Clinical activity and outcomes during Geelong's general surgery response to the coronavirus disease 2019 pandemic.

BACKGROUND: The response to the coronavirus disease 2019 pandemic has required conserving capacity and resources to avoid the health sector being overwhelmed. This paper describes Geelong's general surgical response, surgical activity, outcomes and the effect on surgical training. METHODS: Data collected from surgical audits; hospital databases and patient's medical records were used to compare the first 7 weeks of our new service delivery (30 March to 17 May 2020) to the corresponding 7 weeks in 2019 (1 April 2019 to 19 May 2019). All surgical cases, morbidity and mortality were discussed at weekly surgical audit meetings conducted by videoconference. Treatment performance indicators were tested by chi-squared test for proportions, and by Student's t-test or Mann-Whitney test for continuous variables. RESULTS: Elective general surgery decreased by 45.9% but an essential service was maintained by substantially increasing our public in private operating to perform 81 cases. Despite a 30% decrease in emergency department presentations, general surgery admissions decreased only 6.1% while emergency operations increased 13.9%. We used telehealth to conduct 81.3% of outpatient appointments and 61.8% of pre-operative anaesthetic reviews. No significant differences were found for overall surgical outcomes, including appendicectomy (perforation rates) and laparotomy (length of stay and morbidity). Operative exposure for trainees was maintained. CONCLUSION: Geelong was able to provide a safe and effective general surgery service during the first 7 weeks of the coronavirus disease 2019 pandemic. There are some valuable lessons which could be adopted elsewhere in the event of a surge or second wave of cases.

Successful oral acyclovir desensitization.

A 65-year-old woman with the acquired immunodeficiency syndrome (AIDS) complicated by recurrent mucocutaneous herpes simplex virus (HSV) infection developed angioedema on the initiation of her second course of oral acyclovir therapy. Oral rechallenge in hospital three days later confirmed acyclovir hypersensitivity. Vidarabine and foscarnet therapies were abandoned after treatment failure and unacceptable toxicity. Acyclovir desensitization was accomplished using a protocol derived from oral penicillin desensitization regimens. Mucocutaneous HSV infection responded to intravenous acyclovir followed by chronic oral suppression without recurrences of HSV or hypersensitivity. This report is an example of acyclovir hypersensitivity and successful oral desensitization.

Sudden cardiac death caused by coronary ostial compression by an aneurysm of the sinus of Valsalva.

A 22-year-old man was asymptomatic until he died suddenly after being startled. Post-mortem examination was normal except for aneurysmal dilatation of the left Sinus of Valsalva, the upper margin of which formed a flap-like ridge, partially occluding the ostium of the left main coronary artery which arose immediately above it. Further compression of this "slit-like" orifice by aneurysmal distention was the proposed cause of myocardial ischaemia and arrhythmic death.

Sudden cardiac death caused by coronary ostial compression by an aneurysm of the sinus of valsalva

A 22-year-old man was asymptomatic until he died suddenly after being starled. Post-mortem examination was normal except for aneurysmal dilatation of the left Sinus of Valsalva, the upper margin fo which formed a flap-like ridge, partially occluding the ostium of the left main coronary artery which arose immediately above it. Further compression of this "slit-like" orifice by aneurysmal distention was the proposed cause of myocardial ischaemia and arrhythimic death

Pneumoperitoneum associated with mechanical ventilation.

The true incidence of pneumoperitoneum associated with mechanical ventilation is unknown, but current estimates range from rare to 7 percent of intubated intensive care unit patients. This syndrome should be strongly suspected when pneumoperitoneum develops in a mechanically ventilated patient with a combination of (1) peak inspiratory pressure (PIP) greater than 40 cm H(2)O; (2) positive end expiratory pressure (PEEP) greater than 6 cm H(2)O; and (3) coexistent evidence of significant pulmonary barotrauma. An illustrative case report is presented where this entity was recognized and the patient managed without laparotomy. Controlled prospective studies should determine the true importance of this problem.

Influence of ethanol and ambient temperature on skin blood flow.

Patients frequently arrive in the emergency department under the influence of alcohol after exposure to extreme conditions of heat or cold. While ethanol ingestion and ambient heat are recognized to have vasodilatory action, previous studies of their interactive effect are limited and guidelines for patient care are vague. Xenon-133 skin perfusion studies allow direct quantitative assessment of the net effect of multiple variables on skin vasculature. Using Xenon-133 to measure cutaneous blood flow in the lower extremity, we studied four groups of 12 healthy men at 20, 25, 30, and 35 C. Half of each group ingested 60 mL of 95% ethanol in fruit juice, while the other half received placebo only. Skin perfusion at baseline and 50 minutes after ingestion of ethanol were measured. Vasodilatation was observed at 25 and 30 C in subjects who had ingested ethanol. At 20 and 35 C vasoconstriction or vasodilation, respectively, occurred in all subjects with no additional influence of ethanol observed. The influence of heat or cold on skin blood flow appears to dominate over the influence of moderate amounts of ethanol at these temperature extremes. Specifically, in patients exposed to extreme temperatures while under the influence of ethanol, there is no benefit from the agent on cutaneous blood flow at or below 20 C, and there is no enhanced heat loss at 35 C or above.

Prospective use of xenon Xe 133 clearance for amputation level selection.

Xenon Xe 133 clearance was used to select the most distal amputation level that would allow sufficient blood flow for healing. Capillary blood flow was first measured at the most distal potential amputation level, then at successive proximal levels until an amputation site was found that had a capillary skin blood flow rate greater than or equal to 2.6 mL/min/100 g of tissue. Xenon Xe 133 in saline (100 to 500 mCi) was injected intracutaneously at each level, and flow rates were determined using a gamma camera interfaced with a computer system programmed for the Ketty-Schmidt formula modified for capillary blood flow. There were 45 cases, including one toes, six transmetatarsal, five Syme's, 25 below-knee, four knee disarticulation, three above-knee, and one hip disarticulation amputation. All amputations in patients with flow rates exceeding 2.4 mL/min/100 g of tissue healed, with two exceptions.

Radionuclide imaging of the biliary tract.

Cholescintigraphy with technetium-labeled biliary agents has great value in evaluation of the patient with suspected acute cholecystitis. Visualization of the gall bladder virtually excludes acute cholecystitis and obstruction of the cystic duct. Nonvisualization of the gall bladder, however, is not specific for acute cholecystitis and may also occur in some patients with chronic cholecystitis or pancreatitis. Interpretation of gall bladder nonvisualization, therefore, must be correlated with the clinical presentation. Biliary tract imaging is also useful in evaluation of some focal abnormalities within the liver, neonatal jaundice, detection of bile leaks or bile reflux, and biliary-enteric shunts. The role of technetium-labeled biliary agents in the evaluation of patients with jaundice is less clear. Excretion of tracer into the gut excludes complete biliary tract obstruction, but the test may be nonconclusive at higher serum bilirubin levels. If persistent common bile duct activity is observed with delayed excretion into the gut, the diagnosis of partial obstruction may be made, but this procedure will be inconclusive if the common bile duct is not visualized and/or significant hepatocellular disease is present. Ultrasonography and abdominal CT are the preferred tools for the diagnosis of biliary tract obstruction at present, but newer biliary tract agents which achieve better hepatic extraction and greater bile concentration at high serum bilirubin levels may improve the diagnostic efficacy of cholescintigraphy.

Quantitative measurement of skin perfusion with xenon-133.

Quantitative assessment of skin perfusion has value in both medical and surgical therapeutic decision-making. We have adapted a technique using intradermal xenon-133 dissolved in saline for use with a gamma camera interfaced to a mini-computer. It allows rapid evaluation of several sites simultaneously. The monoexponential washout rate of the injected tracer during the first 6 min is entered into the Schmidt--Kety equation to provide blood-flow rates in ml/min per 100 g. Reproducibility of the method in normal subjects is satisfactory. An important experimental variable is ambient temperature, since perfusion rates in normal limbs at low temperatures can approach those levels found in ischemic limbs. The intradermal technique has practical advantages over other methods for study of limb or skin perfusion.