General principles for the clinical organization and management of a surgical unit

Because health-care costs and demand for services are both rising, appropriate management of resources is yet another essential consideration in efficient clinical practice. Surgical units, with their special features, are a particular focus of attention. Although it is possible to study the circumstances of each hospital individually, in fact surgical units often share the same management concerns. Currently, surgical units are often reorganized and provided with an Operating Room Committee, a Medical director or coordinator and operational protocols, such that the unit is considered a system rather than a sum of its individual parts. Work is goal-oriented, with starting and ending points, flexibility in use of surgical theaters, reserve capacity for unscheduled surgery, low cancellation rates and good output; the use of time indicators is considered essential. Other factors to bear in mind when managing a surgical unit are the universalization of information, which should be accurate and up to date, the involvement of teams such as that of anesthesia and recovery, scheduling that is realistic and tight, the appropriate design and use of circuits, and the use of techniques for continuous improvement and problem solving. Some programs, such as that of major outpatient surgery, orthopedic surgery and others may have special needs.     

Preoperative testing routines for healthy, asymptomatic patients in the Canary Islands (Spain)

OBJECTIVES: To analyze patterns of routine testing before elective/scheduled surgery in healthy/asymptomatic patients classified as ASA I or II according to the American Society of Anesthesiologists. MATERIAL AND METHOD: A questionnaire on the organization of preoperative testing was completed by anesthesiologists at five public hospitals in the Canary Islands. The questionnaire emphasized the most commonly ordered screening procedures, such as chest X-rays, electrocardiograms, laboratory tests and spirometry. RESULTS: Red cell counts were most frequently requested (for 86% of the patients), followed by platelet counts (80%) and blood chemistry (75%) and coagulation studies (72%). Least requested were urine tests and spirometry. The frequencies of electrocardiogram and chest X-ray requests fell between the two extremes, with patient age and the presence of certain indications seeming to affect whether those tests would be ordered or not. The need for such screening was perceived to increase for patients over 40 years of age. The ordering of preoperative tests varied from hospital to hospital and among anesthesiologists at a single site in spite of established protocols. CONCLUSIONS: Hospitals and individual anesthesiologists differ considerably in how they request preoperative tests. The variations can not be explained solely by differing patient needs given that respondents were contemplating only healthy/asymptomatic individuals undergoing relatively simple procedures.     

DNase use in the daily care of cystic fibrosis: who benefits from it and to what extent? Results of a cohort study of 199 patients in 13 centres

Short-term clinical trials with DNase have shown minor to moderate benefits in cystic fibrosis patients. This study was performed to analyse the effectiveness of DNase use in daily practice and to obtain information on its effects in the long term and at different disease stages. Patients being treated in 13 specialised units were included if they started DNase treatment before June 1996. Baseline data before DNase use and data during the DNase treatment period were recorded. Of the 199 patients included in the study 166 continued on DNase treatment while the data were being collected. The mean age (95% CI) was 14.5 (13.7; 15,2) years; 103 (51.8%) patients were female. The mean maximum change in forced expiratory volume in 1 s (FEV₁) was observed during the first month of treatment [11.1% (6.1; 16.1)]. By the end of the first and the second year of treatment mean changes in FEV₁ were 3.3% (−1.1; 7.6) and 5.1% (−0.7; 10.9) respectively; at the end of the same periods 34% of patients had improved their baseline FEV₁ by 10% or more but in around 50% of patients the level fell below the baseline. A large inter-individual variability in changes in pulmonary function after the start of DNase treatment was documented. In addition, the medium-term response to treatment was correlated with early response during the first 3 months. No consistent changes in exacerbation pattern were found during the first year of treatment. Conclusions The benefits of DNase use in daily practice are limited but apparently can be maintained in the medium term in some patients. A large inter-individual variability in response to DNase treatment has been documented and the benefits are doubtful in around 50% of patients. This observation points to the need to set up a withdrawal trial in these patients, using as an eligibility criterion the early response observed during the first 3 months of treatment. Received: 13 July 1999 / Accepted: 26 August 1999     

Recurrent bowel intussusception and celiac disease

We report a 1-year-old girl with acute abdominal pain. Clinical examination revealed distended abdomen with increased intestinal peristalsis without other pathologic signs. Ultrasound of the abdomen showed a small bowel intussusception. Seven days later, after a new episode of sudden acute abdominal pain, ultrasound revealed a new bowel intussusception. Ig A and Ig G antigliadin-antibodies were elevated and intestinal biopsy revealed total villous atrophy. After being placed on a gluten-free diet the girl was free of colicky complaints and on repeated ultrasound there was no sign of intussusception. With recurrent intussusception, celiac disease should be considered as a cause.     

Amiodarone-induced hyperthyroidism

Amiodarone is extensively used in cardiology practice because of its excellent antiarrhythmic properties. It produces alterations in thyroid functional because it contains 37% iodine and it is structurally similar to the thyroid hormones. Amiodarone inhibits 5'-deiodinase in the liver. The incidence of amiodarone-induced hyperthyroidism is between 6% and 12% of treated patients. The figures for pediatric patients are similar. Determination of tri-iodothyronine (T3), thyroxine (T4) and thyroid-stimulating hormone (TSH) plays an important role in the diagnosis and follow-up of thyroid alterations. Treatment options in amiodarone-induced hyperthyroidism in children include thionamide, potassium perchlorate, and prednisone. We present the case of hyperthyroidism secondary to amiodarone in a 10-year-old boy with Marfan's syndrome who was admitted several times for crises of paroxysmal supraventricular tachycardia and atrial fibrillation. After amiodarone treatment he presented a clinical and analytical picture of hyperthyroidism with very low TSH levels and increased free-T4 levels. Thyroid echography and scintigraphy were normal. Treatment with thiamazole did not alter the clinical picture, which returned to normal after prednisone administration. Currently, prednisone is being slowly withdrawn.Amiodarone. Hyperthyroidism. Antiarrhythmics.