Subarachnoid anesthesia vs monitored anesthesia care for outpatient unilateral inguinal herniorrhaphy.

AIM: Inguinal herniorrhaphy is one of the most commonly performed surgical procedures in a same-day surgery setting. The prerequisite of having to discharge the surgical outpatient on the same day has an influence on the choice of the anesthetic technique. METHODS: A randomized clinical trial was performed on 100 outpatients; 50 patients were enrolled in the subarachnoid anesthesia (SA) group and 50 patients in the monitored anesthesia care (MAC) group. Patients in the MAC group received local anesthesia plus target-controlled infusion propofol (LA+TCI). SA was performed using 7.5 mg 0.5% hyperbaric bupivacaine according to the selective technique. In the LA+TCI group, LA was performed with 20 mL 1% mepivacaine + 10 mL 1% ropivacaine; IV propofol sedation using TCI according to Schnider was used to obtain a Ramsay scale response of 4-5. Transferability from the operating room was evaluated based on an Aldrete score > or =9; ability to discharge from the health facility was evaluated based on a Post-Anesthesia Discharge Scoring System (PADSS) > or =9. RESULTS: Of the 100 total patients enrolled, five drop-outs were recorded in the SA group. By comparing the LA+TCI and SA groups, it was determined that the time to an Aldrete > or =9 score from the end of the procedure was 25+/-27 vs 34+/-54 min (P=0.330); the time to a PADSS 9 score was 113+/-58 vs 181+/-65 min (P<0.001); actual discharge occurred after 236+/-83 vs 289+/-78 min (P<0.01). CONCLUSIONS: LA+TCI was shown to be more effective than selective SA at low doses in terms of shorter time to recovery after unilateral inguinal herniorrhaphy procedures.

Surgeon-patient barrier efficiency monitored with an electronic device in three surgical settings.

Blood-borne viral pathogens are an occupational threat to health care workers (HCWs), particularly those in the operating room. A major risk is posed by accidental penetrating injury, but skin contamination with body fluids from an infected patient, with prolonged intimate cutaneous contact, is a frequent occurrence during surgery, carrying further risk of transdermal infection. We have monitored barrier failure in three surgical settings (microsurgery, orthopedic surgery, general surgery) by means of an electronic surveillance device. A total of 111 surgical procedures were monitored: 67 microsurgeries, 22 orthopedic surgeries, and 22 general surgeries. Of the 278 electronic alarms signaling barrier failure, 44 (15.8%) were associated with glove perforation, 39 of which (88.6%) were not perceived by the operator. In 16 of those, the skin was visibly stained with the patient's blood. Altogether, 76 of the alarms (27.3%) were consequent to contacts caused by soaked gowns/sleeves, and 121 (43.5%) were attributed to hydration of latex porosities; 37 alarms (13.4%) were unexplained false positives. On only one occasion did a surgeon observe blood stains on his hands without a previous alarm; this event was classified as a device failure due to incorrect wiring. Double-gloving offered satisfactory protection against skin contamination during microsurgery but not during orthopedic surgery. The data presented here indicate that electronic monitoring of the surgical barrier enables prompt detection of barrier failure, especially at the level of the gloves, thereby limiting skin contamination with patients' body fluids during surgery.

Successful use of central venous catheter as permanent hemodialysis access: 84-month follow-Up in lucania.

Cuffed tunneled venous access catheters are commonly used for temporary and permanent access in hemodialysis (HD) patients. These catheters serve an essential role in providing permanent access in subjects in whom all other access options have been exhausted. The predominant complications are catheter thrombosis, catheter fibrin sheating and infection. The aim of this study was to evaluate long-term survival and complications of permanent venous catheters (PVC) placed for the purpose of HD during the period from January 1992 to December 1998, at the Dialysis Units of Lucania (a southern Italian region). A total of 98 PVC were placed in 88 patients during this period. The catheters used were of three types: (a) 72 VasCath Soft Cell catheters (Bard Instrument Company, Toronto, Ont., Canada); (b) 22 PermCath catheters (Quinton Instrument Company, Seattle, Wash., USA), and (c) 4 Tesio catheters (Bellco SpA, Mirandola, Italy). Survival curves of catheters were calculated using the Kaplan-Meier product-limit estimator. The patient survival was 60% at the 78th month. Actually, 52 patients (27 males, 25 females) are still alive: 15 (26.9%) of these patients have diabetes mellitus and 1 has been transplanted. The actuarial survival rate of PVC was 89% in the whole population studied and 82% in subjects alive after 84 months. Twenty-five patients (28.4%) had PVC as the first reliable vascular access. Long-term complications occurred 27 times (1 episode every 44.81 month/patient) as: breakage (3.1%); thrombosis (10.2%); displacement (2.0%); subcutaneous tunnel bleeding (3.1%); inadequate blood flow (7.1%), and infection (10.2%). In conclusion, our data confirm that PVC might represent an effective long-term blood access route for HD. Again, PVC are getting the access of choice for selected patients (i.e., older subjects with cardiovascular diseases and cancer patients) and are enjoying a dramatic increase in use for subjects who are terrified of repetitive venopuncture.

Periprosthetic bone density in uncemented femoral hip implants with proximal hydroxylapatite coating.

The short term results of a prospective dual energy x-ray absorptiometry (DEXA) study of periprosthetic bone remodeling around titanium femoral stems proximally coated with hydroxyapatite are presented. Thirty patients underwent DEXA scanning on the 15th and 45th postoperative days, 12th, 18th postoperative month. DEXA showed global femoral periprosthetic remodeling during the first 18 postoperative months. However, no significant variation in bone mineral density occurred around the lateral metaphyseal regions, where cancellous bone is greatest.

Association between fracture of the diaphysis of the femur and lesion of the ligaments of the knee.

The authors evaluated 97 knees out of a series of 135 fractures of the femur in 130 patients, revealing 34 cases of capsuloligamentous laxity, equal to 35% of the cases. No specific correlation between type of trauma, type and site of fracture, and lesion of the ligaments was observed. The frequency of unrecognized lesions, particularly in the posterior capsule, was made evident. The frequency of ligamentous lesions rises to 44.4% when fracture of the femur is associated with fracture of the homolateral tibia as compared to 26.7% in cases of isolated fracture of the femur. Recurvatum, which was present in a fair number of the cases, was related more to post-fracture therapy and rehabilitation rather than to specific capsuloligamentous lesion of the knee.