Intensive care medicine in Mongolia's 3 largest cities: outlining the needs

PURPOSE: To evaluate intensive care resources, support, and personnel available in Mongolia's 3 largest cities. MATERIALS AND METHODS: This prospective study was performed as a questionnaire-based survey evaluating intensive care units (ICUs) in Mongolia's 3 main cities. RESULTS: Twenty-one of 31 ICUs participated in the survey. The median number of beds per ICU was 7 (interquartile ranges, 6-10) with 0.7 (0.6-0.9) physicians and 1.5 (0.6-1.8) nurses per bed. A 24-hour physician service was available in 61.9% of the participating ICUs. A median number of 359 patients (250-500) with an average age of 39 (30-49) years were treated annually. Oxygen was available in all ICUs, but only for 60% (17-75) of beds. Pressurized air was available in 33% of the ICUs for 24% (0-15) of beds. Of the ICUs, 52.4% had a lung ventilator serving 20% (0-23) of beds. The most common admission diagnoses were sepsis, stroke, cardiac disease, postoperative or postpartum hemorrhage, and intoxication. Availability of medical equipment, disposables, and drugs was inadequate in all ICUs. CONCLUSIONS: Intensive care medicine in Mongolia's 3 largest cities is an under-resourced and underdeveloped medical specialty. The main problems encountered are insufficient training of staff as well as lack of medical equipment, disposables, and drugs.

Effects of adjunct electroacupuncture on severity of postoperative pain in dogs undergoing hemilaminectomy because of acute thoracolumbar intervertebral disk disease

OBJECTIVE: To compare severity of postoperative pain in dogs undergoing hemilaminectomy because of acute thoracolumbar intervertebral disk disease treated with a combination of conventional analgesics and electroacupuncture (EAP) or with conventional analgesics alone. DESIGN: Controlled clinical trial. ANIMALS: 15 dogs undergoing surgery because of acute thoracolumbar disk disease. PROCEDURES: Dogs were alternately assigned to treatment (conventional analgesics and adjunct EAP) and control (conventional analgesics alone) groups. Analgesic treatment was adjusted as necessary by the attending clinician, who was not aware of group assignment. Pain scores were assigned 1, 3, and 12 hours after surgery and every 12 hours thereafter for 72 hours by the same individual who performed acupuncture treatments. RESULTS: Total dose of fentanyl administered during the first 12 hours after surgery was significantly lower in the treatment group than in the control group, but dosages of analgesics administered from 12 through 72 hours after surgery did not differ between groups. Pain score was significantly lower in the treatment group than in the control group 36 hours after surgery, but did not differ significantly between groups at any other time. CONCLUSIONS AND CLINICAL RELEVANCE: Results provided equivocal evidence that adjunct EAP might provide some mild benefit in regard to severity of postoperative pain in dogs undergoing hemilaminectomy because of acute thoracolumbar intervertebral disk disease.

The role of postoperative prophylactic antibiotics in the treatment of facial fractures: a randomized, double-blind, placebo-controlled pilot clinical study. Part 2: mandibular fractures in 59 patients

The aim of this study was to evaluate the difference between a 5-day and a 1-day postoperative course of antibiotic on the incidence of infection after mandibular fractures involving the alveolus. Sixty-two patients with fractures of the mandible involving the dentoalveolar region were randomly assigned to 2 groups, both of which were given amoxicillin/clavulanic acid 1.2 g intravenously every 8 h from admission until 24 h postoperatively. The 5-day group were then given amoxicillin/clavulanic acid 625 mg orally every 8 h for another 4 days. The 1-day group was given an oral placebo at the same intervals. Follow-up appointments were 1, 2, 4, 6, 12 weeks and 6 months postoperatively. Development of an infection was the primary end point. Fifty-nine of the 62 patients completed this study. Six of the 30 patients in the 5-day group (20%) and 6 out of the 29 in the 1-day group (21%) developed local wound infections. Three of the 6 in the 1-day group developed purulent discharge and swelling. One patient in the 5-day group developed a rash on the trunk. There were no significant differences in the incidence of infection or side effects between the groups. In fractures of the mandible involving the alveolus, a 1-day postoperative course of antibiotic is as effective in preventing infective complications as a 5-day regimen.

The role of postoperative antibiotics in facial fractures: Comparing the efficacy of a 1-day versus a prolonged regimen

BACKGROUND The goal of this study was to evaluate the influence of the duration of postoperative antibiotics (1 day vs. ≥ 5 days) on wound infections following surgical treatment of facial fractures. METHODS Three hundred thirty-nine patient case histories with a total of 498 fractures were reviewed retrospectively with regard to infections occurring within a 6-month period following surgical management. Patients were divided into two groups based on the duration of postoperative antibiotics administered. Group A consisted of 125 patients who had 1 day of postoperative antibiotics, whereas Group B consisted of 214 patients who had five or more days of postoperative antibiotics. Statistical analysis was conducted to assess for possible differences in the rate of postoperative infections. RESULTS Five patients in Group A (4%) and seven patients in Group B (3.27%) developed infections within the follow-up period. Of these 12 patients, seven had sustained multiple facial bone fractures. Eleven infections occurred in patients with mandibular fractures and one in a midfacial fracture. Statistical analysis using Fisher's exact test showed no significant difference (p = 0.77) in the incidence of infection between Groups A and B. CONCLUSION In this retrospective study, the use of prolonged postoperative antibiotics in uncomplicated mandibular and midfacial fractures had no significant benefit in reducing the incidence of infections. LEVEL OF EVIDENCE Therapeutic study, level IV.

Effect of phrenic nerve palsy on early postoperative lung function after pneumonectomy: a prospective study

BACKGROUND The issue of phrenic nerve preservation during pneumonectomy is still an unanswered question. So far, its direct effect on immediate postoperative pulmonary lung function has never been evaluated in a prospective trial. METHODS We conducted a prospective crossover study including 10 patients undergoing pneumonectomy for lung cancer between July 2011 and July 2012. After written informed consent, all consecutive patients who agreed to take part in the study and in whom preservation of the phrenic nerve during operation was possible, were included in the study. Upon completion of lung resection, a catheter was placed in the proximal paraphrenic tissue on the pericardial surface. After an initial phase of recovery of 5 days all patients underwent ultrasonographic assessment of diaphragmatic motion followed by lung function testing with and without induced phrenic nerve palsy. The controlled, temporary paralysis of the ipsilateral hemidiaphragm was achieved by local administration of lidocaine 1% at a rate of 3 mL/h (30 mg/h) via the above-mentioned catheter. RESULTS Temporary phrenic nerve palsy was accomplished in all but 1 patient with suspected catheter dislocation. Spirometry showed a significant decrease in dynamic lung volumes (forced expiratory volume in 1 second and forced vital capacity; p < 0.05) with the paralyzed hemidiaphragm. Blood oxygen saturation levels did not change significantly. CONCLUSIONS Our results show that phrenic nerve palsy causes a significant impairment of dynamic lung volumes during the early postoperative period after pneumonectomy. Therefore, in these already compromised patients, intraoperative phrenic nerve injury should be avoided whenever possible.

Restrictive deferred hydration combined with preemptive norepinephrine infusion during radical cystectomy reduces postoperative complications and hospitalization time: a randomized clinical trial.

BACKGROUND Anesthetics and neuraxial anesthesia commonly result in vasodilation/hypotension. Norepinephrine counteracts this effect and thus allows for decreased intraoperative hydration. The authors investigated whether this approach could result in reduced postoperative complication rate. METHODS In this single-center, double-blind, randomized, superiority trial, 166 patients undergoing radical cystectomy and urinary diversion were equally allocated to receive 1 ml·kg·h of balanced Ringer's solution until the end of cystectomy and then 3 ml·kg·h until the end of surgery combined with preemptive norepinephrine infusion at an initial rate of 2 µg·kg·h (low-volume group; n = 83) or 6 ml·kg·h of balanced Ringer's solution throughout surgery (control group; n = 83). Primary outcome was the in-hospital complication rate. Secondary outcomes were hospitalization time, and 90-day mortality. RESULTS In-hospital complications occurred in 43 of 83 patients (52%) in the low-volume group and in 61 of 83 (73%) in the control group (relative risk, 0.70; 95% CI, 0.55-0.88; P = 0.006). The rates of gastrointestinal and cardiac complications were lower in the low-volume group than in the control group (5 [6%] vs. 31 [37%]; relative risk, 0.16; 95% CI, 0.07-0.39; P < 0.0001 and 17 [20%] vs. 39 [48%], relative risk, 0.43; 95% CI, 0.26-0.60; P = 0.0003, respectively). The median hospitalization time was 15 days [range, 11, 27d] in the low-volume group and 17 days [11, 95d] in the control group (P = 0.02). The 90-day mortality was 0% in the low-volume group and 4.8% in the control group (P = 0.12). CONCLUSION A restrictive-deferred hydration combined with preemptive norepinephrine infusion during radical cystectomy and urinary diversion significantly reduced the postoperative complication rate and hospitalization time.

Randomised trial of clazosentan, an endothelin receptor antagonist, in patients with aneurysmal subarachnoid hemorrhage undergoing surgical clipping (CONSCIOUS-2)

We report here results of a randomized, double-blind, placebo-controlled study ( http://www.ClinicalTrials.gov , NCT00558311) that investigated the effect of clazosentan (5 mg/h, n = 768) or placebo (n = 389) administered for up to 14 days in patients with aneurysmal subarachnoid hemorrhage (SAH) repaired by surgical clipping. The primary endpoint was a composite of all-cause mortality, new cerebral infarction or delayed ischemic neurological deficit due to vasospasm, and rescue therapy for vasospasm. The main secondary endpoint was the Glasgow Outcome Scale Extended (GOSE), which was dichotomized. Twenty-one percent of clazosentan- compared to 25% of placebo-treated patients met the primary endpoint (relative risk reduction [RRR] [95% CI]: 17% [-4% to 33%]; p = 0.10). Poor outcome (GOSE score ≤ 4) occurred in 29% of clazosentan- and 25% of placebo-treated patients (RRR: -18% [-45% to 4%]; p = 0.10). In prespecified subgroups, mortality/vasospasm-related morbidity was reduced in clazosentan-treated patients by 33% (8-51%) in poor WFNS (World Federation of Neurological Surgeons) grade (≥III) and 25% (5-41%) in patients with diffuse, thick SAH. Lung complications, anemia and hypotension occurred more frequently with clazosentan. Mortality (week 12) was 6% in both groups. The results showed that clazosentan nonsignificantly decreased mortality/vasospasm-related morbidity and nonsignificantly increased poor functional outcome in patients with aneurysmal SAH undergoing surgical clipping.

Introduction of a New Policy of no Nighttime Appendectomies: Impact on Appendiceal Perforation Rates and Postoperative Morbidity

Background Working hour limitations and tight health care budgets have posed significant challenges to emergency surgical services. Since 1 January 2010, surgical interventions at Berne University Hospital between 23:00 and 08:00 h have been restricted to patients with an expected serious adverse outcome if not operated on within 6 h. This study was designed to assess the safety of this new policy that restricts nighttime appendectomies (AEs). Methods The patients that underwent AE from 1 January 2010 to 31 December 2011 (“2010-2011 group”) were compared retrospectively with patients that underwent AE before introduction of the new policy (1 January 2006–31 December 2009; “2006-2009 group”). Results Overall, 390 patients were analyzed. There were 255 patients in the 2006–2009 group and 135 patients in the 2010–2011 group. Patients’ demographics did not differ statistically between the two study groups; however, 45.9 % of the 2006–2009 group and 18.5 % of the 2010–2011 group were operated between 23:00 and 08:00 h (p < 0.001). The rates of appendiceal perforations and surgical site infections did not differ statistically between the 2006–2009 group and the 2010–2011 group (20 vs. 18.5 %, p = 0.725 and 2 vs. 0 %, p = 0.102). Additionally, no difference was found for the hospital length of stay (3.9 ± 7.4 vs. 3.4 ± 6.0 days, p = 0.586). However, the proportion of patients with an in-hospital delay of >12 h was significantly greater in the 2010–2011 group than in the 2006–2009 group [55.6 vs. 43.5 %, p = 0.024, odds ratio (95 % confidence interval 1.62 (1.1–2.47)]. Conclusions Restricting AEs from 23:00 to 08:00 h does not increase the perforation rates and occurrence of clinical outcomes. Therefore, these results suggest that appendicitis may be managed safely in a semielective manner.

Intra- and postoperative complications of navigated and conventional techniques in percutaneous iliosacral screw fixation after pelvic fractures: Results from the German Pelvic Trauma Registry

Background: Percutaneous iliosacral screw placement following pelvic trauma is a very demanding technique involving a high rate of screw malpositions possibly associated with the risk of neurological damage or inadequate stability. In the conventional technique, the screw’s correct entry point and the small target corridor for the iliosacral screw may be difficult to visualise using an image intensifier. 2D and 3D navigation techniques may therefore be helpful tools. The aim of this multicentre study was to evaluate the intra- and postoperative complications after percutaneous screw implantation by classifying the fractures using data from a prospective pelvic trauma registry. The a priori hypothesis was that the navigation techniques have lower rates of intraoperative and postoperative complications. Methods: This study is based on data from the prospective pelvic trauma registry introduced by the German Society of Traumatology and the German Section of the AO/ASIF International in 1991. The registry provides data on all patients with pelvic fractures treated between July 2008 and June 2011 at any one of the 23 Level I trauma centres contributing to the registry. Results: A total of 2615 patients were identified. Out of these a further analysis was performed in 597 patients suffering injuries of the SI joint (187 � with surgical interventions) and 597 patients with sacral fractures (334 � with surgical interventions). The rate of intraoperative complications was not significantly different, with 10/114 patients undergoing navigated techniques (8.8%) and 14/239 patients in the conventional group (5.9%) for percutaneous screw implantation (p = 0.4242). Postoperative complications were analysed in 30/114 patients in the navigated group (26.3%) and in 70/239 patients (29.3%) in the conventional group (p = 0.6542). Patients who underwent no surgery had with 66/197 cases (33.5%) a relatively high rate of complications during their hospital stay. The rate of surgically-treated fractures was higher in the group with more unstable Type-C fractures, but the fracture classification had no significant influence on the rate of complications. Discussion: In this prospective multicentre study, the 2D/3D navigation techniques revealed similar results for the rate of intraoperative and postoperative complications compared to the conventional technique. The rate of neurological complications was significantly higher in the navigated group.

The role of postoperative prophylactic antibiotics in the treatment of facial fractures: a randomised, double-blind, placebo-controlled pilot clinical study. Part 3: Le Fort and zygomatic fractures in 94 patients

The aim of this study was to evaluate the difference between the effect of a 5-day and a 1-day postoperative course of antibiotics on the incidence of infection after midfacial fractures. A total of 98 patients with displaced Le Fort or zygomatic fractures that required operation were randomly assigned into 2 groups, both of which were given amoxicillin/clavulanic acid 1.2g intravenously every 8h from the time of admission until 24h postoperatively. The 5-day group was then given amoxicillin/clavulanic acid 625mg orally 8-hourly for another 4 days. The 1-day group was given placebo orally at the same time points. Patients were followed up 1, 2, 4, 6, and 12 weeks, and 6 months, postoperatively. The development of an infection of the wound was the primary end point. Ninety-four of the 98 patients completed the study. Two of the 45 patients in the 5-day group (4%) and 2/49 in the 1-day group (4%) developed postoperative wound infections. One in each group had a purulent infection, while the others had only wound breakdown. Two patients of the 5-day group and one in the 1-day group developed rashes on the trunk. There were no significant differences in the incidence of infection or side effects between the groups. In midfacial fractures a 1-day course of antibiotics postoperatively is as effective in preventing infective complications as a 5-day regimen.