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6 results

  • Sustaining and spreading success: expanding a multicentre quality improvement project to reduce postoperative chest tube duration after paediatric CHD

  • Shreya S. Sheth, Ashlin Tignor, Chloe Connelly, Nicolas L. Madsen, Margaret Graupe, Katherine E. Bates, Mayte Figueroa, Lawrence E. Greiten, Stephen A. Hart, Megan Jensen, Taylor Morse, Madalsa Patel, Amelia St. John, David Saudek, Alaina K. Kipps
  • Journal:
    Cardiology in the Young / Volume 35 / Issue 6 / June 2025
    Published online by Cambridge University Press:
    25 June 2025, pp. 1154-1160
  • Objective:

    The Pediatric Acute Care Cardiology Collaborative (PAC3) previously showed decreased postoperative chest tube duration and length of stay in children undergoing 9 Society of Thoracic Surgeons benchmark operations. Here we report how these gains were sustained over time and spread to 8 additional centers within the PAC3 network.

    Methods:

    Patient data were prospectively collected across baseline and intervention phases at the original 9 centres (Pioneer) and 8 new centres (Spread). The Pioneer baseline phase was 6/2017–6/2018 and Spread was 5/2019–9/2019. The Pioneer intervention phase was 7/2018–7/2021 and Spread 10/2019–7/2021. The primary outcome measure was postoperative chest tube duration in hours, with the aim of 20% overall reduction. Balancing measures included chest tube reinsertion and readmission for pleural effusion. Statistical process control methods and traditional statistics were used to analyse outcomes over time.

    Results:

    Among 5,042 patients at 17 centres, demographics were comparable. The Pioneer cohort (n = 3,383) sustained a 22.6% reduction in mean chest tube duration (from 91.9 hours to 70.5 hours), while the Spread cohort (n = 1,659) showed a 9.7% reduction (from 73.1 hours to 66.0 hours) in the first 13 months following intervention. Across both cohorts, rates of reinsertion (2.0% versus 2.1%, p = 0.869) and readmission for effusion did not change (0.3% versus 0.5%, p = 0.285).

    Conclusions:

    This multicenter prospective quality improvement study demonstrated sustained reduction in chest tube duration at 9 centres while successfully spreading improvement to 8 additional centres. This project serves as a model for post-operative multicentre quality improvement across a large cohort of congenital cardiac surgery patients.

  • Chapter 17 - Perioperative Medical Management of Older People

  • Edited by George Tadros, Aston University, Birmingham, George Crowther, Leeds and York Partnership NHS Foundation Trust, Leeds
  • Book:
    Handbook of Old Age Liaison Psychiatry
    Published online:
    04 April 2024
    Print publication:
    11 April 2024, pp 246-265

  • Summary

    The population of the world is ageing. This has led to an increase in interventions and surgical procedures that would have been unheard of about fifty years ago. In this chapter we discuss the perioperative management of older patients, and the emphasis is on hip fracture patients. Factors such as limited physiological reserve, comorbidities, and the trauma of surgery itself are discussed, together with their perioperative management. The impact of pre-existing dementia and of post-operative delirium and depression is also covered here. The pre-operative management of fluid and electrolyte imbalance, the reversal of anticoagulation before surgery, and the treatment of infections are included. The evidence base around cut-offs for haemoglobin levels acceptable for surgery is also discussed. Finally, the post-operative management of acute kidney injury, infections, myocardial infarction, congestive cardiac failure, post-operative delirium, post-operative cognitive dysfunction, and depression is explored in conjunction with their evidence base.

  • Case 50 - Extubatingthe trachea after prolonged prone surgery

  • from Section I - Neuroanesthesia
  • Edited by George A. Mashour, Ehab Farag
  • Book:
    Case Studies in Neuroanesthesia and Neurocritical Care
    Published online:
    03 May 2011
    Print publication:
    03 February 2011, pp 160-162

  • Summary

    The number of patients with autonomic hyperreflexia returning for various surgeries is increasing due to improved medical management of urinary tract and respiratory tract complications in patients with spinal cord injury. This chapter presents a case study of a 44-year-old male who sustained a motor vehicle accident 6 years previously that resulted in paraplegia secondary to T6 spinal cord injury. The surgery was performed under the block and light sedation using midazolam without any complications or significant hemodynamic perturbations. Spinal cord injuries can be caused by either traumatic or nontraumatic causes. Most of these patients survive to return for elective surgeries, most commonly urological and orthopedic procedures. General anesthesia can be employed while maintaining adequate depth using potent volatile anesthetic, narcotics, and systemic sympatholytics to decrease the afferent sensory discharge. Perioperative management of these patients requires knowledge of the risks associated with this phenomenon as well as the pathophysiology.

  • Case 35 - Epilepsysurgery: intraoperative seizure

  • from Section I - Neuroanesthesia
  • Edited by George A. Mashour, Ehab Farag
  • Book:
    Case Studies in Neuroanesthesia and Neurocritical Care
    Published online:
    03 May 2011
    Print publication:
    03 February 2011, pp 110-112

  • Summary

    The role of the anesthesiologist as a perioperative consultant requires a thorough knowledge of current guidelines, a deep understanding of perioperative risk associated with various noncardiac surgeries in order to follow an evidence-based approach to perioperative management. This chapter presents a case study of a 76-year-old male was scheduled for a right carotid endarterectomies (CEA) under general anesthesia after an episode of transient monocular blindness (amaurosis fugax) prompted a duplex ultrasound of the carotid vessels. Preoperative laboratory work-up was significant for a hematocrit of 33 and a serum creatinine of 1.6 mg/dL. The vascular surgeon consulted the anesthesia team for preoperative evaluation. The classification of cardiac risk in noncardiac surgery is based on the incidence of cardiac death and nonfatal myocardial infarction. Patients undergoing vascular surgery have a high incidence of concomitant coronary artery disease and cardiac causes are the most common causes of morbidity and mortality after CEA.

  • Case 25 - Postoperativenormal perfusion pressure breakthrough

  • from Section I - Neuroanesthesia
  • Edited by George A. Mashour, Ehab Farag
  • Book:
    Case Studies in Neuroanesthesia and Neurocritical Care
    Published online:
    03 May 2011
    Print publication:
    03 February 2011, pp 83-84

  • Summary

    The increasing use of coronary artery angioplasty with deployment of stents for treatment of coronary artery disease poses several dilemmas for perioperative management. These conflicting requirements are manifested most acutely in the management of patients with neurovascular disease. This chapter presents a case study of a 51-year-old female with a past medical history of ischemic heart disease, hypertension, and undifferentiated autoimmune disease with interstitial lung involvement, as an example. The presence of coronary stents in patients undergoing neurosurgical procedures warrants specific consideration prior to anesthesia. It is necessary to balance the risks of stent thrombosis, and the subsequent risk of myocardial infarction, arrhythmia, or cardiac arrest, against the risks of hemorrhage during or after a neurosurgical procedure. There is currently an irresolvable conflict between the risks of with holding and continuing antiplatelet agents in the perioperative period.