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General surgical procedures encompass a multitude of surgical types. For the purposes of this chapter, the focus will be on anesthetic considerations for different types of esophageal, abdominal, intestinal, and peritoneal surgery, as well as colorectal surgery. In addition, common surgical techniques used for general surgical procedures to include in open, endoscopic, laparoscopic, and robotic surgery will be discussed.
To determine the 180-day cumulative incidence of culture-confirmed Staphylococcus aureus infections after elective pediatric surgeries.
Retrospective cohort study utilizing the Premier Healthcare database (PHD).
Inpatient and hospital-based outpatient elective surgical discharges.
Pediatric patients <18 years who underwent surgery during elective admissions between July 1, 2010, and June 30, 2015, at any of 181 PHD hospitals reporting microbiology results.
In total, 74 surgical categories were defined using ICD-9-CM and CPT procedure codes. Microbiology results and ICD-9-CM diagnosis codes defined S. aureus infection types: bloodstream infection (BSI), surgical site infection (SSI), and other types (urinary tract, respiratory, and all other). Cumulative postsurgical infection incidence was calculated as the number of infections divided by the number of discharges with qualifying elective surgeries.
Among 11,874 inpatient surgical discharges, 180-day S. aureus infection incidence was 1.79% overall (1.00% SSI, 0.35% BSI, 0.45% other). Incidence was highest among children <2 years of age (2.76%) and lowest for those 10–17 years (1.49%). Among 50,698 outpatient surgical discharges, incidence was 0.36% overall (0.23% SSI, 0.05% BSI, 0.08% others); it was highest among children <2 years of age (0.57%) and lowest for those aged 10–17 years (0.30%). MRSA incidence was significantly higher after inpatient surgeries (0.68%) than after outpatient surgeries (0.14%; P < .0001). Overall, the median days to S. aureus infection was longer after outpatient surgery than after inpatient surgery (39 vs. 31 days; P = .0116).
These findings illustrate the burden of postoperative S. aureus infections in the pediatric population, particularly among young children. These results underscore the need for continued infection prevention efforts and longer-term surveillance after surgery.
To assess the 180-day incidence of Staphylococcus aureus infections following orthopedic surgeries using microbiology cultures.
Retrospective observational epidemiology study.
National administrative hospital database.
Adult patients with an elective admission undergoing orthopedic surgeries in the inpatient and hospital-based outpatient settings discharged between July 1, 2010, and June 30, 2015.
Patients were identified from 181 hospitals reporting microbiology results to the Premier Healthcare Database. Orthopedic surgeries were defined using International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) procedure and current procedural terminology (CPT) codes. Microbiology cultures and ICD-9/10 diagnosis codes identified surgical site infections (SSIs), bloodstream infections (BSIs), and other infections associated postoperatively (eg, respiratory and urinary tract infections).
Among 359,268 inpatient orthopedic surgical encounters, the S. aureus infection incidence was 1.13%: SSI, 0.68%; BSI, 0.28%; and other types, 0.17%. Among 292,011 outpatient encounters, the S. aureus incidence was 0.78%: SSI, 0.55%; BSI, 0.12%; and other types, 0.11%. Methicillin-resistant S. aureus (MRSA) infections accounted for 46% and 44% in the respective settings. Plastic/hand-limb reattachment and amputation had the highest overall S. aureus incidence in both settings. S. aureus was the most commonly isolated microorganism among culture-confirmed SSIs (48.0%) and BSIs (35.0%), followed by other Enterobacteriaceae (14.0%) for SSIs and Escherichia spp (12.5%) for BSIs.
These findings suggest that S. aureus infections continue to be an important contributor to the burden of postoperative infections after inpatient and outpatient orthopedic procedures.
Good education requires student experiences that deliver lessons about practice as well as theory and that encourage students to work for the public good—especially in the operation of democratic institutions (Dewey 1923; Dewy 1938). We report on an evaluation of the pedagogical value of a research project involving 23 colleges and universities across the country. Faculty trained and supervised students who observed polling places in the 2016 General Election. Our findings indicate that this was a valuable learning experience in both the short and long terms. Students found their experiences to be valuable and reported learning generally and specifically related to course material. Postelection, they also felt more knowledgeable about election science topics, voting behavior, and research methods. Students reported interest in participating in similar research in the future, would recommend other students to do so, and expressed interest in more learning and research about the topics central to their experience. Our results suggest that participants appreciated the importance of elections and their study. Collectively, the participating students are engaged and efficacious—essential qualities of citizens in a democracy.
This chapter focuses on the pharmacology of the drugs commonly used to provide moderate and deep sedation and their available reversal agents. Intravenous sedative and analgesic drugs should be given in small, incremental doses titrated to desired end points of sedation and analgesia, with adequate time allowed between doses to achieve those effects. Preemptive analgesia is a treatment that is initiated before surgical procedure to reduce sensitization of pain pathways. Potential drug interactions require the clinician providing sedation to be cognizant of potential drug-drug effects, which can lead to morbidity and mortality. Opioids in combination with benzodiazepines provide adequate moderate and/or deep sedation and analgesia for many potentially painful procedures. Other drugs used for deep sedation include propofol, ketamine, dexmedetomidine, and etomidate. Local anesthetics (LA) have the potential to produce deleterious side effects. The choice of a local anesthetic and care in its use are the primary determinants of toxicity.
To determine the cost of management of occupational exposures to blood and body fluids.
A convenience sample of 4 healthcare facilities provided information on the cost of management of occupational exposures that varied in type, severity, and exposure source infection status. Detailed information was collected on time spent reporting, managing, and following up the exposures; salaries (including benefits) for representative staff who sustained and who managed exposures; and costs (not charges) for laboratory testing of exposure sources and exposed healthcare personnel, as well as any postexposure prophylaxis taken by the exposed personnel. Resources used were stratified by the phase of exposure management: exposure reporting, initial management, and follow-up. Data for 31 exposure scenarios were analyzed. Costs were given in 2003 US dollars.
The 4 facilities providing data were a 600-bed public hospital, a 244-bed Veterans Affairs medical center, a 437-bed rural tertiary care hospital, and a 3,500-bed healthcare system.
The overall range of costs to manage reported exposures was $71-$4,838. Mean total costs varied greatly by the infection status of the source patient. The overall mean cost for exposures to human immunodeficiency virus (HIV)-infected source patients (n = 19, including those coinfected with hepatitis B or C virus) was $2,456 (range, $907-$4,838), whereas the overall mean cost for exposures to source patients with unknown or negative infection status (n = 8) was $376 (range, $71-$860). Lastly, the overall mean cost of management of reported exposures for source patients infected with hepatitis C virus (n = 4) was $650 (range, $186-$856).
Management of occupational exposures to blood and body fluids is costly, the best way to avoid these costs is by prevention of exposures.
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