Surgery - continued

For hip replacement surgery, consider a dose of 40 mg once daily subcutaneously, given initially 9 to 15 hours prior to surgery. Continue prophylaxis for 3 weeks. 

Cataract surgery Ophthalmic Apply 1 drop to eye 4 times a day commencing 24 hr after cataract surgery. Continue for 2 wk afterward. 

A 49-year-old woman had a tonic-clonic seizure about 15 minutes after a peribulbar block for left trabeculectomy (319). She recovered and surgery continued uneventfully. However, she had severe permanent visual loss in that eye, and an MRI scan at 4 weeks showed swelling of the left optic nerve. The authors suggested that some prilocaine had been injected into the nerve sheath, causing the convulsions, local optic nerve swelling, and subsequent optic nerve atrophy. 

A 50-year-old man with no previous history of seizures was anesthetized with fentanyl 100 micrograms and propofol 100 mg. Within 30 seconds of receiving the propofol, he developed tonic-clonic seizures over the trunk and lower body. Despite thiopental 125 mg the seizures recurred and required further boluses of thiopental and midazolam. Surgery continued uneventfully and postoperative recovery was unremarkable. A CT scan of the brain was normal. 

Liquid helium s use in magnetic resonance imaging (MRI) continues to increase as the medical profession accepts and develops new uses for the equipment. This equipment has eliminated some need for exploratory surgery by accurately diagnosing patients. Another medical application uses MRE to determine (by blood analysis) whether a patient has any form of cancer. 

In any case, I eventually recovered (and so did Jerry), but my immune system must have suffered serious damage, which manifested itself three years later, when I collapsed in my office one day and was found to be bleeding internally from a form of rare stomach cancer, which necessitated major surgery but was fortunately localized. I again recovered and have had no further difficulties since. Whether weakening and knocking out my immune system to overcome the previous problems had any effect is not clear, but it could have been a factor. Despite my health problems I was able to continue my work without much interruption, and the scientific productivity of my group has not... 

Implantable valves, particularly mechanical valves which continue to encroach on tissue valves, are unique. Methods such as valvuloplasty, mitral valve repair, or use of ultrasound are unlikely to reduce the number of valve replacements into the twenty-first century. Valve selection remains in the hands of the surgeon because of the critical nature of the procedure. If anything goes wrong, the result can be catastrophic to the patient. Cost of a valve, from 3000— 4000, is a relatively small part of the cost of open-heart surgery which can mn as high as 30,000. Growth of the cardiovascular valve market has slowed in the United States with the decline of the threat of rheumatic fever. 

Epidural analgesia is frequently used for lower extremity procedures and pain (e.g., knee surgery, labor pain, and some abdominal procedures). Intermittent bolus or continuous infusion of preservative-free opioids (morphine, hydromorphone, or fentanyl) and local anesthetics (bupivacaine) may be used for epidural analgesia. Opiates given by this route may cause pruritus that is relieved by naloxone. Adverse effects including respiratory depression, hypotension, and urinary retention may occur. When epidural routes are used in narcotic-dependent patients, systemic analgesics must also be used to prevent withdrawal since the opioid is not absorbed and remains in the epidural space. Doses of opioids used in epidural analgesia are 10 times less than intravenous doses, and intrathecal doses are 10 times less than epidural doses (i.e., 10 mg of IV morphine is equivalent to 1 mg epidural morphine and 0.1 mg of intrathecally administered morphine).45... 

Since up to 10% of pituitary tumors may recur within 15 years following surgery,6,14 continual postoperative monitoring is recommended. 

Cefazolin or cefuroxime are appropriate for prophylaxis in cardiothoracic and vascular surgeries. In the case of 3-lactam allergy, vancomycin or clindamycin are advised. Debate exists on the duration of antimicrobial prophylaxis. The National Surgical Infection Prevention Project cites data that extending prophylaxis beyond 24 hours does not decrease SSI rates and may increase bacterial resistance.1 American Society of Health-System Pharmacists guidelines from 1999 allow for the continuation of prophylaxis for up to 72 hours.22 Duration of therapy should be based on patient factors and risk of development of an SSI. SSIs are rare after cardiothoracic operations, but the potentially devastating consequences lead some clinicians to support longer periods of prophylaxis. 

Adjuvant tamoxifen therapy generally is initiated shortly after surgery or as soon as pathology results are known and the decision to administer tamoxifen as adjuvant therapy is made. The administration of tamoxifen should be limited to administration after completion of chemotherapy based on results from a study that randomized patients to receive chemotherapy for six cycles with concurrent tamoxifen, followed by continued tamoxifen for a total of 5 years, or chemotherapy with sequential tamoxifen for 5 years.39 After a median follow-up of 8.5 years, the administration of sequential tamoxifen resulted in an estimated DFS advantage of 18% [hazard ratio (HR) = 1.18] compared with the concurrent use of tamoxifen with chemotherapy.39 It is believed the growth-inhibitory effect of... 

In the 12-month safety study (N = 805, 2 1 (alvimopan placebo) randomization) 3 at 0.5 mg twice daily was well tolerated and showed evidence of sustained efficacy when taken continuously for 12 months by patients with nonmalignant pain requiring sustained treatment with opioids. However, unexpectedly, there were more reports of myocardial infarctions in patients treated with 3 at 0.5 mg twice daily compared with placebo-treated patients. The majority of myocardial infarctions occurred between 1 and 4 months after initiation of treatment. This imbalance has not been observed in other studies of 3, including studies in patients undergoing bowel resection surgery who received 3 at 12 mg twice daily for up to 7 days. A causal relationship with 3 has not been established [29]. 

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