impact of reverse trendelenburg versus head-up position on intraoperative bleeding of elective rhinoplasty

In spite of several efforts for decreasing blood loss, our experience sometimes shows that some patients bleed more profusely during rhinoplasty. Patient position could have deep impact on bleeding amount during surgical procedures. In this study, we aimed to compare reverse trendelenburg position and head-up position on intra-operative bleeding of elective rhinoplasty. This was to check the effects of reverse trendelenburg position and head up position on the intraoperative bleeding of elective rhinoplasty. In this study, 30 ASA I [American Society of Anesthesiology physical condition classification] patients between 18 and 40 years of age who were candidate to rhinoplasty operations for first time were included. Patients were randomly assigned to reverse trendelenburg or head-up position. Exclusion criteria was any history or lab indicating coagulation problems or using any drug. All gauzes used and the blood that accumulated in the aspirator throughout the operation were calculated. Our results showed that the mean amount of blood loss in reverse trendelenburg was lower [77.00 +/- 13.20 ml] than head up position [83.33 +/- 21.18 ml], although, there was no statistical difference between two groups. However, there was no significant differences among two groups in different aspects of hemodynamic determinants and bleeding amount during and after rhinoplasty. Our results showed that patient bleeding is not increased because of positioning per se. In conclusion, perhaps in the future reverse trendelenburg will be given more often during rhinoplasry

Ventilator-associated pneumonia: evaluation of etiology, microbiology and resistance patterns in a tertiary respiratory center

Ventilator-associated pneumonia [VAP] has been reported as the most common hospital-acquired infection among patients requiring mechanical ventilation. This study aimed to determine the incidence of ventilator-associated pneumonia in a cardiopulmonary tertiary center, and to evaluate its etiology, resistance patterns, and outcome of admitted patients. In a retrospective study, patients admitted to the Masih Daneshvari Hospital, a tertiary cardiopulmonary center, were evaluated in a 7-month period. A total of 530 patients were admitted to the ICU out of which, 40 acquired VAP. Overall, 99 patients were evaluated [male 57, female= 42] including 40 VAP and 59 non- VAP cases. The incidence of VAP was estimated to be 7.5% in this unit. The underlying conditions included respiratory diseases [COPD, asthma, etc], and cardiac problems [post "coronary artery bypass graft" CABG, etc]. Also, patients in the thoracic surgery ward and those with renal, gastrointestinal, neurologic and other medical problems were evaluated. The patients were divided into two groups of VAP and non-VAP cases. The micro-organisms were recovered from the patients' bronchoalveolar lavage fluid. The most common micro-organisms recovered were Pseudomonas aeruginosa [17 cases] and Staph. aureus species [15 cases]. In VAP patients in whom S. aureus was recovered, 80 percent of species were methicillin-resistant [MRSA] but all were sensitive to Vancomycin. Moreover, resistance to two, three or four antibiotics was seen in 12, 10, and 5 patients, respectively, in whom P. aeruginosa was recovered. The prevalence of S. aureus in patients with respiratory problems was more than other groups [including MRSA species], but the prevalence of recovered P. aeruginosa was the lowest in respiratory patients, compared to other groups. Also the mortality rate in drug resistant S. aureus and P. aeruginosa groups were 42 and 47 percent, respectively. Length of stay for MRSA group was 80% and death rate was 50%. In P. aeruginosa group, there was a positive relationship between resistance to multiple drugs and mortality and also ICU stay. VAP is a common infection in ICU setting and certain interventions may affect its incidence. In our study, P. aeruginosa and S. aureus were more common in ICU patients. Pseudomonas species were associated with the highest mortality rate and were resistant to four antibiotics in the antibiogram testing. S. aureus species were more common in patients with underlying respiratory problems, compared to those with other conditions

Preoperative assessment of mechanical ventilation requirement after surgical treatment of esophageal cancer

The risk of pulmonary complications after esophagectomy is higher than after any other common operation, including major lung resection. In this study, we sought to identify risk factors associated with the development of pulmonary insufficiency requiring mechanical ventilation to identify preoperative parameters involved in the estimation of the risk of pulmonary insufficiency. We performed a retrospective cohort study on consecutive patients undergoing esophagectomy for malignancy in the Thoracic Surgery Department of Modarres Hospital in Tehran from March 2002 to February 2006. Patients were assigned into two groups based on whether they required mechanical ventilation or not. Preoperative, operative, and postoperative data were compared among the two groups. To find predictive variables for requiring mechanical ventilation, backward stepwise regression analysis was carried out with risk factors as independent variables and the need for ventilatory support as the dependent variable. The study population included 77 males and 43 females with a mean age of 60.16 +/- 12.04 years [range 29-79 years]. Twenty-seven patients [27.7%] required mechanical ventilatory support. Multivariate analysis revealed sex [Odds ratio: 4.590, Cl 95%: 1.246-16.411] as a confounder and duration of operation [Odds Ratio: 1.677, Cl95%: 1.102-2.533] as a risk factor for requiring mechanical ventilation. Proper patient selection for esophagectomy is important for reducing the postoperative mortality and morbidity and benefiting from a radical resection

Assessing the performance of two clinical severity scoring systems in the ICU of a tertiary respiratory disease center

The aim of this study is to compare the performance of five applied general severity scoring systems and their ability to predict mortality rate for the intensive care unit patients: Simplified Acute Physiology Score II [SAPS II], Mortality Probability Model II at admission [MPM II[0]], at 24 hours [MPM II[24]], at 48 hours [MPM II[48]] and over time [MPM II[over time]]. These scoring systems have been developed in response to an increased emphasis on the evaluation and monitoring of health care services; and also making cost-effective decisions. In this historical cohort study, all of the scoring systems were applied to 114 patients and the predicted mortality rate and the Standardized Mortality Ratio [SMR] were calculated for them. Calibration of each model and discriminative powers were evaluated by using Hosmer-Lemeshow goodness of fit test and ROC curve analysis, respectively. The predicted mortalities were not significantly deviated from the main systems [SMR for SAPS II: 0.79, MPM II[0]: 1.10, MPM II[24]: 1.32, MPM II[48]: 1.08 and MPM[Over time]: 1.02]. The Hosmer-Lemeshow statistics had the least value for MPM II[48] [C=2.922, p-value=0.939]; and the discrimination was best for MPM II[24] [AUC=0.927] followed by SAPS II [AUC=0.903], MPM II[0] [AUC=0.899], MPM II[48] [AUC=0.848] and MPM II[over time] [AUC=0.861]. All five general ICU morality predictors showed accurate standardized mortality ratio. MPM II[24] had the best discrimination, MPM II[0] had the best SMR before 24 hours and MPM[over time] had the best SMR after 24 hours. Performance of MPM II and its ease of use make it an efficient model for mortality prediction in our study

Predictive accuracy of revised Geneva score in the diagnosis of pulmonary embolism

Revised Geneva score is a clinical prediction rule used in determining the pre-test probability of pulmonary embolism [PE]. It has been recently introduced and is independent of the doctor's experience applying the rule. This study aimed to evaluate the predictive accuracy of revised Geneva score in the diagnostic protocol of pulmonary embolism and its role in decreasing the need for pulmonary imaging studies. In this study, we evaluated the medical records of 242 patients suspected for pulmonary embolism who underwent CT scan of the lung as part of their diagnostic protocol from October 2007 to February 2009. Six patients were excluded from the study due to their indeterminate CT scan results. The mean age of patients was 58 yrs and 62% of patients were males. The overall prevalence of pulmonary embolism was 24%. By increased scoring, the clinical probability of pulmonary embolism increased as well [P=0.011]. According to the classification of revised Geneva score, clinical probability of pulmonary embolism was evaluated to be low in 25% of patients, intermediate in 72% and high in 2%. Prevalence of pulmonary embolism based on the CT scan results was 7.7% ranged [0.5-14.9] in the low probability category, 22.5% ranged [15.6-29.4] in the intermediate, and 50% ranged [0.01-0.99] in the high-probability category which were comparable with the rates reported in the derivation set except for the prevalence rate for high probability patients [9%, 27.5% and 71.7%, respectively]. The area under the ROC curve was calculated based on continuous scoring to be 0.675. Revised Geneva score had an acceptable predictive accuracy in low and intermediate-probability groups. We could not reach a conclusion regarding high probability patients due to the small number of such cases in this study