RESUMO
BACKGROUND: Strategies for the management of patients with necrotizing pancreatitis remain controversial. While consensus opinion supports operative necrosectomy for the treatment of infected pancreatic necrosis, the timing for surgical intervention is not completely resolved. Further, the indication for the surgical management of sterile pancreatic necrosis is also subject to debate. METHODS: The objective of this study was to evaluate outcome measures for the surgical management of necrotizing pancreatitis, independent of documented infection. A retrospective review was undertaken between 1994 and 2002 at a single county hospital. RESULTS: Twenty-one patients with CT-documented necrotizing pancreatitis underwent operative pancreatic necrosectomy with laparostomy within 21 days of initial diagnosis and had an average of three reoperations. Average length of stay (LOS) in the ICU was 36 days and in the hospital 67 days. Ten patients had documented infected necrosis based on initial intra-operative cultures, while I I had sterile necrosis. Overall, 95% (20/21) of the patients had a complication, with an average of three complications per patient. Common complications included ARDS (71%), sepsis (33%), renal failure (24%), and pneumonia (24%). The overall mortality rate was 14% (3/21), with a mean follow-up of 469 days. DISCUSSION: The surgical management of acute necrotizing pancreatitis, independent of documented infection, can be undertaken within 3 weeks of diagnosis with an acceptable morbidity and a low mortality rate. Creation of a laparostomy to enable ready, atraumatic debridement of the retroperitoneum is a safe alternative to standard repeat laparotomies and thus represents a useful adjunct to the surgical management of necrotizing pancreatitis.
Assuntos
Síndrome da Imunodeficiência Adquirida , Infecções por HIV , HIV-1 , Síndrome da Imunodeficiência Adquirida/epidemiologia , Síndrome da Imunodeficiência Adquirida/fisiopatologia , Ciclo Celular , Infecções por HIV/epidemiologia , Infecções por HIV/fisiopatologia , Herpesvirus Humano 4 , Herpesvirus Humano 8 , Humanos , Masculino , Neoplasias/virologia , Papillomaviridae , Pneumonia por Pneumocystis/epidemiologia , Sarcoma de Kaposi/epidemiologia , Sarcoma de Kaposi/virologiaRESUMO
CASE REPORT: A patient with extensive burns was intubated with an 8.0 mm internal diameter endotracheal tube (ETT) equipped with a subglottic suction port (Mallinckrodt HiLo Evac). The ETT was secured to a left upper molar with wire sutures throughout the hospitalization course to ensure airway stability. On the 40th day of intubation, the patient exsanguinated and died from a tracheo-innominate artery fistula. Postmortem examination revealed a 1 cm lesion of the left anterior tracheal wall at the position of the ETT tip. The prolonged stationary position of the ETT was considered the primary factor responsible for the fistula. Yet tracheo-innominate artery fistula normally is associated with high cuff pressures rather than with the tube tip. The special ETT construction required for the subglottic suction feature was suspected to have increased tube rigidity and may have played a contributory role. METHODS: The rigidity of the Mallinckrodt HiLo Evac was measured with a mechanical model and compared to 5 other commercially-available ETTs. Rigidity was expressed as the force generated by the ETT tip when the tube curvature was altered by 5 cm and 10 cm of flexion from its resting position. RESULTS: The mean force exerted by the Mallinckrodt HiLo Evac was 10.1 +/- 2.8 g at 5 cm of flexion and 17.7 +/- 5.1 g at 10 cm of flexion. This was significantly greater than all other ETT brands tested (by one-way analysis of variance and Student-Newman-Kuels test, p < 0.05). CONCLUSION: This case of fatal tracheo-innominate artery fistula formation associated with an ETT tip was unusual because of the extended duration of endotracheal intubation and the complexity of the patient's airway management problems. Our data suggest that the higher rigidity of the HiLo Evac ETT may have contributed to fistula development at the tube tip. However, we do not believe that the higher rigidity of the HiLo Evac ETT necessarily poses any greater risk than other ETTs under normal circumstances, in which the tube tip is not fixed in a stationary position for an extended period.
Assuntos
Tronco Braquiocefálico/lesões , Fístula/etiologia , Intubação Intratraqueal/efeitos adversos , Traqueia/lesões , Adulto , Queimaduras/terapia , Evolução Fatal , Humanos , MasculinoRESUMO
HYPOTHESIS: Cinematic technetium Tc 99m red blood cell ((99m)Tc-RBC) scans, in which real-time scanning is performed and analyzed, can accurately localize gastrointestinal bleeding and thus direct selective surgical intervention. DESIGN: Retrospective medical record review with historical controls. SETTING: Large, university-affiliated public hospital in urban setting. PATIENTS: Twenty-six patients presenting with upper and lower gastrointestinal hemorrhage who underwent cinematic (99m)Tc-RBC scan examinations between 1990 and 1997 and required surgical intervention to control the bleeding. INTERVENTIONS: All patients with gastrointestinal bleeding underwent open surgical procedures to provide cessation of bleeding and resection of appropriate abnormalities. MAIN OUTCOME MEASURES: Patient outcome was based on correlation between preoperative RBC scans and intraoperative findings, surgical pathology, and postoperative clinical course. RESULTS: Twenty-five (96%) of 26 scans were interpreted as positive for gastrointestinal bleeding. In 22 of these 25 scans, the site of bleeding was correctly identified for a sensitivity of 88%. One or more additional diagnostic tests were performed on 19 (73%) of 26 patients, and included angiography and flexible endoscopy. The most common operation performed to control bleeding was a hemicolectomy (14/26). Diverticulosis was the most prevalent diagnosis (46%). Two patients (8%) experienced rebleeding after operation. The overall mortality rate was 19% (5/26). CONCLUSIONS: Cinematic (99m)Tc-RBC scintigraphy is a sensitive, noninvasive alternative to mesenteric angiography for accurately localizing the site of gastrointestinal hemorrhages. As such, this technique can be reliably used to direct selective surgical intervention.
Assuntos
Hemorragia Gastrointestinal/diagnóstico por imagem , Hemorragia Gastrointestinal/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Divertículo do Colo/complicações , Feminino , Hemorragia Gastrointestinal/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Cintilografia , Estudos Retrospectivos , Sensibilidade e Especificidade , Compostos de TecnécioRESUMO
HYPOTHESIS: That the clinical presentations, biochemical profiles, and surgical outcomes of patients treated with laparoscopic vs open adrenalectomy for primary hyperaldosteronism are different. DESIGN, SETTINGS, PATIENTS, AND INTERVENTIONS: The medical records of 80 patients with primary hyperaldosteronism who underwent open adrenalectomy between 1975 and 1986 or laparoscopic adrenalectomy between 1993 and 1998 at the University of California-San Francisco were reviewed by a single unblinded researcher (W.T.S.). MAIN OUTCOME MEASURES: Severity of hypertension and hypokalemia at diagnosis, their improvement after adrenalectomy, and operative complications. RESULTS: Thirty-eight patients underwent open adrenalectomy and 42 patients underwent laparoscopic adrenalectomy. The patients who underwent open adrenalectomy had documented hypertension for a median of 5 years before surgery; all had diastolic blood pressures greater than 100 mm Hg. Laparoscopically treated patients had documented hypertension for a median of 2.5 years preoperatively, and 20 (48%) had diastolic blood pressures greater than 100 mm Hg. The median preoperative serum potassium levels for the open and laparoscopic groups were 2.6 mmol/L and 3.3 mmol/L, respectively; the mean serum aldosterone levels were 1.47 nmol/L and 1.30 nmol/L. Thirty-two (84%) of the 38 patients who underwent open surgery and 41 (98%) of the 42 patients treated laparoscopically had adrenal adenomas. The sensitivity of preoperative computed tomographic scanning for adenomas was 83% for the patients treated with open adrenalectomy and 93% for those treated laparoscopically. There were 4 postoperative complications in the open surgery group and none in the laparoscopic group. Postoperatively, 30(81%) of 37 patients (excluding 1 patient who died of adrenocortical carcinoma) in the open surgery group and 37 (88%) of 42 patients treated laparoscopically were normotensive. Post-operative values were 3.6 to 5.0 of serum potassium per liter and 3.5 to 4.9 of serum potassium per liter in the open and laparoscopic groups, respectively. CONCLUSIONS: Patients who are treated with laparoscopic adrenalectomy for primary hyperaldosteronism are being referred with less severe hypertension and hypokalemia than patients formerly treated with open adrenalectomy. Patients treated laparoscopically had fewer postoperative complications and were equally likely to improve in blood pressure and hypokalemia. Laparoscopic adrenalectomy has become the treatment of choice for patients with primary hyperaldosteronism because of lower morbidity.
Assuntos
Adrenalectomia/métodos , Hiperaldosteronismo/cirurgia , Laparoscopia , Adulto , Feminino , Humanos , Masculino , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: The detection of isolated intestinal injuries after blunt trauma can be difficult because of subtle signs and symptoms, often leading to delayed diagnosis. We hypothesized that specific clinical indicators could be identified to assist in the diagnosis of these injuries. METHODS: Medical records of all patients with such injuries from 1988 to 1996 were reviewed. The patients were stratified into those operated on within 6 hours of presentation (apparent injury) and those operated on after 6 hours (occult injury), and the data were compared. RESULTS: Forty-six patients with isolated intestinal injuries were identified. There were no differences in the rate of peritonitis or free fluid on abdominal computed tomography, blood loss, intraoperative findings, or morbidity and mortality between groups. Leukocytosis (sensitivity, 84.8%; specificity, 55.2%; p = 0.01) and free fluid on computed tomography were frequently present, however, and their significance was underappreciated in the occult injury group. CONCLUSION: After blunt abdominal trauma in patients without obvious indications for invasive evaluation of the abdomen (e.g., peritoneal lavage, laparoscopy, laparotomy), leukocytosis can indicate an intestinal injury. Additionally, unexplained free fluid on abdominal computed tomography must be aggressively evaluated.
Assuntos
Líquidos Corporais , Intestinos/lesões , Leucocitose/etiologia , Tomografia Computadorizada por Raios X , Ferimentos não Penetrantes/diagnóstico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Pressão Sanguínea , Criança , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Fatores de Tempo , Ferimentos não Penetrantes/classificação , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/cirurgiaRESUMO
OBJECTIVE: To assess factors that might predict serious necrotizing soft tissue infections following illicit drug injection. DESIGN: A retrospective review of a consecutive case series. SETTING: An urban municipal hospital. PATIENTS: Thirty patients presenting with cutaneous abscesses resulting from illicit drug injections during a 5-year period. All cases presented clinically with fluctuance, erythema, or induration but required extensive debridement at the time of incision and drainage. INTERVENTIONS: Operative treatment employed wide incision, routine subfascial examination, and aggressive debridement. Clinical management included broad-spectrum antibiotics, critical care support, and reconstructive procedures. MAIN OUTCOME MEASURES: Mortality, extent of debridement, preoperative vital signs and laboratory values, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, bacteriologic and pathologic test results. RESULTS: Postoperatively, all patients were housed in the intensive care unit for 8.4 +/- 14.5 days. Six patients died (20%). On arrival at the intensive care unit, systolic blood pressure was 80 mm Hg or less in 2 patients, 1 of whom died. White blood cell count on hospital admission was elevated in 27 of 30 patients (mean, 27.2 +/- 15.3 x 10(9)/L) and 2 patients were identified as having human immunodeficiency virus infection. All patients underwent initial surgery less than 24 hours after admission; following debridement, the average wound size was 276 +/- 238 cm2 (range, 15-783 cm2). Five patients required extremity amputation, and all other survivors underwent reconstruction with skin grafts and/or myocutaneous flaps. All but 1 patient were reexamined in the operating room within 12 hours and underwent an average of 3.1 +/- 1.6 operative procedures. Of those wound cultures obtained in the operating room, there was no pattern to the bacteriologic isolates. Seventeen patients had mixed isolates and 11 had single organisms. Pathologic findings in 20 patients included panniculitis (3 patients), necrotizing fasciitis (11 patients), myositis (6 patients), and osteomyelitis (1 patient). We failed to identify any clinical factor, including temperature, heart rate, systolic blood pressure, white blood cell count, base deficit, albumin level, PO2, or APACHE II score that could predict mortality or the requirement for extensive debridement. CONCLUSIONS: Parenteral injections of illicit drugs can produce infections that present with signs of simple cutaneous abscess and yet unpredictably become extensive necrotizing soft tissue infections. Treatment requires a high index of suspicion along with an inquisitive operative approach to avoid missing these potentially serious infections.
Assuntos
Infecções dos Tecidos Moles/diagnóstico , Infecções dos Tecidos Moles/etiologia , Transtornos Relacionados ao Uso de Substâncias/complicações , Abscesso/diagnóstico , Adulto , Idoso , Amputação Cirúrgica , Desbridamento , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Necrose , Estudos Retrospectivos , Fatores de Risco , Dermatopatias Infecciosas/diagnóstico , Infecções dos Tecidos Moles/microbiologia , Infecções dos Tecidos Moles/mortalidade , Infecções dos Tecidos Moles/fisiopatologia , Infecções dos Tecidos Moles/cirurgiaRESUMO
BACKGROUND: Recurrent pyogenic cholangitis is a complex biliary tract disease characterized by intrahepatic pigment stones, endemic to Southeast Asia and seen with increasing frequency in the United States. The purpose of this study was to review the management of this disorder in a county hospital. METHODS: A retrospective review of 45 patients with recurrent pyogenic cholangitis evaluated between 1984 and 1995. The clinical and surgical management of patients with localized versus bilateral hepatolithiasis were compared. RESULTS: The prevalence of recurrent pyogenic cholangitis at our hospital has more than doubled since 1983. Fourteen of 45 patients (31%) had bilateral disease and required more abdominal computed tomography scans (P < 0.01), percutaneous cholangiograms (P < 0.05), endoscopies (P < 0.01), clinic visits (P < 0.05), and hospital admissions (P < 0.02) as compared with patients with localized disease. CONCLUSIONS: The effective treatment of recurrent pyogenic cholangitis requires definition of the patients' intrahepatic distribution of disease, prior to surgical intervention, and the coordinated efforts of gastroenterologists, radiologists, and surgeons.
Assuntos
Colangite , Adulto , Idoso , Idoso de 80 Anos ou mais , Colangiopancreatografia Retrógrada Endoscópica , Colangite/diagnóstico , Colangite/epidemiologia , Colangite/cirurgia , Colecistectomia , Coledocostomia , Ducto Colédoco/cirurgia , Diagnóstico Diferencial , Feminino , Seguimentos , Cálculos Biliares/diagnóstico , Hepatectomia , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Recidiva , Estudos Retrospectivos , Supuração , Taxa de Sobrevida , Tomografia Computadorizada por Raios X , Estados Unidos/epidemiologiaRESUMO
A meta-analysis of the literature demonstrates high operation complication rates in HIV-positive patients. Own experience connected with a general hospital in San Francisco, University of California, indicates that such an analysis provides the surgeon with the possibility of optimizing the treatment of HIV-positive patients in the perioperative phase.
Assuntos
Infecções por HIV/terapia , Assistência Perioperatória , Infecções Oportunistas Relacionadas com a AIDS/mortalidade , Infecções Oportunistas Relacionadas com a AIDS/terapia , Infecções por HIV/mortalidade , Humanos , Equipe de Assistência ao Paciente , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapiaRESUMO
Determining the perioperative risks associated with surgical procedures performed in patients with HIV disease is a difficult and complex task. Because HIV is a contagious, blood-borne pathogen, it threatens the health and well-being of both patient and health care provider. Despite poor early results, there is now convincing evidence that HIV infection is not a significant, independent risk factor for major surgical procedures. In practice, the authors evaluate the risk of surgery in patients with HIV infection using the same basic tools and guidelines applied to the uninfected, with the best predictors of surgical morbidity and mortality stemming from a careful and accurate assessment of the patient's cardiopulmonary, renal, endocrine, and nutritional reserve. Although HIV disease provides a unique constellation of diagnoses and challenges to the health care provider, the risk of major surgery in this population is not unlike that for other immunocompromised or malnourished patients. The authors believe that members of the surgical team have a professional, moral, and ethical responsibility to provide the highest possible quality of care for their patients, regardless of their HIV status. If after weighing the risks and benefits to the patient the surgeon believes the procedure will have a positive effect on the patient's life, the surgeon must offer surgical treatment. To do less does a disservice to the patient, the provider, and the profession as a whole.
Assuntos
Infecções por HIV , Medição de Risco , Procedimentos Cirúrgicos Operatórios , Humanos , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controleRESUMO
OBJECTIVE: To compare the lateral transabdominal and posterior retroperitoneal laparoscopic methods for performing adrenalectomy. DESIGN: Nonrandomized. SETTING: Hospitals affiliated with the University of California, San Francisco. PATIENTS: Thirty-six patients (15 men and 21 women), aged 5 to 78 years (mean age, 49 years), were treated for the following conditions: aldosteronoma, 18 patients; pheochromocytoma, 4 patients; Cushing syndrome, 6 patients; androgen-secreting tumor, 1 patient; nonfunctioning adenoma, 3 patients; adrenal hemorrhage, 1 patient; metastatic neoplasm, 2 patients; and myelolipoma, 1 patient. INTERVENTIONS: Twenty-three lateral and 14 posterior laparoscopic adrenalectomies. MAIN OUTCOME MEASURES: Success rate, operating time, complications, and length of hospital stay. RESULTS: The tumors, which ranged in size from 1 to 13 cm (mean, 4.2 cm; median, 2.5 cm), were all successfully resected laparoscopically. All 8 tumors larger than 6 cm were resected by the lateral approach. One critically ill patient died. No patient required blood transfusions or conversion to laparotomy. Mean operating time was 3.8 hours vs 3.4 hours (median, 3.5 hours vs 3 hours) and mean hospital stay was 2.2 days vs 1.5 days (median, 2 days vs 1 day) for the lateral and posterior approaches, respectively. All patients without concomitant procedures were ready to be discharged within 48 hours. CONCLUSIONS: Both approaches were effective and safe. We prefer the lateral approach for tumors larger than 6 cm and the posterior approach for bilateral tumors.
Assuntos
Doenças das Glândulas Suprarrenais/cirurgia , Adrenalectomia/métodos , Laparoscopia/métodos , Adolescente , Adrenalectomia/efeitos adversos , Adrenalectomia/normas , Adulto , Idoso , Criança , Feminino , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/normas , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Estudos Prospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
In concluding whether universal precautions are necessary, it certainly appears that we need something to reduce the significant problem of HIV transmission to health-care providers. As occupational risk goes, it exceeds the occupational risk of a number of other high-risk professions. Unfortunately, we do not know if universal precautions are effective. We also do not know the true compliance rate in use of universal precautions, nor whether they have an impact on transmission even if effectively used. What are the alternatives? They are not great, but some have not been adequately explored or implemented. Re-engineering around needle use in the hospital is clearly the most likely area to produce concrete results, because needlesticks are overwhelmingly the greatest source of infection, but this has not been encouraged to the degree it could be, even with systems already developed. Universal testing does not appear to be a viable alternative, for numerous reasons already discussed. Finally, are universal precautions more important for other pathogens than HIV? I would say yes. Hepatitis B, hepatitis C, and nosocomial infections are more important both as public health issues and as health-care provider prevention issues. If universal precautions are effective in reducing any of these, they are worthwhile.
Assuntos
Infecções por HIV/prevenção & controle , Salas Cirúrgicas , Precauções Universais , HIV-1 , Pessoal de Saúde , Humanos , Controle de Infecções , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controleRESUMO
Health care reform will affect the relationship of trauma centers to health maintenance organizations and other managed care plans. We studied Kaiser Permanente Medical Center (Kaiser) members admitted to the Trauma Center at San Francisco General Hospital (SFGH) to determine: (1) variables predicting transfer from SFGH to a Kaiser Hospital (repatriation), (2) the length of hospital stay (LOS), and (3) the cost of their care. The SFGH trauma registry provided data on 7,794 patients admitted before 1994. To investigate LOS, 89 Kaiser patients over 1 year were matched with non-Kaiser patients on age, maximum Abbreviated Injury Scale score (MAIS) by body region, Injury Severity Score (ISS), head injury severity, and blunt or penetrating injury and disposition. Kaiser patients were significantly younger, more likely to have blunt injury, and had a lower death rate. Significant predictors of repatriation were an MAIS score > or = 3, abdominal or extremity injury, and an ISS score of 26 to 40. The mean LOS for all Kaiser patients was 7.6 days, compared with 4.8 for controls (p = 0.20). However, mean LOS was significantly longer in repatriated Kaiser patients compared with controls (16 vs. 7.8 days, p < 0.0005). Kaiser reimbursement rates were comparable with commercial payors, but higher than others. A relatively small number of severely injured patients account for a large percentage of costly trauma care. Analyses of patient subsets are necessary for trauma centers to negotiate suitable relationships with managed care plans. A prospective study is needed to examine the cost efficiency of early transfer of managed care patients.
Assuntos
Custos de Cuidados de Saúde , Programas de Assistência Gerenciada/organização & administração , Centros de Traumatologia/organização & administração , Ferimentos e Lesões/mortalidade , Adulto , Feminino , Humanos , Escala de Gravidade do Ferimento , Reembolso de Seguro de Saúde , Tempo de Internação/estatística & dados numéricos , Masculino , Programas de Assistência Gerenciada/economia , Mortalidade , Transferência de Pacientes/economia , Sistema de Registros , São Francisco , Fatores Sexuais , Centros de Traumatologia/economia , Ferimentos e Lesões/economiaRESUMO
OBJECTIVE: To provide uncompensated elective low-risk outpatient surgery for uninsured patients through a coalition of volunteer physicians, nurses, and hospitals. DESIGN: Description of the process of establishing the Ambulatory Surgery Access Coalition (ASAC), the political and administrative obstacles encountered, and the clinical results of treatment of the first 25 patients in the pilot project. SETTING: The ASAC includes the Kaiser Foundation Hospital, San Francisco, Calif, the University of California, San Francisco, the San Francisco General Hospital (SFGH), the San Francisco Department of Public Health, the San Francisco Consortium of Community Clinics, the Northern California Chapter of the American College of Surgeons, and the San Francisco Medical Society. A pilot program of uncompensated outpatient surgery was performed at the Kaiser Foundation Hospital. PATIENTS: Twenty-nine patients were referred to the ASAC between January 1 and November 1, 1994. Twenty-six patients were judged to be candidates for surgery, and 25 patients met the criteria for the ASAC program. One patient was referred to SFGH for treatment because of a perceived increased risk for hospitalization after surgery. RESULTS: Twenty-one patients underwent herniorrhaphy; three, excision of large inclusion cysts; and one, anal fistulotomy. Seventeen procedures were done under local anesthesia, seven under general anesthesia, and one under spinal anesthesia. None of the patients required hospital admission. No wound infections occurred. CONCLUSION: The ASAC successfully provided uncompensated low-risk outpatient surgery to 25 low-income uninsured patients in San Francisco. The coalition hopes, first, to include other San Francisco hospitals and surgical specialties, and second, to serve as a model for other communities throughout the country.
Assuntos
Procedimentos Cirúrgicos Ambulatórios , Trabalhadores Voluntários de Hospital/organização & administração , Pessoas sem Cobertura de Seguro de Saúde , Humanos , Fatores de Risco , São FranciscoRESUMO
Several recent reviews have suggested that aggressive surgical intervention can reduce morbidity and mortality associated with intra-abdominal crises in AIDS patients. We reviewed our experience with 57 AIDS patients with 63 emergent laparotomies performed at 4 hospitals affiliated with the University of California in San Francisco. Fifty-five patients (96%) were homosexual men. Thirty-nine (68%) had been treated for an opportunistic infection. Indications for exploration included right lower quadrant pain consistent with appendicitis in 24 patients (38%), visceral perforation or obstruction in 11 (17%), right upper quadrant pain in 9 (14%), diffuse peritonitis in 8 (13%), and uncontrollable hemorrhage in 8 (13%). Perioperative mortality was 12% (7/57). Fifteen patients (26%) suffered major complications including pneumonia, sepsis, multi-organ failure, and intra-abdominal abscess. Forty-five of 50 survivors (90%) were receiving some type of chronic antimicrobial or antineoplastic chemotherapy, compared to only 2 of the 7 patients who died (28.6%) (P < 0.001). Lack of ongoing prophylactic treatment for AIDS-related disease, active opportunistic infections, Walter Reed VI classification, and ongoing sepsis at the time of exploration were noted to be associated with increased morbidity and mortality.
Assuntos
Abdome Agudo/cirurgia , Síndrome da Imunodeficiência Adquirida/complicações , Laparotomia/efeitos adversos , Abdome Agudo/complicações , Abdome Agudo/mortalidade , Emergências , Humanos , Laparotomia/mortalidade , Masculino , Estudos RetrospectivosRESUMO
BACKGROUND: We studied differences in the incidence of appendiceal perforation in patients with acute appendicitis according to their insurance coverage. METHODS: In a retrospective analysis of hospital-discharge data, we examined the likelihood of ruptured appendix among adults 18 to 64 years old who were hospitalized for acute appendicitis in California from 1984 to 1989. RESULTS: After controlling for age, sex, psychiatric diagnoses, substance abuse, diabetes, poverty, race or ethnic group, and hospital characteristics, we found that ruptured appendix was more likely among both Medicaid-covered and uninsured patients with appendicitis than among patients with private capitated coverage (odds ratios, 1.49 [95 percent confidence interval, 1.41 to 1.59] and 1.46 [95 percent confidence interval, 1.39 to 1.54], respectively). After adjustment for the above factors, the risk of appendiceal rupture associated with a lack of private insurance was elevated at both county and other hospitals, but admission to a county hospital was an independent risk factor. In all income groups, appendiceal rupture was more likely with fee-for-service than capitated private coverage (overall odds ratio, 1.20 [95 percent confidence interval, 1.15 to 1.25]). CONCLUSIONS: Among patients with appendicitis an increased risk of ruptured appendix may be due to insurance-related delays in obtaining medical care. Both organizational and financial features of Medicaid and various types or levels of private third-party coverage may be involved. The significant association between ruptured appendix and insurance coverage after adjustment for socio-economic differences suggests barriers to receiving medically necessary acute care that should be considered in current deliberations on health policy.
Assuntos
Apendicite/economia , Apendicite/etiologia , Acessibilidade aos Serviços de Saúde/economia , Seguro de Hospitalização/estatística & dados numéricos , Perfuração Intestinal/etiologia , Adolescente , Adulto , California/epidemiologia , Intervalos de Confiança , Feminino , Humanos , Perfuração Intestinal/economia , Perfuração Intestinal/epidemiologia , Masculino , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Estudos Retrospectivos , Fatores de Risco , Ruptura Espontânea/epidemiologia , Fatores Socioeconômicos , Estados UnidosRESUMO
Geriatric patients often require prolonged postoperative intensive care after complex surgery. These patients frequently are intubated, sedated or confused, and unable to participate in therapeutic decisions. There is much controversy surrounding the use of critical care in the elderly as well as prognostic uncertainty. This article reviews the medical, ethical, and legal issues that define the clinical principles involved in the decision to limit life support in geriatric patients.