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Surgical Setting (surgical + setting)
Selected AbstractsThe Efficacy of Curettage in Delineating Margins of Basal Cell Carcinoma Before Mohs Micrographic SurgeryDERMATOLOGIC SURGERY, Issue 9 2003Désirée Ratner MD Background. Curettage may be helpful as a preliminary step to outline the gross subclinical extensions of high-risk basal cell carcinomas (BCCs) before the first stage of Mohs micrographic surgery. Although many Mohs surgeons use curettage in the Mohs surgical setting, no prospective studies have as yet been performed that demonstrate the efficacy of curettage in delineating tumor margins before Mohs surgery. Objective. To document the efficacy of curettage in delineating BCC margins before Mohs micrographic surgery. Methods. This was a prospective evaluation of 599 patients with biopsy-proven BCCs treated with Mohs surgery. The preoperative dimensions of each tumor, the curetted dimensions before the first surgical stage, the proposed excisional margins before each surgical stage, and the final defect dimensions after each surgical stage were measured. The maximum curetted margin around each tumor was calculated and compared with typical Mohs excisional margins of 1, 2, 3, and 4 mm. A hypothetical 1-, 2-, 3-, or 4-mm excisional margin was added to the preoperative X and Y dimensions of each tumor, and the actual final defect sizes were compared with the hypothetical final defect sizes to determine whether an additional surgical stage would have been needed had curettage not been performed. The amount of tissue stretch occurring after specimen removal was calculated to determine whether tissue stretch falsely elevated the number of instances in which an additional surgical stage would have been needed had curettage not been performed. Results. The curetted margin around the observed extent of each tumor exceeded 1 mm in 87.6% of cases, 2 mm in 47.1% of cases, 3 mm in 19.7% of cases, and 4 mm in 5.7% of cases. The mean curetted margin was 1.7 mm. Taking a 1-mm margin in the first stage of Mohs surgery without first performing curettage would have necessitated an extra surgical stage in 99.2% of cases, whereas taking a 2-, 3-, or 4-mm margin would have necessitated an extra surgical stage in 93.0%, 88.1%, and 49.4% of cases, respectively. After calculating and eliminating the effects of tissue stretch, it was found that a 1-mm excisional margin taken in the first stage of Mohs surgery without first performing curettage would have necessitated an extra surgical stage in 99.0% of the cases. Taking a 2-, 3-, or 4-mm margin would have necessitated an extra surgical stage in 87.5%, 57.9%, and 29.5% of cases, respectively. Conclusion. Careful debulking and palpation with the curette significantly reduce the number of Mohs surgical stages required for BCC clearance. Even after taking the effects of tissue stretch into consideration, a significant proportion of tumors would still require an additional stage for tumor clearance without aggressive presurgical curettage. [source] Nurses' experiences of being present with a patient receiving a diagnosis of cancerJOURNAL OF ADVANCED NURSING, Issue 3 2000Una Dunniece DipN BSc(Hons) RN Nurses' experiences of being present with a patient receiving a diagnosis of cancer This paper reports the findings of a study which describes the experiences of nurses who were present with a patient when they received a diagnosis of cancer, cancer recurrence or prognosis of terminal cancer. Semi-structured interviews were conducted with six nurses who had experience of caring for patients with cancer in an acute surgical setting. Data were analysed using a phenomenological descriptive approach. Participants' descriptions revealed the following seven core themes: ,What if it was me?'; divergent feelings; being there; becoming closer; method of disclosure; time as an influence and learning by reflection. Possible implications for nursing practice and education are discussed and recommendations are made for future research. [source] Patterns and frequency of anxiety in women undergoing gynaecological surgeryJOURNAL OF CLINICAL NURSING, Issue 3 2006Eloise Carr PhD, PGCEA Aims., Within a gynaecological surgical setting to identify the patterns and frequency of anxiety pre- and postoperatively; to identify any correlation between raised anxiety levels and postoperative pain; to identify events, from the patients' perspective, that may increase or decrease anxiety in the pre- and postoperative periods. Background., It is well documented that surgery is associated with increased anxiety, which has an adverse impact on patient outcomes. Few studies have been conducted to obtain the patient's perspective on the experience of anxiety and the events and situations that aggravate and ameliorate it. Method., The study used a mixed method approach. The sample consisted of women undergoing planned gynaecological surgery. Anxiety was assessed using the State Trait Anxiety Inventory. Trait anxiety was measured at the time of recruitment. State anxiety was then assessed at six time points during the pre- and postoperative periods. Postoperative pain was also measured using a 10 cm visual analogue scale. Taped semi-structured telephone interviews were conducted approximately a week after discharge. Results., State anxiety rose steadily from the night before surgery to the point of leaving the ward to go to theatre. Anxiety then increased sharply prior to the anaesthetic decreasing sharply afterwards. Patients with higher levels of trait anxiety were more likely to experience higher levels of anxiety throughout their admission. Elevated levels of pre- and postoperative anxiety were associated with increased levels of postoperative pain. Telephone interviews revealed a range of events/situations that patients recalled distressing them and many were related to inadequate information. Conclusion., This study found higher rates of anxiety than previously reported and anxiety levels appeared raised before admission to hospital. This has important clinical and research implications. Relevance to clinical practice., Patients with high levels of anxiety may be identified preoperatively and interventions designed to reduce anxiety could be targeted to this vulnerable group. Patient experiences can inform the delivery of services to meet their health needs better. [source] Physician assistants: trialling a new surgical health professional in AustraliaANZ JOURNAL OF SURGERY, Issue 6 2010Phyllis Ho Abstract Background:, The Australia health workforce productivity Commission Research Report in 2005 identified workforce shortages. One of the recommendations is that new models of health care be established. As a result South Australia is trialling United States trained physician assistants in a pilot program. This paper summaries the review of literature of the physician assistant role and safety in the surgical setting. Methods:, A literature search using Medline and Pubmed from 1966 until 2009 with key words: physician assistants, midlevel providers, surgery. The references of the results were also searched for suitable articles. The Google search engine was also used with the above keywords to search for latest developments from nontraditional sources. Results:, There were over 200 suitable articles relating to the quality and safety of physician assistants. The overwhelming majority of the articles originate from the United States and these vary in quality. There were 13 published studies identified that documented physician assistants in the surgical setting. Conclusion:, From the published data physician assistants have been shown to provide safe and provide high quality care in surgical units. It is important that prior to their commencement their role is defined to alleviate conflict and confusion in the team. Continued auditing should be conducted to monitor progress and impact. [source] Acute renal failure in the surgical settingANZ JOURNAL OF SURGERY, Issue 3 2003Paul Carmichael Acute renal failure (ARF) is an unwelcome complication of major surgical procedures that contributes to surgical morbidity and mortality. Acute renal failure associated with surgery may account for 18,47% of all cases of hospital-acquired ARF. The overall incidence of ARF in surgical patients has been estimated at 1.2%, although is higher in at-risk groups. Mortality of patients with ARF remains disturbingly high, ranging from 25% to 90%, despite advances in dialysis and intensive care support. Appreciation of at-risk surgical populations coupled with intensive perioperative care has the capacity to reduce the incidence of ARF and by implication mortality. Developments in understanding the pathophysiology of ARF may eventually result in newer therapeutic strategies to either prevent or accelerate recovery from ARF. At present the best form of treatment is prevention. In this review the epidemiology, pathophysiology, diagnosis, treatment and possible prevention of ARF will be discussed. [source] Relationship between elevated preoperative troponin T and adverse outcomes following cardiac surgeryANZ JOURNAL OF SURGERY, Issue 1-2 2003William J. Lyon Background: The prognostic value of troponin T (TnT) has been demonstrated in patients following a myocardial infarction. There are limited data regarding the prognostic utility of preoperative TnT in patients undergoing cardiac surgery. The aim of the present study was to determine if elevated preoperative TnT is a predictor of more complex recovery outcomes in the cardiac surgical setting. Methods: A single preoperative TnT measurement was assessed in 696 patients undergoing isolated coronary artery bypass graft surgery. Elevated preoperative TnT levels were classified as ,0.2 ng/mL. Preoperative, intraoperative, intensive care and postoperative events were prospectively recorded for all patients, and retrospectively reviewed for the present study. Results: Elevated preoperative TnT levels were detected in 10% (71/696) of patients. Compared to patients with normal TnT levels, elevated preoperative TnT increased the risk of mortality at 30 days (7%vs 1%, P = 0.004, odds ratio (OR) = 6.7) and 2 years (14%vs 3%, P < 0.001, OR = 5.0), and resulted in prolonged intensive care unit (ICU) stays (P < 0.001) and longer postoperative hospitalization (P < 0.001). Elevated preoperative TnT was also associated with an increased need for perioperative and postoperative cardiovascular support, early ischaemic change and postoperative congestive cardiac failure. In multivariate analyses preoperative TnT was a significant independent predictor of 30-day and 2-year mortality, and duration of ICU stay. Conclusions: Elevated preoperative TnT highlights a subgroup of cardiac surgical patients who are more likely to have a postoperative course with increased morbidity and mortality. [source] Comparison of closed loop vs. manual administration of propofol using the Bispectral index in cardiac surgeryACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 3 2009J. AGARWAL Background: In recent years, electroencephalographic indices of anaesthetic depth have facilitated automated anaesthesia delivery systems. Such closed-loop control of anaesthesia has been described in various surgical settings in ASA I,II patients (1,4), but not in open heart surgery characterized by haemodynamic instability and higher risk of intra-operative awareness. Therefore, a newly developed closed-loop anaesthesia delivery system (CLADS) to regulate propofol infusion by the Bispectral index (BIS) was compared with manual control during open heart surgery. Methods: Forty-four adult ASA II,III patients undergoing elective cardiac surgery under cardiopulmonary bypass were enrolled. The study participants were randomized to two groups: the CLADS group received propofol delivered by the CLADS, while in the manual group, propofol delivery was adjusted manually. The depth of anaesthesia was titrated to a target BIS of 50 in both the groups. Results: During induction, the CLADS group required lower doses of propofol (P<0.001), resulting in lesser overshoots of BIS (P<0.001) and mean arterial blood pressure (P=0.004). Subsequently, BIS was maintained within ± 10 of the target for a significantly longer time in the CLADS group (P=0.01). The parameters of performance assessment, median absolute performance error (P=0.01), wobble (P=0.04) and divergence (P<0.001), were all significantly better in the CLADS group. Haemodynamic stability was better in the CLADS group and the requirement of phenylephrine in the pre-cardiopulmonary bypass period as well as the cumulative dose of phenylephrine used were significantly higher in the manual group. Conclusion: The automated delivery of propofol using CLADS was safe, efficient and performed better than manual administration in open heart surgery. [source] | ||||||||||