Discharge on the first postoperative day after elective carotid endarterectomy.

BACKGROUND: Medical complications may prolong the hospital stay after elective carotid endarterectomy (CEA). We prospectively assessed the social and medical feasibility and safety of patient discharge on the first postoperative day after elective CEA and unplanned readmissions. METHODS: Between June 2011 and January 2012, 57 consecutive patients scheduled for elective CEA were enrolled with the aim of discharge on the first postoperative day if there were no medical contraindications and on the condition that the patient should not be left alone during the first day and night at home. CEA was carried out under local or general anesthesia. After discharge, the patients were contacted to ascertain the occurrence of arterial hypertension, cerebral hyperperfusion, focal cerebral ischemia, or hospital readmission. RESULTS: Sixty-two CEA were carried out in 57 patients (33 men and 24 women ranging in age from 51-89 years). The indications for CEA were: asymptomatic high grade stenosis in 27, hemispheric transient ischemic attack in 12, amaurosis fugax in 6, recovered stroke in 16, and nonlateralizing signs in 1. There were no cases of perioperative stroke or death. Discharge on the first postoperative day was achieved in 45 cases (73%). In 15 cases (24%), discharge was on the second postoperative day because of the absence of a relative (12 cases) or for medical reasons (3 cases). Discharge was on day 3 in 1 case, and on day 10 in another, both for medical reasons. No cases of severe arterial hypertension, stroke, mortality, or readmission for reasons related to the CEA procedure were recorded up to postoperative day 30. CONCLUSION: In this study, the majority of patients undergoing elective CEA were discharged safely on the first postoperative day. Social reasons, rather than medical reasons, underlied most cases of later discharge. There were no unplanned readmissions for complications of CEA.

Establishing the learning curve for a tunneled dialysis catheter placement.

PURPOSE: To determine how many procedures a surgical trainee requires before they are able to place a tunneled double-lumen dialysis catheter safely on their own. METHODS: Surgical trainees unfamiliar with the procedure received a pre-operative briefing in which we explained 1) why, how, and in what particular order each operational step should be executed and 2) what the possible pitfalls/complications are. Next, an experienced surgeon demonstrated the procedure with the trainee scrubbed-in as their assistant. The trainee then performed all successive procedures, while the supervising surgeon acted as a silent observer and intervened only when an error was made. We recorded all errors as well as near misses and noted if they were severe, recurrent or unanticipated. At least three procedures were required but training was continued until less than three errors were made. RESULTS: Ten trainees were included in the study. On average, a trainee made 11.9 mistakes during 3.4 procedures in a time span of 28.2 days. Only three trainees performed their last procedure flawlessly. The number of errors decreased exponentially from the first procedure onwards (P<.001). A statistically significant correlation was found between the number of mistakes and the number of days since the last procedure (P<.035). Unanticipated errors most frequently involved erroneous fluoroscopy interpretation, flushing with blood-contaminated saline, and incorrect volume injection for the heparin lock. CONCLUSIONS: A theoretically well-prepared surgical trainee should be able to perform the placement of a tunneled dialysis catheter safely after four procedures. Training is more efficient when procedures follow each other quickly.