Difference in length of stay with care managed by clinical nurse specialists or physician assistants.

The purpose of this study was to examine the relationships among patient length of stay, complications, and type of care manager (clinical, nurse specialists [CNSs] vs. physician assistants [PAs]). A descriptive comparison of two groups was performed. Data were collected using a retrospective chart audit of 105 randomly selected patients who had undergone elective coronary artery bypass surgery for the first time between 1991 and 1993. Group 1 comprised patients for whom PAs and cardiac surgeons co-managed postoperative care. Group 2 comprised clients whose care was co-managed by CNSs and cardiac surgeons. Complication rates were similar between the two groups. Findings indicated that the CNS-managed group had a statistically significant shorter length of stay. Results suggested that care managed by CNSs can decrease length of stay, when compared with care managed by PAs.

Cell washing versus immediate reinfusion of intraoperatively shed blood during abdominal aortic aneurysm repair.

Significant hematologic changes are known to occur following intraoperative autotransfusion of shed blood, but the clinical importance of cell washing prior to reinfusion has not been substantiated. To evaluate these changes and their relationship to the use of blood bank products and postoperative morbidity, 26 patients undergoing elective abdominal aortic aneurysm repair were prospectively randomized to reinfusion with washed shed blood or to the use of a collection system in which filtered, but unwashed, whole blood was reinfused intraoperatively. Each patient was evaluated with respect to standard metabolic and hematologic laboratory parameters preoperatively, immediately postoperatively, and 12 to 18 hours postoperatively. Patient demographic data were similar for both groups. Perioperative survival was 100% for both groups. Total blood loss and blood volume autotransfused were significantly greater in the unwashed cell group compared with the washed cell group (p = 0.00014 and p = 0.00011, respectively). Hemoglobin, fibrinogen, prothrombin time, and partial thromboplastin time levels were not significantly different between the two groups at any time perioperatively; fibrin split product and d-dimer levels were significantly higher in the unwashed cell group postoperatively (p = 0.016 and p < 0.001, respectively). Serum free hemoglobin levels were significantly higher in the immediate postoperative period in the unwashed cell group compared with the washed cell group (p = 0.0013); by 12 to 18 hours postoperatively, this difference was not significant. Haptoglobin levels were significantly lower in the unwashed cell group at both postoperative times (123 +/- 86 mg/dL versus 41 +/- 50 mg/dL, p = 0.0086; 102 +/- 66 mg/dL versus 24 +/- 36 mg/dL, p = 0.0001); however, there was no perioperative renal failure in either group. Furthermore, homologous blood product use was not significantly different between the two groups, with an average of 1.5 +/- 2.5 units of packed red blood cells given to patients in the unwashed cell group versus 0.8 +/- 1.7 units in the washed cell group (p = 0.419). Overall complications were higher and critical care and total hospital stays were longer in the unwashed cell group but did not result from autotransfusion of unwashed blood. We conclude that the intraoperative reinfusion of unwashed shed blood is safe and effective, causing transient hematologic abnormalities that normalize in the early postoperative period, and is not associated with increased mortality, or hematologic, cardiopulmonary, or renal complications.

Taking the mystery out of rhythm interpretation: atrial electrograms.

OBJECTIVE: To verify cardiac rhythms in which diagnosis from conventional surface recordings was unclear. DESIGN: Approximately five electrograms were recorded each week from randomly selected patients who had undergone cardiac surgery in a two-year period from 1989 to 1991. SETTING: A 1000 bed acute care medical facility that provides care to more than 1300 patients per year after open heart surgery. PATIENTS: Adult patients in the surgical intensive care unit or stepdown units who were recovering from coronary artery bypass grafting, valve replacement or repair, aneurysm resection, and/or atrial and ventricular septal defect repairs. RESULTS: The atrial electrogram was used to diagnose various dysrhythmias. The most frequent application was the verification of atrial flutter, atrial fibrillation, and junctional rhythm. Another use was to differentiate between ventricular tachycardia and supraventricular tachycardia with aberrant conduction. CONCLUSION: Critical care clinicians caring for patients who have undergone cardiac surgery must be proficient at rapid, accurate rhythm interpretation to give appropriate treatment. The use of atrial electrograms can be extremely helpful in rhythm interpretation and clarification for this population of patients.