Safe and effective protocol for discharge 3 days after cardiac surgery.
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ABSTRACT:
SUBMITTER: Mejia OAV
PROVIDER: S-EPMC8076282 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundWhile fast track clinical pathways have been demonstrated to reduce resource utilization in patients undergoing cardiac surgery, it remains unclear as to whether they adversely affect post-operative outcomes. The purpose of this study was to determine the impact of fast tracking on post-operative outcomes following cardiac surgery.MethodsIn a retrospective study, all patients undergoing first-time, on-pump, non-emergent coronary artery bypass grafting, valve, or coronary artery bypass grafting + valve at a single centre between 2010 and 2017 were included. Patients were considered to have been fast tracked if they were extubated and transferred from intensive care to a step-down unit on the same day as their procedure. The risk-adjusted effect of fast tracking on a 30-day composite of all-cause mortality, stroke, renal failure, infection, atrial fibrillation, and readmission to hospital was determined. Furthermore, propensity score matching was used to match fasting track patients in a 1-to-1 manner with their nearest "neighbor" in the control group and subsequently compared in terms of 30-day post-operative outcomes.Results3252 patients formed the final study population (fast track: n = 245; control: n = 3007). Patients who were fast tracked experienced reduced time to initial extubation (4.3 vs. 5.6 h, p < 0.0001) and lower median initial intensive care unit length of stay (7.8 vs. 20.4 h, p < 0.0001). Fast tracked patients experienced lower 30-day rates of the composite outcome (42.4% vs. 51.5%, p = 0.008). However, following propensity score matching, fast tracked patients experienced similar 30-day rates of the composite outcome as the control group (42.4% vs. 44.5%, p = 0.72). After risk adjustment using multivariable regression modeling, fast tracking was predictive of an improved 30-day composite outcome (OR 0.75, 95% CI 0.57-0.98, p = 0.03).ConclusionFast track clinical pathways was associated with reduced intensive care unit, overall length of stay and similar 30-day post-operative outcomes. These results suggest that fast tracking appropriate patients may reduce resource utilization, while maintaining patient safety.
| S-EPMC8983083 | biostudies-literature
Project description:ObjectivesTo determine the effect of skin-to-skin care on stress, pain, behavioral organization, and physiologic stability of infants with critical congenital heart disease before and after neonatal cardiac surgery.DesignA baseline response-paired design was used, with infants acting as their own controls before, during, and after skin-to-skin care at two distinct time points: once in the preoperative period (T1) and once in the postoperative period (T2).SettingCardiac ICU and step-down unit in a large metropolitan freestanding children's hospital.SubjectsConvenience sample of 30 infants admitted preoperatively for critical congenital heart disease.InterventionsEligible infants were placed into skin-to-skin care for 1 hour with their biological mothers once each at T1 and T2.Measurements and main resultsMeasurements of stress (salivary cortisol), pain and behavior state (COMFORT scale), and physiologic stability (vital signs) were assessed immediately before skin-to-skin care, 30 minutes into skin-to-skin care, and 30 minutes after skin-to-skin care ended.At both T1 and T2, infant pain scores were significantly decreased (p < 0.0001) and infants moved into a calmer behavior state (p < 0.0001) during skin-to-skin care as compared to baseline. At T1, infants also had significantly reduced heart rate (p = 0.002) and respiratory rate (p < 0.0001) and increased systolic blood pressure (p = 0.033) during skin-to-skin care. At both T1 and T2, infant cortisol remained stable and unchanged from pre-skin-to-skin care to during skin-to-skin care (p = 0.096 and p = 0.356, respectively), and significantly increased from during skin-to-skin care to post-skin-to-skin care (p = 0.001 and p = 0.023, respectively). Exploratory analysis revealed differences in cortisol reactivity for infants with higher baseline cortisol (> 0.3 μg/dL) versus lower (≤ 0.3 μg/dL) prior to skin-to-skin care. Infants with higher baseline cortisol at T2 experienced significantly reduced cortisol during skin-to-skin care (p = 0.025). No significant differences in demographics or baseline variables were found between infants in either group.ConclusionsSkin-to-skin care is a low-cost, low-risk intervention that promotes comfort and supports physiologic stability in infants before and after neonatal cardiac surgery.
| S-EPMC8865053 | biostudies-literature
Project description:ObjectivesExpedient extubation after cardiac surgery has been associated with improved outcomes, leading to postoperative extubation frequently during overnight hours. However, recent evidence in a mixed medical-surgical intensive care unit population demonstrated worse outcomes with overnight extubation. This study investigated the impact of overnight extubation in a statewide, multicenter Society of Thoracic Surgeons database.MethodsRecords from 39,812 patients undergoing coronary artery bypass grafting or valve operations (2008-2016) and extubated within 24 hours were stratified according to extubation time between 06:00 and 18:00 (day) or between 18:00 and 6:00 (overnight). Outcomes including reintubation, mortality, and composite morbidity-mortality were evaluated using hierarchical regression models adjusted for Society of Thoracic Surgeons predictive risk scores. To further analyze extubation during the night, a subanalysis stratified patients into 3 groups: 06:00 to 18:00, 18:00 to 24:00, and 24:00 to 06:00.ResultsA total of 20,758 patients were extubated overnight (52.1%) and were slightly older (median age 66 vs 65 years, P < .001) with a longer duration of ventilation (4 vs 7 hours, P < .001). Day and overnight extubation were associated with equivalent operative mortality (1.7% vs 1.7%, P = .880), reintubation (3.7% vs 3.4%, P = .141), and composite morbidity-mortality (8.2% vs 8.0%, P = .314). After risk adjustment, overnight extubation was not associated with any difference in reintubation, mortality, or composite morbidity-mortality. On subanalysis, those extubated between 24:00 and 06:00 exhibited increased composite morbidity-mortality (odds ratio, 1.18; P = .001) but no difference in reintubation or mortality.ConclusionsExtubation overnight was not associated with increased mortality or reintubation. These results suggest that in the appropriate clinical setting, it is safe to routinely extubate cardiac surgery patients overnight.
| S-EPMC6431279 | biostudies-literature
Project description:Background: General or regional anesthesia is predominantly used for anorectal surgery, however in the recent years more attention was drawn in the use of local anesthesia for anorectal surgery. In this study we present the technique and results of the use of local perianal anesthetic infiltration for minor anorectal operations. Methods: In this cohort study patients undergoing surgery for hemorrhoids, anal fissures and low anal fistulas were included. Posterior perineal block was induced with a mixture containing 0.125% bupivacaine and 0.5% lidocaine. All patients were followed up at 30 days either by a post-operative visit or a telephone call and all post-operative complications over the post-operative 30-day period were registered. Results: One thousand and twenty-six consecutive patients were included in our study. For all patients' intraoperative analgesia was achieved after performing perianal anesthetic infiltration and no additional support from the anesthesia team was necessary in any of case. Complications were observed in 14 (1.4%). Urinary retention occurred in 5 (0.5%) cases. Six cases of bleeding occurred after hemorrhoidectomy (0.6%) and 1 (0.1%) after lateral internal sphincterotomy. Perianal abscess developed for two patients (0.2%). Conclusions: Local anesthesia using posterior perineal block technique is safe and effective for intraoperative analgesia in anorectal surgery, saving a substantial operation cost by avoiding the involvement of an anesthesia team and resulting in minimal incidence of urinary retention and other complications.
| S-EPMC8459016 | biostudies-literature
Project description:OBJECTIVES:To understand the effect of tight glycemic control on cardiac surgery-associated acute kidney injury. DESIGN:Secondary analysis of data from the Safe Pediatric Euglycemia after Cardiac Surgery trial of tight glycemic control versus standard care. SETTING:Pediatric cardiac ICUs at University of Michigan, C.S. Mott Children's Hospital, and Boston Children's Hospital. PATIENTS:Children 0-36 months old undergoing congenital cardiac surgery. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Cardiac surgery-associated acute kidney injury was assigned using the Acute Kidney Injury Network criteria with the modification that a greater than 0.1?mg/dL increase in serum creatinine was required to assign cardiac surgery-associated acute kidney injury. We explored associations between cardiac surgery-associated acute kidney injury and tight glycemic control and clinical outcomes. Of 799 patients studied, cardiac surgery-associated acute kidney injury occurred in 289 patients (36%), most of whom had stage II or III disease (72%). Cardiac surgery-associated acute kidney injury rates were similar between treatment groups (36% vs 36%; p = 0.99). Multivariable modeling showed that patients with cardiac surgery-associated acute kidney injury were younger (p = 0.002), underwent more complex surgery (p = 0.005), and had longer cardiopulmonary bypass times (p = 0.002). Cardiac surgery-associated acute kidney injury was associated with longer mechanical ventilation and ICU and hospital stays and increased mortality. Patients at University of Michigan had higher rates of cardiac surgery-associated acute kidney injury compared with Boston Children's Hospital patients (66% vs 15%; p < 0.001), but University of Michigan patients with cardiac surgery-associated acute kidney injury had shorter time to extubation and ICU and hospital stays compared with Boston Children's Hospital patients. CONCLUSIONS:Tight glycemic control did not reduce the cardiac surgery-associated acute kidney injury rate in this trial cohort. We observed significant differences in cardiac surgery-associated acute kidney injury rates between the two study sites, and there was a differential effect of cardiac surgery-associated acute kidney injury on clinical outcomes by site. These findings warrant further investigation to identify causal variation in perioperative practices that affect cardiac surgery-associated acute kidney injury epidemiology.
| S-EPMC5503840 | biostudies-literature
Project description:Traditional hydrodissection may cause posterior capsule rupture (PCR) if excessive fluid accumulates. In this study, we describe the successful application of a novel minimal fluid hydrodissection technique in 100 consecutive cataract surgery cases. This technique separates the nucleus from the capsule utilizing low hydrostatic pressure and precise kinetic movement of a small volume (around 0.2 cc) of balanced salt solution. There were no instances of PCR. This technique is suitable for a range of cases, including femtosecond laser-assisted cataract surgery and posterior subcapsular cataract.
| S-EPMC6432847 | biostudies-literature
Project description:BackgroundSpinal anesthetic choice plays an underappreciated role in total hip arthroplasty (THA). Chloroprocaine, a short-acting local anesthetic, has been limited to short-duration ambulatory procedures and has not been studied in THA. We compare perioperative outcomes of patients undergoing fast-track THA using chloroprocaine spinal anesthesia with those who have surgery with a longer-acting agent (bupivacaine).MethodsA total of 143 THAs performed under spinal anesthesia by 3 arthroplasty surgeons between November 2018 and July 2019 were retrospectively reviewed. Patients receiving chloroprocaine were matched 1:1 by demographics to patients receiving bupivacaine. Ultimately, 74 patients were included (37 chloroprocaine and 37 bupivacaine). The primary outcome was hospital length of stay (LOS). Other perioperative outcomes were also evaluated.ResultsA total of 37 patients (50%) received chloroprocaine (60 mg), whereas 37 (50%) received bupivacaine (median 10 mg, range 8-15 mg). Among the matched groups, chloroprocaine use was associated with shorter hospital LOS (0.9 vs 1.2 days; P = .03), shorter operative time (68.2 vs 83.6 minutes, P = .03), lower estimated blood loss (184.7 vs 218.9 mL, P = .02), shorter postanesthesia care unit LOS (139.4 vs 194.9 minutes; P = .04), and less intraoperative hypotension (59.5% vs 83.8%, P = .02). Patients receiving chloroprocaine were also more commonly discharged home (100% vs 89.2%; P = .04).ConclusionChloroprocaine is a safe and reliable option for patients to mobilize rapidly and leave the hospital sooner after THA. Compared with bupivacaine, it is associated with shorter hospital LOS and higher likelihood for discharge to home.
| S-EPMC7264955 | biostudies-literature
Project description:Background and aimsAn enterocutaneous fistula (ECF) poses a major surgical problem. The definitive surgical repair of persistent fistulas remains a surgical challenge with a high rate of re-fistulation and mortality, and the reasons for that is not the surgical technique alone. Enhanced Recovery after Surgery (ERAS®) is an evidence-based multimodal perioperative protocol proven to reduce postoperative complications. The aim of the study was to assess the clinical value of the ERAS protocol in surgical patients with ECF.MethodsERAS protocol was used in all patients scheduled for surgery for ECF at the Stanley Dudrick's Memorial Hospital in Skawina between 2011 and 2020. A multidisciplinary team (MDT) was in charge of the program and performed annual audits. A consecutive series of 100 ECF patients (44 females, 56 males, mean age 54.1 years) were evaluated. Postoperative complications rate, readmission rate, length of hospital stay, prevalence of postoperative nausea and vomiting were assessed. Registered under ClinicalTrials.gov Identifier no. NCT04771832.ResultsERAS protocol was successfully introduced for ECF surgeries; however, eight modifications to the ERAS program was performed in 2015. They led to improvement of surgical outcomes: reduction of postoperative nausea and vomiting (15 vs. 17% patients, p = 0.025), overall complication rate (11 vs. 10, p = 0.021), median length of hospital stay (overall and after surgery, p = 0.022 and 0.002, respectively).ConclusionsERAS protocol can be successfully used for ECF patients. Prescheduled audits can contribute to the improvement of care.
| S-EPMC8229866 | biostudies-literature
Project description:Systemic administration of interleukin (IL)-12 has been shown to induce potent anti-tumor immune responses in preclinical cancer models. Previous clinical trials using bolus IL-12 injection through maximal tolerable dosing (MTD) strategies indicated limited efficacy alongside unwanted side-effects. Our group developed IL-12-loaded PLGA nanospheres (IL12ns) that release their contents systemically in a slow, controlled manner. An immune diagnostic platform (IDP), capable of monitoring therapeutic response through peripheral blood sampling, was designed alongside this immunostimulatory therapy. The systemic immune responses from MTD and IL12ns dosing strategies were analyzed using this IDP in healthy mice. Importantly, the MTD was associated with aberrant peripheral immune stimulation, evidenced by increased IL-12, interferon gamma (IFNG), and IL-10 signaling. The immune-protective effects of IL12ns were supported by increases in pro-inflammatory plasma cytokines/chemokines without the maladaptive transcriptomic signatures in circulating peripheral immune cells. These data ultimately support the necessity of a vector system for safe immunostimulatory IL-12 therapy.
2024-01-16 | GSE241939 | GEO
Project description: Not available
| S-EPMC11235323 | biostudies-literature