Experience of Immediate Ambulation and Early Discharge After Tumescent Anesthesia and Propofol Infusion in Cosmetic Breast Augmentation.

INTRODUCTION: Current cosmetic breast augmentation relies on general anesthesia that normally requires 40 min to total recovery. With experience, the surgical procedure can be completed expediently in 20 min under tumescent anesthesia and propofol full sedation to achieve immediate postoperative ambulation and home discharge readiness, and thus improve patient satisfaction and reduce cost. We retrospectively examined the outcomes of the protocol. MATERIALS AND METHODS: Per protocol, 1200 female patients underwent simple cosmetic breast augmentation accomplished with tumescent anesthesia, immediate mobilization, and early home discharge readiness after surgery. The following records were analyzed: vital sign stability during mobilization in the first 30 cases (primary goal), duration of surgery and anesthesia, frequency of intraoperative opioid use, frequency of ambulation needing assistance, Verbal Analog Scores and incidences of pain, orthostatic intolerance events, incidences of postoperative nausea and vomiting or anti-emetic use, and complications at follow-up visits (secondary goal). RESULTS: Hemodynamics during immediate postoperative mobilization demonstrated no statistically significant fluctuations and/or orthostatic intolerance requiring interventions. The mean duration of surgery was 20.4 ± 4.1 min. The mean duration of anesthesia was 25.2 ± 6.8 min. All patients tolerated immediate postoperative ambulation well. Adverse postoperative events were scarce. Only 9.1% reported postoperative pain, and 5.7% reported postoperative nausea and vomiting. One percent had transit post-ambulation dizziness needing supine positioning for less than 3 min. The average time to meet home-readiness criteria was 4.7 min, and there was no incidence of hematoma, infection, or complaints at follow-ups. CONCLUSIONS: For simple cosmetic breast augmentation, instead of general anesthesia and 40 min of recovery time, a tumescent anesthetic technique can be used for immediate postoperative ambulation and a 4.7-min home discharge readiness without a decrease in anesthesia quality and safety. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Ischaemia modified albumin cannot be used for rapid exclusion of acute coronary syndrome.

OBJECTIVE: To evaluate ischaemia modified albumin (IMA) as an early negative predictor of acute coronary syndrome (ACS) in different time to presentation groups and different cardiac risk groups. METHODS: A prospective observational study was performed in the emergency department at Royal Perth Hospital. Consecutive patients with symptoms suggestive of ACS needing delayed troponin measurements were recruited. All enrolled patients had both IMA and troponin measurements performed on their initial blood samples. The time of the initial blood tests and thrombolysis in myocardial ischaemia (TIMI) risk scores were recorded. Initial IMA results were compared with 12 h troponin levels and a discharge diagnosis of ACS. More detailed analyses were made according to different times to presentation (0-4 h, 5-12 h) and cardiac risk (TIMI score 0-1, 2-7). Sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratio were calculated. Receiver operating characteristic (ROC) curves were plotted to determine the best diagnostic cut-off for IMA. RESULTS: 248 patients were enrolled (151 (61%) men, mean age 65 years). All 248 patients had 'positive' IMA results using the 85 U/ml cut-off value recommended by the manufacturer. ROC curves failed to show improved cut-off points for diagnosing raised 12 h troponin levels or ACS; the area under the curve (AUC) was 0.52 and 0.53, respectively. ROC curves produced similar poor results in all subgroups. In the subgroup with time to presentation 0-4 h and TIMI score 0-1 for diagnosing ACS, the AUC was slightly better at 0.58. CONCLUSION: This study does not support the use of IMA as a negative predictor for ACS.

Preoperative tibiofemoral angle predicts survival of proximal tibia osteotomy.

A prospective group study was done to clarify whether perioperative variables such as preoperative and postoperative tibiofemoral angles influence the survivorship of proximal tibia osteotomy as measured by conversion to arthroplasty and patient dissatisfaction. The results of 93 proximal tibial osteotomies in 82 consecutive patients with medial compartment osteoarthrosis were followed up for a mean of 10.9 years. All data were analyzed by the Kaplan-Meier survivorship method and the multivariate Cox proportional hazards model. Only the preoperative tibiofemoral angle was a predictor of conversion to arthroplasty and patient dissatisfaction. The ideal prognostic cutoff angle was 9 degrees or less varus. Increasing the preoperative varus alignment 1 degrees would result in a 1.2 (95% confidence intervals, 1.02-1.50) times higher risk of conversion to a total knee arthroplasty and a 1.5 (95% confidence intervals, 1.27-1.76) times higher chance of patient dissatisfaction. Factors such as age, gender, body mass index, Ahlback's classification, and postoperative tibiofemoral angle were not significant. We think that proximal tibial osteotomy should be considered for patients with medial compartment osteoarthrosis and a preoperative varus alignment of 9 degrees or less, whereas arthroplasty is a more suitable alternative for patients with preoperative varus alignment greater than 9 degrees.