Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study.

OBJECTIVE: To evaluate the effect of implementation of the WHO's Surgical Safety Checklist on mortality and to determine to what extent the potential effect was related to checklist compliance. BACKGROUND: Marked reductions in postoperative complications after implementation of a surgical checklist have been reported. As compliance to the checklists was reported to be incomplete, it remains unclear whether the benefits obtained were through actual completion of a checklist or from an increase in overall awareness of patient safety issues. METHODS: This retrospective cohort study included 25,513 adult patients undergoing non-day case surgery in a tertiary university hospital. Hospital administrative data and electronic patient records were used to obtain data. In-hospital mortality within 30 days after surgery was the main outcome and effect estimates were adjusted for patient characteristics, surgical specialty and comorbidity. RESULTS: After checklist implementation, crude mortality decreased from 3.13% to 2.85% (P = 0.19). After adjustment for baseline differences, mortality was significantly decreased after checklist implementation (odds ratio [OR] 0.85; 95% CI, 0.73-0.98). This effect was strongly related to checklist compliance: the OR for the association between full checklist completion and outcome was 0.44 (95% CI, 0.28-0.70), compared to 1.09 (95% CI, 0.78-1.52) and 1.16 (95% CI, 0.86-1.56) for partial or noncompliance, respectively. CONCLUSIONS: Implementation of the WHO Surgical Checklist reduced in-hospital 30-day mortality. Although the impact on outcome was smaller than previously reported, the effect depended crucially upon checklist compliance.

The left gastric artery as an in-situ conduit in coronary artery bypass grafting.

Unsuitability of the in-situ right gastroepiploic artery in coronary bypass grafting occurs. Sometimes free-grafting can be performed, although this should not be considered in patients with a diseased ascending aorta. We describe the successful use of the left gastric artery as an alternative in-situ arterial conduit in a patient with a severely atherosclerotic ascending aorta.

When and how to shunt the coronary circulation in off-pump coronary artery bypass grafting.

OBJECTIVE: To assess the sequelae of temporary coronary artery occlusion in off-pump, beating heart CABG, i.e. ischemia, hemodynamic instability and the need for conversion to cardiopulmonary bypass. METHODS: In 200 patients (150 male), mean age 60 (range 35-81) years, 365 distal anastomoses were performed, i.e. 1.8 anastomoses per patient through limited and full access. One hundred seventy six LAD, 61 diagonal, 71 RCA, 7 RPD and 50 circumflex branches were grafted. Patients were pretreated with calcium antagonists, long-acting beta-blockade and had thoracic epidural blockade. The anastomosis was constructed using two microvascular clamps, preceded by ischemic preconditioning in non-occlusive disease. Myocardial ischemia was defined as > 1 mm S-T segment elevation. A simple aorto-coronary shunt, consisting of two intravenous catheters and a 10 cm connecting tube (flow > 20 ml/min), was used in critical ischemia. RESULTS: Ischemia occurred during 35 (10%) temporary coronary artery occlusions. Fifteen of these (43%) were RCA. In five of these 15 patients, all with non-occlusive disease, critical ischemia occurred with bradycardia, third-degree heart block and subsequently severe hypotension, which normally requires conversion to cardio-pulmonary bypass. Following introduction of the shunt (4 patients) electrocardiographic and hemodynamic parameters normalized within 30 s. The off-pump procedures could be continued uneventfully. There were no peri-operative infarctions. CONCLUSION: Temporary segmental occlusion is an effective method for anastomosis suturing in off-pump, beating heart CABG. Critical ischemia was observed rarely, only in the RCA and in non-occlusive disease. Temporary aorto-coronary shunting could avoid conversion to cardiopulmonary bypass and myocardial infarction.

Enhanced preoperative C-reactive protein plasma levels as a risk factor for postoperative infections after cardiac surgery.

BACKGROUND: We examined the possible predictive role of preoperative C-reactive protein (CRP) levels for postoperative infections in patients who have cardiac operations. METHODS: CRP levels were determined on the day before the operation and on postoperative days 1 to 4 and 6 in 593 consecutive patients. Furthermore, we documented infectious disease-related data. RESULTS: Patients in whom an infection developed during the postoperative course (n = 87) had significantly higher CRP levels on the day before operation (17.8+/-3.9 mg/L compared with 7.7+/-0.7 mg/L; p<0.001) and on postoperative days 4 and 6. The incidence of postoperative infections was significantly higher in patients with increased preoperative CRP levels than in those with normal preoperative CRP levels (25.3% versus 11.2%, respectively; p<0.001). Furthermore, patients with higher preoperative CRP levels had a significantly longer postoperative hospital stay than those with normal preoperative CRP levels (10.8+/-1.2 days versus 7.8+/-0.3 days; p<0.001). Multivariate analysis, including classic risk factors and increased preoperative CRP levels, demonstrated that higher preoperative CRP was the most important variable predicting postoperative infection (odds ratio = 2.7; 95% confidence interval = 1.7 to 4.3; p<0.001). CONCLUSIONS: Patients with higher preoperative CRP levels are at increased risk for postoperative infections. Therefore, preoperative measurement of CRP might be a useful, predictive marker in risk stratification for postoperative infections in patients scheduled for cardiac operations.