Outcomes of a preoperative "bridging" strategy with glycoprotein IIb/IIIa inhibitors to prevent perioperative stent thrombosis in patients with drug-eluting stents who undergo surgery necessitating interruption of thienopyridine administration.

AIMS: Surgery after drug-eluting stent (DES) implantation may be associated with increased risk for perioperative stent thrombosis (ST). METHODS AND RESULTS: We evaluated the outcomes of 67 patients who underwent non-cardiac (n=51) or cardiac (n=16) surgery after DES implantation at our institution between 2008 and 2010 and who underwent preoperative "bridging" with a glycoprotein IIb/IIIa inhibitor. Surgery occurred after a mean time of 13.9 ± 1.7 and 8.7 ± 2 months post stenting for non-cardiac (NCS) and cardiac surgery, respectively. Glycoprotein IIb/IIIa inhibitors were administered preoperatively for a mean of 7.1 ± 0.4 and 7.8 ± 0.7 days, respectively, then discontinued four to six hours before surgery. Most patients received aspirin through the perioperative period (33 NCS patients and 15 cardiac surgery patients). Clopidogrel was restarted as early as possible in the postoperative period. In the non-cardiac surgery group, two patients (3.9%, 95% confidence intervals 0.5% to 13.5%) suffered acute ST in the immediate postoperative period and four patients suffered major bleeding by the Global Utilisation of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) criteria. One cardiac surgery patient had probable ST one hour postoperatively. CONCLUSIONS: In spite of preoperative "bridging" with a glycoprotein IIb/IIIa inhibitor, postoperative stent thrombosis can still occur in patients with prior DES undergoing surgery requiring antiplatelet medication interruption.

Evaluating an evidence-based bundle for preventing surgical site infection: a randomized trial.

OBJECTIVE: To determine if an evidence-based practice bundle would result in a significantly lower rate of surgical site infections (SSIs) when compared with standard practice. DESIGN: Single-institution, randomized controlled trial with blinded assessment of main outcome. The trial opened in April 2007 and was closed in January 2010. SETTING: Veterans Administration teaching hospital. PATIENTS: Patients who required elective transabdominal colorectal surgery were eligible. A total of 241 subjects were approached, 211 subjects were randomly allocated to 1 of 2 interventions, and 197 were included in an intention-to-treat analysis. INTERVENTIONS: Subjects received either a combination of 5 evidenced-based practices (extended arm) or were treated according to our current practice (standard arm). The interventions in the extended arm included (1) omission of mechanical bowel preparation; (2) preoperative and intraoperative warming; (3) supplemental oxygen during and immediately after surgery; (4) intraoperative intravenous fluid restriction; and (5) use of a surgical wound protector. MAIN OUTCOME MEASURE: Overall SSI rate at 30 days assessed by blinded infection control coordinators using standardized definitions. RESULTS: The overall rate of SSI was 45% in the extended arm of the study and 24% in the standard arm (P = .003). Most of the increased number of infections in the extended arm were superficial incisional SSIs (36% extended arm vs 19% standard arm; P = .004). Multivariate analysis suggested that allocation to the extended arm of the trial conferred a 2.49-fold risk (95% confidence interval, 1.36-4.56; P = .003) independent of other factors traditionally associated with SSI. CONCLUSIONS: An evidence-based intervention bundle did not reduce SSIs. The bundling of interventions, even when the constituent interventions have been individually tested, does not have a predictable effect on outcome. Formal testing of bundled approaches should occur prior to implementation.

Gastric bypass and On-Q pump: effectiveness of Soaker Catheter system on recovery of bariatric surgery patients.

BACKGROUND: The continuous infusion of ropivacaine is effective in controlling pain for a wide variety of surgical procedures and reducing opioid adverse effects and dependency. The present study assessed the efficacy of ropivacaine infusion using the I-Flow dual Soaker Catheter system at the surgical site for bariatric surgery recovery at the Dallas Veterans Affairs Medical Center Hospital (Dallas, TX). We hypothesized that patients receiving ropivacaine would report lower levels of morphine requirement and pain, would have shorter hospital stays, and would return to ambulating faster than patients in the control group. METHODS: A total of 45 patients undergoing Roux-en-Y gastric bypass surgery were randomized to 1 of 2 treatment groups, with a target study population of 50 patients, receiving either .2% ropivacaine (n = 24) or saline solution (n = 21). Before incision closure, the surgeon infiltrated the surrounding tissues with 30 mL of ropivacaine (.5%) or saline solution. The catheter was then placed in both the subfascial space and subcutaneously. Next, the infusion pump was connected to the Soaker Catheters to complete the system design and deliver solution to the surgical site. RESULTS: No significant differences were found in the pain scores, morphine requirement, or length of stay between the 2 groups. The ropivacaine group interval to sitting up was one half day shorter than that of patients receiving saline (P = .038). CONCLUSIONS: Patients receiving ropivacaine were found to ambulate much more quickly than did the control group patients. This could be very beneficial in reducing the complications from blood clots and improving patient recovery and overall well-being after surgery by assisting with a quicker return to activities of daily living and reducing the dependence on the nursing staff.

Prolonged recovery associated with dexmedetomidine when used as a sole sedative agent in office-based oral and maxillofacial surgery procedures.

PURPOSE: Office-based oral and maxillofacial surgical procedures that require sedation are popular. Dexmedetomidine has the advantages of having a minimal effect on respiration and an antisialogogue effect that could make it a good choice for dental procedures. MATERIALS AND METHODS: We performed a prospective pilot study in which patients undergoing office-based oral and maxillofacial surgical procedures received dexmedetomidine as a sole sedative agent. The loading dose of dexmedetomidine (1 microg/kg infused over 10 minutes) was followed by a maintenance dose (0.2 to 0.8 microg/kg/hour) to achieve a Ramsay sedation score of 2 to 3. The demographic data were collected, and the pre- and intraprocedural vital signs and Ramsay sedation score were recorded every 5 minutes. The duration of the procedure, recovery time, and patient and surgeon satisfaction were documented. RESULTS: No statistically significant changes were found in the heart rate, respiratory rate, or oxygen saturation during the procedure when compared to baseline. However, we noticed a significant decrease in the heart rate at the end of the loading dose, and statistically significant change in the blood pressure between baseline and during the procedure (P < .05). The initial local anesthetic injections were recalled by 26% of the patients, and 73% had some recollection of the procedure. Nevertheless, the patient satisfaction score (range 1 to 10) was 8.6 +/- 2.3, and 86% of the patients would recommend this type of sedation. The surgeon satisfaction score (range, 1 to 5) was 3.9 +/- 1.3. The recovery time was prolonged (82.2 +/- 24.3 minutes) when compared with the total procedure time (44.6 +/- 27.9 minutes). CONCLUSIONS: Dexmedetomidine has demonstrated hemodynamic and respiratory stability when used as a sole sedative agent. Despite the discomfort on injection and the lack of reliable amnesic property, patient and surgeon satisfaction were high. However, the prolonged recovery time makes this drug unsuitable for busy office-based practices. We believe it should be reserved for patients with a high risk of respiratory complications (eg, obese patients or those with a history of sleep apnea).

Metoclopramide does not influence the frequency of propofol-induced spontaneous movements.

STUDY OBJECTIVE: To evaluate the effects of metoclopramide on the frequency and severity of propofol-induced movements. DESIGN: Randomized, double blind, placebo-controlled trial. SETTING: Veterans Administration Medical Center. PATIENTS: One hundred thirty-seven consenting adults scheduled to receive general anesthesia with propofol induction. INTERVENTIONS: Patients were randomized to receive either metoclopramide 10 mg intravenously (IV) or placebo (saline) 3 min before induction of general anesthesia. All patients received midazolam 1 to 2 mg IV, fentanyl 50 to 150 microg IV, and lidocaine 50 to 80 mg IV before induction of anesthesia. MEASUREMENTS: Occurrence of spontaneous movements and severity during the observation period were recorded after propofol induction by observing movement in the hands/arms and feet/legs, as well as presence of a hiccup. The dosage of anesthetic medications administered was also recorded for each patient. MAIN RESULTS: No differences were noted in the frequency and severity of spontaneous movement in the patients who had received metoclopramide and placebo. However, compared with the patients who did not move, patients who experienced movements received a significantly higher dose of propofol (P = 0.025) and a lower dose of fentanyl (P = 0.049). CONCLUSIONS: Metoclopramide does not affect the frequency of propofol-induced movements, but propofol and fentanyl doses influence the frequency of movements during propofol induction.

Patient state index during a cardiac arrest in the operating room.

A 53-yr-old man undergoing laparoscopic cholecystectomy experienced cardiac arrest intraoperatively. Patient state index values decreased to single digits during the cardiac arrest and returned to baseline after successful cardiopulmonary resuscitation.