Elective Surgery Cancellations During the Time Between Scheduling and Operation.

PURPOSE: Surgery cancellations cause harm to patients, extra work for preoperative staff, and financial loss for organizations. Day of surgery cancellations are a widely used indicator for operative effectiveness, but there is a lack of knowledge concerning the effects of cancellations during earlier stages of a patient's preoperative waiting period. The purpose of this study was to measure the reasons, frequencies, and timing of elective surgery cancellations after scheduling. DESIGN: Qualitative prospective follow-up study. METHODS: Data were collected during a 2-month period in 13 operative specialties by a semistructured follow-up form and analyzed by inductive content analyses and statistical methods. FINDINGS: Most of the cancellations occurred before the day of surgery and appeared because patients were not in a suitable condition for the planned operation or because of lack of organizational resources. CONCLUSIONS: More attention should be focused on patients' suitability and organizational resources in earlier stages of preoperative period.

The impact of a structured preoperative protocol on day of surgery cancellations.

AIMS AND OBJECTIVES: To evaluate the impact of implementing an evidence-based, structured preoperative protocol on day of surgery cancellations in 13 operative specialties. BACKGROUND: Surgery cancellations cause unnecessary harm for patients and organisations as many cancellations could be prevented. Preoperative care has developed in recent years, and several preoperative interventions have been introduced. However, the optimal model for organising preoperative care remains unknown. Cancellations are a commonly used indicator when evaluating the success of preoperative care. DESIGN: Observational study with two study phases: before and after. METHODS: The cancellation data were collected from the hospital register from 1 September 2013-31 May 2014 (n = 591) and from September 2015-May 2016 (n = 542). The compliance rate of the preoperative protocol was evaluated in group sessions (n = 13) during spring 2016 using the participation of preoperative healthcare professionals (n = 49). The data were analysed statistically. RESULTS: Cancellation rates varied between 1.6%-9.7% (in the first phase) and between 1.5%-7.7% (in the second phase). A remarkable decrease was found in patients who failed to attend their scheduled procedures. The mean of compliance to the preoperative protocol across all specialties was 82.3%. A correlation between the rate of cancellation and the rate of compliance with the preoperative protocol was found. CONCLUSIONS: A preoperative protocol promotes the scheduled arrival of surgical patients to the hospital and therefore decreases cancellation rates. RELEVANCE TO CLINICAL PRACTICE: An evidence-based preoperative care protocol should be introduced for all healthcare professionals working in preoperative care to ensure smooth, safe and high-quality care for surgical patients.

An integrative review of a preoperative nursing care structure.

AIMS AND OBJECTIVES: The aims of this integrative literature review are to define the role of a preoperative nurse and to describe the main components and hypothetical outcomes of a preoperative nursing care structure before a surgical patient arrives to an elective procedure. BACKGROUND: The development of medical care has impacted surgical processes, and patients are now spending less time in hospital settings. Patients often enter the hospital on the day of a procedure and are discharged as soon as it is medically safe, creating challenges for nursing care. Preoperative clinics have been opened, and the importance of preoperative nursing care has been widely understood. Previous literature has provided descriptions about the roles, tasks and outcomes of preoperative nurses; however, the terminology is heterogeneous, and the optimal model remains unknown. DESIGN: A systematic procedure for searching, selecting, and evaluating the literature was followed. The data were collected from PubMed and CINAHL between 1 January 2004 and 20 September 2014. In total, 41 articles were included in the study and were analysed by qualitative inductive content analysis. RESULTS: The data provided seven main tasks of a preoperative nurse, tools to support preoperative nursing and outcomes of structured preoperative nursing care. CONCLUSION: A preoperative nurse is a specialised coordinator of patient care, and the main purposes of this role are to meet the patient's and the family's needs individually and to prepare them for the scheduled procedure and postoperative recovery. By following the structure of the seven main tasks and using different supportive tools, preoperative nursing can positively impact patient and provider satisfaction, patient safety, quality of care and cost savings. RELEVANCE TO CLINICAL PRACTICE: A preoperative nursing care structure should be implemented in clinical practice and then evaluated to measure whether the hypothetical outcomes reported in this literature review can be achieved.

Can the efficacy of reduction mammoplasty be predicted? The applicability and predictive value of breast-related symptoms questionnaire in measuring breast-related symptoms pre- and postoperatively.

To measure the impact of reduction mammoplasty, the Breast-Related Symptoms Questionnaire (BRSQ) was translated into Finnish and tested among women seeking reduction mammoplasty. This previously validated questionnaire focuses on 13 breast hypertrophy-related symptoms and their frequency. In this prospective multicentre study, the breast-related symptoms of 98 women were measured preoperatively with BRSQ and the health-related quality of life (HRQoL) with the 15 dimension (15D), a well-established generic tool. A total of 59 participants were followed up at least 6 months postoperatively. The women were middle-aged (mean age 44 years) and most of them overweight (mean Body mass index (BMI) 29). All patients had frequent physical symptoms and disability due to their breasts and reported low breast severity symptom score (BSS mean 27, range 13-38). Mean amount of resected breast tissue was 1310 g per patient. Postoperatively, the breast-related symptoms were significantly relieved, and 55 of 59 operated patients reported less frequent or non-existent symptoms (mean BSS 59, range 22-65). BSS score improved especially in obese women and those with pendulous breasts. A low preoperative BSS was related to considerable benefit from surgery. HRQoL score improved significantly from 0.889 to 0.930 (P < 0.001) and significant improvement was seen especially in dimensions, such as discomfort, usual activities and breathing. In conclusion, BRSQ is an easy tool to use to quantify breast-related symptoms. It visualised effectively the impact of the reduction mammoplasty. Surgical breast reduction significantly improves breast-related symptoms and the HRQoL among women with many breast-related symptoms. The present guidelines for patient selection in breast reduction surgery should be updated to use valid measurement and scientific evidence.

Glucose and lactate metabolism in well-perfused and compromised microvascular flaps.

The success in microvascular flap transfer depends on the maintenance of optimal perfusion postoperatively. In addition to anastomosis thrombosis, other perfusion failures such as venous congestion, spasms, and kinks may appear. As perforator flaps become more frequent, it must be remembered that perforating vessels are more fragile and susceptible for trauma and mechanical compression. Sometimes, a flap is doing not well even though its anastomosis is patent. The flap perfusion can be measured using different tools in addition to clinical surveillance. We have used microdialysis in monitoring 268 microsurgical flaps and compared the metabolic data of normally perfused flaps to those that suffered from relative or absolute perfusion failure. We found that tissue glucose and lactate concentrations and especially their relation (lactate-to-glucose ratio) can show the presence of ischemia and aid in decision making, whether to reoperate or not. High lactate-to-glucose ratio may also predict total or partial flap necrosis.

[Punch biopsy in the diagnosis of skin tumors]. / Stanssibiopsia ihokasvainten diagnostiikassa.

Punch biopsy is a feasible method in the early diagnosis of nonmelanotic skin cancer in primary health care, but should not be applied to lesions that appear clinically as melanomas. Small skin lesions suspected to be malignant can often be completely excised in primary health care. If the skin tumor is large, a biopsy from the tumor area is worth taking so that the edge of the tumor remains intact. A sufficient specimen for histological examination is usually obtained with a punch having a diameter of 3 to 4 millimeters.

[Plastic surgery needed after surgical treatment of obesity]. / Plastiikkakirurgiaa tarvitaan lihavuuden kirurgisen hoidon jälkeen.

Surgical treatment of obesity often leads to rapid weight loss of a severely obese patient. Loose skin may transform into inconvenient folds that cause functional, social and health problems. Correction of the folds by plastic surgery can improve the quality of life. It is essential that a symptomatic patient is admitted to a plastic surgery evaluation at a stage when the weight has stabilized. In selecting the method and time for surgery, the patient's current weight and degree of disability will be considered. Safety of the operation is most important.

The effects of hypotension and norepinephrine on microvascular flap perfusion.

Microvascular flap surgery is a common technique in reconstructive surgery. The wide indications and variable patients provide challenge also for anesthesiologist. Both hypotension and hypoperfusion can be harmful to the flap. Hypotensive patients are treated with fluid resuscitation and vasopressors (e.g., norepinephrine), if needed. As vasoconstrictors, vasopressors might impair microvascular flap perfusion. In this experimental pig model we studied the effect of sevoflurane-induced hypotension on the perfusion of microvascular and superiorly pedicled rectus abdominis myocutaneous flaps. In addition, we evaluated the effect of norepinephrine on flap perfusion when it was used for correction of hypotension. Microdialysis (MD) was used to detect metabolic changes, as it is a sensitive method to detect early changes of tissue metabolism and ischemia in different tissue components of soft tissue flaps. The main finding of this study was that moderate degree of normovolemic hypotension or the use of norepinephrine for the correction of this hypotension did not affect flap perfusion as assessed by MD. More studies are clearly needed to confirm the safety of norepinephrine in clinical use in microsurgery.

Cost analysis of 109 microsurgical reconstructions and flap monitoring with microdialysis.

Few studies have examined the cost-effectiveness of microsurgery, and little is known about the cost-effectiveness of flap monitoring. We studied the costs related to microsurgery during 2004 to 2006 in Kuopio University Hospital. A total of 99 patients were reconstructed with 109 flaps. Primary success was achieved in 64% of cases. Reoperation for anastomosis was conducted in 25% and for other surgical complications in 27%. The intended result was achieved in 94% of cases. The mean total cost of hospital care was 20,000 euro in head and neck cancer surgery, 15,500 euro in defects of the lower extremities, and 9200 euro in breast reconstruction. The costs were greatly influenced by surgical complications (i.e., if the primary reconstruction failed, then the secondary microvascular flap almost doubled the expense involved; mean expenses per case 27,900 euro). Microdialysis was used in flap monitoring with an additional cost of 535 euro per patient. We found that microdialysis provided an early diagnosis of perfusion failure and helped to save the flap. It was estimated that if one or two flaps per year are saved due to more effective monitoring, then the extra costs of using microdialysis are covered.

Metabolic response in microvascular flaps during partial pedicle obstruction and hypovolemic shock.

To investigate tissue metabolism during suboptimal blood perfusion, we used in situ microdialysis in an experimental model of myocutaneous flaps. We assessed concentrations of glucose, lactate, and pyruvate in flaps subjected to partial pedicle obstruction and to hemorrhagic shock. When the arterial flow was restricted, the glucose concentration decreased in the flap muscle, and the lactate concentration increased in all flap components. The restriction ofvenous outflow resulted in lactate overproduction and a decrease of glucose in skin and muscle. The lactate-to-pyruvate ratio remained normal during arterial obstruction but increased during venous obstruction. During hypovolemic shock, the lactate production increased and the glucose concentration decreased or remained normal. The metabolic changes occurring during partial pedicle obstruction and hypovolemic shock are moderate and different from those seen in total pedicle obstruction. Microdialysis is a feasible method for assessing local tissue metabolism and can be used to monitor flap ischemia.

Microdialysis detects postoperative perfusion failure in microvascular flaps.

In microvascular tissue transfers, it is essential postoperatively to follow-up on the perfusion of the transferred flap because of the risk of anastomotic failure. The diagnosis of pedicle obstruction is usually made by clinical observation, but some techniques have been reported as more reliable than clinical observation in detecting perfusion failure. The authors used microdialysis (MD), a method developed to assess in situ tissue metabolism, in the follow-up of 80 consecutive microvascular flaps from October, 2001 to October, 2003. Of the 78 flaps with postoperative data, 58 flaps were uneventful clinically and using MD, and served as the reference material for normal postoperative metabolism. Twenty flaps showed some abnormality in the clinical course or with MD. Of these, 13 flaps were reoperated for anastomosis thrombosis (9 arterial, 4 venous). All thromboses were clearly recognized by MD via a decrease in the glucose concentration in the tissue (< 2.7 mmol/l) and an increase in the lactate concentrations (> 5.7 mmol/l). In some cases, MD indicated a pathological trend in glucose and lactate concentrations hours before there were any clinical signs. A system of alarm levels was developed for the staff: when the limits were reached, a critical evaluation of the situation was undertaken, and the need for reoperation was considered. In the series, the salvage rate of all thrombosed flaps was 77 percent, with a final success rate in microvascular reconstruction of 95 percent. No flap was lost due to a delay in the diagnosis of secondary ischemia, if on-line MD monitoring was available. Microdialysis is a clinically feasible and sensitive monitoring method for all kinds of microvascular flaps, especially for those in which clinical observation is difficult or impossible. The performance of the analysis is easy and can be done by even less experienced nursing staff working in institutes with a low frequency of microsurgery.

Glucose, lactate, and pyruvate response in an experimental model of microvascular flap ischemia and reperfusion: a microdialysis study.

Early diagnosis of postoperative perfusion failure is essential in microsurgical tissue transfer. In order to determine if microdialysis could be used in diagnosing flap ischemia, we tested this method in an experimental pig model. Sixty-six flaps (34 myocutaneous and 29 cutaneous) were created in 18 anesthetized pigs. During the experiment, secondary ischemia was induced for 5 h by selective clamping of the artery (20 flaps) or vein (21 flaps). Glucose, lactate, and pyruvate concentrations were measured hourly from the muscular and dermal layers. We found that decreasing glucose levels and increasing lactate concentrations were associated with arterial and venous occlusions from the first hour of ischemia. In venous ischemia, lactate concentrations remained lower than those in arterial ischemia. The increase in lactate-to-pyruvate and lactate-to-glucose ratios was related to ischemia and also discriminated arterial occlusion from venous occlusion. In conclusion, microdialysis can be used to facilitate early detection of ischemia.