Is there a need for guidelines for OB/GYN residents to use the laser?

Background and Objective: With the developing technologies and the extensive use of different wavelength lasers for treatment of some gynecologic conditions, many residencies in the United States face pressure to give credentialing to residents wishing to utilize the laser(s). The objective of this study was to assess the need for credentialing. Study Design/Materials and Methods: A survey was sent to all U.S. program directors of obstetrics and gynecology. Results: Of 281 surveys mailed, 138 responded (49.1%); 136 utilized some wavelength laser in the treatment of some gynecologic conditions. The most commonly used laser was the carbon dioxide (CO₂), and the least used was the argon laser. Eighty-four programs (61.8%) had a written policy; 54 (38.2%) did not. Postgraduate courses were necessary in 81 programs (59.6%), leading to some form of credentialing. Conclusions: The vast majority of programs (98.6%) utilized some wavelength laser as a therapeutic modality in gynecology, and 73.5% of the residency programs would like standardized guidelines for residents. © 1995 Wiley-Liss, Inc.     

Disclosure of Adverse Events and Errors in Surgical Care: Challenges and Strategies for Improvement

The disclosure of adverse events to patients, including those caused by medical errors, is a critical part of patient-centered healthcare and a fundamental component of patient safety and quality improvement. Disclosure benefits patients, providers, and healthcare institutions. However, the act of disclosure can be difficult for physicians. Surgeons struggle with disclosure in unique ways compared with other specialties, and disclosure in the surgical setting has specific challenges. The frequency of surgical adverse events along with a dysfunctional tort system, the team structure of surgical staff, and obstacles created inadvertently by existing surgical patient safety initiatives may contribute to an environment not conducive to disclosure. Fortunately, there are multiple strategies to address these barriers. Participation in communication and resolution programs, integration of Just Culture principles, surgical team disclosure planning, refinement of informed consent and morbidity and mortality processes, surgery-specific professional standards, and understanding the complexities of disclosing other clinicians’ errors all have the potential to help surgeons provide patients with complete, satisfactory disclosures. Improvement in the regularity and quality of disclosures after surgical adverse events and errors will be key as the field of patient safety continues to advance.     

Incidence and Risk Factors for Perioperative Adverse Respiratory Events in Children Who Are Obese

Background: Consistent with the increasing prevalence of obesity in the United States and many countries worldwide, anesthesiologists are now presented with a greater number of adult and pediatric patients who are significantly overweight. This prospective study was designed to examine the relation between age-adjusted body mass index, preoperative comorbidities, and perioperative outcome in children.

Methods: Children aged 2-18 yr undergoing noncardiac elective procedures were classified as overweight or obese based on their age- and sex-adjusted body mass index. Information was elicited regarding patient demographics, presence of comorbidities, and anesthetic technique. Data regarding the incidence and severity of perioperative adverse events were collected prospectively.

Results: Two thousand twenty-five children comprised the sample (1,380 normal weight, 351 overweight, and 294 obese). Obese children had a significantly higher prevalence of comorbidities than nonobese children, including asthma, hypertension, sleep apnea, and type II diabetes. Furthermore, obese children had a higher incidence of difficult mask ventilation, airway obstruction, major oxygen desaturation (>10% of baseline), and overall critical respiratory adverse events. Logistic regression analysis revealed several risk factors for adverse events, including procedures involving the airway, obesity, age younger than 10 yr, and a history of obstructive sleep apnea.     

Risk Factors for Perioperative Adverse Respiratory Events in Children with Upper Respiratory Tract Infections

Background: Anesthesia for the child who presents for surgery with an upper respiratory infection (URI) presents a challenge for the anesthesiologist. The current prospective study was designed to determine the incidence of and risk factors for adverse respiratory events in children with URIs undergoing elective surgical procedures.

Methods: The study population included 1,078 children aged 1 month to 18 yr who presented for an elective surgical procedure. Parents were given a short questionnaire detailing their child's demographics, medical history, and presence of any symptoms of a URI. Data regarding the incidence and severity of perioperative respiratory events were collected prospectively. Adverse respiratory events (any episode of laryngospasm, bronchospasm, breath holding > 15 s, oxygen saturation < 90%, or severe cough) were recorded. In addition, parents were contacted 1 and 7 days after surgery to determine the child's postoperative course.

Results: There were no differences between children with active URIs, recent URIs (within 4 weeks), and asymptomatic children with respect to the incidences of laryngospasm and bronchospasm. However, children with active and recent URIs had significantly more episodes of breath holding, major desaturation (oxygen saturation < 90%) events, and a greater incidence of overall adverse respiratory events than children with no URIs. Independent risk factors for adverse respiratory events in children with active URIs included use of an endotracheal tube (< 5 yr of age), history of prematurity, history of reactive airway disease, paternal smoking, surgery involving the airway, the presence of copious secretions, and nasal congestion. Although children with URIs had a greater incidence of adverse respiratory events, none were associated with any long-term adverse sequelae.     

Perioperative Complications and Adverse Events after Surgery for Peripheral Nerve- and Para-lumbar Spine Diseases

Peripheral nerve diseases are common. Para-lumbar spine diseases (PLSDs) include peripheral neuropathy around the lumbar spine, e.g., cluneal nerve entrapment and gluteus medius muscle pain. While these diseases can be treated by less invasive surgery, postoperative complications have not been sufficiently investigated. We document complications after surgery for peripheral nerve diseases and PLSDs. Between July 2014 and December 2020, 678 consecutive patients with peripheral nerve diseases and PLSDs underwent 1068 surgical procedures (upper limb 200 sites, lower limb 447 sites, para-lumbar spine 394 sites, and tumor 27 sites). After excluding 27 procedures to address tumors, we examined the remaining 1,041 procedures undergone by 672 patients (average age 68.2 years) and recorded the complication rate observed within 30 days after the procedures. The overall surgical complication rate was 3.9% (41/1041 procedures); 6 procedures required surgical salvage and 35 were treated conservatively. There were no long-term sequelae from complications. The complication rate was high after surgery for lateral femoral cutaneous-, saphenous-, and common peroneal nerve entrapment and tarsal tunnel syndrome; all sites involved the lower limbs. As a result, intergroup comparison showed that the complication rate was significantly higher for the upper limb (3.0%) procedures than the lower limb (6.7%) and PLSD (1.3%) procedures. It was significantly lower for PLSD operations than lower and upper limb operations. The patient age and diabetes mellitus were significant risk factors for postoperative complications. Their rate was low in patients treated for peripheral nerve diseases and PLSDs; 34 of the 41 complications (82.9%) were related to the surgical wound.     

Serious Adverse Vascular Events Associated With Perioperative Interruption of Antiplatelet and Anticoagulant Therapy

BACKGROUND: Antithrombotic medications may increase perioperative bleeding during cutaneous surgery. Whether to discontinue these medications before surgery is controversial. OBJECTIVE: To evaluate the available evidence in order to generate preliminary guidelines regarding the perioperative use of antithrombotics. METHODS: Presentation of two cases of adverse events after preoperative discontinuation of antithrombotics, review of current anticoagulant and antiplatelet drugs, and review of the literature concerning perioperative antithrombotics in cutaneous surgery. RESULTS: Perioperative withholding of antithrombotics in cutaneous surgery may be associated with serious adverse vascular events. Continuing antithrombotics in these circumstances does not appear to significantly increase bleeding complications. The complexity of available antithrombotics makes case-by-case determinations regarding their use difficult. CONCLUSION: Cutaneous surgeons should strongly consider perioperative continuation of patients' antithrombotic drugs. The final determination should be made by the surgeon after evaluation of the circumstances and, if necessary, consultation with other experts.     

Stratification of Standardized TKA Complications and Adverse Events: A Brief Communication

Background

The Total Knee Arthroplasty (TKA) Complications Workgroup of the Knee Society developed a standardized list and definitions of complications associated with TKA. Twenty-two complications and adverse events believed important for reporting outcomes of TKA were identified. The Editorial Board of Clinical Orthopaedics and Related Research ^®, the Executive Board of the Knee Society, and the members of the Knee Society TKA Complications Workgroup came to the conclusion that reporting of a list of TKA adverse events and complications would be more valuable if they were stratified using a validated classification system.

Questions/purposes

The purpose of this article was to stratify the previously published standardized list of TKA adverse events and complications.

Methods

A modified version of the Sink adaptation of the Clavien-Dindo Surgical Complication Classification was applied to the list of standardized TKA complications and adverse events.

Results

The proposed stratified classifications of TKA complications were reviewed and endorsed by the Knee Society.

Conclusions

Stratification of TKA complications will allow more in-depth and detailed outcome reporting for surgeons, hospitals, third-party payers, government agencies, joint replacement registries, and orthopaedic researchers. This improvement in reporting of TKA complications will also improve the quality of orthopaedic literature.     

The Effect of Statins on Perioperative Events in Patients Undergoing Vascular Surgery

Despite recent advancements in perioperative care and guideline recommendations, patients undergoing vascular surgery remain at risk for perioperative cardiovascular complications. In this review, the results are summarized of the most recent studies on the effectiveness and safety of perioperative statin use for the prevention of these perioperative cardiovascular complications. Perioperative statin therapy was associated with an improvement in postoperative cardiovascular outcome and a reduction in serum lipid levels and levels of inflammation markers.