Where do you insert a drain tube during breast reconstruction?

PURPOSE: A drain tube is commonly inserted during breast reconstruction surgery. This leads to a scar in addition to the scar on the breast. This study was performed to investigate how patients feel about the drain scar and to clarify its ideal location. METHODS: A questionnaire survey about the drain scar was distributed to 38 consecutive breast reconstruction patients and a total of 104 female doctors and nurses engaged in breast reconstruction. The drain scars were evaluated using the Japan Scar Workshop (JSW) Scar Scale. RESULTS: A total of 32% of the patients expressed some anxiety about the drain scar. Patients who were anxious about the drain scar had higher scores on the JSW Scar Scale than those who were not anxious. Younger doctors and nurses preferred the drain scar to be on the side of the chest, while older doctors and nurses preferred the drain scars to be at the axilla. CONCLUSIONS: About a third of the patients had some anxiety associated with their drain scar after breast reconstruction surgery, and this anxiety level was correlated with objective assessment of the scar. Thus, more patient involvement or the provision of more information regarding drain placement is required.

Awake Craniotomy in a Patient with Previously Diagnosed Post-Traumatic Stress Disorder.

BACKGROUND: Awake craniotomy (AC) with brain mapping has been successfully used for the resection of lesions located in or near eloquent areas of the brain. The selection process includes a thorough presurgical evaluation to determine candidates suitable for the procedure. Psychiatric disorders including post-traumatic stress disorder (PTSD) are considered potential contraindications for this type of surgery because these patients may be less cooperative to tolerate AC. Here we present the management of a patient with PTSD who underwent an AC using a multidisciplinary team for removal of a dominant hemisphere low-grade insular glioma with speech, motor, and cognitive mapping. CASE DESCRIPTION: A 34-year-old right-handed male military veteran with a previous history of PTSD was scheduled for a left AC for resection of a low-grade insular glioma. He underwent preoperative neurocognitive assessment with a neuropsychologist and clinic visit with a neurosurgeon to characterize his PTSD and potential triggers, explain the procedure in a stepwise fashion, and address any concerns. The intraoperative environment was modified to minimize triggering stimuli, and an asleep-awake-asleep anesthetic protocol was followed. The patient tolerated the procedure well without any postoperative neurologic deficits including cognitive deficits. At 1-month follow-up, he denied any worsening of his PTSD symptoms and recalls the AC as a positive experience. CONCLUSIONS: With a multidisciplinary team, adequate preoperative education, detailed clinical interview to identify triggers, and a controlled intraoperative environment, awake surgery can be carried out safely in a patient with PTSD.

Development and implementation of a novel child life protocol to enhance psychosocial support for pediatric awake craniotomies: technical note.

Awake craniotomies are a crucial tool for identifying eloquent cortex, but significant limitations frequently related to patient tolerance have limited their applicability in pediatric cases. The authors describe a comprehensive, longitudinal protocol developed in collaboration with a certified child life specialist (CCLS) in order to enhance patient experiences and develop resiliency related to the intraoperative portion of cases. This protocol includes preoperative conditioning, intraoperative support, and postoperative positive reinforcement and debriefing. A unique coping plan is developed for each prospective patient. With appropriate support, awake craniotomy may be applicable in a wider array of preadolescent and adolescent patients than has previously been possible. Future prospective studies are needed to validate this approach.

Music Interventions in Pediatric Surgery (The Music Under Surgery In Children Study): A Randomized Clinical Trial.

BACKGROUND: Perioperative music interventions have been shown to reduce anxiety and pain in adults. This inexpensive, easily applicable intervention could be of benefit to children as well. Our objective was to determine the effects of music interventions on distress, anxiety, and postoperative pain in infants undergoing surgery. METHODS: The Music Under Surgery In Children study was designed as a parallel, single-blind, randomized controlled trial with an a priori formulated hypothesis. Data were collected between August 2015 and October 2016 in a single tertiary care children's hospital. There was a 24-hour follow-up with blind primary outcome assessment. A random sample of 432 eligible 0-3 years of age infants admitted for orchidopexy, hypospadias, or inguinal hernia repair receiving general anesthesia and caudal block were asked for participation. Subjects were assigned to a preoperative music intervention, pre- and intraoperative music intervention, or no music intervention (control) via random allocation using a computer-generated list with the use of opaque envelopes. The main outcome measure was the postoperative level of distress assessed with the COMFORT-Behavior scale, which is an observational scale; furthermore, preoperative level of distress, preoperative anxiety, and physiological measurements such as heart rate (HR) and blood pressure were measured. The trial was registered at the Dutch Trial Register, number NTR5402 (www.trialregister.nl). RESULTS: One hundred ninety-five infants with median age 6.9 months (interquartile range, 3.3-11.1) were randomized, 178 of whom were included in the primary analysis. A nonsignificant difference in COMFORT-Behavior scale scores between the pre- and intraoperative music intervention group and control group at 4 hours after surgery was found (mean difference, -1.22; 95% CI, 2.60-0.17; P = .085). Additional analysis showed weak nonsignificant evidence for an interaction effect between music exposure and COMFORT-Behavior score at baseline (P = .027 with a Bonferroni-adjusted significance level of .025). General linear modeling showed a statistically significantly reduced HR after the preoperative music intervention in the holding area in the combined preoperative music intervention and intraoperative music intervention group compared to the control group (P = .003). The differences in HR among the 3 study arms at all time points were not statistically significant (P = .069). CONCLUSIONS: Music interventions do not seem to benefit all young infants undergoing surgery. The potential benefits of music interventions in the preoperative period and in more distressed children warrant further exploration.

Health-related quality of life of breast cancer patients after accelerated partial breast irradiation using intraoperative or external beam radiotherapy technique.

PURPOSE: To compare health-related quality of life (HRQL) in elderly breast cancer patients between two types of Accelerated Partial Breast Irradiation: intraoperative radiotherapy (IORT) and external beam APBI (EB-APBI). METHODS: Between 2011 and 2016 women ≥60 years undergoing breast conserving therapy for early stage breast cancer were included in a prospective multi-centre cohort study. Patients were treated with electron IORT (1 × 23.3 Gy) or photon EB-APBI (10 × 3.85 Gy daily). HRQL was measured by the EORTC-QLQ C30 and BR23 questionnaires before surgery and at several time points until 1 year. RESULTS: HRQoL data was available of 204 IORT and 158 EB-APBI patients. In longitudinal analyses emotional functioning and future perspective were significantly, but not clinically relevantly, worse in IORT-treated patients, and improved significantly during follow-up in both groups. All other aspects of HRQL slightly worsened after treatment and recovered within 3 months with an improvement until 1 year. Cross-sectional analysis showed that postoperatively fatigue and role functioning were significantly worse in IORT patients compared to EB-APBI patients who were not yet irradiated, but the difference was not clinically relevant. At other timepoints there were no significant differences. Multivariable analysis at 1 year identified comorbidity and systemic therapy as risk factors for a worse global health score (GHS). CONCLUSIONS: EB-APBI and IORT were well tolerated. Despite a temporary deterioration after treatment, all HRQL scales recovered within 3 months resulting in no clinically relevant differences until 1 year between groups nor compared to baseline levels.

Enfermedades crónicas no transmisibles y el estrés de los trabajadores de enfermería de unidades quirúrgicas / Doenças crônicas não transmissíveis e o estresse dos trabalhadores de enfermagem de bloco cirúrgico / Chronic noncommunicable diseases and the stress of nursing workers in surgical units

Este estudio tuvo como objetivo determinar la prevalencia de enfermedades crónicas no transmisibles autoreferidas y su correlación con el estrés entre los trabajadores de enfermería de unidades quirúrgicas. Estudio analítico, transversal, con enfoque cuantitativo, cuya colecta de datos se llevó a cabo a partir de un cuestionario sociodemografico y de la escala Job Stress Scale. Se identificó que 68.6% de los trabajadores negó tener enfermedades crónicas no transmisibles, mientras que el 12,9% informó obesidad, 4,3%, presión arterial alta y 2,9%, depresión. En cuanto al nivel de estrés, se encontró que 51,4% tenía nivel intermedio, 30%, nivel alto y 18,6, nivel bajo. Se concluyó que no hubo correlación entre la autorreferencia de enfermedades crónicas no transmisibles y el nivel de estrés (AU)

Objetivou-se verificar a prevalência de doenças crônicas não transmissíveis autorreferidas e a sua correlação com o estresse entre trabalhadores de enfermagem de bloco cirúrgico. Estudo analítico, seccional, com abordagem quantitativa, cuja coleta de dados foi realizada a partir de um questionário sociodemográfico e da escala Job Stress Scale. Identificou-se que 68,6% dos trabalhadores negou ter doenças crônicas não transmissíveis, enquanto 12,9% referiram obesidade, 4,3%, hipertensão arterial e 2,9%, depressão. Quanto ao nível de estresse, verificou-se que 51,4% apresentou nível intermediário, 30%, nível alto e 18,6%, nível baixo. Conclui-se que não houve correlação entre a autorreferência de doenças crônicas não transmissíveis e o nível de estresse (AU)

This study aimed to determine the prevalence of self-reported chronic noncommunicable diseases and their correlation with stress among nursing staff in the surgical block. Analytical study, sectional, with a quantitative approach, which data collection was carried out from a socio-demographic questionnaire and the Job Stress Scale. It was identified that 68.6% of workers denied having chronic noncommunicable diseases, while 12.9% reported obesity, 4.3%, high blood pressure and 2.9%, depression. About the stress level, it was found that 51.4% had intermediate level, 30%, high level and 18.6%, low level. It was concluded that there was no correlation between self-reported chronic noncommunicable diseases and the stress level (AU)

Humane Surgical Positioning During Minor Limb Surgeries Under Local Anesthesia in Young Children.

Injured children are in pain, anxious, scared, and intimidated by the emergency room environment and parents often compound this anxiety by their own fears. During minor surgical procedures, a child held in the "humane position" by the parent is helpful. The child is positioned on the parent's lap so that the affected extremity is drawn out and placed on the side of the parent. The surgeon and instruments are positioned behind the parent's back out of the child's and parent's field of vision especially if the wound is bleeding actively. Physical intimacy with the parent is capitalized upon; this makes the child feel secure, comfortable, relaxed, and reassured during the procedure.

Efficacy of hypnosis in adults undergoing surgery or medical procedures: a meta-analysis of randomized controlled trials.

This meta-analysis investigates the efficacy of hypnosis in adults undergoing surgical or medical procedures compared to standard care alone or an attention control. Through a comprehensive literature search N=34 eligible randomized controlled trials (RCTs) were included, comprising a total of 2597 patients. Random effects meta-analyses revealed positive treatment effects on emotional distress (g=0.53, CI 95% [0.37; 0.69]), pain (g=0.44, CI 95% [0.26; 0.61]), medication consumption (g=0.38, CI 95% [0.20; 0.56]), physiological parameters (g=0.10, CI 95% [0.02; 0.18]), recovery (g=0.25, CI 95% [0.04; 0.46]), and surgical procedure time (g=0.25, CI 95% [0.12; 0.38]). In conclusion, benefits of hypnosis on various surgically relevant outcomes were demonstrated. However, the internal validity of RCTs seems limited and further high methodological quality RCTs are needed to strengthen the promising evidence of hypnosis for adults undergoing surgery or medical procedures.

"First, do no harm": balancing competing priorities in surgical practice.

PURPOSE: To explore surgeons' perceptions of the factors that influence their intraoperative decision making, and implications for professional self-regulation and patient safety. METHOD: Semistructured interviews were conducted with 39 academic surgeons from various specialties at four hospitals associated with the University of Toronto Faculty of Medicine. Purposive and theoretical sampling was performed until saturation was achieved. Thematic analysis of the transcripts was conducted using a constructivist grounded-theory approach and was iteratively elaborated and refined as data collection progressed. A preexisting theoretical professionalism framework was particularly useful in describing the emergent themes; thus, the analysis was both inductive and deductive. RESULTS: Several factors that surgeons described as influencing their decision making are widely accepted ("avowed," or in patients' best interests). Some are considered reasonable for managing multiple priorities external to the patient but are not discussed openly ("unavowed," e.g., teaching pressures). Others are actively denied and consider the surgeon's best interests rather than the patient's ("disavowed," e.g., reputation). Surgeons acknowledged tension in balancing avowed factors with unavowed and disavowed factors; when directly asked, they found it difficult to acknowledge that unavowed and disavowed factors could lead to patient harm. CONCLUSIONS: Some factors that are not directly related to the patient enter into surgeons' intraoperative decision making. Although these are probably reasonable to consider within "real-world" practice, they are not sanctioned in current patient care constructs or taught to trainees. Acknowledging unavowed and disavowed factors as sources of pressure in practice may foster critical self-reflection and transparency when discussing surgical errors.

Audiovisual aid viewing immediately before pediatric induction moderates the accompanying parents' anxiety.

BACKGROUND: Parents accompanying their child during induction of anesthesia experience stress. The impact of audiovisual aid (AVA) on parental state anxiety and assessment of the child's anxiety at induction have been studied previously but need closer scrutiny. METHODS: One hundred and twenty parents whose children were scheduled for day-care surgery entered this randomized, controlled study. The intervention group (n = 60) was exposed to an AVA in the holding area. Parental anxiety was measured with the Spielberger State-Trait Anxiety Inventory and the Amsterdam Preoperative Anxiety and Information Scale (APAIS) at three time points: (i) on admission [T1]; (ii) in the holding area just before entering the operating theater [T2]; and (iii) after leaving [T3]. Additionally, at [T3], both parent and attending anesthetist evaluated the child's anxiety using a visual analogue scale. The anesthetist also filled out the Induction Compliance Checklist. RESULTS: On the state anxiety subscale, APAIS parental anxiety at T2 (P = 0.015) and T3 (P = 0.009) was lower in the AVA intervention group than in the control group. After induction, the child's anxiety rating by the anesthetist was significantly lower than by the parent, in both intervention and control groups. CONCLUSIONS: Preoperative AVA shown to parents immediately before induction moderates the increase in anxiety associated with the anesthetic induction of their child. Present results suggest that behavioral characteristics seem better predictors of child's anxiety during induction than anxiety ratings per se and that anesthetists are better than parents in predicting child's anxiety during induction.

PERCEPTION OF NIGERIAN ANAESTHETISTS ON INTRA-OPERATIVE DEATH.

BACKGROUND: Intra-operative death is an unusual devastating occurrence in anaesthetic practice, and it is of serious concern when it happens. OBJECTIVES: To assess the causes, the effects and the perception of Nigerian anaesthetists to intra-operative death. DESIGN: A cross-sectional and questionnaire-based study. SETTING: Five University Teaching Hospitals in South-Western Nigeria. SUBJECTS: Nurse anaesthetists, resident doctors in anaesthesia and consultant anaesthetists. RESULTS: One hundred and five anaesthetists participated in the study (72.9% response rate). Seventy seven (73.3%) of the respondents had experienced an intra-operative death with most of them having five or more years of experience (p = 0.0001). Majority 53 (68.8%) of the respondents felt that the deaths were avoidable, and most deaths occurred mainly during emergency surgery (96.1%). Forty three (55.8%) of them were psychologically disturbed, fifty six (53.3%) respondents were of the opinion that it is reasonable for the anaesthetists involved not to take partin further surgery for that day. Sixty (57.1%) respondents considered discussion at mortality meeting as appropriate after an intra-operative death. CONCLUSION: This study showed that most anaesthetists would want those involved in the intra-operative death not to take part in further surgery for that day. Adequate preventive measures should be put in place with departmental or institutional policies on what to do after such events.

Intra-operative natural sound decreases salivary amylase activity of patients undergoing inguinal hernia repair under epidural anesthesia.

BACKGROUND: The perioperative period is psychologically as well as physically stressful for patients. Although music and sound are known to reduce patients' psychological stress, a few previous studies showed an objective outcome of music. The aim of the present study was to evaluate the relaxing effect of music during epidural anesthesia, using patients' salivary amylase activity. METHODS: Thirty-two American Society of Anesthesiologists (ASA) I or II patients presenting for inguinal hernia repair under epidural anesthesia were randomly assigned to listen to sounds of a soft wind and a twitter (S group) or to have no sounds (N group). Patients' salivary amylase activity was evaluated on arrival to the operating room and at wound closure. RESULTS: Intra-operative music significantly decreased salivary amylase activity at wound closure in the S group and the activity at wound closure of the S group was significantly smaller than that of the N group. CONCLUSION: Intra-operative natural sound significantly decreased salivary amylase activity of patients undergoing inguinal hernia repair under epidural anesthesia.

The effect of music listening on older adults undergoing cardiovascular surgery.

The purpose of this study was to determine the effect of music listening on postoperative anxiety and intubation time in patients undergoing cardiovascular surgery. Coronary artery disease and valvular heart disease affect approximately 15 million Americans and 5 million persons in the U.K. annually, with the majority of these patients being older adults. The anxiety experienced before, during and after surgery increases cardiovascular workload, thereby prolonging recovery time. Music listening as a nursing intervention has shown an ability to reduce anxiety. The study used a randomized control trial design. Sixty adults older than 65 years were randomly assigned to the control and the experimental groups. The experimental group listened to music during and after surgery, while the control group received standard postoperative care. The Spielberger State Trait Anxiety Inventory was administered to both groups before surgery and 3 days postoperatively. The mean of the differences between scores was compared using analysis of variance. Differences in mean intubation time were measured in both groups. Older adults who listened to music had lower scores on the state anxiety test (F = 5.57, p = .022) and had significantly fewer minutes of postoperative intubation (F = 5.45, p = .031) after cardiovascular surgery. Older adults undergoing cardiovascular surgery who listen to music had less anxiety and reduced intubation time than those who did not.

Pediatric ophthalmology and anesthesia pearls in the operating room.

Providing nursing care to pediatric patients is both challenging and rewarding. The pediatric ophthalmic caregiver must remain acutely aware of physiologic changes, which may be subtle. Though most pediatric procedures are performed by an anesthesiologist using general anesthesia, the ophthalmic nurse needs to remain vigilant. Problems that arise must be attended to within mere seconds. This paper discusses distraction techniques and gives an overview of the care provided to children under general anesthesia at a major pediatric specialty hospital. This paper relates one ophthalmic nurse's experiences in a hospital-based outpatient surgery center that employs 14 board-certified faculty pediatric anesthesiologists as well as rotational anesthesia residents in their first, second, third, and fellowship years. The outpatient center has five operating rooms, and the inpatient surgery area has 14 operating rooms. Nearly 800 pediatric ophthalmology procedures are done in the outpatient area each year; approximately 20 ophthalmology procedures are done at the inpatient surgery area annually.

Prophylaxis to avert exacerbation/relapse of multiple sclerosis in affected patients undergoing surgery. Surgical observations and recommendations.

To provide the neurological and neurosurgical communities with case evidence of postoperative multiple sclerosis (MS) relapse, literature review to support operative stress-induced relapse and recommendations for perioperative prophylaxis to prevent relapse in patients undergoing surgery. Two case studies are presented with recommendations based on an extensive review of the medical literature and personal experience to support perioperative prophylactic suggestions. Both patients fully recovered to preoperative functional status after treatment. We now routinely implement perioperative prophylaxis to MS patients undergoing surgery at our institution with no complications to date. Perioperative prophylaxis in patients with MS undergoing surgery can prevent relapse. It is of utmost importance that the surgical community realizes that prophylactic treatment is available and should be utilized during elective and emergent surgical situations.

Continuous subcutaneous insulin infusion during general anesthesia: a case report.

Care of the patient with diabetes mellitus presents numerous challenges to the anesthesia practitioner. There is no perfect way to care for these patients nor are any 2 patients with diabetes exactly alike. With the advent of subcutaneous insulin pumps, the anesthesia practitioner has another tool to assist him or her in giving high quality care. This case study describes the anesthesia care provided to a patient with type 1 diabetes who wore his continuous subcutaneous insulin infusion (CSII) pump during general anesthesia for surgical repair of a herniated lumbar disk. Importantly, the anesthesia plan involved a collaborative effort with the patient. Blood glucose levels were stable throughout the perioperative period. Little or no extra work was required of the CRNA. This case showed that the CSII could be used to minimize perioperative fluctuations in blood sugar. Postoperatively, the patient expressed a high degree of satisfaction with the anesthetic.