAL TUBERCULOSIS USING DIAGNOSTIC LAPAROSCOPY IN CLINICALLY SUSPECTED CASES

Abstract: Introduction: Diagnostic laparoscopy allows the visual examination and documentation of intra-abdominal organs in order to detect any pathology. It is an important tool for final minimally invasive exploration of patients with abdominal tuberculosis, the diagnosis of which remains uncertain despite employing the requisite laboratory and non-invasive imaging investigations. Objective: To determine the frequency of peritoneal tuberculosis using diagnostic laparoscopy in clinically suspected cases of peritoneal tuberculosis. Study Design : Cross sectional survey. Setting: The study was conducted in all the four Surgical Wards on surgical floor of Mayo Hospital Lahore. Duration of Study with Dates: Six months (1 st July 2009 to 31 st December 2009). Material and Methods: 35 patients aged between 13-60 years with clinical suspicion of peritoneal tuberculosis were selected. The patients underwent the procedure accordingly. Per operative diagnosis of peritoneal tuberculosis made on the basis of presence of any or all of the operative (laparoscopic) findings such as multiple peritoneal adhesions, fibrous bands, whitish peritoneal tubercles, omental thickening and ascites. Diagnosis was confirmed with histopathology of peritoneal tissue biopsy. Also the biochemical analysis and culture sensitivity of ascetic fluid was routinely performed if any ascites is present. Results: Out of 35 patients, 40% were males and 60% females with mean age of 24.91±6.69 years. The laparoscopic findings of peritoneal tuberculosis were whitish peritoneal tubercles (57.2%) peritoneal adhesions (28.6%), ascites (17.2%), omental thickening (14.3%), fibrous bands (11.4%) and swollen edematous appendix (5.7%). Eighty percent were labeled with diagnosis of peritoneal tuberculosis on basis of diagnostic laparoscopy. These patients were confirmed to have peritoneal tuberculosis on histopathology of tissue biopsy. Conclusion: Diagnostic laparoscopy is useful in patients with suspected peritoneal tuberculosis. It helps in diagnosis by allowing the direct visualization of gross findings as well as collection of histopathological specimens. It also helps by reducing the number of unnecessary laparotomies and avoiding delays in the diagnosis and treatment. Key words: Frequency, Peritoneal tuberculosis, Diagnostic laparoscopy.

Local Infiltration Analgesia Followed by Continuous Infusion of Local Anesthetic Solution for Total Hip Arthroplasty

We studied the efficacy of local infiltration analgesia in surgical wounds with 0.2% ropivacaine (50 mL), ketorolac (15 mg), and adrenaline (0.5 mg) compared with that of local infiltration analgesia combined with continuous infusion of 0.2% ropivacaine as a method of pain control after total hip arthroplasty. We hypothesized that as a component of multimodal analgesia, local infiltration analgesia followed by continuous infusion of ropivacaine would result in reduced postoperative opioid consumption and lower pain scores compared with infiltration alone, and that both of these techniques would be superior to placebo. In this prospective, double-blind, placebo-controlled study, 105 patients were randomized into three groups: Group I, in which patients received infiltration with ropivacaine, ketorolac, and adrenaline followed by continuous infusion of 0.2% ropivacaine at 5 mL/hr; Group II, in which patients received infiltration with ropivacaine, ketorolac, and adrenaline followed by continuous infusion of saline solution at 5 mL/hr; and Group III, in which patients received infiltration with saline solution followed by continuous infusion of saline solution at 5 mL/hr.All patients received celecoxib, pregabalin, and acetaminophen perioperatively and patient-controlled analgesia; surgery was performed under general anesthesia. Before wound closure, the tissues and periarticular space were infiltrated with ropivacaine, ketorolac, and adrenaline or saline solution and a fenestrated catheter was placed. The catheter was attached to a pump prefilled with either 0.2% ropivacaine or saline solution set to infuse at 5 mL/hr.The primary outcome measure was postoperative opioid consumption and the secondary outcome measures were pain scores, adverse side effects, and patient satisfaction. There were no differences between groups in the administration of opioids in the operating room, in the recovery room, or on the surgical floor. The pain scores on recovery room admission and discharge and the floor were low and similar between groups. There were no differences in the incidence of adverse side effects among groups. Patient satisfaction with pain management was similar in all groups. Local infiltration analgesia alone or followed by continuous infusion of ropivacaine as part of multimodal analgesia provides no additional analgesic benefit or reduction in opioid consumption compared with placebo following total hip arthroplasty. Therapeutic level I. See Instructions for Authors for a complete description of levels of evidence.

Management of pelvic organ prolapse and quality of life: a systematic review and meta-analysis

One of the main outcomes in the assessment of the treatment of pelvic organ prolapse in women is quality of life. Using quality of life as an outcome measure is increasing in the majority of clinical trials. The aim of current study was to determine the effects of the treatment of pelvic organ prolapse on patients' quality of life using systematic review and meta-analysis. A systematic search for finding randomized controlled studies on pelvic organ prolapse published before October 2012 was conducted. The JAMA users' guide to the medical literature quality assessment scales for randomized clinical trials was used to assess the quality of included articles. The mean difference in total quality of life score between before and after intervention (surgical or pelvic floor training) with 95 % confidence interval (CI) was considered as a primary summary measure. Egger's test was used to evaluate the publication bias. Heterogeneity was assessed using I(2) Index. Fifty-seven RCT were critically appraised. Thirty-two articles were eligible after critical evaluation. Mean difference in change in the total quality of life score with 95 % CI for surgical treatment was 74.03 (66.3-81.6) by PFDI-20 and was 44.57 (22.53-66.65) by PFIQ-7. The mean difference in changed in the total quality of life score with 95 % CI was 1.32 (-2.8-5.4) for pelvic floor training (PFT). We found that surgical interventions on prolapse can improve the quality of life of women. There was a relative effect of PFT on the quality of life of women with prolapse in systematic review. This effect was not seen in meta-analysis, probably because of finding few eligible studies to pool the effect size.

Abstract 1377: Guided imagery use in the peri-operative period of gynecologic oncology surgery.

Abstract Objective: To assess the feasibility of using guided imagery therapy in the peri-operative period at the time of Gynecologic Oncology surgery. Methods: IRB approval was obtained for this randomized control trial. Patients were recruited based on having an exploratory laparotomy surgery with the gynecologic oncology group. Research staff performed a phone interview and obtained written consent. Patients were randomized to standard of care therapy, blank CD which was to simulate noise reduction headphones, or a validated guided imagery CD. The intervention would be used in pre op waiting area, during surgery, and after surgery. VAS scores, amount of narcotics used, amount of anti-emetics used, FACT G and POMS surveys were collected. Results: 12 patients were attempted to be recruited for the study from April 2012 to the present. Prior to study enrollment, all patients were excited about the study and willing participants. All 12 pre op nurses were a barrier to discuss the study with the patients in the pre op area. 2 patients were unable to be consented due to the pre-operative nursing staff baring the research staff from consenting. 3 of the 10 RNAs stated that the player was dysfunctional, though the players were tested prior to delivery to the pre-operative area. 7 of the 12 patients stated that they ‘forgot’ to listen to the CD prior to surgery, or that the nurses did not let them take the time to listen. Only 2 of the 12 patients actually listened to the CD prior to surgery; only 2 of the 12 had the CD played during surgery. 4 of the 12 never received the CD player and surveys after surgery on the surgical oncology floor. Only 1 of the 12 actually listened to the CD throughout the entire hospital stay. 5 patients were told that it was “too busy” to listen to the CD by the floor nursing staff. 6 CD players were lost or stolen during the course of the study. To date, only 1 patient in the control group completed all surveys. However, 3 patients voiced excitement and satisfaction when using the intervention CD during their immediate peri-operative time, and were documented by external observers to have resolution of their anxiety while using the intervention CD. Conclusions: While subjectively beneficial for patients to decrease stress responses peri-operatively, integrative medicine techniques such as guided imagery will be difficult to implement until the culture of medicine embraces this novel modality. Citation Format: Elizabeth L. Dickson, Matt Gerber, Amy L. Jonson. Guided imagery use in the peri-operative period of gynecologic oncology surgery. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 1377. doi:10.1158/1538-7445.AM2013-1377

Analysis of Routine Intensive Care Unit Admission following Fronto-Orbital Advancement for Craniosynostosis

Intensive care unit admission following fronto-orbital advancement for craniosynostosis is routine at most institutions. The authors determined the frequency of postoperative events requiring intensive care unit care that justify this practice. Infants with craniosynostosis who underwent primary fronto-orbital advancement at a single institution from 1997 to 2011 were included. Patient demographics, operative factors, and hemodynamic outcomes were recorded. Adverse postoperative events/interventions were graded as none (group I); minor (group II), easily managed on a surgical floor; or major (group III), requiring intensive care unit care. One hundred seven infants were included. Average length of hospitalization was 3.7 ± 1.6 days, with 1.3 ± 1.0 days in the intensive care unit and 2.4 ± 1.0 days on the floor. Seventy-eight patients (72.9 percent) were categorized into group I, 24 (22.4 percent) into group II, and five (4.7 percent) into group III. Major events/interventions included prolonged intubation (n = 2), reintubation (n = 2), and continuous positive airway pressure support (n = 1). Preexisting end-organ dysfunction was significantly associated with group III patients, who also had significantly higher intraoperative blood loss requiring greater resuscitation. Mean daily charges were $7652.33 (10.9 percent of total charges) for intensive care unit care and $2470.62 (6.9 percent of total charges) for floor care. In this study, 4.7 percent of patients had event/interventions requiring intensive care unit care after fronto-orbital advancement. Predictors included preexisting end-organ dysfunction and higher intraoperative blood loss requiring greater resuscitation. Financial savings from selective postoperative intensive care unit admission may not outweigh the potential cost of an emergent event on the surgical floor.

Serious Fall Injuries in Hospitalized Patients With and Without Cancer

Characteristics of adults hospitalized with and without cancer were compared to determine factors of serious injuries after fall events. More patients with cancer who had a serious injury received corticosteroids (P = .005) and were treated on a palliative care floor. More patients without cancer had higher prevalence of stroke (P = .026) and diabetes (P = .041) history and were treated on a surgical floor. Future research is needed to identify interventions that could prevent serious injuries after fall events.

Zolpidem Linked to Higher Inpatient Fall Rates

Administration of zolpidem was associated with a significantly higher risk of falls in a Mayo Clinic study published online in the Journal of Hospital Medicine. The study included hospital patients of a broad range of ages. After accounting for a range of confounders, the researchers found that one additional fall could be expected for every 55 inpatients who received zolpidem. Patients receiving zolpidem were more than three times as likely to fall as were people who were prescribed it but did not receive it. Dr. Bhanu Prakash Kolla at the Mayo Clinic's Center for Sleep Medicine in Rochester, Minn., and colleagues analyzed falls among 16,320 patients admitted to Mayo Clinic hospitals in 2010. Using an electronic pharmacy database and patient records, the authors compared the rate of falls among patients who were actually administered zolpidem to the rate among those who did not receive the medication despite being prescribed it “as needed.” The 4,962 patients who received zolpidem had a fall rate of 3.04% (151 falls), compared with 0.71% (81 falls) in the 11,358 patients who were not administered zolpidem while in the hospital. Incidentally, patients not prescribed zolpidem (n = 25,627) had a fall rate of 1.42%, which was slightly lower than the overall fall rate of 1.47% among all patients prescribed zolpidem, whether they received it or not. The authors recommended that, given the current absence of evidence for other safer hypnotic alternatives for inpatients, “nonpharmacological measures to improve the sleep of hospitalized patients should be investigated as preferred methods to provide safe relief from complaints of disturbed sleep.” The researchers controlled for confounders that may increase fall risk, including age, length of hospital stay, being on a surgical floor, zolpidem dose, visual impairment, gait abnormalities, cognitive impairment/dementia, insomnia, delirium, comorbidities (measured with the Charlson comorbidity index), and patient's Hendrich's fall risk score. The analysis also controlled for medications that patients received in the 24 hours before the fall that are already associated with an increased fall risk, including antidepressants, antipsychotics, antihistamines, sedative antidepressants including trazodone and mirtazapine, benzodiazepines, and opioids. A univariate analysis revealed that all factors significantly associated with a higher fall rate included zolpidem use (OR = 4.37), being male (OR = 1.36), and having insomnia (OR = 2.37) or delirium (OR = 4.96), as well as increasing age, zolpidem dose, comorbidity scores, and fall risk scores. When the researchers accounted for all statistically significant additional fall risk factors, the association between zolpidem use and fall risk was still significant with an OR of 6.39. There was no statistically significant association identified for the other medications accounted for in the analysis. The study was funded through the Mayo Clinic's fellowship training program, and the authors had no conflict of interest to disclose. Editor's NoteAlthough this study involved hospitalized patients, there's no reason to suspect that things would be any different in the nursing home setting. It's no surprise that a hypnotic, potentially anterograde-amnestic drug would be associated with an increase in falls, but the fourfold increase in risk reported in this study is pretty impressive.Falls are most certainly a bad thing. While quality of life (including good sleep) is an important goal for our residents, we may want to consider whether the benefits of hypnotic therapy (and not just zolpidem, obviously) truly outweigh the risks. And if we are using these meds, it's probably a good idea to disclose these specific risks to our residents and their decision makers.–Karl Steinberg, MD, CMD,Editor in Chief Although this study involved hospitalized patients, there's no reason to suspect that things would be any different in the nursing home setting. It's no surprise that a hypnotic, potentially anterograde-amnestic drug would be associated with an increase in falls, but the fourfold increase in risk reported in this study is pretty impressive. Falls are most certainly a bad thing. While quality of life (including good sleep) is an important goal for our residents, we may want to consider whether the benefits of hypnotic therapy (and not just zolpidem, obviously) truly outweigh the risks. And if we are using these meds, it's probably a good idea to disclose these specific risks to our residents and their decision makers. –Karl Steinberg, MD, CMD, Editor in Chief

Care of Nonsurgical Patients in the PACU

Many nurses remember the days when the postanesthesia care unit (PACU), or the recovery room, was a place only for patients who had surgery. The unit was somewhat predictable, in that patients came to the area, recovered, and went to a bed on a surgical floor. The years have brought same day surgery, and now many surgical procedures are performed as outpatient surgeries, that only a few years ago would have warranted a 2- to 3-day stay in the hospital. As the PACU has evolved over time, it has become an area for any patient receiving sedation and/or anesthesia, regardless of the procedure.

Spontaneous Idiopathic Pneumoperitoneum: A Case Report

Purpose: An 86-year-old Caucasian male has presented with recurrent chronic abdominal bloating and dyspepsia since the late 1990s. He had a colonoscopy that showed diverticulosis and a non-diagnostic endoscopy in June 2001 for his evaluation. The patient underwent a CT scan of the Abd/pelvis in August 2001. Free air was noted in the splenic flexure region. Although patient had no abdominal pain, he was advised to report to the emergency room as a caution. Plain abdominal films confirmed air under the diaphragm. The patient's abdominal exam was completely benign; he was afebrile with a normal white blood cell count. His past medical history was unremarkable. The patient was admitted for observation on the surgical floor. The next day the patient remained asymptomatic, tolerated his meal and was discharged for home. He remained fairly stable for the next several years and it was not until August 2006 when he was reevaluated for recurrent gas and bloating. Another CT Abd/pelvis was done which again showed intraperitoneal free air. He was sent to the emergency room for evaluation. His ER workup, which included barium small bowel follow through, was negative. A repeat CT scan was performed in October 2006 to follow up on the pneumoperitoneum. This time, there was no evidence of the condition. In June 2007 patient was evaluated again for gas and bloating. A lactose-free diet was instituted, to which patient showed some improvement. During his September 2008 visit, he was significantly better. The patient presented again to his primary care physician's office with abdominal bloating and distention in October 2011. Another CT Abd/pelvis was performed which revealed massive pneumoperitoneum. This was patient's third abdominal CT that had shown pneumoperitoneum over the course often years. Around this time, patient was also dealing with a progressively advancing dementia. After discussing with the family, a decision was made to avoid further testing. To date, the patient is comfortably living in an assisted living facility as he deals with his progressive dementia. Discussion: Over 90% of cases of pneumoperitoneum are the result of perforation of an intra-abdominal viscus. In 5-10% of cases, the condition does not reflect perforation and results from another source that does not require emergent surgery. Causes of spontaneous pneumoperitoneum include postoperative, thoracic, abdominal, gynecologic, and idiopathic. This case is unique in that no etiology could be identified. This patient has been followed for over a twelve-year period with no clinical consequences. Conservative treatment should always be considered as the preferred treatment in asymptomatic patients with spontaneous idiopathic pneumoperitoneum.

Combined Burch urethropexy and anterior rectopexy in pelvic organ prolapse: skip the mesh

Pelvic organ prolapse (POP) is a common accompaniment of advancing age. Current repair techniques incorporate transvaginal and transabdominal approaches with or without prosthetic mesh insertion. In this paper, we present the short- and medium-term results of a unit policy directed at patients with POP of combined abdominal rectopexy and Burch retropubic urethropexy without the use of prosthetic mesh assessing its safety profile in selected cases. Between January 2009 and January 2011, 16 women with tri-compartmental prolapse who had all undergone prior hysterectomy underwent combined surgical pelvic floor repair. Preoperative symptom assessment by validated questionnaires and clinical examination were pre- and postoperatively recorded. Cures were defined as either optimal or satisfactory outcomes based on combined clinical, radiological examinations and reported patient satisfaction. The mean age of the 16 patients was 57.2 years, and their mean BMI was 28.6 (±5 SD). Pelvic examination revealed a POP-Q stage III prolapse in 12 patients and stage IV in 4 patients. The mean operating time was 57.5 min (range 40-85), with a mean length of hospital stay of 4.5 days. Cystocele and enterocele resolution was noted in every case on dynamic magnetic resonance imaging (MRI). Our results in a small patient cohort employing a simple 'all-in-one' repair approach combining a retropubic colposuspension with an anterior rectopexy appear to be satisfactory. Further larger randomized studies are required, incorporating a laparoscopic arm in order to determine the longer-term effectiveness of this approach.

TAP Into Pain Control

A multidisciplinary team approach was implemented in the educational process for the care of the patient with Transversus Abdominis Plane (TAP) blocks. Coordinating pharmacy, surgeons, PACU, OR and Surgical floor staff to facilitate optimal care for the patient receiving TAP blocks was imperative to the success of our process.

APPENDICECTOMY;

Objective: The objective of this study was to compare length of hospital stay, pain scores and the rate of wound infectionsbetween laparoscopic and open appendectomy. Design: Randomized Controlled trial. Place and Duration of study: This study wasconducted in surgical unit I Holy Family hospital, Rawalpindi from 1st June 2009 to 31st May 2010. Patients and methods: The patients weredivided into open and laparoscopy groups and their age, sex, time of discharge, pain scores and wound infection rates were compared andanalyzed. Results: Total of 160 patients were included in the study, 80 in each group. There were 58% male and 42% female patients. Mean agewas 22.78 years (±6.2).Post operative pain scores were significantly less in the laparoscopic group (p&lt;0.05). The length of hospital stay in opengroup was 35.10 hrs (±5.4) hours and in the laparoscopic group was 38.70(4.8) hrs with a p value of 0.592.Wound infection was 0.037% in openand 0.025% in the laparoscopic group. Conclusions: Laparoscopic appendectomy is superior in terms of less morbidity and shorter postoperative hospital stay in the setting of an overworked tertiary care surgical floor of a Pakistani hospital.