ABSTRACT
INTRODUCTION: Immediate implant-based breast reconstruction (IBR) rates have increased considerably with the advent of acellular dermal matrices. Implant loss is a significant complication and is costly to patients and the NHS. National Mastectomy and Breast Reconstruction Audit and Implant-Based Breast Reconstruction Audit data have demonstrated national implant loss rate of 9% at 3 months. National Oncoplastic Guidelines for Best Practice cite a < 5% target. We aimed to reduce implant loss by introducing a protocol with pre-, intra- and post-operative interventions. METHODS: Audit of IBR at a single oncoplastic breast unit was commenced and implant loss at 3 months was recorded (May 2012-July 2014). Patients were identified from a prospectively maintained database, and case notes were examined by identifying factors associated with implant loss. A team involving microbiology, theatre staff, infection control and surgeons was established. A novel, evidence-based intervention bundle, including more than 25 protocol changes, was introduced. Prospective re-audit of IBR (April 2015-December 2017) was completed following introduction of the new protocol and implant loss was recorded at 3 months. RESULTS: The first retrospective audit of 77 reconstructions (54 patients) demonstrated 11 implant losses at 3 months (14%). Re-audit, post-intervention, comprised 129 reconstructions (106 patients) with no implant loss at 3 months. Fisher's exact analysis revealed statistically significant reduction in implant loss rate (P < 0.00001) following protocol introduction. CONCLUSIONS: Implant loss rate following IBR can be reduced to an exceptionally low level, well below national targets, by adhering to this evidence-based intervention bundle. Our protocol could improve outcomes nationally.
Subject(s)
Breast Implantation/methods , Clinical Protocols , Quality Assurance, Health Care/methods , Adult , Breast Implantation/adverse effects , Breast Implantation/standards , Breast Implants/adverse effects , Breast Neoplasms/surgery , Female , Humans , Medical Audit , Middle Aged , Prosthesis Failure , Quality Improvement , Retrospective Studies , Risk FactorsSubject(s)
Fentanyl/metabolism , Horses/metabolism , Animals , Biotransformation , Humans , Kinetics , MaleABSTRACT
Gas concentrations and ventilation levels have been measured within a conventional Magill circuit when conscious volunteers breathed a non-narcotic gas mixture at varying fresh gas flows. When evidence of rebreathing of alveolar gas was detected, the fresh gas flow was kept constant until a steady state developed. All subjects showed evidence of rebreathing when the fresh gas flow approached the predicted alveolar ventilation levels. A variety of subject-circuit interactions was seen and shown to be precipitated by naturally occurring breath-to-breath variations in ventilation. A single large breath could perturb the system. This could have a temporary effect, when the fresh gas flow was sufficient to wash the increased aliquot of expired carbon dioxide from the circuit. At other times a progressive response occurred as ventilatory stimulation as a result of the increased inspired carbon dioxide concentrations caused alveolar gas to reach the reservoir bag and converted the system behaviour from that of a simple added deadspace to that of a total mixing device. Whilst marked changes occurred commonly in both ventilation and inspired gas concentrations, only slight changes in end-tidal gas concentrations occurred.
Subject(s)
Anesthesia, Inhalation/instrumentation , Carbon Dioxide , Oxygen , Respiration , Humans , Nitrogen , Plethysmography, Impedance , Pulmonary Alveoli/physiology , Tidal VolumeABSTRACT
The anatomy of the inferior cervical ganglion is described. The theory of the effects of its infiltration in paralysis is briefly discussed. The technique of infiltration and a recommended course of treatment are described. Twelve case reports are presented (AU)