Faculty Bibliography

GENERAL PURPOSE: To provide information on risk factors for surgical site infections (SSIs) and actions to mitigate that risk. TARGET AUDIENCE: This continuing education activity is intended for surgeons, surgical teams, physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Identify modifiable risk factors associated with the development of SSIs.2. Select steps to mitigate the risks for and morbidity from SSIs. ABSTRACT: Given the current reimbursement structure, the avoidance of a surgical site infection (SSI) is crucial. Although many risk factors are associated with the formation of an SSI, a proactive and interprofessional approach can help modify some factors. Postoperative strategies also can be applied to help prevent an SSI. If an SSI becomes a chronic wound, there are recommended guidelines and strategies that can foster healing.

With the rising epidemic of obesity, interventional radiologists are treating increasing numbers of obese patients, as comorbidities associated with obesity preclude more invasive treatments. These patients are at heightened risk of vascular and oncologic disease, both of which often require interventional radiology care. Obese patients pose unique challenges in imaging, technical feasibility, and periprocedural monitoring. This review describes the technical and clinical challenges posed by this population, with proposed methods to mitigate these challenges and optimize care.

The bispectral (BIS) monitor uses brain electroencephalographic data to measure the depth of sedation and pharmacological response during anaesthetic procedures. In this case, the BIS monitor was used for another purpose, to demonstrate postoperatively to the nursing staff that a patient with history of locked-in syndrome (LIS), who underwent pressure ulcer debridement, had periods of wakefulness and apparent sensation, even with his eyes closed. Furthermore, as patients with LIS can feel pain, despite being unable to move, local block or general anaesthesia should be provided for sharp surgical debridement and other painful procedures. This use of the BIS has shown that as a general rule, the staff should treat the patient as though he might be awake and sensate even if he does not open his eyes or move his limbs. The goal of this study was to continuously monitor pain level and communicate these findings to the entire wound team, i.e. anaesthesiologists, surgeons and nurses.

Highly active antiretroviral therapy has dramatically reduced morbidity and mortality among patients who are HIV-positive. A retrospective review of the authors' data separated subjects into cohorts based on HIV status and matched them for age and gender. The authors' data reveal a higher fraction of venous ulcers compared with a lower fraction of pressure ulcers in the seropositive population.

A treatment challenge for patients with sacral pressure ulcers is balancing the need for adequate surgical debridement with appropriate anaesthesia management. We are functioning under the hypothesis that regional anaesthesia has advantages over general anaesthesia. We describe our regional anaesthesia protocol for perioperative and postoperative management.

INTRODUCTION: The objective of this study was to determine the effects of isoproterenol infusion on level of consciousness during ablation using total intravenous anesthesia. METHODS AND RESULTS: Seven patients undergoing total intravenous anesthesia for atrial fibrillation ablation were monitored for level of consciousness using bispectral EEG levels (BIS). Isoproterenol infusion was performed after the ablation during anesthesia. BIS levels prior to, during, and post-isoproterenol infusion were recorded and correlated to isoproterenol infusion doses. In all patients, BIS levels significantly increased during isoproterenol infusion (median BIS prior to infusion, 46; during infusion, 64 (p < 0.02)). With a subsequent increase in anesthetic medication, BIS levels could again be reduced. CONCLUSION: Isoproterenol infusion alters consciousness level during total intravenous anesthesia for atrial fibrillation ablation. BIS monitoring is a novel way to modulate anesthesia during ablation to potentially optimize patient comfort and ablation success.

Hydroxyurea (HU) has been shown to induce a variety of cutaneous adverse reactions, including severe leg ulcers. This report shows a successful treatment of a HU-induced chronic wound associated with squamous cell carcinomas (SCC). A 62-year-old patient affected with polycythemia vera and treated with HU for 10 years, presented with a non healing ulcer on a left heel. The patient gave a history of suffering from the wound for over 2 years. Biopsy showed evidence of invasive SCC. The patient underwent Mohs surgery and a greater saphenous vein ablation for polycythemia vera-associated vascular complications. The wound consistently decreased in size following successive debridements and coverage with human skin equivalent. The wound healed completely after a 6-month period. A multidisciplinary team approach to the treatment proved to be effective resulting in healing of this multifactorial chronic ulcer.

ABSTRACT: Heel ulcers are clinically challenging. Limited subcutaneous tissue covering the calcaneus bone makes the heel vulnerable to pressure injury. Adequate debridement of fibrotic, infected, and necrotic tissue is essential for healing. The authors report a standardized anesthesia protocol using regional anesthesia with sedation rather than general anesthesia for heel debridement.