Same day admission for elective cardiac surgery: how to improve outcome with satisfaction and decrease expenses.

Admission on the day of surgery for elective cardiac and non-cardiac surgery has been established as a prevalent, critical practice. This approach realizes medical, logistical, psychological and fiscal benefits, and its success is predicated on an effective outpatient pre-operative evaluation. The establishment of a highly functional pre-operative clinic with a comprehensive set-up and efficient logistical pathways is invaluable. This notion has been expanded in recent years to include the entire peri-operative period and the concept of a 'peri-operative anesthesia/surgical home' is gaining popularity and support. Evaluating patients prior to admission for surgery, anesthesiologists can place themselves at the forefront of reducing unnecessary pre-operative hospital admissions, excess lab tests, unneeded consultations, and ultimately decrease the cancellations on the day of surgery. Furthermore, by taking a leadership role in the pre-operative clinic, anesthesiologists place themselves squarely at the forefront of the burgeoning movement for the peri-operative surgical home and continue to cement the indispensability of the anesthesiologist during the entire peri-operative course. The authors present this review as a follow-up describing the successful implementation of a pre-operative same-day cardiac surgery clinic and offer these experiences over the last 8 years as a guide to helping other anesthesiologists do the same.

The year in cardiothoracic and vascular anesthesia: selected highlights from 2013.

This article reviewed selected research highlights of 2013 that pertain to the specialty of cardiothoracic and vascular anesthesia. The first major theme is the commemoration of the sixtieth anniversary of the first successful cardiac surgical procedure with cardiopulmonary bypass conducted by Dr Gibbon. This major milestone revolutionized the practice of cardiovascular surgery and invigorated a paradigm of mechanical platforms for contemporary perioperative cardiovascular practice. Dr Kolff was also a leading contributor in this area because of his important contributions to the refinement of cardiopulmonary bypass and mechanical ventricular assistance. The second major theme is the diffusion of echocardiography throughout perioperative practice. There are now guidelines and training pathways to guide its generalization into everyday practice. The third major theme is the paradigm shift in perioperative fluid management. Recent large randomized trials suggest that fluids are drugs that require a precise prescription with respect to type, dose, and duration. The final theme is patient safety in the cardiac perioperative environment. A recent expert scientific statement has focused attention on this issue because most perioperative errors are preventable. It is likely that clinical research in this area will blossom because this is a major opportunity for improvement in our specialty. The patient care processes identified in these research highlights will further improve perioperative outcomes for our patients.

Preoperative cardiac risk assessment for noncardiac surgery: defining costs and risks.

Cardiac risk stratification before noncardiac surgery remains important. Two major areas have been emphaized, namely, cost-effective risk stratification and enhanced identification of high risk populations. Recent studies have highlighted the lack of quality and affordable medical consultation. The indications for resting preoperative echocardiography merit streamlining, given recent data that failed to demonstrate tangible benefit. Further more, noninvasive cardiac stress testing is expensive and unnecessary in low risk patients. Perioperative troponin determination significantly improves the detection of myocardial infarction, facilitating its early management. The revised cardiac risk index is a standard tool for risk stratification, despite multiple limitations. The first approach has been tore calibrate the traditional risk index to specific high-risk surgical subgroups. The second approach has been to develop new cardiac risk models with more power. Both approaches have yielded risk calculators that out perform the traditional risk model. Furthermore, this latest generation of risk models is available as online calculators that can be accessed at the bedside. Further clinical trials are indicated to test the validity, clinical utility, and cost-effectiveness of these novel risk calculators. It is likely that these powerful instruments will refine the indications for specialized cardiac testing, offering multiple opportunities to reduce perioperative risk and cost simultaneously.

Use of the BATHE method in the preanesthetic clinic visit.

BACKGROUND: In the primary care setting, use of the BATHE (Background, Affect, Trouble, Handling, and Empathy) method of interviewing has been shown to increase patient satisfaction. This technique is a brief psychotherapeutic method used to address patients' physical and psychosocial problems. The BATHE technique has not been evaluated in the perioperative setting as a way of improving patient satisfaction. In this study, we sought to determine whether satisfaction could be enhanced by use of the BATHE technique during the preoperative evaluation by anesthesiologists. METHODS: Fifty cardiac and 50 general surgery patients were interviewed in the preanesthesia clinic (PAC) of an academic hospital. They were randomly enrolled in the BATHE group or the control group and asked to complete an anonymous satisfaction survey after their visit. This survey was modified from current studies and not validated elsewhere. The relative influence of the BATHE condition was examined as it pertained to interview duration, patient satisfaction, and patient report of the BATHE items being asked. RESULTS: Ninety-two percent of patients approached by the study group voluntarily enrolled. Patients interviewed using the BATHE method reported being asked about all BATHE questions significantly more often than control patients: t(98)=19.10, P=0.001 (95% confidence interval [CI]=2.59, 3.20). Patients in the BATHE group were more satisfied with their visit to the PAC than those in the control group: t(98)=5.37, P=0.001 (95% CI=0.19, 0.41). The use of the BATHE method did not significantly increase the amount of time physicians spent evaluating patients: t(98)=0.110, P=0.912 (95% CI=-1.519, 1.359). CONCLUSIONS: Use of the BATHE method in an academic medical center's cardiac and general PAC showed promising results in this preliminary study. A validated and fully developed survey instrument is needed before we can convincingly conclude that the BATHE method is an effective way of improving patient satisfaction.

The anaesthetic management of patients with thoracic ascending aortic aneurysms: A review.

Thoracic aortic aneurysms present significant challenges to clinicians, especially due to their complex nature and an evolving understanding of the safest and most effective ways to manage this condition in the perioperative setting. Thoracic aortic aneurysms have a prevalence rate of 1.3-8.9% in men and 1.0-2.2% in women, and they are estimated to affect more than five per 100,000 person-years. This is notable because the complications of thoracic aortic aneurysms can be catastrophic. The current understanding of the optimal intraoperative management of thoracic aortic aneurysms is changing, as more evidence becomes available regarding lung protective ventilation and its role in enhancing patient safety and wellbeing. This review strives to provide a brief historical understanding of thoracic aortic aneurysms and highlight some of the key discoveries and advances in the management of this condition. This review then describes an overview of the general anaesthetic principles associated with thoracic aortic aneurysms, including ventilatory modalities and how these impact a patient's physiology and intraoperative haemodynamics. A brief discussion on one-lung ventilation is then provided, drawing from current literature in the field, to describe the most up-to-date management of thoracic aortic aneurysms.

Dental clearance and postoperative heart infections: Observations from a preoperative evaluation clinic for day-admission surgery.

Every year, two-million hospitalised patients develop healthcare-associated infections with a consequent mortality eclipsing 90,000. The literature suggests that dental infections are one of many potential sources of these infections and may be associated with an increased risk of endocarditis in surgical patients, especially those undergoing cardiac procedures, though some studies have conversely shown no heightened risk of cardiac infections in patients forgoing pre-surgical dental screenings. We sought to elucidate whether patients seen at our preoperative evaluation clinic who obtained pre-surgical dental clearance experienced improved outcomes compared to those who did not receive dental clearance prior to their surgical interventions. The medical records of 196 consecutive patients were reviewed who were seen at the pre-anaesthesia evaluation prior to elective cardiac surgery from July 2017 to February 2018. Of this cohort, 102 patients had pre-surgical dental clearance, while 94 did not have dental clearance. Preoperative demographic and comorbidity data were analysed using independent t-tests. We found no significant differences between these group in terms of post-operation infections (zero instances versus four instances, p > 0.05), length of intensive care unit stay (two days versus two days, p = 0.815), or mortality associated with elective cardiac procedures (zero instances). Further evaluation of preoperative dental clearance and its potential to prevent morbidity (e.g. postoperative infections) is warranted.

Excellent results of cardiac surgery in patients with previous kidney transplantation.

OBJECTIVES: Patients with a kidney allograft are at high risk for the development of cardiovascular diseases that may require surgical intervention. Little is known about the outcome of cardiac surgery in these patients. DESIGN: A retrospective study. SETTING: A university hospital (single institution). PARTICIPANTS: Twenty-nine patients with a kidney allograft who underwent cardiac surgery between January 1998 and December 2006. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Main outcome measures were hospital mortality, postoperative complications, allograft function, and late survival. Twenty-nine patients (mean age, 53 +/- 14 years; 18 (62%) male; 22 preserved allograft function, 2 acute failure, and 5 chronic failure) were identified. Hospital mortality was 3.4% (n = 1). Temporary allograft dysfunction determined by a >30% increase of creatinine and blood urea nitrogen was noticed in 5 (23%) patients with preserved allograft and recovered before discharge. Two patients required postoperative dialysis (1 temporary and 1 permanent). Six (21%) other major complications occurred and included respiratory failure (n = 4, 14%) and sepsis (n = 2, 7%). One- and 5-year survival was 89% +/- 6% and 50% +/- 14%, respectively. Four of 9 patients who died during follow-up had chronic allograft failure. CONCLUSIONS: Cardiac surgery can be performed safely in kidney transplant recipients with low mortality and acceptable morbidities. Allograft dysfunction is a common finding, but it is transient with early functional recovery. Late survival of kidney recipients with chronic allograft failure undergoing cardiac procedures is limited when compared with that of the general cardiac surgery population. The present data suggest that these patients should be considered for cardiac surgery in reference centers with expertise in complex cardiac procedures and perioperative management of these highly specific patients.

Epidemiology of deep sternal wound infection in cardiac surgery.

OBJECTIVES: The aim of this study was to investigate the incidence and predictors of deep sternal wound infection (DSWI) in a contemporary cohort of patients undergoing cardiac surgery. The early and late outcomes of patients with this complication also were analyzed. DESIGN: A retrospective study of consecutive patients undergoing cardiac surgery using a computerized database based on the New York State Department of Health registry. Data collection was performed prospectively. SETTING: A university hospital (single institution). PARTICIPANTS: Five thousand seven hundred ninety-eight patients who underwent cardiac surgery between January 1998 and December 2005 including isolated coronary artery bypass graft (CABG) (n = 2,749, 47%), single- or multiple-valve surgery (n = 1,280, 22%), combined valve and CABG procedures (n = 934, 16%), and surgery involving the ascending aorta or the aortic arch (n = 835, 15%). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The overall incidence of DSWI was 1.8% (n = 106). The highest rate of DSWI occurred after combined valve/CABG surgery (2.4%, n = 22) and aortic procedures (2.4%, n = 19). Multivariate analysis revealed 11 predictors of DSWI: obesity (odds ratio [OR] = 2.2), previous myocardial infarction (OR = 2.1), diabetes (OR = 1.7), chronic obstructive pulmonary disease (OR = 2.3), preoperative length of stay >3 days (OR = 1.9), aortic calcification (OR = 2.7), aortic surgery (OR = 2.4), combined valve/CABG procedures (OR = 1.9), cardiopulmonary bypass time (OR = 1.8), re-exploration for bleeding (OR = 6.3), and respiratory failure (OR = 3.2). The mortality rate was 14.2% (n = 15) versus 3.6% (n = 205) in the control group (p < 0.001). One- and 5-year survival after DSWI were significantly decreased (72.4% +/- 4.4% and 55.8% +/- 5.6% v 93.8% +/- 0.3% and 82.0% +/- 0.6%, p < 0.001). CONCLUSION: DSWI remains a rare but devastating complication and is associated with significant comorbidity, increased hospital mortality, and reduced long-term survival.