Bedside Procedures for General Surgeons: Part 2

2017 ◽  
Author(s):  
Thomas H. Cogbill ◽  
Basem S Marcos
Keyword(s):  
Temporal Artery ◽  
Tube Thoracostomy ◽  
Temporal Artery Biopsy ◽  
Abscess Drainage ◽  
Skeletal Muscle Biopsy ◽  
Sterile Technique ◽  
General Surgeons ◽  
Key Steps ◽  
Biopsy Tube

This review focuses on four procedures that are commonly performed by general surgeons in the emergency department and critical care unit and three procedures that are usually performed in the outpatient clinic. Although considered basic procedures, all have their own set of key steps that must be learned, practiced, and mastered. Included in the description for each procedure are technical points that are intended to facilitate successful performance of the procedures and pitfalls to avoid. The most frequent complications for each procedure are briefly discussed in an effort to raise awareness so that they can be recognized and managed expeditiously. Common to all of these procedures is a need to understand the indications based on a careful history, physical examination, and review of pertinent objective data. Whenever possible, informed consent should be obtained from the patient or family prior to the procedure and a complete surgical timeout performed. Sterile technique and personal protective gear/universal precautions should be employed whenever feasible. Finally, these patients should be followed postoperatively and appropriate follow-up studies and/or treatments arranged. This review contains 24 figures, 9 tables, and 33 references. Key words: extended focused assessment with sonography for trauma, focused assessment with sonography for trauma, pericardiocentesis for trauma, pigtail tube thoracostomy, skeletal muscle biopsy, superficial abscess drainage, temporal artery biopsy, tube thoracostomy

Bedside Procedures for General Surgeons: Part 2

2017 ◽  
Author(s):  
Thomas H. Cogbill ◽  
Basem S Marcos
Keyword(s):  
Temporal Artery ◽  
Tube Thoracostomy ◽  
Temporal Artery Biopsy ◽  
Abscess Drainage ◽  
Skeletal Muscle Biopsy ◽  
Sterile Technique ◽  
General Surgeons ◽  
Key Steps ◽  
Biopsy Tube

This review focuses on four procedures that are commonly performed by general surgeons in the emergency department and critical care unit and three procedures that are usually performed in the outpatient clinic. Although considered basic procedures, all have their own set of key steps that must be learned, practiced, and mastered. Included in the description for each procedure are technical points that are intended to facilitate successful performance of the procedures and pitfalls to avoid. The most frequent complications for each procedure are briefly discussed in an effort to raise awareness so that they can be recognized and managed expeditiously. Common to all of these procedures is a need to understand the indications based on a careful history, physical examination, and review of pertinent objective data. Whenever possible, informed consent should be obtained from the patient or family prior to the procedure and a complete surgical timeout performed. Sterile technique and personal protective gear/universal precautions should be employed whenever feasible. Finally, these patients should be followed postoperatively and appropriate follow-up studies and/or treatments arranged. This review contains 24 figures, 9 tables, and 33 references. Key words: extended focused assessment with sonography for trauma, focused assessment with sonography for trauma, pericardiocentesis for trauma, pigtail tube thoracostomy, skeletal muscle biopsy, superficial abscess drainage, temporal artery biopsy, tube thoracostomy

Bedside Procedures for General Surgeons: Part 2

2017 ◽  
Author(s):  
Thomas H. Cogbill ◽  
Basem S Marcos
Keyword(s):  
Temporal Artery ◽  
Tube Thoracostomy ◽  
Temporal Artery Biopsy ◽  
Abscess Drainage ◽  
Skeletal Muscle Biopsy ◽  
Sterile Technique ◽  
General Surgeons ◽  
Key Steps ◽  
Biopsy Tube

This review focuses on four procedures that are commonly performed by general surgeons in the emergency department and critical care unit and three procedures that are usually performed in the outpatient clinic. Although considered basic procedures, all have their own set of key steps that must be learned, practiced, and mastered. Included in the description for each procedure are technical points that are intended to facilitate successful performance of the procedures and pitfalls to avoid. The most frequent complications for each procedure are briefly discussed in an effort to raise awareness so that they can be recognized and managed expeditiously. Common to all of these procedures is a need to understand the indications based on a careful history, physical examination, and review of pertinent objective data. Whenever possible, informed consent should be obtained from the patient or family prior to the procedure and a complete surgical timeout performed. Sterile technique and personal protective gear/universal precautions should be employed whenever feasible. Finally, these patients should be followed postoperatively and appropriate follow-up studies and/or treatments arranged. This review contains 24 figures, 9 tables, and 33 references. Key words: extended focused assessment with sonography for trauma, focused assessment with sonography for trauma, pericardiocentesis for trauma, pigtail tube thoracostomy, skeletal muscle biopsy, superficial abscess drainage, temporal artery biopsy, tube thoracostomy

Bedside Procedures for General Surgeons: Part 1

2017 ◽  
Author(s):  
Thomas H. Cogbill ◽  
Basem S Marcos
Keyword(s):  
Percutaneous Tracheostomy ◽  
Venous Catheter ◽  
Central Venous ◽  
Successful Performance ◽  
Protective Gear ◽  
Sterile Technique ◽  
General Surgeons ◽  
Key Steps ◽  
Chest Decompression

This review focuses on six procedures that are commonly performed by general surgeons in the emergency department, critical care unit, and operating room. Although considered basic procedures, all have their own set of key steps that must be learned, practiced, and mastered. Included in the description for each procedure are technical points that are intended to facilitate successful performance of the procedures and pitfalls to avoid. The most frequent complications for each procedure are briefly discussed in an effort to raise awareness so that they can be recognized and managed expeditiously. Common to all of these procedures is a need to understand the indications based on a careful history, physical examination, and review of pertinent objective data. Whenever possible, informed consent should be obtained from the patient or family prior to the procedure and a complete surgical timeout performed. Sterile technique and personal protective gear/universal precautions should be employed whenever feasible. Finally, these patients should be followed postoperatively and appropriate follow-up studies and/or treatments arranged. This review contains 19 figures, 7 tables, and 33 references. Key words: central venous catheter, intraosseous vascular access, needle chest decompression, percutaneous arterial catheter, percutaneous tracheostomy, tracheostomy, venous cutdown

Bedside Procedures for General Surgeons: Part 1

2017 ◽  
Author(s):  
Thomas H. Cogbill ◽  
Basem S Marcos
Keyword(s):  
Percutaneous Tracheostomy ◽  
Venous Catheter ◽  
Central Venous ◽  
Successful Performance ◽  
Protective Gear ◽  
Sterile Technique ◽  
General Surgeons ◽  
Key Steps ◽  
Chest Decompression

This review focuses on six procedures that are commonly performed by general surgeons in the emergency department, critical care unit, and operating room. Although considered basic procedures, all have their own set of key steps that must be learned, practiced, and mastered. Included in the description for each procedure are technical points that are intended to facilitate successful performance of the procedures and pitfalls to avoid. The most frequent complications for each procedure are briefly discussed in an effort to raise awareness so that they can be recognized and managed expeditiously. Common to all of these procedures is a need to understand the indications based on a careful history, physical examination, and review of pertinent objective data. Whenever possible, informed consent should be obtained from the patient or family prior to the procedure and a complete surgical timeout performed. Sterile technique and personal protective gear/universal precautions should be employed whenever feasible. Finally, these patients should be followed postoperatively and appropriate follow-up studies and/or treatments arranged. This review contains 19 figures, 7 tables, and 33 references. Key words: central venous catheter, intraosseous vascular access, needle chest decompression, percutaneous arterial catheter, percutaneous tracheostomy, tracheostomy, venous cutdown

Bedside Procedures for General Surgeons

2015 ◽  
Author(s):  
Thomas H. Cogbill ◽  
Benjamin T Jarman
Keyword(s):  
Critical Care ◽  
Percutaneous Tracheostomy ◽  
Venous Catheter ◽  
Temporal Artery ◽  
Outpatient Setting ◽  
Catheter Placement ◽  
Ultrasound Images ◽  
Temporal Artery Biopsy ◽  
General Surgeons ◽  
Key Steps

This review is focused on 12 procedures that are commonly performed by general surgeons in the emergency department, critical care unit, operating room, and outpatient clinic. The review begins with eight critical care procedures: percutaneous tracheostomy, saphenous vein cutdown, percutaneous arterial cannulation, subclavian venous catheter placement by landmark technique, internal jugular venous catheter placement under ultrasound guidance, needle chest decompression, tube thoracostomy, and pericardiocentesis for trauma. Next, the diagnostic procedure of focused assessment with sonography for trauma (FAST) is described. The review finishes with three procedures that are frequently performed in the outpatient setting: temporal artery biopsy, simple abscess drainage, and muscle biopsy. Although considered basic procedures, each has its own set of key steps that must be learned, practiced, and mastered. Included in the description for each procedure are technical points that are intended to facilitate successful performance of the procedures as well as pitfalls to avoid. The most frequent complications for each procedure are briefly discussed in an effort to raise awareness so that they can be recognized and managed expeditiously. Common to all of these procedures is a need to understand the indications based on careful history, physical examination, and review of pertinent objective data. Whenever possible, informed consent should be obtained from the patient or family prior to the procedure and a complete surgical timeout performed. Sterile technique and personal protective gear/universal precautions should be employed whenever feasible. Finally, these patients should be followed postoperatively and appropriate follow-up studies and/or treatments arranged. The figures illustrate key steps used in a number of the procedures and typical ultrasound images of the internal jugular vein during central venous catheter placement and the four standard FAST views, along with photo insets depicting appropriate ultrasound probe positioning. The tables include the lists of equipment necessary to perform each procedure. This review contains 17 figures, 14 tables, and 47 references

Bedside Procedures for General Surgeons: Part 1

2017 ◽  
Author(s):  
Thomas H. Cogbill ◽  
Basem S Marcos
Keyword(s):  
Percutaneous Tracheostomy ◽  
Venous Catheter ◽  
Central Venous ◽  
Successful Performance ◽  
Protective Gear ◽  
Sterile Technique ◽  
General Surgeons ◽  
Key Steps ◽  
Chest Decompression

This review focuses on six procedures that are commonly performed by general surgeons in the emergency department, critical care unit, and operating room. Although considered basic procedures, all have their own set of key steps that must be learned, practiced, and mastered. Included in the description for each procedure are technical points that are intended to facilitate successful performance of the procedures and pitfalls to avoid. The most frequent complications for each procedure are briefly discussed in an effort to raise awareness so that they can be recognized and managed expeditiously. Common to all of these procedures is a need to understand the indications based on a careful history, physical examination, and review of pertinent objective data. Whenever possible, informed consent should be obtained from the patient or family prior to the procedure and a complete surgical timeout performed. Sterile technique and personal protective gear/universal precautions should be employed whenever feasible. Finally, these patients should be followed postoperatively and appropriate follow-up studies and/or treatments arranged. This review contains 19 figures, 7 tables, and 33 references. Key words: central venous catheter, intraosseous vascular access, needle chest decompression, percutaneous arterial catheter, percutaneous tracheostomy, tracheostomy, venous cutdown

scholarly journals Lyme carditis mimicking giant cell arteritis

2015 ◽  
Vol 7 (1) ◽  
Author(s):  
Krati Chauhan
Keyword(s):  
Giant Cell Arteritis ◽  
Giant Cell ◽  
Temporal Artery ◽  
Interesting Case ◽  
Temporal Artery Biopsy ◽  
Laboratory Findings ◽  
Reactive Protein ◽  
System Disease ◽  
Lyme Carditis

Presenting an interesting case of a patient who complained of myalgias, fatigue, headache, jaw claudication and scalp tenderness. Patient’s physical examination was unremarkable. Laboratory findings showed elevated erythrocyte sedimentation rate and C-reactive protein, bilateral temporal artery biopsy results were negative and first degree atrioventricular block was seen on electrocardiogram. Serology for <em>Borrelia burgdorferi</em> was positive; patient was diagnosed with Lyme carditis and treated with doxycycline. Lyme is a tick-borne, multi-system disease and occasionally its presentation may mimic giant cell arteritis. On follow-up there was complete resolution of symptoms and electrocardiogram findings.

scholarly journals AB0515 COMPARISON OF THE PERFORMANCE OF THE 1990 ACR CLASSIFICATION CRITERIA AND THE GIACTA INCLUSION CRITERIA FOR THE CLASSIFICATION OF GCA: RESULTS FROM A SINGLE-CENTRE STUDY.

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 1554.1-1555
Author(s):  
F. Muratore ◽  
L. Boiardi ◽  
E. Galli ◽  
G. Pazzola ◽  
A. Cavazza ◽  
...  
Keyword(s):  
Sensitivity And Specificity ◽  
Temporal Artery ◽  
Final Diagnosis ◽  
Classification Criteria ◽  
Temporal Artery Biopsy ◽  
Inclusion Criteria ◽  
Small Vessels ◽  
Imaging Results

Background:The classification criteria currently used to define giant cell arteritis (GCA) were developed in 1990 by the American College of Rheumatology (ACR), and strongly focus on patients with cranial manifestations. Patients with large-vessel GCA (LV-GCA) have less frequently cranial symptoms and a positive temporal artery biopsy, and are less likely to be captured by the ACR criteria. GiACTA, a trial of tocilizumab in GCA, has recognized the concept of GCA as a clinical syndrome, and included patients with cranial and/or polymyalgic symptoms as long as GCA diagnosis was supported by either biopsy or appropriate LV imaging results. However, these inclusion criteria were elaborated by experts and were not validated in patients with GCA.Objectives:To compare the performance of the 1990 ACR classification criteria and the GiACTA inclusion criteria for the classification of GCA in a single-center cohort of patients with GCA.Methods:All consecutive patients with a diagnosis of GCA seen between January 2008 and December 2016 in our center were included (GCA cohort). Control cohort consisted of consecutive patients with a negative temporal artery biopsy (TAB) performed in the same time period and a final diagnosis different than GCA. For both study cohort, the final diagnosis was made at the end of the follow-up period by consensus by 2 rheumatologists, who retrospectively evaluated all the medical records from symptoms’ onset to December 2019, last visit, or death. Subjects were classified by each of the different criteria. TABs showing inflammation limited to adventitial or periadventitial small vessels were considered negative for both ACR and GiACTA criteria.Two-by-two classification tables were generated to estimate sensitivity and specificity, and receiver operating characteristic (ROC) curves with corresponding areas under the curve (AUC) were calculated.Results:213 patients were included in the study (75% female, mean age 71.7 years). 55 patients had TAB showing transmural inflammation (TMI); 30 patients had TAB showing inflammation limited to adventitial or periadventitial small vessels (PAI); 67 patients had evidence of LV-GCA at imaging (LV-GCA) and 61 patients had TAB without inflammatory changes (negTAB). 1990 ACR and GiACTA criteria were satisfied respectively by 55 (100%) and 51 (93%) TMI, 18 (60%) and 1 (3%) PAI, 23 (35%) and 31 (46%) LV-GCA and 27 (44%) and none (0%) negTAB patients.After a median follow-up of 52.6 months, 174 of the 213 (84%) patients had a final diagnosis of GCA (55 TMI, 22 PAI; 67 LV-GCA and 30 negTAB) and the remaining 33 patients had a diagnosis different than GCA (2 PAI and 31 negTAB). Sensitivity and specificity of 1990 ACR classification criteria for GCA were 67% and 90%, AUC (95% CI) 0.790 (0.715 – 0.864). Sensitivity and specificity of GiACTA inclusion criteria were 48% and 100%, AUC (95% CI) 0.740 (0.669 – 0.811). By adding systemic symptoms in the symptoms domain of GiACTA inclusion criteria, sensitivity increased to 59% and sensitivity remained 100%, AUC (95% CI) 0.792 (0.730 – 0.854).Conclusion:Both 1990 ACR classification criteria and GiACTA inclusion criteria showed a good specificity but a low sensitivity in classifying patients with a clinical diagnosis of GCA from this large monocentric cohort. There is an urgent need for new classification criteria for GCA.Disclosure of Interests:Francesco Muratore: None declared, Luigi Boiardi: None declared, Elena Galli: None declared, Giulia Pazzola: None declared, Alberto Cavazza: None declared, Giovanna Restuccia: None declared, Carlo Salvarani Grant/research support from: consulting and investigator fees from Abbvie, Pfizer, MSD, Roche, Celgene, Novartis, Consultant of: consulting and investigator fees from Abbvie, Pfizer, MSD, Roche, Celgene, Novartis

Abstract TP217: Intra-arterial Verapamil Can Help Differentiate Reversible From Non-reversible Vasculopathy

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Eileen C Vallin ◽  
Joseph C Serrone ◽  
Aaron M Betts ◽  
Ryan D Tackla ◽  
Todd Abruzzo ◽  
...  
Keyword(s):  
Post Partum ◽  
Superficial Temporal Artery ◽  
Brain Biopsy ◽  
Temporal Artery ◽  
Small Vessel ◽  
Temporal Artery Biopsy ◽  
Radiographic Findings ◽  
Presenting Symptoms ◽  
Vasodilatory Response

Introduction: Cerebral angiography (DSA) is commonly used to characterize small vessel vasculopathy, yet it is difficult to establish etiology by angiographic patterns alone. Hypothesis: Responsiveness to intra-arterial verapamil (IA-V) can help differentiate etiology of small vessel vasculopathy by characterizing it as reversible or non-reversible. Methods: We performed a retrospective analysis from 2013-15 of patients referred for DSA to evaluate cerebral vasculopathy. We characterized symptoms, radiographic findings, angiographic pattern and responsiveness to IA-V, if given, as well as biopsy and follow-up angiography. Results: Thirty-three patients were identified (70% female; mean age 47.7). Presenting symptoms were headache (48%), focal neurologic deficit (45%), cognitive impairment (30%) and seizure (18%). Three patients presented in the post-partum period. Radiographic findings included infarct (42%), cortical subarachnoid hemorrhage (33%) and cerebral edema (3%). Arteriopathy was present on DSA in 19 of 33 patients (58%). Twelve patients had smooth segmental narrowing, 6 had irregular narrowing, 1 had diffuse narrowing. IA-V was administered in 12 of the 19 patients with arteriopathy (63%), including 9 of 12 with smooth segmental, 2 of 6 with irregular, and the patient with diffuse narrowing. Of 9 patients with smooth segment narrowing that received IA-V, 8 exhibited a vasodilatory response (89%). In 1 of these patients, superficial temporal artery biopsy was normal. Follow-up DSA was performed in 4 of the 8 patients with verapamil-responsive arteriopathy at a median time of 86 days. All 4 had angiographic resolution of their arteriopathy, consistent with reversible cerebral vasoconstriction syndrome. The 3 patients with irregular or diffuse narrowing who received IA-V did not exhibit vasodilatory response or have follow-up angiography. In 3 patients with irregular narrowing, brain biopsy was performed; 1 revealed CNS vasculitis, 2 were normal, consistent with atherosclerosis. Conclusion: Our series is consistent with reports of patients with reversible vasculopathy exhibiting a response to IA vasodilators. Response to IA-V may better characterize small vessel vasculopathy than angiographic pattern alone.

scholarly journals FRI0204 COMPARISON BETWEEN TRANSMURAL AND ISOLATED (PERI)ADVENTITIAL INFLAMMATION AT TEMPORAL ARTERY BIOPSY: A SINGLE CENTER COHORT OF BIOPSY-POSITIVE GCA WITH LONG TERM FOLLOW-UP

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 685.2-685
Author(s):  
E. Galli ◽  
F. Muratore ◽  
L. Boiardi ◽  
A. Cavazza ◽  
G. Restuccia ◽  
...  
Keyword(s):  
Temporal Artery ◽  
Temporal Artery Biopsy ◽  
Long Term Outcomes ◽  
Prednisone Dose ◽  
Small Vessels ◽  
Long Term Follow Up ◽  
The Media ◽  
Transmural Inflammation

Background:Temporal artery biopsy (TAB) showing transmural inflammation is considered the gold standard for the diagnosis of giant cell arteritis (GCA). In some cases, inflammation is confined to periadventitial small vessels and/or the adventitia. However, the clinical significance of this more limited inflammation remains unclear. Up to date, no studies have compared treatment, prognosis and long-term outcomes of patients with transmural inflammation with those of patients with isolated (peri)adventitial inflammation.Objectives:To compare treatment and long-term outcomes of patients with transmural inflammation with those of patients with (peri)adventitial inflammation in a single center cohort of patients with biopsy-positive GCA with long-term follow-up.Methods:All TABs performed for suspected GCA between 1986 and 2013 were reviewed by a single pathologist. Based on the localization of the inflammation, inflamed TABs were classified into 2 categories: transmural inflammation (TMI), with external elastic lamina disruption and extension of the inflammation to the media; (peri)adventitial inflammation (PAI), with inflammation limited to small periadventitial vessels and/or to the adventitia without extension to the media. All medical records of these patients were retrospectively reviewed from the date of TAB to 31 December 2018 or death. Only patients with a follow-up of at least 18 months after GCA diagnosis were included. Cohort characteristics were compared using Wilcoxon rank sum tests for continuous variables and chi-square tests for categorical variables. Kaplan-Meier methods and log-rank tests were used to estimate the rate of development of outcomes.Results:In the study period 254 TMI and 80 PAI were identified. Baseline clinical manifestations and laboratory findings of the 2 cohorts were previously reported (1). Similar frequencies of systemic symptoms, visual manifestations and polymyalgia rheumatica were found in the 2 cohorts. Compared with patients with TMI, those with PAI had a significantly lower frequency of cranial symptoms, abnormalities of TA at physical examination, halo at TA color duplex sonography, lower levels of ESR and CRP and higher frequency of male gender and peripheral arthritis. Large vessel involvement was found in 6/22 (27%) patients with PAI and 32/81 (40%) patients with TMI, p=0.292.118 patients with TMI and 35 with PAI had a follow-up longer than 18 months and were included for outcome analysis. Median (IQR) follow-up was 79.8 months (52, 115) for patients with TMI and 67.9 (34, 125) for those with PAI, p=0.125. Compared to patients with TMI, those with PAI received a significantly lower initial prednisone dose (35.8±22.0 vs 46.8±15.0 mg, p<0.0001), reached sooner a prednisone dose <10 mg/day (median 4.7 months vs 6.3, p=0.001) and <5 mg/day (median 7.5 months vs 10.3, p=0.005), had a lower cumulative prednisone dose at 1 year (5.7±3.8 vs 7.2±2.3 g, p=0.005) and at the end of the follow-up period (10.0±9.0 vs 12.9±9.6 g, p=0.015). There were no differences in the frequencies of relapses, long-term remission, time to first GC discontinuation and treatment duration between patients with TMI and PAI (p>0.05).Conclusion:Patients with PAI seem to have a disease course similar to those with the transmural pattern, but may require lower GC dosage. Our data confirm that inflammation confined to periadventitial small vessels and/or the adventitia could be considered part of the histopathologic spectrum of GCA.References:[1]Restuccia G, et Al. Small-vessel vasculitis surrounding an uninflamed temporal artery and isolated vasa vasorum vasculits of the temporal artery: Two subsets of giant cell arteritis. Arthritis Rheum. 2011.Disclosure of Interests:None declared

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