Fast-track office-based anesthesia: a comparison of propofol versus desflurane with antiemetic prophylaxis in spontaneously breathing patients.

IMPLICATIONS: Compared to propofol, maintenance of anesthesia with desflurane provided significantly better intraoperative conditions during office-based surgery. In addition, desflurane with routine antiemetic prophylaxis was associated with a faster early recovery and similar incidence of postoperative side effects.

Report of the Council on Scientific Affairs. Use of restraints for patients in nursing homes. Council on Scientific Affairs, American Medical Association.

OBJECTIVE: To examine issues related to the use of restraints on nursing home patients, including regulations and guidelines, risks and benefits of restraint use, system problems, and measures to reduce restraint use, to determine when the use of restraints results in clinically desirable outcomes. METHODS: Sources of information included a review of published articles and reports, a survey of federal and state regulations and guidelines relating to restraint use in nursing homes, review of current legislative initiatives, and consultation with experts in the field. RESULTS: The data reveal that restraint use imposes more risk of falls and other undesirable outcomes than it prevents. In response to legislative initiatives and regulatory activities and by implementing alternatives, the prevalence of restraint use has decreased by 20% in recent years. In many states, facilities have created restraint-free environments or restraint-free policies and goals. The Council on Scientific Affairs finds that current federal and state regulations on the use of restraints have benefited the vast majority of nursing home patients. CONCLUSIONS: While guidelines are in place for the use of restraints when clinically necessary, the Council on Scientific Affairs recommends increased research to determine when the use of restraints results in desirable outcomes. Extraregulatory initiatives, such as widespread educational programs, are needed for professionals and consumers to improve awareness of the risks and benefits of restraints, as well as the rights of residents with respect to restraint use.

Manganese in gasoline. Council on Scientific Affairs, American Medical Association.

This report responds to a resolution that asked the American Medical Association (AMA) to take action to reduce potential health risks from the use of methylcyclopentadienyl manganese tricarbonyl (MMT) in gasoline. Information for this report was derived from a search of the MEDLINE database and references listed in pertinent articles, as well as through communications with medical and public health experts. Based on this information, the AMA Council on Scientific Affairs determined that there is insufficient scientific evidence to assess the public health impact of MMT use. While limited evidence indicates that general-population exposures to manganese from the use of MMT in gasoline are low, more research is needed to determine possible health effects from long-term, low-dose exposures to MMT and its combustion products. Until such data are available, educational and informational strategies should be developed to improve public awareness of the health and environmental issues surrounding MMT use.

Silicone elastomer cerebrospinal fluid shunt systems. Council on Scientific Affairs, American Medical Association.

A 1995 resolution of the American Medical Association House of Delegates, introduced by the American Academy of Neurology, the American Association of Neurological Surgeons, and the Congress of Neurological Surgeons, asked the American Medical Association Council on Scientific Affairs to add the use of hardened silicone shunts to its study of the effects of silicone gel used in breast implants. On consideration of the important differences between the two materials, silicone elastomer ("hardened silicone") and silicone gel, the Council on Scientific Affairs elected to address the subject of silicone elastomer shunt systems separately. This report describes the different types of medical-grade silicone used in medical devices, the incidence of hydrocephalus and its causes and treatment, and the use of cerebrospinal fluid shunt systems made of silicone elastomer. Published case reports of possible immunological disease in patients who have had silicone elastomer cerebrospinal fluid shunt systems implanted are reviewed. The Council on Scientific Affairs concluded that the evidence presented does not support the occurrence of immune-mediated systemic reactions to implanted silicone elastomer cerebrospinal fluid shunt systems. The local granulomatous or inflammatory responses observed in some patients with silicone shunt systems have not been shown to be immunologically mediated; similar reactions have been described with other implanted foreign bodies.

Calcifications in breast biopsy specimens: discrepancies in radiologic-pathologic identification.

To analyze the effectiveness and accuracy of the diagnostic process from screening mammography to final diagnosis at pathologic examination, the authors conducted a prospective study of 277 consecutive patients who underwent 291 mammographically directed biopsies of nonpalpable lesions. Of the 170 lesions that demonstrated findings consistent with calcification on preoperative mammograms and radiographs of specimens, 12 (7.1%) were not described by the pathologist as being calcified. These discrepancies were due to inadequate sampling in three cases (25%), lack of explicit description by the pathologist in four (33%), presence of oxalate crystals that required examination with polarizing lenses in two (17%), and unexplained loss of tissue probably related to processing in three (25%). Of the 121 lesions that did not demonstrate findings consistent with calcification at radiography, eight (6.6%) were described as calcified by the pathologist. The authors recommend a protocol for avoiding these discrepancies that involves performance of a more comprehensive examination of histologic sections by the pathologist, including the use of polarizing lenses, if necessary, and radiographic reexamination of paraffin-embedded tissue blocks with subsequent step sectioning by the pathologist when results are positive.

Immediate postoperative mammogram for failed surgical excision of breast lesions.

In a series of 200 consecutive preoperative needle localizations of non-palpable breast lesions, 128 lesions (64%) were calcified and 72 lesions (36%) were noncalcified on preoperative mammograms. Radiographs of the surgical specimen failed to confirm excision of 11 lesions (5.5%), seven calcified and four noncalcified. These 11 patients were taken directly from the surgical suite to the radiology suite, where an immediate postoperative mammogram was obtained. In five patients (2.5%), immediate postoperative mammograms showed surgical failure with the lesion still present. In six patients (3.0%), immediate postoperative mammograms showed that the lesion had been removed, even though the lesion had not been identified on surgical-specimen radiographs. No errors occurred in the interpretation of immediate postoperative mammograms, a fact corroborated by examination of surgical specimens obtained at repeat surgery in three patients and identification of skin calcifications in two patients, and with follow-up mammograms in six patients. Whenever a discrepancy between preoperative localization radiographs and surgical-specimen radiographs exists, the authors suggest immediate postoperative mammography to improve the diagnostic process.

Safe instrumentation in laser surgery.

Safe instrumentation in laser surgery involves three basic principles. First, the armamentarium used in conjunction with the operative procedure should be nonflammable. Second, the surfaces of instruments should be nonreflective. Finally, there must be a provision for adequately evacuating smoke and steam from the operative field. This article discusses these principles and reviews instrumentation currently used in microlaryngeal and bronchoscopic laser surgery that satisfies these standards.

A new laser-laryngoscope coupler.

A new generation of laser surgery of the larynx is possible with this laser-laryngoscopic coupler. The applications are numerous. The surgeon can custom-tailor his working environment rather than stretching himself to the demands of the equipment and can adjust the laser to meet the surgical needs of the patient's disease. No longer must large quantities of tissue be ablated. Fine incisions can be made, pathologic margins can be more clearly examined, and smaller lesions can be treated and biopsied with increased tissue conservation and precision.

Laser surgery for benign laryngeal disease. Conservation and ergonomics.

In surgery, the era of tissue conservation and advanced engineering ergonomics has arrived. As a surgical tool, lasers will undergo extensive development. The most precise of surgical tools, its ability to focus to spots equal to its wavelength will permit intracellular surgery. A new technology must be mastered by the operator, who must have a solid foundation in laser physics. The small spot size possible with the new laser laryngoscopy coupler introduces one more refinement in the growing trend toward "conservational" surgery of the larynx for both benign and malignant laryngeal disease.

Instrumentation for CO2 laser surgery of the larynx and tracheobronchial tree.

This article discusses the safety principles necessary in laser surgery of the aerodigestive tract, and reviews the instrumentation currently used in microlaryngeal and bronchoscopic laser surgery that satisfies these criteria. Such use will contribute to reduction of morbidity rates associated with laser surgery in these procedures.

A safe technique for thyroidectomy with complete nerve dissection and parathyroid preservation.

A series of 1,000 consecutive thyroid operations is presented, without a case of permanent recurrent laryngeal nerve injury. Emphasis is placed on the identification of variations and complete dissection of the recurrent laryngeal nerve, including peripheral branches and technical aspects of the dissection. Sixty-five percent of the cases had multiple terminal branches of the recurrent laryngeal nerve and five cases on the right side had a nonrecurrent course. A low incidence of hypoparathyroidism is presented, due in part to the avoidance of ligating the inferior thyroid artery in continuity and the technique of extracapsular dissection of the thyroid gland. The external branch of the superior laryngeal nerve was protected by the early mobilization of the superior thyroid vessels and ligatures placed flush on the capsule of the superior pole.

CO2 laser in otolaryngology-head and neck surgery: a retrospective analysis of complications.

A retrospective review was conducted of all patients undergoing CO2 laser surgery by members of the Department of Otolaryngology-Head and Neck Surgery at Northwestern University Medical School from January 1, 1980 through December 31, 1981; 204 cases were identified and all are included in this report. Early in our department's experience with laser surgery, an endotracheal tube fire occurred. This incident precipitated a departmental review of complications associated with the use of the CO2 laser and resulted in the formulation of a laser safety protocol. All patients in this group were treated under the directives of this protocol; the operative complication rate was low. This retrospective analysis of complications associated with the use of the CO2 laser under a strictly applied protocol demonstrates the relative safety associated with judicious use of this instrument.

Nonrecurrent inferior laryngeal nerves and their association with a recurrent branch.

Seven cases of nonrecurrent inferior laryngeal nerves have been presented from a review of 1,000 consecutive thyroidectomies over a 20 year period. In two of these seven cases, both a nonrecurrent nerve and an additional recurrent branch were present on the right side. This double nerve presentation has not been described before. Unless one is aware of this possibility, one might inadvertently injure the major nonrecurrent trunk, having identified only a small recurrent branch. We emphasize the need for a complete nerve identification technique.

Comparison of tracheal damage from laser-ignited endotracheal tube fires.

Studies were undertaken by the Departments of Otolaryngology-Head and Neck Surgery and Anesthesiology at Northwestern University Medical School and the Medical College of Wisconsin (Milwaukee) to compare the potential for tissue injury to the trachea and lungs of canines. Polyvinylchloride (PVC), Rusch red rubber, and silicone tubes were tested. The effects of an intraluminal tube fire on the larynx and trachea were documented with laryngeal and bronchoscopic photographs taken immediately postburn and at the time of sacrifice six hours later. The most severe burns were associated with the PVC tube. Silica ash was seen in the airway after the silicone tube fires and raises the possibility of future problems with silicosis. Histological examination of the trachea showed acute injury in all of the animals; specimens from the dogs with the PVC tube fires demonstrated the most severe cellular damage.

Posterior commissure laryngoscope for carbon dioxide laser surgery.

A laryngoscope has been developed for microlaryngeal laser surgery in the posterior commissure of the larynx. The tip has been designed to facilitate exposure of one entire arytenoid and the posterior commissure. Other features include a concavity on the superior lip of the tip to hold the endotracheal tube anteriorly, a bifurcated smoke evacuation channel and a nonreflective finish. It is anticipated that this laryngoscope will be available in pediatric and adolescent sizes in addition to the adult size that we have worked with.

Endoscopic laser arytenoidectomy.

Most patients with bilateral vocal cord paralysis have a fairly satisfactory voice, but their airway is usually inadequate for day-to-day exertion. In some patients, the airway may be inadequate for even quiet respiration and an indwelling tracheotomy is required. Solution to this problem has involved the following techniques: tracheotomy, lateralization of the vocal cord by either endoscopic or external routes, or vocal cord reinnervation by the nerve-muscle transposition technique. Endoscopic laser arytenoidectomy has been mentioned in the literature. However, the actual technique as well as the attendant morbidity associated with this procedure has not been highlighted. Four patients with bilateral vocal cord paralysis of the larynx have been treated by endoscopic laser arytenoidectomy at Northwestern University Medical School. The technique, problems, and results are discussed.