RESUMEN
BACKGROUND: Same-day discharge (SDD) after colectomy is feasible but requires effective post-discharge remote follow-up. Previous studies have used in-person home visits or a mobile health (mHealth) phone app, but the use of simple telephone calls for remote follow-up has not yet been studied. Therefore, the objective of this study was to compare outcomes after SDD for minimally invasive colectomy using mHealth or telephone remote post-discharge follow-up. METHODS: A prospective cohort study was undertaken at two university-affiliated colorectal referral institutions from 02/2020 to 05/2021. Adult patients without significant comorbidities undergoing elective minimally invasive colectomy. Patients were discharged on the day of surgery based on set criteria. Post-discharge remote follow-up was performed using a mHealth app at site 1 and scheduled telephone calls at site 2 up to postoperative day (POD) 7. The main outcome for this study was the success rate of SDD, defined as discharge on POD0 without emergency department (ED) visit or readmission within the first 3 days. RESULTS: A total of 105 patients were recruited (site 1, n = 70; site 2, n = 35). Overall, 75% of patients were discharged on POD0 (site 1 81% vs. site 2 63%, p = 0.038), of which only two patients required an ED visit within the first 3 days, leading to an overall success rate of 73% (site 1 80% vs. site 2 60%, p = 0.029). The incidence of 30-day complications (16% vs. 20%, p = 0.583), ED visits (11% vs. 11%, p = 1.00), and readmissions (9% vs. 14%, p = 0.367) were similar between the two sites. There was only one patient at each study site that went to the ED without instructions through remote follow-up. CONCLUSIONS: A high proportion of patients planned for SDD were discharged on POD0 with few patients requiring an early unplanned ED visit. These results were similar with an mHealth app or telephone calls for post-discharge remote follow-ups, suggesting that SDD is feasible regardless of the method of post-discharge remote follow-up.
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Cirugía Colorrectal , Telemedicina , Adulto , Humanos , Alta del Paciente , Readmisión del Paciente , Cuidados Posteriores/métodos , Estudios Prospectivos , Teléfono , América del Norte , Estudios Retrospectivos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios Multicéntricos como AsuntoRESUMEN
PURPOSE: This study sought to evaluate the impact of implementation of a comprehensive enhanced recovery after surgery (ERAS) protocol upon patients undergoing maxillary and mandibular osteotomy (MMO). METHODS: This study was a retrospective, observational study of patients undergoing MMO. The study intervention group consisted of patients who underwent MMO with utilization of ERAS protocol compared to control group without ERAS. The primary outcome measure was same-day discharge. Secondary outcome measures included hospital length-of-stay (LOS), overall dose of opioids administered, total operating room time, estimated blood loss, need for hospital admission, and complications. Descriptive statistics and multivariable analysis were computed and the P value was set at .05. RESULTS: We compared 189 patients who underwent MMO with and without genioplasty and received a comprehensive surgical and multimodal analgesic regimen to 170 control patients who underwent MMO with or without genioplasty without receiving the above protocol. There was a statistically significant decrease in hospital admission post-surgery (83.5% - control vs 22.2% - intervention) and in overall hospital length-of-stay in the intervention group. There was no change in the overall operating room time, but there was a decrease in blood loss in the intervention group. CONCLUSION: The results suggest that use of a comprehensive ERAS protocol for patients undergoing MMO will decrease hospital length-of-stay without an increase in readmissions or complications. Future studies are needed to evaluate if pain scores, postoperative nausea and vomiting, and other complications differed when using a ERAS protocol.
Asunto(s)
Recuperación Mejorada Después de la Cirugía , Cirugía Ortognática , Analgésicos Opioides/uso terapéutico , Humanos , Tiempo de Internación , Estudios Observacionales como Asunto , Alta del Paciente , Complicaciones Posoperatorias , Estudios RetrospectivosRESUMEN
PURPOSE: The use of intercostal nerve cryoablation (INC) is becoming increasingly common in patients undergoing pectus excavatum (PE) repair. This study sought to evaluate the use of INC compared to traditional use of thoracic epidural (TE). METHODS: A retrospective review of 79 patients undergoing PE repair with either INC or TE from May 2009 to December 2019 was conducted. The operations were performed by four surgeons who worked together at four different hospitals and have the same standardized practice. The primary outcome measure was hospital length of stay (LOS). Secondary variables included surgical time, total operating room time, operating room time cost, total hospital cost, inpatient opioid use, long-term opioid use after discharge, and postoperative complications. RESULTS: LOS decreased to 2.5 days in the INC group compared to 5 days in the TE group (p < 0.0001). Surgical time was increased in the INC group, but there was no difference in total OR time. The INC group experienced significantly lower hospital costs. Total hospital opioid administration was significantly lower in INC group, and there was a significant decrease in long-term opioid use in the INC group. CONCLUSIONS: INC is a newer modality that decreases LOS, controls pain, and results in overall cost savings. We recommend that INC be included in the current practice for postoperative pain control in PE patients undergoing Nuss procedure.
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Analgésicos Opioides/administración & dosificación , Criocirugía/métodos , Tórax en Embudo/cirugía , Tiempo de Internación/estadística & datos numéricos , Dolor Postoperatorio/tratamiento farmacológico , Adolescente , Adulto , Niño , Femenino , Humanos , Nervios Intercostales/cirugía , Masculino , Tempo Operativo , Complicaciones Posoperatorias , Estudios Retrospectivos , Adulto JovenAsunto(s)
Neoplasias Cardíacas/cirugía , Ventrículos Cardíacos/cirugía , Hemangioma/cirugía , Pericardio/cirugía , Arteria Pulmonar/cirugía , Obstrucción del Flujo Ventricular Externo/cirugía , Manejo de la Enfermedad , Neoplasias Cardíacas/inducido químicamente , Neoplasias Cardíacas/diagnóstico por imagen , Ventrículos Cardíacos/diagnóstico por imagen , Hemangioma/complicaciones , Hemangioma/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Pericardio/diagnóstico por imagen , Atención Perioperativa/métodos , Arteria Pulmonar/diagnóstico por imagen , Obstrucción del Flujo Ventricular Externo/diagnóstico por imagen , Obstrucción del Flujo Ventricular Externo/etiologíaAsunto(s)
Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Infecciones por Mycobacterium/etiología , Osteomielitis/etiología , Enfermedades de la Columna Vertebral/etiología , Infección de la Herida Quirúrgica/etiología , Anciano , Resultado Fatal , Humanos , Vértebras Lumbares , Imagen por Resonancia Magnética , Masculino , Mycobacterium/aislamiento & purificación , Infecciones por Mycobacterium/diagnóstico , Infecciones por Mycobacterium/microbiología , Osteomielitis/diagnóstico , Osteomielitis/microbiología , Enfermedades de la Columna Vertebral/diagnóstico , Enfermedades de la Columna Vertebral/microbiología , Infección de la Herida Quirúrgica/diagnóstico , Infección de la Herida Quirúrgica/microbiología , Vértebras TorácicasAsunto(s)
Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Puente Cardiopulmonar/métodos , Paro Circulatorio Inducido por Hipotermia Profunda/métodos , Complicaciones Cardiovasculares del Embarazo/cirugía , Ultrasonografía Prenatal/métodos , Adulto , Disección Aórtica/complicaciones , Disección Aórtica/diagnóstico por imagen , Aorta/diagnóstico por imagen , Aneurisma de la Aorta/complicaciones , Aneurisma de la Aorta/diagnóstico por imagen , Femenino , Humanos , Recién Nacido , Masculino , Embarazo , Complicaciones Cardiovasculares del Embarazo/diagnóstico por imagenRESUMEN
Administration of post-operative opioids following pediatric tonsillectomy can elicit respiratory events in this patient population that often arise as central and obstructive sleep apnea. The primary objective of this study was to determine whether a perioperative combination of dexmedetomidine and acetaminophen could eliminate post-operative (in recovery and at home) opioid requirements. Following IRB approval and a waiver for informed consent, the medical records of 681 patients who underwent tonsillectomy between 1 January 2013 and 31 December 2018 were evaluated. Between 1 January 2013 and 31 December 2015, all patients received a fentanyl-sevoflurane-based anesthetic, without acetaminophen or dexmedetomidine, and received opioids in recovery and for discharge home. On 1 January 2016, an institution-wide practice change replaced this protocol with a multimodal perioperative regimen of acetaminophen (intravenous or enteral) and dexmedetomidine and eliminated post-operative opioids. This is the first time that the effect of an acetaminophen and dexmedetomidine combination on the perioperative and home opioid requirement has been reported. Primarily, we compared the need for rescue opioids in the post-anesthesia care period and after discharge. The multi-modal protocol eliminated the need for post-tonsillectomy opioid administration. Dexmedetomidine in combination with acetaminophen eliminated the need for post-operative opioids in the recovery period.
RESUMEN
PURPOSE: Intercostal Nerve Cryoablation (INC) has significantly improved pain control following the Nuss repair of pectus excavatum (PE). This study sought to evaluate patients undergoing the Nuss repair with INC compared to the Nuss repair with an ERAS protocol, INC, and intercostal nerve blocks (INB). METHODS: In June 2020, a new protocol was implemented involving surgery, anesthesia, nursing, physical therapy, and child life with the goal of safe same day discharge for patients undergoing the Nuss repair. They were compared to a control group who underwent the Nuss repair with INC alone in 2017-2019. The primary outcome measure was hospital length of stay (LOS) in hours, secondary outcomes were number of patients discharged on postoperative day (POD) 0, and returns to the emergency department (ED), urgent care (UC), and operating room (OR). RESULTS: The characteristics between the groups were the same (Table 1). The mean LOS was 11.8 h in the INB group versus 58.2 h in the INC group, p < 0.01. 10 of 15 patients in the INB group went home on POD 0 (average of 5.5 h postop), versus 0 patients in the INC only group, p < 0.01. Five patients in the INB stayed overnight. Two patients stayed owing to anxiety, one owing to urinary retention, one owing to nausea, and one owing to drowsiness. None stayed for pain control. Four patients in the INC group returned to the ED for pain control, versus 0 in the INB group, and 1 patient in the INB returned to UC for constipation. CONCLUSIONS: The majority of patients undergoing the Nuss repair of PE with a multidisciplinary regimen of pre and postoperative nursing education, precise intraoperative anesthesia care, performance of direct vision INB and INC, as well as careful surgery can go home on the day of surgery without adverse outcomes or unanticipated returns to the hospital. LEVEL-OF-EVIDENCE: Level II.
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Anestesia de Conducción , Tórax en Embudo , Niño , Tórax en Embudo/cirugía , Humanos , Dolor Postoperatorio/etiología , Alta del Paciente , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
PURPOSE: The use of intercostal nerve cryoablation (INC) has been an effective modality for treating pain in patients undergoing pectus excavatum (PE) repair. This study sought to evaluate if PE patients undergoing Nuss procedures with INC and intercostal nerve block (INB) could safely be discharged the same day of surgery. METHODS: A prospective study with IRB approval of 15 consecutive patients undergoing PE Nuss repair with INC, INB, and an enhanced recovery after surgery (ERAS) protocol was conducted. The primary outcome measure was hospital length of stay (LOS) in hours. Secondary variables included same day discharge, postoperative complications, emergency department (ED) visits, urgent care (UC) visits, opioid use, and return to the operating room (OR). RESULTS: LOS averaged 11.9 h amongst 15 patients. Ten patients (66.7%) went home on postoperative day (POD) 0, and the rest went home on POD 1. No patients stayed in the hospital due to pain. Reasons for failure to discharge included urinary retention, drowsiness, vomiting, and anxiety, but not pain. No patients were readmitted to the ED. One patient visited UC for constipation. One patient had bar migration requiring return to the OR for revision. Ten (66.7%) patients did not use opioids after discharge. CONCLUSIONS: Same day discharge is feasible and safe in PE patients undergoing Nuss procedure with INC and INB. INC with INB can adequately control pain without significant complications. Same day discharge can be safely considered for PE patients undergoing Nuss procedure with INC with INB. TYPE OF STUDY: Prognosis study LEVEL-OF-EVIDENCE RATING: Level II.
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Tórax en Embudo , Tórax en Embudo/cirugía , Humanos , Dolor Postoperatorio/etiología , Dolor Postoperatorio/terapia , Alta del Paciente , Estudios Prospectivos , Estudios RetrospectivosRESUMEN
BACKGROUND: The impact of CD4+ T-cell count and highly active antiretroviral therapy (HAART) on the rate of surgical site infection (SSI) in patients with human immunodeficiency virus (HIV) undergoing total hip arthroplasty is still unclear. The goals of this study were to assess the rate of perioperative infection at a large tertiary care referral center and to identify risk factors in HIV+ patients undergoing total hip arthroplasty (THA). METHODS: This study was a prospective, observational study at a single medical center from 2000-2017. Patients who were HIV+ and underwent THA were followed from the preoperative assessment period, through surgery and for a 2-year follow-up period. RESULTS: Sixteen of 144 HIV+ patients (11%) undergoing THA developed perioperative surgical site infections. Fourteen patients (10%) required revision THA within a range of 12 to 97 days after the initial surgery. The patients' mean age was 49.6 ± 4.5 years, and the most common diagnosis prompting THA was osteonecrosis (96%). Patients who developed SSI had a lower waist-hip ratio (0.86 vs. 0.93, p = 0.047), lower high density lipoprotein cholesterol (45.8 vs. 52.5, p = 0.015) and were more likely to have post-traumatic arthritis (12.5% vs. 0%, p = 0.008). Logistic regression analysis demonstrated that current alcohol use and higher waist-hip ratio were significant protectors against infection (p < 0.05). No other demographic, medical, immunologic parameters, or specific HAART regimens were associated with perioperative infection. CONCLUSIONS: Immunologic status as measured by CD4+ cell count, HIV viral load, and medical therapy do not appear to influence the development of SSI in HIV+ patients undergoing THA. Metabolic factors and post-traumatic arthritis may influence the increased rate of infection in HIV+ patients following THA.
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Terapia Antirretroviral Altamente Activa , Artroplastia de Reemplazo de Cadera , Linfocitos T CD4-Positivos/metabolismo , Infecciones por VIH/complicaciones , Infecciones por VIH/tratamiento farmacológico , Infección de la Herida Quirúrgica/etiología , Adulto , Humanos , Huésped Inmunocomprometido , Persona de Mediana Edad , Estudios Prospectivos , Carga ViralRESUMEN
This case describes a parturient with Barnes syndrome, a rare disorder characterized by subglottic stenosis, thoracic dystrophy, and small pelvic inlet, who underwent cesarean delivery of a neonate diagnosed with Barnes syndrome. Live simulation training was performed by multidisciplinary team to prepare for the spinal anesthetic, personnel flow between 2 operating rooms, and management of various airway scenarios for the newborn. After delivery, the neonate underwent laryngoscopy-bronchoscopy with successful intubation in the operating room because of labored breathing. Airway evaluation revealed subglottic stenosis, tracheomalacia/bronchomalacia. Collaboration among perinatologists, obstetric/pediatric anesthesiologists, pediatric head and neck surgeons, and neonatologists was integral to perioperative management of both the mother and child.
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Anomalías Múltiples/cirugía , Asfixia Neonatal/cirugía , Cesárea/métodos , Laringe/anomalías , Osteocondrodisplasias/cirugía , Pelvis/anomalías , Tórax/anomalías , Adulto , Broncoscopía , Manejo de la Enfermedad , Femenino , Humanos , Recién Nacido , Intubación Intratraqueal , Laringoscopía , Laringe/cirugía , Pelvis/cirugía , Sistemas de Atención de Punto , Embarazo , Entrenamiento SimuladoRESUMEN
We have recently reported that the RD114-pseudotyped MFGS-gp91phox vector achieves unprecedented levels of correction of the NADPH-oxidase gp91phox (approved gene symbol CYBB) defect in CD34(+) cells from patients with X-linked chronic granulomatous disease in the NOD/SCID mouse model. Considering clinical use of this vector, we transplanted autologous mobilized peripheral blood CD34(+) progenitor cells, transduced with the RD114-MFGS-gp91phox vector, into two healthy rhesus macaques following nonmyeloablative conditioning. The moderately high levels of in vivo marking seen in the first months following transduction decreased and stabilized at about 8 months posttransplant. Marking for both healthy animals after 15 months was 0.3 to 1.3 vector copies per 100 cells in lymphocytes, neutrophils, and monocytes. Vector insertion analyses performed by linear amplification-mediated PCR and sequencing identified 32 and 45 separate insertion sites in the animals. Identical insertion sites were found in myeloid cells and lymphocytes, demonstrating the successful transduction of lymphomyeloid progenitors. Some inserts landed in the vicinity of genes controlling cell cycle and proliferation. Statistical analyses of insertion sites 1 year posttransplant suggest a high diversity of insertion sites despite low marking.
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Trasplante de Células Madre Hematopoyéticas , Células Madre Hematopoyéticas , Glicoproteínas de Membrana/genética , NADPH Oxidasas/genética , Transducción Genética , Animales , Antígenos CD34/análisis , Gammaretrovirus/genética , Dosificación de Gen , Vectores Genéticos , Macaca mulatta , Masculino , NADPH Oxidasa 2 , Transgenes , Acondicionamiento Pretrasplante , Trasplante Autólogo , Integración Viral , Irradiación Corporal TotalRESUMEN
Hematopoietic stem cells (HSCs) lose marrow reconstitution potential during ex vivo culture. HSC migration to stromal cell-derived factor (SDF)-1 (CXCL12) correlates with CXC chemokine receptor 4 (CXCR4) expression and marrow engraftment. We demonstrate that mobilized human CD34+ peripheral blood stem cells (CD34+ PBSCs) lose CXCR4 expression during prolonged culture. We transduced CD34+ PBSCs with retrovirus vector encoding human CXCR4 and achieved 18-fold more CXCR4 expression in over 87% of CD34+ cells. CXCR4-transduced cells yielded increased calcium flux and up to a 10-fold increase in migration to SDF-1. Six-day cultured CXCR4-transduced cells demonstrated significant engraftment in nonobese diabetic/severe combined immunodeficient mice under conditions in which control transduced cells resulted in low or no engraftment. We conclude that transduction-mediated overexpression of CXCR4 significantly improves marrow engraftment of cultured PBSCs.