Enhanced Recovery After Cardiac Surgery: A Propensity-Matched Analysis.

Enhanced Recovery After Surgery (ERAS) pathways have improved clinical outcomes, cost-effectiveness, and patient satisfaction across multiple non-cardiac surgical specialties. Since the adaptation of ERAS in cardiac surgery is rapidly increasing yet still evolving, herein, we demonstrate early results of our implementation of ERAS cardiac guidelines. We retrospectively reviewed all patients who were managed with our institutional ERAS Cardiac Surgery guidelines between 5/2018 and 6/2019(N = 102). Postoperative primary outcomes (total ventilation times(hours), intensive-care unit(ICU) stay, and postoperative hospital length of stay (LOS)) were compared to 1:1 propensity matched controls from the pre ERAS era between January 2017 and March 2019. A total of 76 propensity-matched pairs were identified. Compared to the matched controls, ERAS patients had significantly shorter median ventilation times(3.5 vs. 5.3 hours, p = .01), ICU stays(median 28 vs 48 hours, p=.005) and postoperative hospital LOS (median 5 vs. 6 days, p = .03). There were no operative mortalities and no significant differences in 30-day readmission rates. There were also no significant differences in post-operative stroke, acute kidney injury, atrial fibrillation, and reoperation rates for bleeding. Two-year survival was also not statistically different between the two cohorts (p = .22). Our initial experience with implementation of ERAS protocols in cardiac surgery appear to demonstrate that these protocols are associated with shorter ventilation times, ICU stay, and hospital LOS without compromising patient outcomes. While these results are promising yet preliminary, further studies are warranted to demonstrate whether ERAS algorithms in cardiac surgery can consistently expedite postoperative recovery and improve outcomes.

Ten-year clinical experience of humanitarian cardiothoracic surgery in Rwanda: Building a platform for ultimate sustainability in a resource-limited setting.

OBJECTIVE: Despite its near complete eradication in resource-rich countries, rheumatic heart disease remains the most common acquired cardiovascular disease in sub-Saharan Africa. With a ratio of physicians/population of 1 per 10,500, including only 4 cardiologists for a population of 11.4 million, Rwanda represents a resource-limited setting lacking the local capacity to detect and treat early cases of strep throat and perform lifesaving operations for advanced rheumatic heart disease. Humanitarian surgical outreach in this region can improve the delivery of cardiovascular care by providing sustainability through mentorship, medical expertise, training, and knowledge transfer, and ultimately the creation of a cardiac center. METHODS: We describe the experience of consecutive annual visits to Rwanda since 2008 and report the outcomes of a collaborative approach to enable sustainable cardiac surgery in the region. The Ferrans and Powers Quality of Life Index tool's Cardiac Version (http://www.uic.edu/orgs/qli/) was administered to assess the postoperative quality of life. RESULTS: Ten visits have been completed, performing 149 open procedures, including 200 valve implantations, New York Heart Association class III or IV, with 4.7% 30-day mortality. All procedures were performed with the participation of local Rwandan personnel, expatriate physicians, nurses, residents, and support staff. Early complications included cerebrovascular accident (n = 4), hemorrhage requiring reoperation (n = 6), and death (n = 7). Quality of life was assessed to further understand challenges encountered after cardiac surgery in this resource-limited setting. Four major domains were considered: health and functioning, social and economic, psychologic/spiritual, and family. The mean total quality of life index was 20.79 ± 4.07 on a scale from 0 to 30, for which higher scores indicated higher quality of life. Women had significantly lower "social and economic" subscores (16.81 ± 4.17) than men (18.64 ± 4.10) (P < .05). Patients who reported receiving their follow-up care in rural health centers also had significantly lower "social and economic" subscores (15.67 ± 3.81) when compared with those receiving follow-up care in urban health facilities (18.28 ± 4.16) (P < .005). Value afforded to family and psychologic factors remained high among all groups. Major postsurgical challenges faced included barriers to follow-up and systemic anticoagulation. CONCLUSIONS: This report represents the first account of a long-term humanitarian effort to develop sustainability in cardiac surgery in a resource-limited setting, Rwanda. With the use of volunteer teams to deliver care, transfer knowledge, and mentor local personnel, the results demonstrate superior outcomes and favorable indices of quality of life. The credibility gained over a decade of effort has created the opportunity for a partnership with Rwanda to establish a dedicated center of cardiac care to assist in mitigating the burden of cardiovascular disease throughout sub-Saharan Africa.

Preoperative paravertebral blocks for the management of acute pain following mastectomy: a cost-effectiveness analysis.

PURPOSE: Preoperative paravertebral blocks (PPVBs) are routinely used for treating post-mastectomy pain, yet uncertainties remain about the cost-effectiveness of this modality. We aim to evaluate the cost-effectiveness of PPVBs at common willingness-to-pay (WTP) thresholds. METHODS: A decision analytic model compared two strategies: general anesthesia (GA) alone versus GA with multilevel PPVB. For the GA plus PPVB limb, patients were subjected to successful block placement versus varying severity of complications based on literature-derived probabilities. The need for rescue pain medication was the terminal node for all postoperative scenarios. Patient-reported pain scores sourced from published meta-analyses measured treatment effectiveness. Costing was derived from wholesale acquisition costs, the Medicare fee schedule, and publicly available hospital charge masters. Charges were converted to costs and adjusted for 2016 US dollars. A commercial payer perspective was adopted. Incremental cost-effectiveness ratios (ICERs) were evaluated against WTP thresholds of $500 and $50,000 for postoperative pain control. RESULTS: The ICER for preoperative paravertebral blocks was $154.49 per point reduction in pain score. 15% variation in inpatient costs resulted in ICER values ranging from $124.40-$180.66 per pain point score reduction. Altering the probability of block success by 5% generated ICER values of $144.71-$163.81 per pain score reduction. Probabilistic sensitivity analysis yielded cost-effective trials 69.43% of the time at $500 WTP thresholds. CONCLUSION: Over a broad range of probabilities, PPVB in mastectomy reduces postoperative pain at an acceptable incremental cost compared to GA. Commercial payers should be persuaded to reimburse this technique based on convincing evidence of cost-effectiveness.

Endovascular repair of abdominal aortic aneurysms.

Endovascular repair of abdominal aortic aneurysms is an important technique in the vascular surgeon's armamentarium, which has created a seismic shift in the management of aortic pathology over the past two decades. In comparison to traditional open repair, the endovascular approach is associated with significantly improved perioperative morbidity and mortality. The early survival benefit of endovascular abdominal aortic aneurysm repair is sustained up to 3 years postoperatively, but longer-term life expectancy remains poor regardless of operative modality. Nonetheless, most abdominal aortic aneurysms are now repaired using endovascular stent grafts. The technology is not perfect as several postoperative complications, namely endoleak, stent-graft migration, and graft limb thrombosis, can develop and therefore lifelong imaging surveillance is required. In addition, a postoperative inflammatory response has been documented after endovascular repair of aortic aneurysms; the clinical significance of this finding has yet to be determined. Subsequently, the safety and applicability of endovascular stent grafts are likely to improve and expand with the introduction of newer-generation devices and with the simplification of fenestrated systems.

The pathophysiology of aortic cross-clamping.

During open aortic surgery, interrupting the blood flow through the aorta by applying a cross-clamp is often a key step to allow for surgical repair. As a consequence, ischemia is induced in parts of the body distal to the clamp site. This significant alteration in the blood flow is almost always associated with hemodynamic changes. Upon release of the cross-clamp, the blood flow is restored, triggering an ischemia-reperfusion response, leading to many pathophysiological processes such as inflammation, humoral changes, and metabolite circulation that could lead to injury in many organ systems and may significantly influence the postoperative outcome. It is therefore important to understand these processes and how they can be treated in order to allow for safe surgical aortic repairs while ensuring the best possible outcomes.

A behaviourally anchored rating scale for evaluating the use of the WHO surgical safety checklist: development and initial evaluation of the WHOBARS.

BACKGROUND: Realising the full potential of the WHO Surgical Safety Checklist (SSC) to reduce perioperative harm requires the constructive engagement of all operating room (OR) team members during its administration. To facilitate research on SSC implementation, a valid and reliable instrument is needed for measuring OR team behaviours during its administration. We developed a behaviourally anchored rating scale (BARS) for this purpose. METHODS: We used a modified Delphi process, involving 16 subject matter experts, to compile a BARS with behavioural domains applicable to all three phases of the SSC. We evaluated the instrument in 80 adult OR cases and 30 simulated cases using two medical student raters and seven expert raters, respectively. Intraclass correlation coefficients were calculated to assess inter-rater reliability. Internal consistency and instrument discrimination were explored. Sample size estimates for potential study designs using the instrument were calculated. RESULTS: The Delphi process resulted in a BARS instrument (the WHOBARS) with five behavioural domains. Intraclass correlation coefficients calculated from the OR cases exceeded 0.80 for 80% of the instrument's domains across the SSC phases. The WHOBARS showed high internal consistency across the three phases of the SSC and ability to discriminate among surgical cases in both clinical and simulated settings. Fewer than 20 cases per group would be required to show a difference of 1 point between groups in studies of the SSC, where α=0.05 and ß=0.8. CONCLUSION: We have developed a generic instrument for comprehensively rating the administration of the SSC and informing initiatives to realise its full potential. We have provided data supporting its capacity for discrimination, internal consistency and inter-rater reliability. Further psychometric evaluation is warranted.