The root cause of the majority of wrong-site surgeries result from:
The risk of performing wrong-site surgery increases when there are multiple surgeons involved in the same operation or multiple procedures are performed on the same patient, especially if the procedures are scheduled or performed on different areas of the body. Time pressure, emergency surgery, abnormal patient anatomy, and morbid obesity are also thought to be risk factors. Communication errors are the root cause in more than 70% of the wrong-site surgeries reported to The Joint Commission. Other risk factors include receiving an incomplete preoperative assessment; having inadequate procedures in place to verify the correct surgical site; or having an organizational culture that lacks teamwork or reveres the surgeon as someone whose judgment should never be questioned.
Which of the following have been shown to decrease the time of postoperative ileus?
Pharmacologic agents commonly used to stimulate bowel function include metoclopramide and erythromycin. Metoclopramide's action is limited to the stomach and duodenum, and it may help primarily with gastroparesis. Erythromycin is a motilin agonist that works throughout the stomach and bowel. Several studies demonstrate significant benefit from the administration of erythromycin in those suffering from an ileus. Alvimopan, a newer agent and a mu-opioid receptor antagonist, has shown some promise in many studies for earlier return of gut function and subsequent reduction in length of stay. Neostigmine has been used in refractory pan-ileus patients (Ogilvie syndrome) with some degree of success. It is recommended for patients receiving this type of therapy to be in a monitored unit.
In order to reduce the overall risk of stress gastritis in ICU patients mechanically ventilated for >48 hours, their gastric pH level should be kept greater than:
When patients in the ICU have a major bleed from stress gastritis, the mortality risk is as high as 50%. It is important to keep the gastric pH greater than 4 to decrease the overall risk for stress gastritis in patients mechanically ventilated for 48 hours or greater and patients who are coagulopathic. Proton pump inhibitors, H2-receptor antagonists, and intragastric antacid installation are all effective measures. However, patients who are not mechanically ventilated or who do not have a history of gastritis or peptic ulcer disease should not be placed on gastritis prophylaxis postoperatively because it carries a higher risk of causing pneumonia.
The treatment of choice for a biloma after laparoscopic cholecystectomy is:
A bile leak due to an unrecognized injury to the ducts may present after cholecystectomy as a biloma. These patients may present with abdominal pain and hyperbilirubinemia. The diagnosis of a biliary leak can be confirmed by computed tomography (CT) scan, endoscopic retrograde cholangiopancreaticogram (ERCP), or radionuclide scan. Once a leak is confirmed, a retrograde biliary stent and external drainage are the treatment of choice.
The most frequent nosocomial infection is:
The most frequent nosocomial infection is urinary tract infection (UTI). These infections are classified into complicated and uncomplicated forms. The uncomplicated type is a UTI that can be treated with outpatient antibiotic therapy. The complicated UTI usually involves a hospitalized patient with an indwelling catheter whose UTI is diagnosed as part of a fever workup. The interpretation of urine culture results of less than 100,000 CFU/mL is controversial. Before treating such a patient, one should change the catheter and then repeat the culture to see whether the catheter was simply colonized with organisms. Cultures with more than 100,000 CFU/mL should be treated with the appropriate antibiotics and the catheter should be changed or removed as soon as possible. Under-treatment or misdiagnosis of a UTI can lead to urosepsis and septic shock.
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