Surgical considerations for treatment of amiodarone-induced thyrotoxicosis.

PURPOSE: We present our experience with surgical management of amiodarone-induced thyrotoxicosis, including preoperative, intraoperative, and postoperative considerations. METHODS: Retrospective review of the medical records and the histological slides and a Medline search of amiodarone and thyroid gland. CONCLUSIONS: Amiodarone is a drug used to treat potentially lethal ventricular arrhythmia. One of the known side effects is thyroid dysfunction. In patients who cannot safely discontinue amiodarone or when medical therapy is ineffective in controlling thyrotoxicosis, thyroidectomy is the treatment of choice.

Minocycline-induced black thyroid gland: Medical curiosity or a marker for papillary cancer?

PURPOSE: Black pigmentation of the thyroid gland is a rare side effect of minocycline. METHODS: Only 26 cases, in addition to the 2 we present, have been reported in the literature. Eleven cases of thyroid carcinoma associated with black thyroid syndrome have been reported. CONCLUSIONS: The incidence of papillary cancer may be increased in thyroid glands stained by the minocycline pigment, which warrants an increased index of suspicion in patients who develop thyroid nodules and have previously been treated with minocycline.

Competency-based instruction to improve the surgical resident technique and accuracy of the trauma ultrasound.

In a surgical trauma center, programs and workshops have improved the performance on focused abdominal sonogram for trauma (FAST). The purpose of this single-blind study was to prove that a cadaver laboratory competency-based instruction program may be an effective method of FAST training to acquire the skills that would be applied in the trauma room. The study was divided in two parts, laboratory and clinical. Nine surgical residents were divided into two groups: Group I performed the test only once, and Group II performed the training twice. A third "group" was the senior ultrasound technician, whose readings served as our "gold standard" with which to compare the resident readings (Group III). Using cadavers, a 2-cm catheter was introduced into the peritoneal cavity. Sequential aliquots of normal saline were introduced into the abdominal cavity at 0-, 200-, 400-, 600-, and 1000-cc increments in each group tested. The residents were asked to describe their examinations for the presence or absence of fluid in the abdomen. The ultrasound examination was then performed with the cadaver in three different positions to study if there was any difference of fluid detection in varied positions. True positive, true negative, and accuracy were then calculated comparing the three different groups of test sonographers. In the second part of the study, the same residents were then followed in the trauma room, where they performed the FAST in the absence of the ultrasound technician during emergencies. As in the laboratory, the accuracy of their reading compared with that of the ultrasound technician was also evaluated. From 400 cc and upward, Group II began having an overall significantly superior accuracy than the first group and the technician in most quadrants examined. The trend was apparent for more accurate results in all quadrants and positions by all groups as the fluid was increased. Overall, group II was most superior in detection of intra-abdominal fluid in the cadaver. In the clinical scenario, the residents as a whole had similar accuracy (92% vs 96%) in reading FAST as the ultrasound technician. Our results suggest that surgical residents have the ability to detect fluid in the abdomen, there exists a fast learning curve, and the minimum detection level of fluid was between 200 and 400 cc in the peritoneal cavity in the laboratory. Surgical residents were able to detect intra-abdominal fluid in the trauma situation, as shown by the 92 per cent accuracy of the FAST in the emergency situation. We conclude that a cadaver laboratory training program is an important adjunct to improve the skills of the resident in performing and reading FAST.

The predictive power of baseline hemoglobin for transfusion risk in surgery patients.

Preoperative hemoglobin concentration may be an important predictor of transfusion risk in surgical procedures with significant expected blood loss. Contemporary studies investigating transfusion risk with regard to the relationship between perioperative administration of Epoetin alfa and baseline hemoglobin provide data to test this hypothesis. The predictive power of seven preoperative variables (hemoglobin concentration, age, erythropoietin level, ferritin concentration, serum iron, total iron-binding capacity, and predicted blood volume) on transfusion risk was examined via retrospective logistic regression analysis of 276 orthopedic surgical patients. In the two studies used to perform the regression analysis, patients were treated daily with either Epoetin alfa or placebo. Based on the retrospective analyses, a prospective study was conducted to validate the hypothesis. Of the seven variables evaluated, baseline hemoglobin concentration and predicted blood volume were significantly predictive of transfusion risk in both Epoetin alfa- and placebo-treated patients. Further, an inverse correlation between hemoglobin concentration and transfusion risk was demonstrated in placebo-treated patients. Placebo-treated patients with hemoglobin > 10 to < or = 13 g/dL had an approximately twofold greater risk of transfusion than patients with hemoglobin > 13 g/dL. In contrast to placebo treatment, Epoetin alfa significantly reduced transfusion risk in patients with hemoglobin > 10 to < or = 13 g/dL. Baseline hemoglobin concentration is an excellent predictor of transfusion risk in orthopedic surgical patients. As a result, hemoglobin testing should be considered a part of routine preoperative testing for orthopedic surgical patients.

Opportunity.

Opportunities abound in all we see and do. We must view life as filled with opportunities if we are to take advantage of all that life has to offer. The future of surgery and the monetarization of healthcare may seem grim to some, but to those who see the opportunities in these changes and prepare for the evolution in surgical practice through education and discipline will go the leadership roles.

A new model for recognizing and rewarding the educational accomplishments of surgery faculty.

Faculty members' educational endeavors have generally not received adequate recognition. The Association for Surgical Education in 1993 established a task force to determine the magnitude of this problem and to create a model to address the challenges and opportunities identified. To obtain baseline information, the task force reviewed information from national sources and the literature on recognizing and rewarding faculty members for educational accomplishments. The group also developed and mailed to surgery departments at all U.S. and Canadian medical schools a questionnaire asking about the educational endeavors of the surgery faculty and their recognition for such activities. The response rate after two mailings was only 56%, but the responses reaffirmed the inadequacy of systems for rewarding and recognizing surgeon-teachers and surgeon-educators, and confirmed that the distinction between the roles of teacher and educator was rarely made. The task force created a four-tier hierarchical model based on the designations teacher, master teacher, educator, and master educator as a framework to offer appropriate recognition and rewards to the faculty, and endorsed a broad definition of educational scholarship. Criteria for various levels of achievement, ways to demonstrate and document educational contributions, appropriate support and recognition, and suggested faculty ranks were defined for these levels. The task force recommended that each surgery department have within its faculty ranks a cadre of trained teachers, a few master teachers, and at least one educator. Departments with a major commitment to education should consider supporting a master educator to serve as a resource not only for the department but also for the department's medical school and other medical schools. Although this model was created for surgery departments, it is generalizable to other disciplines.

How you look determines what you find: severity of illness and variation in blood transfusion for hip fracture.

PURPOSE: Utilization report cards are commonly used to assess hospitals. However, in practice, they rarely account for differences in patient populations among hospitals. Our study questions were: (1) How does transfusion utilization for hip fracture patients vary among hospitals? (2) What patient characteristics are associated with transfusion and how do those characteristics vary among hospitals? (3) Is the apparent pattern of variation of utilization among hospitals altered by controlling for these patient characteristics? SUBJECTS AND METHODS: We included consecutive hip fracture patients aged 60 years or older who underwent surgical repair between 1982 and 1993 in 19 hospitals from four states, excluding those who refused blood transfusion, had multiple trauma, metastatic cancer, multiple myeloma, an above the knee amputation, or were paraplegic or quadriplegic. The outcome of interest was postoperative blood transfusion. "Trigger hemoglobin" was the lowest hemoglobin recorded before transfusion or recorded at any time during the week before or after surgery for patients who were not transfused. RESULTS: There was considerable variation in transfusion among hospitals postoperatively (range 31.2% to 54.0%, P = 0.001). Trigger hemoglobin also varied considerably among hospitals. In unadjusted analyses, four of nine teaching and two of nine nonteaching hospitals had postoperative transfusion rates significantly higher than the reference (teaching) hospital, while one nonteaching hospital had a lower rate. In an analysis controlling for trigger hemoglobin and multiple clinical variables, one of nine teaching and four of nine nonteaching hospitals had rates higher than the reference hospital, while four teaching hospitals and one nonteaching hospital had lower rates. CONCLUSIONS: The apparent pattern of variation of transfusion among hospitals varies according to how one adjusts for relevant patient characteristics. Utilization report cards that fail to adjust for these characteristics may be misleading.

Competency-based instruction in critical invasive skills improves both resident performance and patient safety.

BACKGROUND: Correct performance of invasive skills is essential, but residents often undertake such procedures after no or minimal instruction. METHODS: We instructed eight postgraduate year 1 (PGY1) residents in the cadaver laboratory using a competency-based approach (CBI). Each resident had been evaluated before the laboratory during patient encounters. Group instruction in endotracheal tube insertion (ET), venous cutdown (VC), and chest tube insertion (CT) was followed by individual pretesting and hands-on teaching, with 100% competency the goal. Failure was considered an inability to perform the task correctly or within 120 seconds. After the laboratory, residents were evaluated for correctness and rapidity of performance. RESULTS: Prelaboratory failures consisted of ET, 7; CT, 5; VC, 7. Postlaboratory failures were 0 for all. Prelaboratory complications consisted of ET, 3.3 +/- 1.1; CT, 1.9 +/- 1.0; VC, 3 +/- 1.0. Postlaboratory complications were 0 for all. Prelaboratory times (seconds) were ET, 66.5 +/- 30.8; CT, 104 +/- 4.1; VC, 116.3 +/- 0.7. Postlaboratory times were ET, 25 +/- 7; CT, 65.5 +/- 10.7; VC, 81.3 +/- 2.5. Changes were statistically significant for all (P < .03, nonparametric). Residents performed 20 CTs with 1 pneumothorax, 80 ETs with 2 failures, and 20 VCs with no complications. Initial trauma resuscitation time decreased from 25 to 10 minutes. CONCLUSIONS: (1) Residents' skills rapidly improve with CBI; (2) skills learned through CBI in the laboratory can be translated to and sustained in the clinical setting; (3) CBI produces competent residents who perform skills rapidly and with minimal complications.

Anemia in the patient undergoing surgery and the transfusion decision. A review.

The heightened awareness of the problems of transfusion reactions, disease transmission, and potential immunosuppression has led surgeons to reevaluate their reasons for transfusion. Current practice policies recommend that elective transfusion of allogeneic blood be avoided whenever possible in patients having surgery. If patients are to have appropriate transfusion, the basic pathophysiology and clinical response of the patient to anemia must be understood. This article reviews the physiologic response to anemia in the patient having surgery and explores the components of the decision to use transfusion.

Emerging trends in surgical blood transfusion.

The traditional belief of surgeons that allogeneic blood is an effective and safe therapy with minimal risks has been challenged by a heightened awareness of the problems of transfusion reactions, disease transmission, and immunomodulation related to red blood cell (RBC) transfusion. Surgeons have responded to those challenges by reassessing the reasons for transfusion, increasing autologous blood use, modifying surgical techniques to reduce blood loss, and employing various drugs to reduce transfusion requirements. Of primary importance is the need for the surgeon to thoughtfully plan allogenic blood transfusion requirements for each patient. Blood should be transfused only when there is a documented need to increase oxygen delivery in patients unable to meet demands through normal cardiopulmonary mechanisms. Autologous blood use, an alternative to allogeneic transfusion, is a standard of care for elective orthopedic procedures and radical prostatectomy. Surgical principles of gentle tissue handling, anatomic dissection, and blood loss minimization are increasingly practiced. Surgical approaches include vascular isolation, use of a water jet dissector, microwave tissue coagulation, arthroscopic joint repair, and cold compression. Surgical techniques that decrease bleeding morbidity and mortality include the transjugular intrahepatic portosystemic shunt, intraluminal stents and grafts, laparoscopic techniques, electrocautery, and laser techniques. Pharmacologic agents also affect surgical blood loss and transfusion requirements. Anesthetic agents, locally acting clotting agents, and antifibrinolytics each may reduce blood loss. In addition, perioperative recombinant human erythropoietin use significantly decreased the need for allogeneic transfusions in both anemic and nonanemic surgical patients. Since allogeneic transfusion-induced immunomodulation may have significant effects on mortality related to increased rates of postoperative infection and cancer recurrence, these new approaches and techniques may have an important clinical impact on surgical patients.

Inelastic versus elastic leg compression in chronic venous insufficiency: a comparison of limb size and venous hemodynamics.

PURPOSE: Compression of the lower extremity is the mainstay of therapy in patients who have chronic venous insufficiency. We evaluated the ability of two forms of compression-elastic stockings and an inelastic compression garment-with air plethysmography to determine how well they corrected abnormal deep venous hemodynamics in patients who had class III chronic venous insufficiency and how well this correction was sustained over time. METHODS: Patients had measurements taken with no compression, with a 30 to 40 mm Hg below-knee stocking, and with the inelastic compression garment 2 hours and 6 hours after donning the garments. Therapies were compared with baseline and with themselves over time. RESULTS: Inelastic compression maintained limb size and reduced venous volume better than no compression or stockings over time (ankle circumference at 2 hr vs 6 hr: baseline, 24.7 +/- 7 cm vs 26.1 +/- 1.1 cm; stocking, 23.9 +/- 1.1 cm vs 26.2 +/- 1.2 cm; inelastic compression, 25.4 +/- 1.1 cm vs 25.4 +/- 0.9 cm; venous volume at 2 hr vs 6 hr: baseline, 97.5 +/- 14.1 ml vs 105.2 +/- 17.9 ml; stocking, 112.4 +/- 29.7 ml vs 77.5 +/- 13.2 ml; inelastic compression, 72.2 +/- 14.1 ml vs 56.1 +/- 10.2 ml). At 6 hours, the ejection fraction was increased and the venous filling index was significantly less with inelastic compression compared with the stocking and baseline (ejection fraction at 6 hr: baseline, 61.6% +/- 6.9%; stocking, 75.9% +/- 17.7%; inelastic compression, 78.8% +/- 12.2%). CONCLUSIONS: Inelastic compression has a significant effect on deep venous hemodynamics by decreasing venous reflux and improving calf muscle pump function when compared with compression stockings, which may exert their primary effect on the superficial venous system.

Effect of anaemia and cardiovascular disease on surgical mortality and morbidity.

BACKGROUND: Guidelines have been offered on haemoglobin thresholds for blood transfusion in surgical patients. However, good evidence is lacking on the haemoglobin concentrations at which the risk of death or serious morbidity begins to rise and at which transfusion is indicated. METHODS: A retrospective cohort study was performed in 1958 patients, 18 years and older, who underwent surgery and declined blood transfusion for religious reasons. The primary outcome was 30-day mortality and the secondary outcome was 30-day mortality or in-hospital 30-day morbidity. Cardiovascular disease was defined as a history of angina, myocardial infarction, congestive heart failure, or peripheral vascular disease. FINDINGS: The 30-day mortality was 3.2% (95% CI 2.4-4.0). The mortality was 1.3% (0.8-2.0) in patients with preoperative haemoglobin 12 g/dL or greater and 33.3% (18.6-51.0) in patients with preoperative haemoglobin less than 6 g/dL. The increase in risk of death associated with low preoperative haemoglobin was more pronounced in patients with cardiovascular disease than in patients without (interaction p < 0.03). The effect of blood loss on mortality was larger in patients with low preoperative haemoglobin than in those with a higher preoperative haemoglobin (interaction p < 0.001). The results were similar in analyses of postoperative haemoglobin and 30-day mortality or in-hospital morbidity. INTERPRETATION: A low preoperative haemoglobin or a substantial operative blood loss increases the risk of death or serious morbidity more in patients with cardiovascular disease than in those without. Decisions about transfusion should take account of cardiovascular status and operative blood loss as well as the haemoglobin concentration.

A pilot study of the effects of a perflubron emulsion, AF 0104, on mixed venous oxygen tension in anesthetized surgical patients.

A pilot study of a perfluorochemical (PFC) emulsion was undertaken to determine whether administration of a perflubron emulsion could result in measurable changes in mixed venous oxygen tension. Seven adult surgical patients received a 0.9-g PFC/kg intravenous dose of perflubron emulsion after acute normovolemic hemodilution (ANH). Hemodynamic and oxygen transport data were collected before and after ANH, immediately after PFC infusion, and at approximate 15-min intervals throughout the surgical period. There were no clinically significant hemodynamic changes associated with the administration of the PFC emulsion. There was a significant increase in mixed venous oxygen tension (PVO2) after the PFC infusion, while cardiac output and oxygen consumption were unchanged. As surgery progressed, the hemoglobin concentration decreased with ongoing blood loss while PVO2 values remained at or above predosing levels. Peak perflubron blood levels were 0.8 g/dL immediately postinfusion, and approximately 0.3 g/dL at 1 h. This pilot study demonstrates that administration of perflubron emulsion results in measurable changes in mixed venous oxygen tension during intraoperative ANH.

Aortocaval fistula treated by aortic exclusion.

Aortocaval fistulas are a rare complication of spontaneous rupture of an abdominal aortic aneurysm, representing an incidence of 2% and 4%. A review of the literature revealed 159 reported cases of aortocaval fistulas. We recently had a patient admitted to our institution with an abdominal aortic aneurysm that ruptured into the vena cava. The presence of the fistula was only recognized during operation. Primary closure of the fistula was not possible, and the aneurysmal segment was excluded. To our knowledge, this is the first report of aortic exclusion being used as the surgical treatment of an aortocaval fistula.

Practical nursing measures for vascular compromise in the lower leg.

Among the many factors that contribute to a nonhealing wound, circulatory compromise is a dominant variable. Regardless of whether the circulatory compromise is arterial or venous, the patient should be educated and supported in their efforts to quit smoking, minimize stress, achieve ideal body weight, limit fats in their diet, keep underlying disorders within check, and avoid a sedentary lifestyle. Patients with peripheral arterial disease (PAD) can maximize their tissue perfusion when nurses help them implement a few basic strategies into their lifestyles. Patients with chronic venous insufficiency (CVI) need to apply counterpressure and combat gravity to reduce venous hypertension, without which healing will not occur. When resources are limited, nurses can bridge the gap through coordination of care, patient teaching and support.