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Lawand J, Hantouly A, Bouri F, Muneer M, Farooq A, Hagert E. Complications and side effects of Wide-Awake Local Anaesthesia No Tourniquet (WALANT) in upper limb surgery: a systematic review and meta-analysis. INTERNATIONAL ORTHOPAEDICS 2024; 48:1257-1269. [PMID: 38367058 PMCID: PMC11001684 DOI: 10.1007/s00264-024-06104-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/21/2024] [Indexed: 02/19/2024]
Abstract
PURPOSE Wide-Awake Local Anaesthesia No Tourniquet (WALANT), a groundbreaking anaesthetic technique resurging in practice, warrants a comprehensive safety analysis for informed adoption. Our study aimed to identify complications/side effects of WALANT upper limb procedures through a systematic review and meta-analysis. METHODS This PROSPERO-registered study was performed with strict adherence to PRISMA guidelines. Embase, OVIDMedline, Cochrane, Web of Science, and Scopus databases were searched until February 2023. Inclusion criteria involved English articles, reporting complications/side effects in primary WALANT upper limb surgeries. Outcomes included all complications and side effects, data on the anaesthetic mixture, publication year/location, study type, and procedures performed. The meta-analysis employed the Freeman-Tukey Double Arcsine Transformation, computed I2 statistics, and utilized common or random effects models for pooled analysis. RESULTS 2002 studies were identified; 79 studies met the inclusion criteria representing 15,595 WALANT patients. A total of 301 patients had complications, and the meta-analysis using a random effects model provided a complication rate of 1.7% (95% CI: 0.93-2.7%). The most reported complications were superficial infection (41%, n = 123/300), other/specified (12%, n = 37/300), and recurrent disease (6.7%, n = 20/300). A decade-by-decade analysis revealed no statistically significant difference in complication rates spanning the last three decades (p = 0.42). Adding sodium bicarbonate to the anaesthetic solution significantly reduced postoperative complications (p = 0.025). CONCLUSION WALANT has a low overall complication rate of 1.7%, with no significant temporal variation and a significant reduction in complications when sodium bicarbonate is added to the anaesthetic solution. Our findings support the safety of WALANT in upper limb procedures. REGISTRATION PROSPERO: CRD42023404018.
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Affiliation(s)
- Jad Lawand
- Medical Branch, University of Texas, 301 University Blvd, Galveston, TX, 77555, USA
| | - Ashraf Hantouly
- Department of Orthopedic Surgery, Hamad Medical Cooperation, Doha, Qatar
| | - Fadi Bouri
- Department of Orthopedic Surgery, Hamad Medical Cooperation, Doha, Qatar
| | - Mohammad Muneer
- Department of Plastic Surgery, Hamad Medical Corporation, Doha, Qatar
| | | | - Elisabet Hagert
- Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar.
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden.
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Ash A, Brune M, Willson TD, Colbert SH, Klifto KM. Tumescent technique for split-thickness skin graft donor sites: A systematic review of randomized controlled trials. J Plast Reconstr Aesthet Surg 2024; 90:292-304. [PMID: 38394837 DOI: 10.1016/j.bjps.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 12/06/2023] [Accepted: 01/29/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Split-thickness skin grafting (STSG) is widely used for reconstructive wound management. This review aimed to use level I evidence to determine if tumescent techniques were safe and effective compared to other interventions for STSG donor sites. It was hypothesized that tumescent techniques were safe and effective for STSG donor sites. METHODS Five databases (MEDLINE via PubMed, Embase, Cochrane Library, Web of Science, and Scopus) were searched to identify studies concerning the use of tumescent solutions for STSG. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) and Cochrane's guidelines were strictly followed. RESULTS Nine randomized controlled trials met the criteria. Included studies were published from 2001 to 2021, with results from 40 of 121 possible queried outcomes and complications. Outcomes included patient demographics, formulations of tumescent solutions, tumescent technique, hemodynamics, pain, perfusion, graft take, healing time, and postoperative complications. The tumescent technique reduced estimated blood loss (standard mean differences [SMD]: -2.68, 95%CI: -3.41 to -1.94; participants = 72; studies = 2; I2 = 96%; p < 0.001), and postoperative analgesic use within 24 hours (SMD: -1.75, 95%CI: -2.09 to -1.41; participants = 202; studies = 2; I2 = 96%; p < 0.001), without increasing graft loss/take (SMD: 0.29, 95%CI: -0.02 to 0.61; participants = 158; studies = 3; I2 = 41%; p = 0.07) and infection (risk ratios [RR]: 0.52, 95%CI: 0.08 to 3.54; participants = 87; studies = 3; I2 = 0%; p = 0.58) complications compared to other interventions. CONCLUSIONS Level I evidence demonstrated tumescent techniques were safe and effective for STSG donor sites. Tumescent techniques reduced blood loss and postoperative analgesic use within 24 hours without increasing graft loss/take and infection complications compared to other interventions. Inconsistencies between studies limit conclusions and emphasize the need for standardized protocols regarding tumescent solution formulations, techniques, and reported outcomes.
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Affiliation(s)
- Angela Ash
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Madison Brune
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Thomas D Willson
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Stephen H Colbert
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Kevin M Klifto
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA.
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Bajwa MS, Bashir MM, Bajwa MH, Iqbal Z, Salahuddin MA, Hussain A, Shahzad F. How long to wait after local infiltration anaesthesia: systematic review. BJS Open 2023; 7:zrad089. [PMID: 37768699 PMCID: PMC10538258 DOI: 10.1093/bjsopen/zrad089] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/27/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Conflicting evidence exists regarding the optimal waiting time for stable analgesic and vasoconstrictive effects after local infiltration of lidocaine with epinephrine. An objective review is needed to dispel surgical dogma. METHODS This systematic review (PROSPERO ID: CRD42022362414) included RCTs and prospective cohort studies. Primary outcomes were (1) onset of analgesia and (2) onset of stable hypoperfusion, assessed directly, or measured indirectly using perfusion imaging. Other data extracted include waiting strategies, means of outcome assessment, anaesthetic concentrations, volume/endpoint of infiltration, and injection sites. Methodological quality was evaluated using the Cochrane risk-of-bias tool for randomized trials. Articles describing waiting strategies were critically appraised by the Joanna Briggs Institute tools. RESULTS Twenty-four articles were analysed, comprising 1013 participants. Ten investigated analgesia onset. Their pooled mean was 2.1 min (range 0.4-9.0 min). This varied with anatomic site and targeted nerve diameter. Fourteen articles investigated onset of stable hypoperfusion. Four observed bleeding intraoperatively, finding the minimum time to hypoperfusion at 7.0 min in the eyelid skin and 25.0 min in the upper limb. The ten remaining studies used perfusion imaging, reporting a wide range of results (0.0-30.0 min) due to differences in anatomic sites and depth, resolution and artefacts. Studies using near-infrared reflectance spectroscopy and hyperspectral imaging correlated with clinical observations. Thirteen articles discussed waiting strategies, seven relating to large-volume tumescent local infiltration anaesthesia. Different waiting strategies exist for emergency, arthroscopic and cosmetic surgeries, according to the degree of hypoperfusion required. In tumescent liposuction, waiting 10.0-60.0 min is the norm. CONCLUSION Current literature suggests that around 2 min are required for most patients to achieve complete analgesia in all sites and with all anaesthesia concentrations. Waiting around 7 min in eyelids and at least 25 min in other regions results in optimal hypoperfusion. The strategies discussed inform decisions of when and how long to wait.
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Affiliation(s)
- Mohammad Suleman Bajwa
- Department of Plastic & Reconstructive Surgery/Mayo Burn Centre, Mayo Hospital, King Edward Medical University, Lahore, Pakistan
- Department of Surgery, Montefiore Medical Center, New York, USA
| | - Muhammad Mustehsan Bashir
- Department of Plastic & Reconstructive Surgery/Mayo Burn Centre, Mayo Hospital, King Edward Medical University, Lahore, Pakistan
| | | | - Zafar Iqbal
- Department of Plastic & Reconstructive Surgery/Mayo Burn Centre, Mayo Hospital, King Edward Medical University, Lahore, Pakistan
| | - Muhammad Aizaz Salahuddin
- Department of Plastic & Reconstructive Surgery/Mayo Burn Centre, Mayo Hospital, King Edward Medical University, Lahore, Pakistan
| | - Ahmad Hussain
- Department of Plastic & Reconstructive Surgery/Mayo Burn Centre, Mayo Hospital, King Edward Medical University, Lahore, Pakistan
| | - Farooq Shahzad
- Plastic & Reconstructive Surgery Service, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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In search of the optimal pain management strategy for children undergoing cleft lip and palate repair: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2022; 75:4221-4232. [DOI: 10.1016/j.bjps.2022.06.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 05/11/2022] [Accepted: 06/05/2022] [Indexed: 11/24/2022]
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Wieschollek S, Forster S, Megerle K. [WALANT - Wide Awake Local Anaesthesia No Tourniquet: Complications in elective and acute traumatological Hand Surgery Procedures]. HANDCHIR MIKROCHIR P 2022; 54:44-50. [PMID: 35168268 DOI: 10.1055/a-1552-3567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The WALANT (Wide Awake Local Anaesthesia No Tourniquet) technique has rapidly gained popularity. The advantages are often described, whereas information about complications is rare. Therefore, we followed up on our own patients regarding complications.Patients and Method Between January 2013 und June 2017, the complications experienced by one single surgeon were evaluated. The study included all elective (n = 195) and acute (n = 90) surgical procedures performed in WALANT. Minimum age of the patients was 18 years. All patients received Articaine 1 % and Suprarenine (1:200.000). Different volumes were injected with a minimum delay to surgery of 30 minutes. Complications were identified retrospectively by evaluation of patient files and a survey via telephone using a standardised questionnaire. Mean follow-up was 73 weeks. RESULTS In 285 patients, there were 13 (4.6 %) complications. After injection of 16 ml of Articaine/Suprarenine, one patient had coronary symptoms, which ceased when two puffs of nitroglycerin spray were given. In one patient with a neurovascular injury in the palm, a bloodless field could not be obtained. A short tourniquet time was necessary for exploration. In one patient undergoing flexor tendon tenolysis, there was a need to convert to general anaesthesia with tourniquet because there was insufficient vasoconstriction due to marked scar tissue. One patient had an erythema around the injection site for a prolonged time, two had extensive erythema on the dorsum of the hand and seven patients reported swelling of the hand that lasted more than one week. SUMMARY The WALANT method is safe. Perioperative complications are rare. Nevertheless, there are some disadvantages that should be considered.Vascular injuries, especially in fingers, are to be monitored closely regarding perfusion, and the off-label use should be remembered. Also, caution should be exercised in patients with cardiac disease. Larger injuries may need a short tourniquet time. Tissue that was operated on before does not always seem to be suitable for the technique as diffusion may be compromised. In rare cases, patients may suffer from prolonged erythema or swelling. Generally, patients should be evaluated for suitability to an operation in local anaesthesia.
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Affiliation(s)
- Stefanie Wieschollek
- Schön Klinik München Harlaching; Zentrum für Handund Ellenbogenchirurgie, Mikrochirurgie und Plastische Chirurgie
| | - Selma Forster
- Klinikum rechts der Isar der Technischen Universität München, Sektion für Handchirurgie
| | - Kai Megerle
- Schön Klinik München Harlaching; Zentrum für Handund Ellenbogenchirurgie, Mikrochirurgie und Plastische Chirurgie
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Dargan D, Kazzazi D, Limnatitou D, Cochrane E, Stubbington Y, Shokrollahi K, Ralston D. Acute Management of Thermal Hand Burns in Adults: A 10-Year Review of the Literature. Ann Plast Surg 2021; 86:517-531. [PMID: 33675628 DOI: 10.1097/sap.0000000000002755] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Advances in the evidence base of acute thermal hand burns help to guide the management of these common injuries. The aim of this literature review was to evaluate recent evidence in the field over 10 years. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols methodology was used as a guide for this literature review. PubMed, MEDLINE, EMBASE, CINAHL, and Google Scholar were searched for English language articles related to hand burns published between 2009 and 2018 inclusive, and the Cochrane Library was reviewed. Exclusion criteria were as follows: participants younger than 18 years, scar or contracture management, rehabilitation, outcomes assessment, late reconstruction, and electrical or chemical burns. RESULTS An initial search retrieved 6493 articles, which was narrowed to 403 full-text articles that were reviewed independently by 3 of the authors and categorized. Of 202 included articles, there were 8 randomized controlled trials and 2 systematic reviews. Six evidence-based guidelines were reviewed. Referral of hand burns to specialist centers, use of telemedicine, early excision and grafting, and immediate static splintage have been recommended. Enzymatic debridement results in earlier intervention, more accurate burn assessment, preservation of vital tissue, and fewer skin grafts, and ideally requires regional anesthesia. Guidance on escharotomy emphasizes indication, technique and adequate intervention, and potential for enzymatic debridement. Inclusion of topical negative pressure, dermal regenerative templates, acellular dermal matrices, and noncellular skin substitutes in management has helped improve scar and functional outcomes. DISCUSSION The results of this literature review demonstrate that multiple national and international societies have published burns guidelines during the decade studied, with aspects directly relevant to hand burns, including the International Society for Burn Injuries guidelines. There are opportunities for evidence-based quality improvement across the field of hand burns in many centers. CONCLUSIONS More than 200 articles globally in 10 years outline advances in the understanding of acute management of thermal hand burns. Incorporating the evidence base into practice may facilitate optimization of triage referral pathways and acute management for hand burns.
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Affiliation(s)
| | - Diana Kazzazi
- From the Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital
| | | | - Elliott Cochrane
- From the Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital
| | | | - Kayvan Shokrollahi
- Mersey Regional Burns Centre, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Merseyside, Prescot, United Kingdom
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Liu H, Liu Z, Zhang Q, Guo W. Utilization of epinephrine-soaked gauzes to address bleeding from osteotomy sites in non-tourniquet total knee arthroplasty: a retrospective cohort study. BMC Musculoskelet Disord 2020; 21:578. [PMID: 32843003 PMCID: PMC7448967 DOI: 10.1186/s12891-020-03595-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/17/2020] [Indexed: 02/03/2023] Open
Abstract
Background Reducing tourniquet inflation time is important because of the complications of tourniquet extensively used for the control of hemorrhage in total knee arthroplasty (TKA). Bleeding management is critical to acquire a relative bloodless arthrotomy interface for maximize cement fixation in non-tourniquet TKA. The purpose of this study was to investigate hemostatic and hemodynamic effects of epinephrine-soaked gauzes in cemented TKAs. Methods A retrospective cohort study of 101 patients in two groups was performed. The first group (n = 51) underwent unilateral TKA with our procedures of epinephrine use, the second group (n = 50) had the same protocol with tourniquet and no epinephrine utilization. Surgical field visualization was assessed by grading scale for difficulty of intraoperative visualization due to blood and number of surgical field clearances. Perioperative blood loss was recorded. Hemodynamic parameters were observed in the epinephrine group. Results There was statistically significant difference (p < 0.01) on surgeon-rated difficulty in visualization in the epinephrine group between before and after use of epinephrine, and no statistically significant difference (p = 0.96) between two groups before cementing. No statistically significant result on numbers of surgical field clearances between two groups (p = 0.25) was found. Epinephrine group showed significant difference in hidden blood loss compared with no epinephrine group (576.6 ± 229.3 vs 693.2 ± 302.9, respectively, p = 0.04). The hemodynamic effects of epinephrine may be under control. Conclusion The procedure of epinephrine soaked gauzes, as a prudent adjunct, may be effective to reduce blood loss and obtain bloodless bone sections in non-tourniquet TKAs, regardless of hemodynamics.
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Affiliation(s)
- Hongzhi Liu
- Beijing University of Chinese Medicine, 11 N 3rd Ring Rd E, Chaoyang District, Beijing, China
| | - Zhaohui Liu
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, No. 2, Yinghuadong Road, Chaoyang District, Beijing, 100029, China
| | - Qidong Zhang
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, No. 2, Yinghuadong Road, Chaoyang District, Beijing, 100029, China.,Beijing Key Lab Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, No. 2, Yinghuadong Road, Chaoyang District, Beijing, 100029, China
| | - Wanshou Guo
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, No. 2, Yinghuadong Road, Chaoyang District, Beijing, 100029, China. .,Beijing Key Lab Immune-Mediated Inflammatory Diseases, China-Japan Friendship Hospital, No. 2, Yinghuadong Road, Chaoyang District, Beijing, 100029, China.
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Xing SG, Mao T. Temporary tourniquet use after epinephrine injection to expedite wide awake emergency hand surgeries. J Hand Surg Eur Vol 2018; 43:888-889. [PMID: 30071788 DOI: 10.1177/1753193418790499] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Shu Guo Xing
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Jiangsu, China
| | - Tian Mao
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Jiangsu, China
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Bashir MM, Sohail M, Wahab A, Iqbal U, Qayyum R, Jan SN. Outcomes of post burn flexion contracture release under tourniquet versus tumescent technique in children. Burns 2018; 44:678-682. [DOI: 10.1016/j.burns.2017.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 07/25/2017] [Accepted: 10/14/2017] [Indexed: 11/17/2022]
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Abstract
WALANT (wide-awake local anesthesia no tourniquet) appears to be a safe and effective anesthesia technique for many hand and wrist surgeries. Patient satisfaction is high because of the avoidance of preoperative testing and hospital admission. Postoperative recovery is rapid, and procedures can be done in outpatient settings, resulting in substantial savings in time and money.
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Abstract
Background: “Wide awake hand surgery”, where surgery is performed in local anaesthesia with adrenaline, without sedation or a tourniquet, has become widespread in some countries. It has a number of potential advantages and we wished to evaluate it among our patients. Methods: All 122 patients treated by this method during one year were evaluated by the surgeons and the patients on a numerical scale from 0 (best/least) to 10 (worst/most). Theatre time was compared to that recorded for a year when regional or general anaesthesia had been used. Results: The patients’ mean score for the general care they had received was 0.1 (SD 0.6), for pain during lidocaine injection 2.4 (SD 2.2), for pain during surgery 0.9 (SD 1.5), and for other discomfort during surgery 0.5 (SD 1.4). Eight reported that they would want general anaesthesia if they were to be operated again. The surgeons’ mean evaluation of bleeding during surgery was 1.6 (SD 1.8), oedema during surgery 0.4 (SD 1.1), general disadvantages with the method 1.0 (SD 1.6) and general advantages 6.5 (SD 4.3). The estimation of advantages was 9.9 (DS 0.5) for tendon suture. 28 patients needed intra-operative additional anaesthesia. The proportion was lower among trained hand surgeons and fell significantly during the study period. Non-surgical theatre time was 46 (SD 15) minutes during the study period and 55 (SD 22) minutes during the regional/general period (p < 0.001). This gain was cancelled out by a longer surgery time during the wide awake period. Conclusions: Wide awake surgery is fully acceptable to most patients. It has a number of advantages over general or regional anaesthesia, but we feel it is unlikely to improve the efficiency of the operating theatre.
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Affiliation(s)
- Line Lied
- Department of Orthopedic Surgery, St.Olav’s University Hospital, Trondheim, Norway
| | | | - Vilhjalmur Finsen
- Department of Orthopedic Surgery, St.Olav’s University Hospital, Trondheim, Norway
- Faculty of Medicine, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
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Prevention of Surgical Site Infections and Biofilms: Pharmacokinetics of Subcutaneous Cefazolin and Metronidazole in a Tumescent Lidocaine Solution. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1351. [PMID: 28607871 PMCID: PMC5459654 DOI: 10.1097/gox.0000000000001351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 04/07/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Tumescent anesthesia antibiotic delivery (TAAD) consists of subcutaneous infiltration of antibiotic(s) dissolved tumescent lidocaine anesthesia. Tumescent lidocaine anesthesia contains lidocaine (≤ 1 g/L), epinephrine (≤ 1 mg/L), sodium bicarbonate (10 mEq/L) in 0.9% saline. Our aim was to measure cefazolin and metronidazole concentrations over time in subcutaneous tumescent interstitial fluid (TISF) after TAAD, in serum after TAAD and after intravenous antibiotic delivery (IVAD). We hypothesize that the pharmacokinetic/pharmacodynamic profiles of TAAD + IVAD are superior to IVAD alone for the prevention of surgical site infections and biofilms. METHODS Concentrations of cefazolin and metronidazole in TISF and serum following TAAD and in serum following IVAD were compared in 5 female volunteers. Subjects received cefazolin or cefazolin plus metronidazole by IVAD alone and by TAAD alone. One subject also received concomitant IVAD and TAAD of these 2 antibiotics. Sequential samples of serum or subcutaneous TISF were assayed for antibiotic concentration. RESULTS Cefazolin (1 g) by TAAD resulted in an area under the curve of the concentration-time profile and a maximum concentration (Cmax) in subcutaneous tissue that were 16.5 and 5.6 times greater than in serum following 1 g by IVAD. Metronidazole (500 mg) by TAAD resulted in an area under the curve and Cmax that were 8.1 and 24.7 times greater in TISF, than in serum after 500 mg by intravenous delivery. IVAD + TAAD resulted in superior antibiotic concentrations to IVAD alone. CONCLUSIONS TAAD + IVAD produced superior antibiotic bioavailability in both subcutaneous interstitial fluid and serum compared with IVAD alone. There was no evidence that TAAD of cefazolin and metronidazole poses a significant risk of harm to patients.
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Evidence-Based Medicine: Options for Dupuytren's Contracture: Incise, Excise, and Dissolve. Plast Reconstr Surg 2017; 139:240e-255e. [PMID: 28027258 DOI: 10.1097/prs.0000000000002857] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Understand updates in the basic science, epidemiology, and treatment of Dupuytren's disease. 2. Understand treatment with needle aponeurotomy, collagenase, and fasciectomy. 3. Understand advanced needle techniques for Dupuytren's contracture. 4. Understand the safety and effectiveness of a new treatment, collagenase. SUMMARY The literature on Dupuytren's disease encompasses many specialties. Its treatment is generally by perforating, excising, or dissolving the affected tissues. This article reviews the changing understanding of this disease and treatment options.
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Sumathy S, Mangalakanthi J, Purushothaman K, Sharma D, Remadevi C, Sreedhar S. Symptomatology and Surgical Perspective of Scar Endometriosis: A Case Series of 16 Women. J Obstet Gynaecol India 2016; 67:218-223. [PMID: 28546671 DOI: 10.1007/s13224-016-0945-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 11/10/2016] [Indexed: 11/27/2022] Open
Abstract
AIM The prevalence of scar endometriosis is increasing with the increasing caesarean deliveries and laparoscopic procedures done for pelvic endometriosis. To analyse the symptomatology and surgical perspective of scar endometriosis. MATERIALS AND METHODS Retrospective review of 16 women who underwent surgery for scar endometriosis in the period of 4 years in Amrita institute of medical sciences. RESULTS Mean age of the patients is 35.19 years. Mean interval from the index surgery to the presentation is 4.56 years. Mean size of the swelling is 2.84 cm. In 68.8% of the patients, caesarean section was the inciting surgery. 18.7% had port site endometriosis. Cyclical pain and swelling at the scar site was present in 93.8% of the women. 18.9% had concurrent pelvic endometriosis. All women had involvement of the subcutaneous tissue followed by 11 women with the involvement of rectus sheath. There was no recurrence of the lesion in the operated patients in the mean follow-up period of 11.91 months. CONCLUSION In all women presenting with cyclical scar site pain and swelling, scar endometriosis should be considered. It commonly follows caesarean section and laparoscopic surgeries done for endometriosis. Wide local excision with or without reconstruction is the method of choice for this condition. Role of tumescent solution during surgery and postoperative medical management to reduce recurrence needs further prospective studies.
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Affiliation(s)
- Sudha Sumathy
- Department of Obstetrics and Gynaecology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala India
| | - Janu Mangalakanthi
- Department of Obstetrics and Gynaecology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala India
| | - Kishore Purushothaman
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala India
| | - Deepti Sharma
- Department of Obstetrics and Gynaecology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala India
| | - Chithra Remadevi
- Department of Obstetrics and Gynaecology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala India
| | - Sarala Sreedhar
- Department of Obstetrics and Gynaecology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala India
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