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British Journal of Hospital Medicine... Sep 2023Medical errors resulting in treatment-related harm have been a challenge for many years, with particularly severe consequences in surgery. Efforts to improve safety...
Medical errors resulting in treatment-related harm have been a challenge for many years, with particularly severe consequences in surgery. Efforts to improve safety should focus on system-based changes to response and rescue pathways, and will require further research and adequate engagement by clinical staff.
Topics: Humans; Medical Errors; Surgical Procedures, Operative
PubMed: 37769265
DOI: 10.12968/hmed.2023.0180 -
Diabetes Care Feb 2011The optimal treatment of hyperglycemia in general surgical patients with type 2 diabetes mellitus is not known. (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
The optimal treatment of hyperglycemia in general surgical patients with type 2 diabetes mellitus is not known.
RESEARCH DESIGN AND METHODS
This randomized multicenter trial compared the safety and efficacy of a basal-bolus insulin regimen with glargine once daily and glulisine before meals (n = 104) to sliding scale regular insulin (SSI) four times daily (n = 107) in patients with type 2 diabetes mellitus undergoing general surgery. Outcomes included differences in daily blood glucose (BG) and a composite of postoperative complications including wound infection, pneumonia, bacteremia, and respiratory and acute renal failure.
RESULTS
The mean daily glucose concentration after the 1st day of basal-bolus insulin and SSI was 145 ± 32 mg/dL and 172 ± 47 mg/dL, respectively (P < 0.01). Glucose readings <140 mg/dL were recorded in 55% of patients in basal-bolus and 31% in the SSI group (P < 0.001). There were reductions with basal-bolus as compared with SSI in the composite outcome [24.3 and 8.6%; odds ratio 3.39 (95% CI 1.50-7.65); P = 0.003]. Glucose <70 mg/dL was reported in 23.1% of patients in the basal-bolus group and 4.7% in the SSI group (P < 0.001), but there were no significant differences in the frequency of BG <40 mg/dL between groups (P = 0.057).
CONCLUSIONS
Basal-bolus treatment with glargine once daily plus glulisine before meals improved glycemic control and reduced hospital complications compared with SSI in general surgery patients. Our study indicates that a basal-bolus insulin regimen is preferred over SSI in the hospital management of general surgery patients with type 2 diabetes.
Topics: Aged; Blood Glucose; Diabetes Mellitus, Type 2; Female; General Surgery; Humans; Hypoglycemic Agents; Inpatients; Insulin; Insulin Glargine; Insulin, Long-Acting; Male; Middle Aged; Perioperative Care; Postoperative Complications; Prospective Studies
PubMed: 21228246
DOI: 10.2337/dc10-1407 -
European Journal of Trauma and... Jun 2021
Topics: COVID-19; Emergencies; Emergency Medicine; Europe; Humans; Pandemics; Practice Guidelines as Topic; Surgical Procedures, Operative; Traumatology; Wounds and Injuries
PubMed: 34100964
DOI: 10.1007/s00068-021-01682-4 -
American Family Physician Dec 2010Aspirin is recommended as a lifelong therapy that should never be interrupted for patients with cardiovascular dis- ease. Clopidogrel therapy is mandatory for six weeks... (Review)
Review
Aspirin is recommended as a lifelong therapy that should never be interrupted for patients with cardiovascular dis- ease. Clopidogrel therapy is mandatory for six weeks after placement of bare-metal stents, three to six months after myocardial infarction, and at least 12 months after placement of drug-eluting stents. Because of the hypercoagulable state induced by surgery, early withdrawal of antiplatelet therapy for secondary prevention of cardiovascular disease increases the risk of postoperative myocardial infarction and death five- to 10-fold in stented patients who are on continuous dual antiplatelet therapy. The shorter the time between revascularization and surgery, the higher the risk of adverse cardiac events. Elective surgery should be postponed beyond these periods, whereas vital, semiurgent, or urgent operations should be performed under continued dual antiplatelet therapy. The risk of surgical hemorrhage is increased approximately 20 percent by aspirin or clopidogrel alone, and 50 percent by dual antiplatelet therapy. The present clinical data suggest that the risk of a cardiovascular event when stopping antiplatelet agents preoperatively is higher than the risk of surgical bleeding when continuing these drugs, except during surgery in a closed space (e.g., intracranial, posterior eye chamber) or surgeries associated with massive bleeding and difficult hemostasis.
Topics: Humans; Platelet Aggregation Inhibitors; Postoperative Complications; Preoperative Care; Surgical Procedures, Operative; Thrombosis
PubMed: 21166368
DOI: No ID Found -
Scandinavian Journal of Gastroenterology Oct 2016Pancreas surgery has developed into a fairly safe procedure in terms of mortality, but is still hampered by considerable morbidity. Among the most frequent and dreaded... (Review)
Review
BACKGROUND
Pancreas surgery has developed into a fairly safe procedure in terms of mortality, but is still hampered by considerable morbidity. Among the most frequent and dreaded complications are the development of a post-operative pancreatic fistula (POPF). The prediction and prevention of POPF remains an area of debate with several questions yet to be firmly addressed with solid answers.
METHODS
A systematic review of systematic reviews/meta-analyses and randomized trials in the English literature (PubMed/MEDLINE, Cochrane library, EMBASE) covering January 2005 to December 2015 on risk factors and preventive strategies for POPF.
RESULTS
A total of 49 systematic reviews and meta-analyses over the past decade discussed patient, surgeon, pancreatic disease and intraoperative related factors of POPF. Non-modifiable factors (age, BMI, comorbidity) and pathology (histotype, gland texture, duct size) that indicates surgery are associated with POPF risk. Consideration of anastomotic technique and use of somatostatin-analogs may slightly modify the risk of fistula. Sealant products appear to have no effect. Perioperative bleeding and transfusion enhance risk, but is modifiable by focus on technique and training. Drains may not prevent fistulae, but may help in early detection. Early drain-amylase may aid in detection. Predictive scores lack uniform validation, but may have a role in patient information if reliable pre-operative risk factors can be obtained.
CONCLUSIONS
Development of POPF occurs through several demonstrated risk factors. Anastomotic technique and use of somatostatin-analogs may slightly decrease risk. Drains may aid in early detection of leaks, but do not prevent POPF.
Topics: Digestive System Surgical Procedures; Drainage; Humans; Morbidity; Pancreas; Pancreatic Fistula; Postoperative Complications; Predictive Value of Tests; Randomized Controlled Trials as Topic; Risk Factors
PubMed: 27216233
DOI: 10.3109/00365521.2016.1169317 -
Anaesthesia Jan 2018Cardiac complications are common after non-cardiac surgery. Peri-operative myocardial infarction occurs in 3% of patients undergoing major surgery. Recently, however,... (Review)
Review
Cardiac complications are common after non-cardiac surgery. Peri-operative myocardial infarction occurs in 3% of patients undergoing major surgery. Recently, however, our understanding of the epidemiology of these cardiac events has broadened to include myocardial injury after non-cardiac surgery, diagnosed by an asymptomatic troponin rise, which also carries a poor prognosis. We review the causation of myocardial injury after non-cardiac surgery, with potential for prevention and treatment, based on currently available international guidelines and landmark studies. Postoperative arrhythmias are also a frequent cause of morbidity, with atrial fibrillation and QT-prolongation having specific relevance to the peri-operative period. Postoperative systolic heart failure is rare outside of myocardial infarction or cardiac surgery, but the impact of pre-operative diastolic dysfunction and its ability to cause postoperative heart failure is increasingly recognised. The latest evidence regarding diastolic dysfunction and the impact on non-cardiac surgery are examined to help guide fluid management for the non-cardiac anaesthetist.
Topics: Cardiovascular Diseases; Humans; Intraoperative Complications; Postoperative Complications; Surgical Procedures, Operative
PubMed: 29313903
DOI: 10.1111/anae.14138 -
Canadian Journal of Surgery. Journal... Oct 2019
Topics: Canada; General Surgery; Humans; Racism; Sexism
PubMed: 31549798
DOI: 10.1503/cjs.014619 -
International Journal of Surgery... Sep 2020Globally, a staggering 310 million major surgeries are performed each year; around 40 to 50 million in USA and 20 million in Europe. It is estimated that 1-4% of these...
Globally, a staggering 310 million major surgeries are performed each year; around 40 to 50 million in USA and 20 million in Europe. It is estimated that 1-4% of these patients will die, up to 15% will have serious postoperative morbidity, and 5-15% will be readmitted within 30 days. An annual global mortality of around 8 million patients places major surgery comparable with the leading causes of death from cardiovascular disease and stroke, cancer and injury. If surgical complications were classified as a pandemic, like HIV/AIDS or coronavirus (COVID-19), developed countries would work together and devise an immediate action plan and allocate resources to address it. Seeking to reduce preventable deaths and post-surgical complications would save billions of dollars in healthcare costs. Part of the global problem resides in differences in institutional practice patterns in high- and low-income countries, and part from a lack of effective perioperative drug therapies to protect the patient from surgical stress. We briefly review the history of surgical stress and provide a path forward from a systems-based approach. Key to progress is recognizing that the anesthetized brain is still physiologically 'awake' and responsive to the sterile stressors of surgery. New intravenous drug therapies are urgently required after anesthesia and before the first incision to prevent the brain from switching to sympathetic overdrive and activating secondary injury progression such as hyperinflammation, coagulopathy, immune activation and metabolic dysfunction. A systems-based approach targeting central nervous system-mitochondrial coupling may help drive research to improve outcomes following major surgery in civilian and military medicine.
Topics: Global Health; Glycocalyx; Humans; Hypothalamo-Hypophyseal System; Mitochondria; Pituitary-Adrenal System; Postoperative Complications; Stress, Physiological; Surgical Procedures, Operative
PubMed: 32738546
DOI: 10.1016/j.ijsu.2020.07.017 -
Cirugia Espanola 2020In view of the current pandemic by SARS-CoV-2 it deems essential to understand the key concepts about the infection: its epidemiological origin, presentation, clinical... (Review)
Review
In view of the current pandemic by SARS-CoV-2 it deems essential to understand the key concepts about the infection: its epidemiological origin, presentation, clinical course, diagnosis and treatment (still experimental in many cases). The knowledge about the virus is still limited, but as the pandemic progresses and the physiopathology of the disease is understood, new evidence is being massively published. Surgical specialists are facing an unprecedented situation: they must collaborate in the ER or medical wards attending these patients, while still needing to make decisions about surgical patients with probable COVID-19. The present narrative review aims to summarize the most relevant aspects and synthetize concepts on COVID-19 for surgeons.
Topics: COVID-19; Coronavirus Infections; Humans; Infection Control; Pandemics; Pneumonia, Viral; Spain; Surgeons; Surgical Procedures, Operative
PubMed: 32345443
DOI: 10.1016/j.ciresp.2020.04.009 -
The British Journal of Surgery Jul 2020
Topics: Betacoronavirus; COVID-19; Coronavirus Infections; Disease Transmission, Infectious; Education, Medical; General Surgery; Humans; Pandemics; Pneumonia, Viral; SARS-CoV-2; Safety; Surgical Procedures, Operative
PubMed: 32492170
DOI: 10.1002/bjs.11740