Preoperative CT angiography reduces surgery time in perforator flap reconstruction

The use of perforator flaps in breast reconstructions has increased considerably in the past decade. A disadvantage of the perforator flap is difficult dissection, which results in a longer procedure. During spring 2006, we introduced CT angiography (CTA) as part of the diagnostic work-up in perforator flap reconstructions to visualise each perforator more accuratety. The main objectives were to reduce surgery time and the number of complications. A chart review was conducted 1 year after CTA introduction to investigate if these objectives were met. Materials and methods: Patients with a deep inferior epigastric perforator (DIEP) flap who underwent preoperative analysis through CTA were retrospectively evaluated. The population Results: One hundred and thirty-eight DIEP breast reconstructions were done; 70 underwent preoperative CTA analysis, and 68 had preoperative Doppler investigation. Surgery time in the CTA group was significantly lower (P <0.001) than in the control group, 264 min (SD +/- 62) versus 354 min (SD +/- 83), respectively. There was a tendency for fewer complications in the CTA group compared with the control group. All flaps were successful in the CTA group. In the control group, one flap failed and partial necrosis occurred in three flaps. The differences were not statistically significant. Conclusions: Preoperative CTA in the assessment of vascular anatomy during perforator flap reconstruction was safe and reliable. It helped reduce surgery time, and may prevent the number of postoperative complications. (C) 2008 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons

Perceived Physical and Psychological Outcome After Severe Burn Injury

There is very little data on physical and psychological long-term outcome after severe burn injury. The aim of the present thesis was to improve current instruments for assessment of these issues, to assess long-term outcome in a cohort of patients with burn injuries, and to explore the contribution of the individual factors of personality and coping on perceived outcome. Patients treated at the Burn Unit, Uppsala University Hospital, between 1980 and 1995 were included on a consecutive basis if they were 18 years of age or older at follow-up, had burn injuries of ten percent or more, or hospitalization times of seven days or more. A total of 350 patients fulfilled these inclusion criteria. A factor analytic approach was used to derive a 40-item instrument called the Burn Specific Health Scale-Brief (BSHS-B), resulting in nine well-defined domains. Most burn patients reported a very good perceived outcome but a subgroup reported problems years after injury. On a group level most problems were related to Heat Sensitivity, Work and Body Image. The depth of injury, gender, marital status and living conditions were all related to outcome. Neurotic personality traits were related to perceived health, and were not confined only to psychological aspects of life but also included physical aspects. A 33-item burn-specific coping scale, the Coping with Burns Questionnaire (CBQ), with six clearly separated domains with acceptable internal consistencies was developed. Coping strategies were strongly related to outcome in the subgroup of patients reporting most problems in perceived health, and coping contributed more to psychosocial than physical health. Avoidant coping and Emotional support seeking had independent effects on outcome. The observation that Neuroticism and Avoidant coping strategies are related to bad outcome after severe burn injury indicates that patients with such characteristics should be given special attention during rehabilitation

Intranasal dexmedetomidine and rectal ketamine for young children undergoing burn wound procedures

Background: Safe and effective methods for sedation and analgesia in pediatric burn patients are strongly warranted. This retrospective study of electronic health care records aims to evaluate the safety and efficacy of intranasal dexmedetomidine combined with rectal ketamine as procedural sedation for young children undergoing dressing changes and debridement of burn wounds. Methods: Documentation was analyzed from 90 procedures in 58 pediatric patients aged &lt;5 years. Safety and efficacy of the method were assessed based on documentation for complications, adverse effects, pain level, level of sedation and preoperative and recovery time. Results: All 90 sedations were completed without significant adverse events with acute airway management or medical intervention. The combination of dexmedetomidine-ketamine produced acceptable analgesia during the procedure and effectively relieved postoperative pain. However, the approach was insufficient for 7/58 patients (7.8%); these patients were converted from the dexmedetomidine-ketamine combination to intravenous anesthesia. In 23% of the cases an extra dose of either ketamine of dexmedetomidine was administered. Moreover, there were two cases of delayed awakening with recovery time &gt;120 min. Conclusion: The drug combination intranasal dexmedetomidine and rectal ketamine is a safe and reliable approach for procedural sedation and analgesia in pediatric patients undergoing burn wound procedures, producing a clinically stable sedative condition requiring only basic monitoring

Ethical and Practical Concerns of Heart Rate Monitoring: Enabling Communication for Patients with Severe Communication Difficulties

Background Monitoring technologies to aid communication in long-term patient care may enhance safety and well-being but may also infringe on privacy. While autonomy is a primary value in medical ethics, definitions of autonomy often take for granted a minimum level of communicative ability. For the ethical debate on autonomy to be extended to people with severe communication difficulties who cannot explicitly approve or disapprove of the use of monitoring technologies, we need to consider the ethical implications of using or not using such technologies for this patient group specifically. Main text This paper explores how contemporary philosophical arguments on monitoring physiological responses can be made applicable to people with severe communication difficulties. It further discusses autonomy concerning the ethical principles of beneficence and nonmaleficence when evaluating the use of heart rate monitoring for this patient group. While monitoring someone without their consent is ethically problematic, providing heart rate monitoring may be morally imperative as a necessary means of interaction, as this patient group is effectively isolated without much possibility to interact with their caregivers. Conclusion Although heart rate monitoring of people with severe communication difficulty can be considered a privacy infringement and a violation of the principle of respect for a person’s autonomy, it can also be autonomy-enabling and of potential beneficence. Balancing the principles and interests of a person with severe communication difficulties is challenging and demands careful and critical ethical reflection