Upper limb phlegmasia cerulea dolens treated with single-session suction thrombectomy: a case report.

Phlegmasia cerulea dolens (PCD) of the lower limbs is a rare condition. PCD of the upper limbs is extremely uncommon, with only a select few cases documented in the literature. A complication of severe deep venous thrombosis, PCD, is characterized by the clinical triad of oedema, pain and limb cyanosis. Delays in treatment are associated with high rates of morbidity and mortality. We present a case of sudden-onset upper limb PCD in a 68-year-old man following haemodialysis through a long-term arteriovenous fistula. Prompt diagnosis and rapid initiation of intravenous anticoagulation followed by urgent single-session suction thrombectomy resulted in the successful restoration of vessel patency without any significant adverse sequelae on 3-month follow-up.

The Australian Trauma Registry.

INTRODUCTION: Injuries are a major cause of disability and lost productivity. The case for a national trauma registry has been recognized by the Australian Commission on Safety and Quality in Health Care and at a policy level. BACKGROUND: The need was flagged in 1993 by the Royal Australasian College of Surgeons and the Australasian Trauma Society. In 2003, the Centre of National Research and Disability funded the Australian and New Zealand National Trauma Registry Consortium, which produced three consecutive annual reports. The bi-national trauma minimum dataset was also developed during this time. Operations were suspended thereafter. METHOD: In response to sustained lobbying the Australian Trauma Quality Improvement Program including the Australian Trauma Registry (ATR) commenced in 2012, with data collection from 26 major trauma centres. An inaugural report was released in late 2014. RESULT: The Federal Government provided funding in December 2016 enabling the work of the ATR to continue. Data are currently being collected for cases that meet inclusion criteria with dates of injury in the 2017-2018 financial year. Since implementation, the number of submitted records has been increased from fewer than 7000 per year to over 8000 as completeness has improved. Four reports have been released and are available to stakeholders. CONCLUSION: The commitment shown by the College, other organizations and individuals to the vision of a national trauma registry has been consistent since 1993. The ATR is now well placed to improve the care of injured people.

The National Alcohol Strategy 2018-2026 has to become a set of commitments.

Alcohol consumption is behind only smoking and obesity among leading contributors to the burden of disease in Australia. For the first time in over a decade, Australian governments are developing a National Alcohol Strategy, and plan to finalise it in 2018. The draft contains evidence-based recommendations but lacks a framework for accountability, and the Commonwealth Minister of Health recently suggested that the alcohol industry help devise the final version. We recommend that the Government rely on advice from health experts for health policy, pre-specify outcome indicators, commit to modest activities initially, to develop momentum; and commission independent evaluation after 3 years.

Carotid endarterectomy: What difference does a clinical protocol make?

BACKGROUND: The initial eight hours after carotid endarterectomy (CEA) are crucial to patient outcome as many potential complications can occur during this period. Hypotension is one of the most common issues observed after patients have returned to the surgical ward. Postoperative management of patients undergoing CEA varies between facilities, with reported direct intensive care unit or surgical high dependence unit admission. Patients that underwent a CEA procedure at the study hospital were monitored in the Recovery Unit for a minimum of four hours before being transferred to the surgical ward. Episodes of hypotension, on return to the surgical ward, were one of the main issues identified. This observation resulted in revision of the CEA management policy with collaboration from all specialties involved in the care of patients undergoing a CEA. The aim of this study was to compare whether there was any difference in short-term clinical outcomes between preupdate and postupdate of the carotid management policy in a tertiary referral hospital in New South Wales. METHODOLOGY: Retrospective review of health care records was undertaken for the following two time intervals: prepolicy change from July 2008 to June 2009; postpolicy change from June 2011 to May 2012. Hypotension was defined as a systolic blood pressure less than 90 mm Hg. State SE 12.1 was used for data analysis. RESULTS: After assessing for potential confounding factors-such as postoperative heart rate, risk factors, gender, and age-patients from the postpolicy change group were less likely to receive vasoactive medications to manage blood pressure deviation (OR, 0.33; 95% CI, 0.12-0.91; P = 0.026), the odds of receiving vasoactive medications was 0.33 times lower than that of the pre-policy change group patients, and is 95% confident that the true association lies between 0.12 and 0.91 in the underlying population. Over 90% of intensive care unit admission was avoided in patients from the postpolicy change group with estimated cost saving of $807 Australian dollars per patient. CONCLUSIONS: The study hospital postoperative carotid surgery management policy has driven practice change with an extended Recovery Unit observation. This is a cost effective and safer management method. The Clinical Nurse Consultant was essential for clinical policy development, implementation, and evaluation.

Endovascular repair of thoracic aortic pathologies: postoperative nursing implications.

Endovascular stent grafting is increasingly used to manage descending thoracic aortic pathologies. The procedure was introduced at the study hospital in 2001. We sought to examine the short-term clinical outcomes of patients who underwent this endovascular stent grafting, with the aim of using the result as baseline for development of an in-center clinical management protocol. We undertook a single-center, retrospective review of health care records of patients managed with thoracic stent grafts from 2001 to 2009. Patient characteristics, in-hospital data, and procedural data were obtained. SPSS was used to analyze the data. A total of 30 patients were treated with thoracic stent; 23 were male, 7 were female, and the mean age was 55.0. Aortic pathologies treated were traumatic aortic dissection/transection (n = 15), acute/chronic aortic dissection (n = 9), and degenerative aneurysms (n = 6). Endoleak occurred in 3 patients, with 1 requiring further endograft repair. Two patients underwent combined open and endovascular repair of acute thoracic aortic dissection; 1 died 4 days after the procedure, and the other developed stroke and acute renal failure not requiring dialysis. Of the 28 patients who underwent endovascular repair, paraplegia and paraparesis occurred in 2 patients but resolved with cerebrospinal fluid drainage. Stroke occurred in 1 patient. Patients who underwent combined procedure of open and endovascular repair of thoracic aortic dissection had a greater risk of developing major adverse events than patients who underwent endovascular repair alone (Fisher's exact test P = .023). There was no association between the risk of stroke and the coverage of left subclavian artery in this series (P = .483). Graft stenting treatment for descending thoracic aortic pathologies has been shown to result in high in-hospital survival rates. It is essential for nurses who work in acute care settings to have knowledge of this procedure and potential complications associated with the procedure to enable postoperative assessment and immediate action if any deviation is observed.

Alcohol consumption and injury risk: a case-crossover study in Sydney, Australia.

INTRODUCTION AND AIMS: Alcohol contributes to traumatic outcomes that kill or disable at a relatively young age, resulting in the loss of many years of life or disability. Harm from alcohol consumption can result from chronic or acute alcohol use. The aims of this study are to determine the prevalence of alcohol-related injury and contextual factors contributing to injury risk in an ethnically diverse population of Sydney. DESIGN AND METHODS: The study was undertaken in emergency departments of six hospitals between 2005 and 2006 and used a case-crossover design. The 1599 attendees surveyed (response rate 64.2%) were aged over 14 years and had presented with an injury to the emergency department. RESULTS: Attendees were predominantly male, young, 40% spoke a language other than English at home and 17% had been drinking in the 6 h prior to their injury. Those born overseas drank at lower levels than their Australian born counterparts. The risk of sustaining an injury was 1.42 times greater in attendees consuming alcohol compared with those who had not. At very high intake levels (>90 g) the risk of injury was statistically significant for both men and women (men odds ratio: 1.88, 95% confidence interval: 1.46-2.42; women odds ratio: 1.89, 95% confidence interval: 1.04-3.43). Drinking at a licensed premise and drinking alone or with a group of people also significantly increased the risk of injury. DISCUSSION AND CONCLUSIONS: The results support current Australian policy concerning alcohol but indicate that further restrictions and increased warnings for the community may be warranted.

Vertical or transverse incisions for access to the femoral artery: a randomized control study.

BACKGROUND: To look at wound complications with either a transverse or vertical groin incision in vascular surgery. METHODS: All patients undergoing vascular procedure requiring access to femoral vessels were randomized to either a vertical or transverse incision. Patients were followed up for 28 days after the procedure and examined for wound infection, wound breakdown, development of lymphatic leak and lymphatic collection. RESULTS: 88 patients (116 groins) were randomised to either incision. Of these, 55 groins had transverse incisions and the remaining had vertical incisions. There was no significant difference in the patient's age, sex, smoking, diabetes, operative times and use of prosthetic material. 29/61 (47.5%) of vertical incisions and 7/55 (12.7%) of transverse incisions had wound complications (p<0.001). There were 13(11%) wound infections in the 116 groins by day 28. There were 3 wound infections in the transverse group and 10 infections in the vertical group (p=0.062). There were 17 (27.9%) lymphatic leaks in the vertical incisions compared to 7(12.7%) in the transverse incisions (p=0.044). The majority of infections were diagnosed after patient discharge from hospital. CONCLUSION: Wound complications are higher with vertical incision. Many infections are diagnosed after patient discharge. We recommend transverse incisions for access to the femoral vessels in the groin.

Time for a change in injury and trauma care delivery: a trauma death review analysis.

Safety and error reduction in medical care is crucial to the future of medicine. This study evaluates trauma patients dying at a level 1 trauma centre to determine the adequacy of care. All trauma deaths at a level 1 trauma centre between 1996 and 2003 were reviewed by an eight-member multidisciplinary death review panel. Errors in care were classified according to their location, nature, impact, outcome and whether the deaths were avoidable or non-avoidable. Avoidable deaths were categorized as potentially, probably and definitely avoidable. Between 1996 and 2003, there were 17 157 trauma admissions, including 307 trauma deaths. The mean patient age was 47.7 years +/- 24.8 years, mean injury severity score 38.1 +/- 19.6. Of all deaths, 69 (22.5%) were deemed avoidable. Of the avoidable deaths, 61 (88%) were potentially avoidable, 7 (10%) probably avoidable and 1 (1.4%) definitely avoidable. Avoidable deaths were associated with patients with increased age, lower injury severity score, admissions to intensive care unit, longer hospital stay and treatment by a non-trauma surgeon (P < 0.05). Of the 307 trauma deaths, 271 (89.3%) patients experienced a total of 1063 errors, an overall error rate of 3.5 per patient. The error rate in the non-avoidable group was 2.9 per patient and 5.3 per patient in the avoidable group (P < 0.0001). Most errors occurred in the resuscitation area. Age, severity of injury, hospital length of stay and care by a non-trauma surgeon are factors associated with avoidable deaths. A new approach to trauma and injury care is required.

Unfractionated heparin use after percutaneous coronary intervention: results of a trial with a vascular ultrasound endpoint.

BACKGROUND: Previous studies in the pre-stent era have evaluated the postprocedural use of unfractionated heparin (UFH) on clinically defined vascular complications and ischaemic cardiac complications. We prospectively evaluated the benefits and risks of this practice, using vascular ultrasound determined endpoints in the current stent era. METHODS: Patients undergoing percutaneous coronary intervention (PCI) and enrolled in two of our previous routine and prospective vascular ultrasound studies were included in the analysis. Generally the decision to use UFH after sheath removal was at the discretion of the operator, however a subset of patients was randomised to receive UFH or not. Femoral vascular ultrasound was performed prior to hospital discharge and interpreted by an experienced vascular ultrasonographer blinded to whether UFH was used or not. The primary endpoint was a composite of significant vascular ultrasound determined complications including major haematoma, pseudoaneurysm, arterio-venous fistula, femoral venous or arterial thrombosis and retroperitoneal haemorrhage. Secondary endpoints included in hospital ischaemic events, length of stay and outcome at 30 days. RESULTS: A total of 530 patients (43% receiving UFH) were included in the analysis. The incidence of the primary endpoint for the entire population was 4.0% in both the UFH and no UFH groups (p=1.00). In the 226 (43%), randomised patient subset, the primary endpoint occurred in 5.2% in the UFH group and 4.5% in the no UFH group (p=0.80). Time to ambulation and discharge was similar in both groups. At 30 days, the incidence of major adverse cardiac events (4.7% for entire cohort) was similar in all groups whether randomised or not. CONCLUSIONS: When vascular ultrasound is used to determine major vascular complications the use of UFH after PCI in the stent era was not associated with increased major vascular complications. We also failed to provide evidence of a meaningful clinical benefit with the routine use of postprocedural heparin in this selected patient cohort.

Operation Sumatra Assist: surgery for survivors of the tsunami disaster in Indonesia.

The tsunami of 26 December 2004 was one of the deadliest natural disasters recorded, with the Indonesian province of Aceh being the most devastated region. As part of the Australian Government's response to the disaster, the Australian Defence Force deployed personnel from the Sydney-based 1st Health Support Battalion to Banda Aceh, the capital of the province. This unit joined with medical personnel from the New Zealand Defence Force to form the ANZAC field hospital. The mission of this unit as part of Operation Sumatra Assist was to provide medical and surgical care to the people of Aceh during the critical stages of rebuilding of the tsunami-devastated region. Surgical teams of the ANZAC field hospital were some of the first to provide definitive surgical care to the critically injured survivors of the disaster. During the first 4 weeks of the deployment, 173 surgical procedures were carried out for 71 patients in this facility. Thirty patients underwent 119 procedures (69% of total) for injuries sustained in the tsunami. Most of these patients required debridements, dressing changes and wound management procedures for the management of severe soft tissue infections. Three amputations were carried out. The remaining 41 patients underwent 54 procedures (31%) for emergent surgical conditions unrelated to the disaster.

Comparison of 6 and 7 French guiding catheters for percutaneous coronary intervention: results of a randomised trial with a vascular ultrasound endpoint.

OBJECTIVE: To perform a randomized, ultrasound controlled trial to define the procedural and clinical advantages and limitations of 6 French (Fr) compared with 7 Fr transfemoral coronary intervention in the stenting era. BACKGROUND: The use of 7 Fr guiding catheters may facilitate Percutaneous Coronary Intervention (PCI), but may be associated with increased vascular complications when compared with 6 Fr catheters. METHODS: Patients undergoing PCI considered suitable for either a 6 or 7 Fr sheath and guiding catheter system were included. All vascular sheaths were removed with assisted manual compression. Femoral vascular ultrasounds were performed prior to hospital discharge and interpreted by a vascular surgeon blinded to treatment assignment. The primary endpoint was a composite of significant vascular complications including major haematoma, retroperitoneal haematoma, pseudoaneurysm, arterio-venous fistula, or femoral venous or arterial thrombosis. RESULTS: During the study, 414 patients (mean age 61+/-11 years, 27% females) were randomly assigned to 6 Fr or 7 Fr sheath groups. The incidence of major vascular complications was 5.7% in the 6 Fr group and 3.9% in the 7 Fr group (P=0.383). There was no significant difference in procedural or angiographic success between the groups. The use of contrast volume was higher in the 7 Fr group (157+/-58 ml vs. 144+/-58 ml; P=0.029). There was a trend toward better operator satisfaction with the 7 Fr guide (P=0.08). CONCLUSIONS: This prospective, randomized trial indicates no reduction in major peripheral vascular complications with the use of smaller guiding catheters in PCI. There was less contrast used in the 6 Fr group, which may benefit some patient subsets, however operators tended to prefer the larger 7 Fr system. The target coronary anatomy and need for complex device intervention should mandate the choice of guiding catheter size, not a perceived impact on vascular complications.

Patient tolerance and resource utilization associated with an arterial closure versus an external compression device after percutaneous coronary intervention.

We assessed patient tolerance and resource utilization of using the AngioSeal closure device versus assisted manual compression using the Femostop device after percutaneous coronary intervention (PCI). Patients undergoing PCI with clean arterial access and no procedural hematoma were randomized to receive the AngioSeal or Femostop device to achieve femoral arterial hemostasis. Times from procedure end to removal from angiography table, hemostasis, ambulation, and hospital discharge were recorded. Bedside nursing/medical officer care time, vascular complications, and disposable use were also documented. Patient comfort was assessed using Present Pain Intensity and Visual Analogue scales at baseline, 4 hr, 8 hr, and the morning after the procedure. One hundred twenty-two patients were enrolled (62 AngioSeal, 60 Femostop). Patients in the AngioSeal group took longer to be removed from the angiography table (11 +/- 4 vs. 9 +/- 3 min; P = 0.002) compared with the Femostop group. Time to hemostasis (0.4 +/- 1.1 vs. 6.4 +/- 1.7 hr; P < 0.001) and ambulation (17 +/- 8 vs. 22 +/- 13 hr; P = 0.004) were less in the AngioSeal group, although time to discharge was not different. Nursing and medical officer time was no different. Disposables including device cost were higher in the AngioSeal group (209 dollars +/- 13 vs. 53 dollars +/- 9; P < 0.001). On a Visual Analogue scale, patients reported more pain at 4 hr (P < 0.001) and 8 hr (P < 0.001) in the Femostop group. The worst amount of pain at any time point was also more severe in the Femostop group (P < 0.001). Similar results were found on a Present Pain Intensity scale of pain. There were no differences in ultrasound-determined vascular complications (two each). Femoral access site closure using the AngioSeal device resulted in a small delay in leaving the angiography suite and a higher disposable cost compared to using the Femostop device. However, patients receiving the AngioSeal were able to ambulate sooner and reported less pain, which may justify the increased costs involved.

Australian Defence Force surgical support to peacekeeping operations in East Timor.

BACKGROUND: The Australian Defence Force (ADF) has provided surgical support to peacekeeping operations in East Timor since September 1999. The aim of the present paper is to document the wide range of surgical procedures performed by the ADF in East Timor from September 1999 to December 2002 on peacekeeping force personnel and the civilian population. METHODS: Records of all surgical procedures performed by the ADF in East Timor from their arrival in September 1999 to December 2002 were retrospectively reviewed. Details of the type of procedures performed and anaesthetic administered, the age and sex of the patients and whether they were a member of peacekeeping forces or East Timorese civilian were recorded. RESULTS: There were 702 surgical procedures performed by the ADF in East Timor during this period, of which 401 (57%) were for peacekeeping force personnel and 301 (43%) were for East Timorese or other civilians. The most commonly performed procedures were for the management of non-battle wounds, accounting for 181 cases (26%). Battle-type wounds accounted for only 36 procedures (5%). Obstetric and gynaecology cases accounted for 30 procedures (4%). Fifty-six procedures (8%) were on children 12 years or younger. CONCLUSIONS: The wide range of surgical procedures performed by the ADF during peacekeeping operations in East Timor highlights the requirement for deployed surgeons to possess a broad range of clinical skills and has implications for their preparation and training. Battle-type wounds accounted for only a small proportion of procedures.

Implications for urgent transfusion of uncrossmatched blood in the emergency department: The prevalence of clinically significant red cell antibodies within different patient groups.

OBJECTIVE: To define the prevalence of alloantibodies as a factor of age and underlying clinical disease, with particular relevance to the prediction of the safety of uncrossmatched blood in different demographic groups. METHODS: A retrospective review was conducted of all immunohaematological studies on blood samples submitted to the blood bank of a tertiary referral hospital between January 1998 and December 1999. RESULTS: A total of 27 968 antibody screens in 15 966 patients were analysed. When only clinically significant antibodies were considered, the total alloimmunization prevalence was 1.9% and the prevalence of antibodies capable of causing an immediate transfusion reaction was 0.6%. The prevalence of antibodies capable of causing an immediate transfusion reaction was 0.1% in the under 30 years of age group. Clinically significant antibodies were found in 5.1% in the haematology and oncology unit patients. The risk rises with age and female sex. CONCLUSION: We conclude that uncrossmatched blood is associated with low risk in patients < 30 years of age. The knowledge that patients have not been exposed to previous transfusion or pregnancy will reduce the risk even further.

Genetic modulation of metalloprotein electron transfer at bare gold.

Engineered metalloproteins and enzymes can be self assembled on pristine gold electrodes in robust, electrochemically-addressable, arrays.

Vascular injury in Australia.

Vascular injury poses a small but significant challenge in Australian trauma care. Opportunities such as better practice guidelines and minimum standards will allow surgeons to improve delivery of quality care to the next generation of vascular trauma victims. Training in the management of vascular trauma surgery with integration of vascular and general surgery in trauma care should optimize outcomes. The authors' vision is that all vascular and general surgery trainees would eventually undertake the Definitive Surgical Trauma Care Course and improve vascular trauma outcomes and reduce mortality.