Surgical factors

An ongoing assessment is one that is made at the time of each patient contact and may include the collection of objective data, subjective data, or both. The scope of an ongoing assessment depends on many factors, such as the patient s diagnosis, the severity of illness, the response to treatment, and the prescribed medical or surgical treatment. 

Specific predictive factors for outcome after surgical intervention have not been well defined in the literature. In one prospective, multicenter observational study of 95 patients, the state of consciousness was the only predictive factor retained in a logistic regression analysis." In this study, there was a 2.8-fold increased risk for poor outcome for each increase on a three-step scale (awake/drowsy, somnolent/ stuporous, and comatose), and good outcomes (modified Rankin Scale score <2) were achieved in 86%, 76%, and 47% of patients within each group, respectively. 

The benefit of carotid endarterectomy for prevention of recurrent stroke has been studied previously in major trials.25,26 A recent meta-analysis has been completed that has combined these clinical trials to evaluate 6,092 patients.27 Carotid endarterectomy has been shown to be beneficial for preventing ipsilateral stroke in patients with symptomatic carotid artery stenosis of 70% or greater and is recommended in these patients. In patients with symptomatic stenosis of 50% to 69%, a moderate reduction in risk is seen in clinical trials. In all patients with stenosis of 50% to 69% and a recent stroke, carotid endarterectomy is appropriate. In other patients, surgical risk factors and surgeon skill should be considered prior to surgery. The patient should have, at a minimum, a life expectancy of 5 years, and the surgical risk of stroke and/or death should be less than 6%. Carotid endarterectomy is not beneficial for symptomatic carotid stenosis less than 50% and should not be considered in these patients. 

If surgical intervention does not achieve satisfactory disease control, select subsequent appropriate pharmacologic therapy based on patient-specific factors. In selecting therapy, be sure to consider if the patient has any contraindications or allergies to therapies. 

It is likely that the dynamic factor may predominate as the cause of symptoms in these patients. In contrast, drug treatment failures after an initial good response to drug therapy will likely be an indication of progressive BPH disease. In such patients, surgical intervention may be indicated. 

CNS, intracranial, retropharyngeal, retroperitoneal, surgical prophylaxis 80%-100% 80%-100% Factor VIII q8-12 hours over 10-14 days Factor IX q12 hours over 10-14 days... 

Additionally, the patient needs to be counseled on the necessity of prophylactic antibiotics prior to any dental or surgical procedure in order to prevent recurrent infections. This is critical in patients with risk factors that predispose them to developing IE, such as prosthetic heart valves, other valvular defects, or previous IE. 

Table 74—2 presents the recommended agents for treatment of community-acquired and complicated intraabdominal infections from the Infectious Diseases Society of America and the Surgical Infection Society.21-23 These recommendations were formulated using an evidence-based approach. Most community-acquired infections are mild to moderate, whereas health care-associated infections tend to be more severe and difficult to treat. Table 74-3 presents guidelines for treatment and alternative regimens for specific situations. These are general guidelines there are many factors that cannot be incorporated into such a table. 

In addition to medical and surgical management, non-pharmacologic interventions that reduce risk factors for developing osteomyelitis should be communicated to the patient. Examples include smoking cessation, weight-control, exercise, and good nutrition.2 Additionally, a diabetic patient... 

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. 

Refacto Antihemophilic factor Genetics Institute Hemorrhagic episodes and surgical prophylaxis in patients with hemophilia A... 

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