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Wound Healing in Chronic Steroid Use

December 6th, 2009

Chronic steroid use causes an increased risk of wound infection and a decrease in wound healing. Signs and symptoms of wound infection in chronic steroid use can be subtle, such as wound dehiscence (i.e., breakdown) or non-healing.

There are some studies that show that the use of preoperative vitamin A has been shown to improve wound healing. The mechanism of action is unknown but it maybe related to an increased TGF-beta level.

Generally, experienced surgeons will allow incision sutures or staples to remain in place several days longer than in incisions where there is no steroid exposure.

Acetaminophen Toxicity (Tylenol Poisioning)

December 3rd, 2009

The treatment of choice for Tylenol overdose is administration of intravenous acetylcysteine (Mucomyst).

Acetaminophen overdose causes liver damage and has been known to cause liver failure requiring emergent transplant. The Kings College Criteria for listing a patient for liver transplant due to Tylenol overdose are:

pH < 7.3 after treatment

or

Serum creatinine > 3mg/dL

INR > 6.5

Grade 3 or 4 encephalopathy

Carbon Dioxide (CO2) Embolism

December 2nd, 2009

Carbon dioxide embolism is a condition where this gas enters the blood stream at an above normal level. It most typically happens when carbon dioxide is placed into the abdominal cavity (insufflation) during laparoscopic surgery.

It most classically presents as hypotension (decreased blood pressure) and a sudden drop in end-tidal CO2 (a measurement of the amount of CO2 that leaves the lungs at the end of each breath.)

NSQIP – National Surgical Quality Improvement Program

November 14th, 2009

NSQIP is a healthcare improvement program designed by the American College of Surgeons and first adopted by the Veterans Health Administration in the 1990s.

Dedicated teams of non-surgeons were selected to gather operative morbidity and mortality statistics. After implementation of the program, morbidity (complications) and mortality (deaths) were decreased 45% and 27% respectively in the VA system.

It has now been widely adopted in non-governmental hospitals to effect better outcomes and to evaluate both individual surgical programs and hospitals as a whole. It allows objective comparisons between hospitals.

One drawback of NSQIP is that it measures outcomes only after patients have undergone surgery and does not capture outcomes data for patients who may be admitted to a surgical service but who do not undergo surgery (e.g., trauma patients.)

Selenium Deficiency

November 12th, 2009

Selenium deficiency, while not common, does occur in surgical patients, particularly those patients on TPN (total parenteral nutrition.)

Selenium is essential for most tissues in the body and acts as a cofactor in peroxidase enzyme reactions.

Signs and symptoms of selenium deficiency include cardiomyopathy (can be fatal), discoloration of the nails, hyperpigmentation of the skin, vision changes, and loss of neurological function.

Women Cancer Patients at Higher Risk of Divorce

November 10th, 2009

A new study just published has shown that 21% of women who receive who are diagnosed with life-threatening cancer go on to get divorced, as opposed to 3% of men who receive a similar diagnosis. The study was conducted by Dr. Marc Chamberlain of the neuro-oncology division at the Seattle Cancer Care Alliance (SCCA).

Respiratory Quotient (RQ)

November 10th, 2009

Respiratory quotient is the ratio of carbon dioxide (CO2) produced to oxygen consumed (O2). The normal value is .8

For patients where CO2 retention is a concern such as intubated  and ventilated patients (i.e., patients on the breathing machine), decreasing calorie intake from carbohydrates and increasing calorie intake from fats will decrease CO2 production and decrease the RQ

Odontoid (C2) Fracture – Type 2

November 8th, 2009

Type 2 odontoid fracture (i.e., fracture of the C2 vertebrae) is a fracture through the base of the dens. It is the most common type of fracture of the odontoid.

odontoid2

Odontoid (C2) fracture – type 1
Odontoid (C2) fracture – type 3

Odontoid (C2) Fracture – Type 1

November 7th, 2009

Odontoid fracture type 1 is a fracture of the tip of the dens where the alar ligament inserts.

It is considered mechanically stable but is associated with dislocation of the atlanto-occipital joint, which is life-threatening.

odontoid1

Odontoid (C2) fracture – type 3

Meckel’s Diverticulum Diagnostic Imaging

November 6th, 2009

The most accurate test to diagnose the presence of Meckel’s diverticulum in a young child, particularly one who presents with painless bleeding from the rectum, is a “Meckel’s scan.”

This test uses 99mTC – pertechnate scintigraphy which is taken up by gastric mucosa – both in the stomach and in ectopic (i.e., abnormally located) mucosa found in the diverticulum.