Evaluating and improving the delivery of heart care: the University of Michigan experience.
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With increasing pressure to curb escalating costs in medical care, there is particular emphasis on the delivery of cardiovascular services, which account for a substantial portion of the current healthcare dollar spent in the United States. A variety of tools were used to improve performance at the University of Michigan Health System, one of the oldest university-affiliated hospitals in the United States. The tools included initiatives to understand outcomes after coronary bypass operations and coronary angioplasty through use of proper risk-adjusted models. Critical pathways and guidelines were implemented to streamline care and improve quality in interventional cardiology, management of myocardial infarction, and preoperative assessment of patients undergoing vascular operations. Strategies to curb unnecessary costs included competitive bidding of vendors for expensive cardiac commodities, pharmacy cost reductions, and changes in nursing staff. Methods were instituted to improve guest services and partnerships with the community in disease prevention and health promotion. (+info)
Experimental and clinical evaluation of the harmonic scalpel in thoracic surgery.
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The Harmonic Scalpel is an ultrasonic instrument for cutting and coagulating tissue. We are reporting our evaluation of the Harmonic Scalpel safety and efficacy in both experimental and clinical thoracic surgery. First, we confirmed the safety in thoracic surgery by following two preliminary studies using the Harmonic Scalpel. 1: Pulmonary parenchyma was incised using "Coagulating Shears" to evaluate hemostasis and air leakage. 2: Pulmonary hilar vessels were contacted directly with "Dissecting Hook" blade at optimum cutting power mode to evaluate potential vascular wall injury by the Harmonic Scalpel. Subsequently, the Harmonic Scalpel was used for a partial lung resection due to metastatic lung cancer. Particular application was for a chest wall incision, interlobar separation of the lung, and dissection of a pulmonary artery, in lung cancer operations. We concluded that cutting and hemostasis of pulmonary parenchyma could be achieved with minimal tissue damage using the Harmonic Scalpel. Compared to electric coagulation, the Harmonic Scalpel minimizes tissue charring and dissection, and eliminates thermal injury in thoracic surgery. (+info)
Obstacles to early discharge after cardiac surgery.
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CONTEXT: Cardiovascular disease and cardiac surgery, in particular, are associated with a large expenditure of healthcare resources. Identifying the factors that affect length of stay for patients hospitalized for cardiac surgery and ways to safely and effectively shorten stays could have significant impact on healthcare costs. OBJECTIVE: To identify obstacles to and the effects of early discharge on outcome after cardiac surgery. STUDY DESIGN: A prospective approach using a protocol consisting of modifying anesthesia, limiting the use of postoperative narcotics, early extubation, and early mobilization, with a goal of discharge at < 5 days. PATIENTS AND METHODS: The study group consisted of 422 consecutive patients (age range 15-89 years, 65% males): coronary artery bypass graft (CABG) (n = 290), valve procedures (n = 54), and CABG + valve procedures (n = 78). The discharge criteria included hemodynamic stability, normal bowel function, independence in activities of daily living, absence of fever, and no incision problems. RESULTS: Predictors of prolonged postoperative stay were prolonged intensive care unit stay (P < 0.0001), postoperative atrial fibrillation (P = 0.0006), preoperative congestive heart failure (P = 0.002), combined CABG and valve procedure (P = 0.005), prolonged ventilator support (P = 0.01), increasing age (P = 0.012), history of peripheral vascular disease (P = 0.02), and female gender (P = 0.025). The 30-day readmission rate for the early discharge group was 7.8% vs 16.2% for the late discharge group (P = 0.01). The mortality rate for the entire group was 3.3%. (+info)
I.v. diclofenac and ketorolac for pain after thoracoscopic surgery.
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We studied intensity of pain, cumulative morphine consumption, ventilatory and renal function, and haemostasis in patients undergoing video-assisted thoracoscopic surgery and receiving a 2-day i.v. infusion of diclofenac, ketorolac or saline. Plasma concentrations of the two NSAID were also measured. The study was randomized, double-blind and placebo-controlled, with 10 patients in each group. Patients experienced mainly moderate pain. Mean consumption of i.v. morphine during the first day after operation was 57 (SEM 11) mg in the placebo group. Diclofenac and ketorolac were equally effective in reducing total morphine consumption (61% and 52%, respectively). Adverse events were similar and minor. Greater variability in plasma concentrations of ketorolac were detected compared with diclofenac. (+info)
Video-assisted cardiac surgery: preliminary results in Chang Gung Memorial Hospital.
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OBJECTIVE: To summarize the experience of utilization of video-assisted endoscopy in 91 patients operated on at Chang Gung Memorial Hospital, Taipei, China. METHODS: From October 1995, through August 1996, 91 patients (44 male and 47 female) received video-assisted cardiac surgery (VACS). Their ages ranged from 1 year to 79.5 years (25.7 +/- 21.7). Indications for surgery were atrial septal defect (59 patients), ventricular septal defect (15), coronary artery disease (4), severe mitral regurgitation (4), severe tricuspid regurgitation (3), thrombosis of mitral mechanical prosthesis (3), left atrial tumor (2), and left ventricular thrombus with dilated cardiomyopathy (1). The VACS was performed through right or left anterior minithoracotomy and guided by video-assisted endoscopic techniques by means of projected images on the video monitor under extracorporeal circulation. The aorta was not cross-clamped and the myocardium was protected by continuous coronary perfusion with hypothermic fibrillatory arrest (rectal temperature 22.6 +/- 4.0 degrees C). Conventional instruments were used. RESULTS: All lesions were corrected successfully. The bypass time was 27 to 335 minutes (72.8 +/- 52.7). The operative time was 1.3 to 8.5 hours (3.0 +/- 1.7). There were no operative deaths and 3 late deaths. Follow-up was complete in all survivors (6 to 16 months, mean 8.7). Most of them were found to be in NYHA functional I or II. CONCLUSION: Our preliminary experiences demonstrate that VACS is simple and effective in surgical correction of selected cardiac lesions. Short-term results show good outcomes. (+info)
Sternal splitting approach to upper thoracic lesions located anterior to the spinal cord.
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The sternal splitting approach for upper thoracic lesions located anterior to the spinal cord is described. The sternal splitting approach can be effectively applied to lesions from the T-1 to T-3 levels. The aortic arch prevents procedures below this level. The approach is straight toward the T1-3 vertebral bodies and provides good surgical orientation. The sternal splitting approach was applied to five patients with metastatic spinal tumors at the C7-T3 levels and three patients with ossification of the posterior longitudinal ligament at the T1-3 levels. No postoperative neurological deterioration occurred. Two patients had postoperative hoarseness. The sternal splitting approach to the upper thoracic spine is recommended for hard lesions, extensive lesions requiring radical resection, and lesions requiring postoperative stabilization with spinal instrumentation. (+info)
Signal-averaged P-wave duration does not predict atrial fibrillation after thoracic surgery.
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BACKGROUND: Atrial fibrillation (AF) is the most common dysrhythmia seen early after major thoracic surgery but occurs infrequently after minor thoracic or other operations. A prolonged signal-averaged P-wave duration (SAPWD) has been shown to be an independent predictor of AF after cardiac surgery. The authors sought to determine whether a prolonged SAPWD alone or in combination with clinical or echocardiographic correlates predicts AF after elective noncardiac thoracic surgery. METHODS: Of the 250 patients enrolled, 228 were included in the final analysis. Preoperative SAPWD was obtained in 155 patients who had major thoracic surgery and in 73 patients undergoing minor thoracic or other operations who served as comparison control subjects. The SAPWD was recorded from three orthogonal leads using a sinus P-wave template. The filtered vector composite was used to measure total P-wave duration. Clinical, surgical, and echocardiographic parameters were collected and patients followed for 30 days after surgery for the development of symptomatic AF. RESULTS: Symptomatic AF developed in 18 of 155 (12%) patients undergoing major thoracic surgery and in 1 of 73 (1%) patients having minor thoracic or abdominal surgery, most commonly 2 or 3 days after surgery. In comparison with similar patients undergoing major thoracic surgery without AF, those who developed AF were older (66+/-8 vs. 62+/-10 yr; P = 0.04) but did not differ in SAPWD (145+/-17 vs. 147+/-16, ms) in standard electrocardiographic P-wave duration (105+/-7 vs. 107+/-10 mns), incidence of left-ventricular hypertrophy on 12-lead electrocardiography, male sex, history of hypertension, diabetes, or coronary heart disease. Thoracic-surgery patients at risk for postoperative AF did not differ from all other patients at low risk for AF in clinical or SAPWD parameters. CONCLUSIONS: Under the conditions of this study, SAPWD did not differentiate patients who did or did not develop AF after noncardiac thoracic surgery, and therefore its measurement cannot be recommended for the routine evaluation of these patients. Older age continues to be a risk factor for AF after thoracic surgery. (+info)
Surgical management of superior sulcus tumors.
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Superior sulcus tumor refers to any primary lung cancer presenting with constant pain in the nerve distribution of the eighth cervical, first and second thoracic nerve roots and Horner's syndrome caused by invasion of the stellate ganglion. The pain is steady, severe, and unrelenting, involving the shoulder, the vertebral margin of the scapula and ulnar distribution of the arm to the elbow and finally to the ulnar surface of the forearm, and the small and ring fingers of the hand (Pancoast-Tobias syndrome). Weakness and atrophy of the hand muscles can also occur as the lesions spreads to involve the first and second ribs and vertebrae. Radiologically, there is a small shadow at the extreme apex of the lung with rib and possible vertebral body invasion. Pulmonary symptoms are less frequent because of the peripheral location of the lesions. Since Shaw and Paulson approached superior sulcus tumors in 1961 by using preoperative radiation-therapy (30 to 45 Gy in four weeks including the primary tumor, mediastinum and supraclavicular region) followed by surgical resection, this radiosurgical approach shortly became the standard treatment yielding better disease control and survival than that offered by other treatment modalities. It has now become evident that en bloc resection of the chest wall, involved adjacent structures as well as lobectomy must be considered the standard surgical approach for superior sulcus tumors combined with external radiation (preoperative, postoperative, or both). The goal of the operation is the complete and en bloc resection of the upper lobe in continuity with the invaded ribs, transverse processes, subclavian vessels, T1 nerve root, upper dorsal sympathetic chain and prevertebral muscles. (+info)