The Effects of Dexmedetomidine on Preventing/Decreasing Severity of Delirium When Given to Surgical Intensive Care Unit Patients: A Systematic Review of Randomized Control Trials

The purpose of this systematic review was to integrate research evidence from studies published from 2010 to 2020 on the relationship between administration of dexmedetomidine and severity/prevalence of postprocedural delirium in patients in the surgical intensive care unit. In this review, clinical trial studies were recovered by searching the MEDLINE Complete and PubMed databases and utilizing MeSH terminology search. The MeSH terms utilized to search for applicable articles on PubMed included: “intensive care units” or “critical care” or “critical care nursing”, and “delirium”, “dexmedetomidine”, and “surgical procedures, operative”. On MEDLINE Complete, the search terms utilized were “ICU or intensive care unit or critical care” and “dexmedetomidine” and “delirium” and “surgical procedures, operative”. Search limiters applied to both databases included English language, and peer-reviewed journal articles from 2009-2020. Overall, 4 articles were included in this review and the data and dexmedetomidine was found to reduce incidence of delirium in patients who had received surgery in 2 studies. In the other study conducted, there was no statistical significance between delirium incidence between the placebo and experimental group; and the last study was a 3-year follow-up of another one of the studies explored in this review. Regarding secondary outcomes, significantly lower pain scores were reported in all three studies. Other secondary outcomes related to dexmedetomidine administration that were found to differ significantly in the studies include significantly lower need for pain rescue, shorter time to extubation, lower pneumonia incidence, and higher amount of discharges within 7 days. Regarding long-term follow up, patients in the dexmedetomidine group were found to have higher scores in cognition and higher 6 month, 1-year, and 2-year survival rates

The Surgical Release of Dupuytren's Contracture Using Multiple Transverse Incisions.

Dupuytren's contracture is a condition commonly encountered by hand surgeons, although it is rare in the Asian population. Various surgical procedures for Dupuytren's contracture have been reported, and the outcomes vary according to the treatment modalities. We report the treatment results of segmental fasciectomies with multiple transverse incisions for patients with Dupuytren's contracture. The cases of seven patients who underwent multiple segmental fasciectomies with multiple transverse incisions for Dupuytren's contracture from 2006 to 2011 were reviewed retrospectively. Multiple transverse incisions to the severe contracture sites were performed initially, and additional incisions to the metacarpophalangeal (MCP) joints, and the proximal interphalangeal (PIP) joints were performed if necessary. Segmental fasciectomies by removing the fibromatous nodules or cords between the incision lines were performed and the wound margins were approximated. The mean range of motion of the involved MCP joints and PIP joints was fully recovered. During the follow-up periods, there was no evidence of recurrence or progression of disease. Multiple transverse incisions for Dupuytren's contracture are technically challenging, and require a high skill level of hand surgeons. However, we achieved excellent correction of contractures with no associated complications. Therefore, segmental fasciectomies with multiple transverse incisions can be a good treatment option for Dupuytren's contracture

Ultrasound Guided Placement of Single-Lumen Peripheral Intravenous Catheters in the Internal Jugular Vein

Introduction: The peripheral internal jugular (IJ), also called the “easy IJ,” is an alternative to peripheral venous access reserved for patients with difficult intravenous (IV) access. The procedure involves placing a single-lumen catheter in the IJ vein under ultrasound (US) guidance. As this technique is relatively new, the details regarding the ease of the procedure, how exactly it should be performed, and the safety of the procedure are uncertain. Our primary objective was to determine the success rate for peripheral IJ placement. Secondarily, we evaluated the time needed to complete the procedure and assessed for complications. Methods: This was a prospective, single-center study of US-guided peripheral IJ placement using a 2.5-inch, 18-gauge catheter on a convenience sample of patients with at least two unsuccessful attempts at peripheral IV placement by nursing staff. Peripheral IJ lines were placed by emergency medicine (EM) attending physicians and EM residents who had completed at least five IJ central lines. All physicians who placed lines for the study watched a 15-minute lecture about peripheral IJ technique. A research assistant monitored each line to assess for complications until the patient was discharged. Results: We successfully placed a peripheral IJ in 34 of 35 enrolled patients (97.1%). The median number of attempts required for successful cannulation was one (interquartile range (IQR): 1 to 2). The median time to successful line placement was 3 minutes and 6 seconds (IQR: 59 seconds to 4 minutes and 14 seconds). Two lines failed after placement, and one of the 34 successfully placed peripheral IJ lines (2.9%) had a complication – a local hematoma. There were, however, no arterial punctures or pneumothoraces. Although only eight of 34 lines were placed using sterile attire, there were no line infections. Conclusion: Our research adds to the growing body of evidence supporting US-guided peripheral internal jugular access as a safe and convenient procedure alternative for patients who have difficult IV access

Demographic Predictors of Adult Behaviors in the Pediatric Postoperative Environment

Over 85% of children experience postoperative pain. If poorly treated, pediatric postoperative pain may lead to various negative health outcomes. Adult behaviors may be associated with child experiences in the postoperative environment. For example, adult behaviors such as distraction, humor, and coping advice divert a child’s attention away from their pain and thus, may significantly reduce child postoperative distress. In contrast, adult behaviors such as empathy, reassurance, and apology direct a child’s attention towards their pain which may increase a child’s overall postoperative distress. Moreover, patient demographic factors, like child ethnicity, may significantly alter the frequency of use of these adult behaviors. Therefore, this study aimed to determine which participant demographic factors are associated with the use of certain adult behaviors in response to child postoperative distress. This study included children ages 2 to 10 years old (N=112) undergoing elective surgery at the Children’s Hospital of Orange County. Participant demographics including ethnicity and race were collected prior to surgery. Nurse, parent, and child postoperative behavioral interactions were video recorded in the Post Anesthesia Care Unit (PACU). From these video recordings, adult behaviors were coded for their frequency of use. Multiple regressions analyses showed that adults were more likely to use humor with Non-Hispanic White children compared to Hispanic children (b = 0.393, p = 0.049). Moreover, fathers were marginally more likely to use empathy, reassurance, and apology with Hispanic children compared to Non-Hispanic White children (b = 0.249, p = 0.05). These results suggest that Hispanic and Non-Hispanic White children may receive different behavioral treatment in response to their postoperative distress. Implications for these findings suggest that child ethnicity may be predictive of different adult PACU behaviors which may illustrate how cultural differences can influence the child postoperative experience

Risk of postoperative pulmonary complications in adult surgical patients with metabolic syndrome: a systematic review and meta-analysis protocol

Background: Metabolic syndrome (MetS) is defined as an accumulation of risk factors that include chronic hypertension, dyslipidaemia, insulin resistance and obesity and leads to an increased risk for diabetes, cardiovascular disease and stroke. MetS is widespread and estimated to affect up to a quarter of the global population. Patients with MetS who undergo surgery are associated with an increased risk of postoperative complications when compared with patients with a non-MetS profile. An emerging body of literature points to MetS being associated with a greater risk of postoperative pulmonary complications (PPC) in the surgical patient. PPC are associated with increased postoperative morbidity and mortality, Intensive care unit (ICU) admission, length of stay (ICU and hospital), health care costs, resource usage, unplanned re-intubation and prolonged ventilatory time. Methods/design: We will search for relevant studies in the following electronic bibliographic databases: EMBASE, MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Scopus as well as scan the reference lists of included studies for potential additional literature. Two authors will independently screen titles and abstracts to identify potentially relevant studies for inclusion based on predefined inclusion and exclusion criteria. The Cochrane Collaboration Review Manager (Review Manager 5) statistical software will be used to conduct this systematic review and meta-analysis and generate forest plots to demonstrate comparison of findings across studies included for meta analysis. Subgroup and sensitivity analysis will be performed to assess the heterogeneity of included studies. A descriptive synthesis of the statistical data will be provided to summarise the results and findings of the systematic review and meta-analysis. Discussion: This review will be the first to report and summarise the risk for and incidence of PPC in adult patients with MetS undergoing surgery across a range of surgical specialities. The results have the potential to inform the development of evidenced-based interventions to improve the management of PPC in the surgical patient with MetS. Findings from this systematic review and meta-analysis will inform a subsequent Delphi study on priorities and responses to PPC in patients with MetS. We will also disseminate our results through publication in scientific peerreviewed journals, conference presentations and promotion throughout our network of surgical safety champions in clinical settings

Ulnar Collateral Ligament Reconstruction with Traditional Docking Compared to Novel Surgical Techniques

Background: Ulnar Collateral Ligament Reconstruction (UCLR) is a surgical procedure on one of the main ligaments that provides normal stability for the elbow joint against excessive valgus stress. Damage to this ligament is common in athletes performing overhead throwing activities, primarily baseball players, due to excessive valgus stress during the throwing motion. The most common form of treatment for this type of injury is reconstructive surgery of the ligament, especially if athletes wish to return to sport participation. This type of surgery is extremely invasive and requires extensive post-operative rehabilitation in order to facilitate return to play. To date, many surgical techniques have been proposed and evaluated, but there are no conclusive comparison studies on patient outcomes following UCLR. Purpose: The purpose of this paper is to analyze previous studies on UCLR techniques and determine if there is a single superior surgical method leading to improved biomechanical outcomes and decreased failure measures. Our focused clinical question was identifying if the traditional docking technique compared to novel docking techniques during UCLR superior in relation to biomechanical outcomes and failure measures in cadaveric tissue. Methodology: The study design in this paper is a critically appraised topic. Various scholarly databases such as PubMed, MEDLINE and SportDiscus were utilized to search for studies related to UCLR surgical techniques. After an initial search, a list of fifteen relevant studies were identified. Each study was then scrutinized and evaluated to meet predetermined inclusion criteria and a minimum score of 6/9 on the PEDro scale. All studies not meeting these requirements were excluded. This left a total of five articles which were then used to answer the clinical question for this paper. The inclusion criteria involved meeting a cadaveric age of 16-60 y, objective measures of valgus testing, angular displacement, stiffness and modes of failure as post-operative outcomes. Further, we included studies that had a minimum of seven cadaver pairs tested, and studies were required to compare traditional docking to at least one novel technique. Results: All five studies involved compared at least one novel surgical technique to the docking technique. Four studies found no significant overall difference between the native and reconstructed states of any surgical technique. One study found no overall significant difference, but did identify slight differences in biomechanical properties. Discussion: All conclusions from individual studies demonstrate comparable findings between all UCLR techniques. Biomechanics, kinematics and failure modes in the acute stages following surgery in cadavers are similar between UCLR techniques. Despite all that has been done, additional research is still necessary to determine a superior surgical technique

Selective Use of Pericardial Window and Drainage as Sole Treatment for Hemopericardium from Penetrating Chest Trauma

Background Penetrating cardiac injuries (PCIs) are highly lethal, and a sternotomy is considered mandatory for suspected PCI. Recent literature suggests pericardial window (PCW) may be sufficient for superficial cardiac injuries to drain hemopericardium and assess for continued bleeding and instability. This study objective is to review patients with PCI managed with sternotomy and PCW and compare outcomes. Methods All patients with penetrating chest trauma from 2000 to 2016 requiring PCW or sternotomy were reviewed. Data were collected for patients who had PCW for hemopericardium managed with only pericardial drain, or underwent sternotomy for cardiac injuries grade 1–3 according to the American Association for the Surgery of Trauma (AAST) Cardiac Organ Injury Scale (OIS). The PCW+drain group was compared with the Sternotomy group using Fisher’s exact and Wilcoxon rank-sum test with P\u3c0.05 considered statistically significant. Results Sternotomy was performed in 57 patients for suspected PCI, including 7 with AAST OIS grade 1–3 injuries (Sternotomy group). Four patients had pericardial injuries, three had partial thickness cardiac injuries, two of which were suture-repaired. Average blood drained was 285mL (100–500 mL). PCW was performed in 37 patients, and 21 had hemopericardium; 16 patients proceeded to sternotomy and 5 were treated with pericardial drainage (PCW+drain group). All PCW+drain patients had suction evacuation of hemopericardium, pericardial lavage, and verified bleeding cessation, followed by pericardial drain placement and admission to intensive care unit (ICU). Average blood drained was 240mL (40–600 mL), and pericardial drains were removed on postoperative day 3.6 (2–5). There was no significant difference in demographics, injury mechanism, Revised Trauma Score exploratory laparotomies, hospital or ICU length of stay, or ventilator days. No in-hospital mortality occurred in either group. Conclusions Hemodynamically stable patients with penetrating chest trauma and hemopericardium may be safely managed with PCW, lavage and drainage with documented cessation of bleeding, and postoperative ICU monitoring. Level of evidence Therapeutic study, level IV

Evaluation of the accuracy of a patient-specific instrumentation

Patient-specific instruments (PSI) has been introduced with the aim to reduce the overall costs of the implants, minimizing the size and number of instruments required, and also reducing surgery time. The aim of this study was to perform a review of the current literature, as well as to report about our personal experience, to assess reliability and accuracy of patient specific instrument system in total knee arthroplasty (TKA). A literature review was conducted of PSI system reviewing articles related to coronal alignment, clinical knee and function scores, cost, patient satisfaction and complications. Studies have reported incidences of coronal alignment ≥3° from neutral in TKAs performed with patient-specific cutting guides ranging from 6% to 31%. PSI seem not to be able to result in the same degree of accuracy as for the CAS system, while comparing well with standard manual technique with respect to component positioning and overall lower axis, in particular in the sagittal plane. In cases in which custom-made cutting jigs were used, we recommend performing an accurate control of the alignment before and after any cuts and in any further step of the procedure, in order to avoid possible outliers