James H. Paxton

Proximal Humerus Intraosseous Infusion: A Preferred Emergency Venous Access

PURPOSEnTo assess the proximal humerus intraosseous (PHIO) catheter placement as a preferred method for venous access over conventional methods, including peripheral intravenous (PIV) and central venous catheters (CVCs), during emergency room resuscitation.nnnMETHODSnIn phase 1, conventional methods for venous access (PIV and CVC) were assessed for all patients presenting to the emergency department resuscitation bay. Outcome measures in both phases were speed, immediate complications, and pain. CVC placement was performed when PIV access was deemed impossible or when rapid volume resuscitation was needed. In phase 2, resuscitations requiring venous access or complicated by failed PIV access attempts underwent PHIO catheter placement.nnnRESULTSnSixty-two patients received either PIV (57) or CVC (5) catheterization, and 29 patients received 30 PHIO catheters. PHIO catheter placement was significantly faster than conventional methods (1.5 [SD 1.1] versus 3.6 minutes [SD 3.7; p < 0.001 for PIV, and 15.6 minutes [SD 6.7; p < 0.0056] for CVC). No major complications were identified in either phase. Minor complications for PIV access included extravasation and placement failure. Minor complications for CVC placement included inability to thread the guidewire. Minor complications with PHIO catheter placement included placement failure, poor flow, and catheter dislodgement. Pain scores associated with PHIO insertion and infusion were higher than those associated with PIV and CVC catheter placement.nnnCONCLUSIONnPHIO catheter placement is significantly faster than PIV and CVC placement with increased minor complication profile and perceived pain. PHIO venous access is absolutely life saving when PIV or CVC placement is difficult or impossible.

The Cost Effectiveness of Laparoscopic versus Open Gastric Bypass Surgery

Background: Over the last decade, laparoscopic gastric bypass (LGBP) has been proven to be a safe and well-tolerated approach to the Roux-en-Y gastric bypass, despite its increased cost when compared to the open approach (OGBP). This increased expense has led many to question whether LGBP is a cost effective alternative to OGBP. The aim of this study is to determine which approach is most cost effective, considering costs associated with the operation itself, perioperative complications, and income lost during convalescence. Methods: A PubMed search of the National Library of Medicine online journal database was conducted. Studies that met predetermined criteria for selection were included in the analyses of patient demographics, perioperative complications, length of hospital stay, excess weight loss, and time to recovery. Data on 6,425 OGBP and 5,867 LGBP patients were used to compare the outcomes associated with each approach. Results: Significant differences were found in the perioperative complication profiles, time to recovery, and overall expense of the two approaches. OGBP was associated with an increased incidence of major perioperative complications, especially extraintestinal complications, and greater perioperative mortality. LGBP was associated with shorter hospital stays, increased incidence of intestinal complications, and a 2.25% incidence of conversion to OGBP. Patient demographics and percent excess weight loss (%EWL) at 3 years follow-up were found to be similar with both OGBP and LGBP. Conclusion: LGBP is a cost effective alternative to OGBP for surgical weight loss. Despite the increased cost of LGBP, patients suffer fewer expensive and lifethreatening perioperative complications.

Medical Errors Education: A Prospective Study of a New Educational Tool

Medical errors training is an important yet often overlooked aspect of medical education. A medical errors educational session was developed for rotating medical students (MSs) with prospective analysis of the educational tool. Students completed the same 12-question test before and after the educational session and a long-term posttest 1 to 12 months later. Control students who did not take part in the session completed the test twice with a 6-month interval. In all, 51 students completed a pretest and a short-term posttest, and 35 students completed a long-term posttest. Test scores for the study group increased significantly from a pretest mean of 29.3% to a short-term posttest mean of 73.7% ( P < .001) and a long-term posttest mean of 49.1% (P < .001). Long-term test scores for 24 control group students were significantly lower (P < .001). This brief educational intervention led to statistically significant improved performance in general understanding of medical errors and could be a useful tool to enhance MS awareness and proactive handling of medical errors.

Intraosseous vascular access: A review

Intraosseous cannulation is an increasingly common means of achieving vascular access for the administration of fluids and medications during the emergent resuscitation of both paediatric and adult patients. Improved tools and techniques for intraosseous vascular access have recently been developed, enabling the healthcare provider to choose from a wide range of devices and insertion sites. Despite its increasing popularity within the adult population, and decades of use in the paediatric population, questions remain regarding the safety and efficacy of intraosseous infusion. Although various potential complications of intraosseous cannulation have been theorized, few serious complications have been reported. This article aims to provide a review of the current literature on intraosseous vascular access, including discussion on the various intraosseous devices currently available in the market, the advantages and disadvantages of intraosseous access compared to conventional vascular access methods, complications of intraosseous cannulation and current recommendations on the use of this approach.

Intraosseous Injection of Iodinated Computed Tomography Contrast Agent in an Adult Blunt Trauma Patient

Intraosseous venous access can be life-saving in trauma patients when traditional methods for obtaining venous access are difficult or impossible. Because many blunt trauma patients require expeditious evaluation by computed tomography (CT) scans with intravenous contrast, it is important to evaluate whether intraosseous catheters can be used for administering CT contrast agents in lieu of waiting until secure peripheral intravenous or central venous catheter access can be established. Previous case reports have demonstrated that tibial intraosseous catheters can be used to safely administer CT contrast in the pediatric patient population. Here we report a case in which intraosseous access was the only means of administering intravenous contrast agent in an adult blunt trauma patient. An intraosseous catheter was placed in the standard manner in the right proximal humerus. Intravenous contrast agent was administered through the intraosseous catheter, using the standard blunt trauma protocol at our institution. CT scans were evaluated by a staff radiologist and assessed for the adequacy of diagnosis for blunt traumatic injuries. CT scans of the thorax, abdomen, and pelvis were considered to be adequate for diagnostic purposes and subjectively equivalent to those of studies using traditional central venous access. The intraosseous catheter was discontinued the following day. No complications of intraosseous placement or of contrast administration were identified. Intraosseous catheterization appears to be a feasible and effective alternative to traditional methods of venous access in the administration of iodinated contrast agents for CT evaluation in adult blunt trauma patients. Further study is warranted.

Medical Errors Education for Students of Surgery: A Pilot Study Revealing the Need for Action

BACKGROUNDnMedical errors training is an important yet often overlooked aspect of surgical education. In response to a perceived deficiency in medical errors training at our institution, we implemented an educational session on medical errors concepts for the benefit of rotating medical students.nnnMATERIALS AND METHODSnMedical students completed the same 12-question test before and after the 90-minute educational session. Pretest and posttest scores were compared for evidence of enhanced understanding. No personal identifiers were used, and students were provided unlimited time to complete the tests. Six groups of medical students (who ranged from 5 to 8 students per session) completed the educational session. All sessions were moderated by the same surgical resident and attending surgeon, who used a standard slide presentation. Test scores were analyzed with SPSS statistical software (version 14.0; SPSS Inc., Cary, NC), which employed the paired samples t-test (alpha = 0.05).nnnRESULTSnTest scores increased significantly from a pretest mean of 27.3% correct (3.28 of 12 possible, SD = 1.57) to a mean posttest score of 70.1% (8.41, SD = 1.52) (p < 0.001).nnnCONCLUSIONSnThis retrospective pilot study demonstrated that a brief educational intervention led to statistically significant improved performance on a general understanding of medical errors. The study also revealed the dearth of baseline knowledge in our participating medical students on the subject. We believe that these results underscore the need for action in providing improved and ongoing education in medical errors concepts to enhance medical student awareness and proactive handling of medical errors.

The Role of Lymphangiogenesis in Regional Lymph Node Metastasis: Animal Models

A combination of clinicopathological, molecular, and sophisticated animal experiments have demonstrated the critical importance of lymphangiogenesis in the pathogenesis of sentinel lymph node (SLN) metastasis. This chapter highlights the animal models and experiments that confirmed the association of tumoral and peritumoral lymphangiogenesis and metastasis. The initiating events may have been the observation of lymphatic development in embryos. Using classic embryological models and modern molecular techniques allowed a dissection of the developing lymphatic system that previously was unattainable. Lymphangiogenesis has also been identified in wounds, inflammation, infections, and tumors. The biochemical and molecular events in embryologic development of the lymphatic system were used in animal models of tumors to identify lymphangiogenesis and to dissect the sequence of events during tumor dissemination. The tools available for these experiments have continued to advance and are summarized in the chapter.

Interposition of a jejunal segment as an alternative one-stage operation for acute left colon obstruction

Abstract.Purpose: Much debate surrounds the one-stage surgical management of acute left colon obstruction. Many surgeons are still reluctant to perform primary anastomosis in unprepared bowel fearing the risk of anastomotic dehiscence. Although intraoperative lavage and subtotal colectomy have recently proved effective for preventing fecal loading, both of these procedures have drawbacks and the search for additional alternative surgical procedures continues. We conducted an experimental study to examine a new one-stage operation, consisting of the interposition of a jejunal segment to the resection site of the colon, to manage acute left colon obstruction.Methods: The colons of 20 domestic pigs were obstructed, and 2 days later, segmental resection and either primary colo-colonic anastomosis or interposition of a jejunal segment was performed. Autopsies were done 6 weeks after the operations and the anastomotic regions were subjected to bursting pressure analysis.Results: The operating time was longer in the interposition group at 49 ± 14 vs 38 ± 12u2009min (P < 0.01). There was no mortality or clinical signs of anastomotic dehiscence in either group. A perianastomotic abscess was detected on autopsy in one animal from the primary colo-colonic anastomosis group. The bursting pressures of the jejunocolic anastomoses were significantly higher (P < 0.001) than those of the primary colo-colonic anastomoses.Conclusions: These experimental results suggest that jejunal interposition may be a feasible alternative to primary colonic anastomosis to create intestinal continuity after resection for acute obstruction of the left colon.