The effect of new clinical pathways on the outcome of vascular access surgery

Purpose: Prior to 2007, the waiting time for vascular access surgery at our center was approximately 107 days compared to a UK average of 45 days. Two new pathways were developed; the rapid and super-rapid pathways incorporating an access liaison nurse who organized vessel mapping and referred patients for surgery. This audit was to determine whether the pathways were effective in reducing the waiting times and improving vascular accesses outcomes. Methods: All 210 patients with established renal failure undergoing 232 vascular access procedures between January 2008 and March 2011 were studied. Detailed patient information including type of procedure and cause of access failure were stored in an Excel spreadsheet and analyzed using SPSS for Windows. Results: One hundred and twenty patients had a brachiocephalic fistula, 61 a radiocephalic fistula, 39 an access using the basilic vein ± transposition, and 11 a transposition of the long saphenous vein and one a brachio-axillary graft. Overall median waiting time from referral to access surgery was 23 days. Patients were followed up for a median of 248 days after surgery. The overall primary failure rate was 9.1% and 25 of 27 accesses failed because of thrombosis. The overall cumulative survival probability of accesses at one year was 61.4% with a mean survival of 621.2 days (SEM = 34.8). Conclusion: The clinical pathways have improved VA service to patients with a drastic reduction in waiting times, elimination of synthetic access, and maintenance of satisfactory results.     

Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery

To examine the interaction of epidural anesthesia, coagulation status, and outcome after lower extremity revascularization, 80 patients with atherosclerotic vascular disease were prospectively randomized to receive general anesthesia combined with postoperative epidural analgesia (GEN-EPI) or general anesthesia with on-demand narcotic analgesia (GEN). Demographics did not differ between groups except that the GEN-EPI group had a higher incidence of diabetes mellitus and of previous myocardial infarction. Coagulation status was monitored using thromboelastography. An additional 40 randomly selected patients without atherosclerotic vascular disease undergoing noncardiovascular procedures served as controls for coagulation status. Vascular surgical patients were hypercoagulable compared with control patients before operation and on the first postoperative day. Postoperatively, this hypercoagulability was attenuated in the GEN-EPI group and was associated with a lower incidence of thrombotic events (peripheral arterial graft coronary artery or deep vein thromboses). The rates of cardiovascular, infectious, and overall postoperative complications, as well as duration of intensive care unit stay, were significantly reduced in the GEN-EPI group. Stepwise logistic regression demonstrated that the only significant predictors of postoperative cardiovascular complications were preoperative congestive heart failure and general anesthesia without epidural analgesia. We conclude that in patients with atherosclerotic vascular disease undergoing arterial reconstructive surgery (a) thromboelastographic evidence of increased platelet-fibrinogen interaction is associated with early postoperative thrombotic events, and (b) epidural anesthesia and analgesia is associated with beneficial effects on coagulation status and postoperative outcome compared with intermittent on-demand opioid analgesia.     

Tracheostomy after major vascular surgery

OBJECTIVES: Major vascular surgery such as aortic aneurysm repair may be associated with prolonged in-patient hospitalization. Certain patients undergo a tracheostomy to aid in weaning from mechanical ventilation or for secretion management. The authors hypothesized that tracheostomy after aortic reconstruction for aneurysmal disease was associated with poor outcomes. DESIGN: A retrospective, observational study. SETTING: Vascular surgical intensive care unit (ICU) of a tertiary referral hospital. PARTICIPANTS: Eighty-one patients who underwent a tracheostomy after open thoracoabdominal or abdominal aortic aneurysm (AAA) repair between 1993 and 2002. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 1,940 patients who underwent aneurysm repair, 81 (4.2%) had a tracheostomy during their index hospitalization. Of those patients, 40.7% did not survive to hospital discharge. Postoperative sepsis was associated with an increased mortality (relative risk 2.45, 95% confidence interval [CI] 1.22-4.90). Many developed postoperative renal failure and were more likely to die in the hospital (relative risk 1.53, 95% CI 1.00-2.33). The preoperative diagnosis of chronic obstructive pulmonary disease (COPD) was not associated with increased mortality (relative risk 0.471, 95% CI 0.23-0.96). Thirty-two (39.5%) patients were transferred from the ICU to a chronic ventilator dependency unit (CVDU). CONCLUSIONS: Tracheostomy in patients after aortic reconstruction for aneurysmal disease is associated with a high incidence of in-hospital mortality. Patients who survive to ICU discharge are likely to be transferred to a CVDU for further respiratory management. The preoperative diagnosis of COPD is associated with improved survival, whereas postoperative sepsis is associated with an increased mortality. These observations should be considered when counseling patients and their families regarding tracheostomy after aortic surgery.     

Impact of clinical pathways in surgery

Background  One strategy to reduce the consumption of resources associated to specific procedures is to utilize clinical pathways, in which surgical care is standardized and preset by determination of perioperative in-hospital processes. The aim of this prospective study was to establish the impact of clinical pathways on costs, complication rates, and nursing activities. Method  Data was prospectively collected for 171 consecutive patients undergoing laparoscopic cholecystectomy (n = 50), open herniorrhaphy (n = 56), and laparoscopic Roux-en-Y gastric bypass (n = 65). Results  Clinical pathways reduced the postoperative hospital stay by 28% from a mean of 6.1 to 4.4 days (p < 0.001), while the 30-day readmission rate remained unchanged (0.5% vs. 0.45%). Total mean costs per case were reduced by 25% from € 6,390 to € 4,800 (p < 0.001). Costs for diagnostic tests were reduced by 33% (p < 0.001). Nursing hours decreased, reducing nursing costs by 24% from € 1,810 to € 1,374 (p < 0.001). A trend was noted for lower postoperative complication rates in the clinical pathway group (7% vs. 14%, p = 0.07). Conclusions  This study demonstrates clinically and economically relevant benefits for the utilization of clinical pathways with a reduction in use of all resource types, without any negative impact on the rate of complications or re-hospitalization.     

Cardiac complications after elective major vascular surgery

Cardiac complications are the major cause of perioperative and late mortality and morbidity in patients undergoing elective major vascular surgery. This review focuses on the pathophysiology of perioperative complications, risk assessment and risk reduction strategies, all related to cardiovascular disease. Patients without cardiac risk factors are considered to be at low risk and no additional evaluation for coronary artery disease is recommended; β-adrenergic blockers may reduce perioperative cardiac events; patients with one or more risk factors represent an intermediate to high-risk population. β-Adrenergic blockers should be prescribed to all patients and coronary revascularization should be reserved for patients who have a clearly defined need for revascularization independent of the need for vascular surgery.     

Impact of intraoperative hypotension on hospital stay in major abdominal surgery

Purpose  

Although the relationship between preoperative risk factors and outcomes has been extensively studied, the effect of intraoperative hemodynamic changes in a patient’s postoperative course has been less well defined.     

Intraoperative variables and early outcome after aneurysm surgery

BACKGROUND: The purpose of this study was to investigate the effects of blood pressure, temperature, and anesthetic agents on outcome in patients undergoing craniotomy for cerebral aneurysms. METHODS: All ruptured and unruptured intracranial aneurysms operated on from 1992 to 1998 were reviewed retrospectively. The data included 297 aneurysms (190 ruptured and 107 unruptured). Data were collected on variables known to influence outcome after aneurysmal subarachnoid hemorrhage as well as on intraoperative factors that might influence outcome (intraoperative blood pressure, temperature, temporary clipping, anesthetic agents). Outcome was assessed at discharge using the Glasgow Outcome Scale. RESULTS: In univariate analysis of patients with ruptured aneurysms, younger age, better clinical grade, lower Fisher grade, lower intraoperative blood pressure (maximum systolic and mean blood pressure), smaller decrease in intraoperative compared to preoperative systolic blood pressure, shorter duration of surgery, and use of propofol, pancuronium, or N(2)O were associated with significantly better outcome. In patients with unruptured aneurysms, increased intraoperative minimum diastolic and mean blood pressure, a decrease in the difference between multiple measures of preoperative and intraoperative blood pressure, and a shorter duration of surgery were associated with significantly better outcome. Intraoperative temperature did not affect outcome in either group. In multivariate analysis of patients with ruptured aneurysms, younger age, better clinical grade, lower maximum systolic intraoperative blood pressure, shorter duration of surgery, and use of propofol were independently associated with better outcome. CONCLUSIONS: Multivariate analysis of intraoperative factors affecting outcome in patients undergoing craniotomy for ruptured aneurysms shows that decreased intraoperative blood pressure and use of propofol are associated with improved outcome. Univariate analysis suggests that decreasing the magnitude of drop in blood pressure intraoperatively from preoperative values in patients with ruptured or unruptured aneurysms is associated with better outcome. Intraoperative hypothermia did not affect outcome.     

Impact of diverticular disease on hospital costs and activity

Background Diverticulosis is very common in the UK and patients with clinically significant diverticular disease present regularly to departments of surgery as acute emergencies or chronic problems. There are no national data on the hospital prevalence, clinical implications or financial impact of diverticular disease hence the extent of the clinical problem is as yet not quantified. Aim To detect the prevalence, clinical implications and financial impact of diverticular disease over a one year period in a large district hospital. Methods Retrospective review of all patients treated for diverticular disease during one financial year. Clinical and cost analysis of inpatient and outpatient investigations, treatment and hospitalization. Results A total of 148 patients were treated of whom 83 were admitted for more than 1 day, 55 of those were emergency admissions. Five of 83 admitted patients died (in‐patient mortality 6%, peri‐operative mortality 26.3%). There was a total number of 982 hospitalization days of which 94 Intensive Care Unit days and 68 High Dependency Unit days. Nineteen operations were performed (16 sigmoid colectomies, 1 oversewing of perforated sigmoid, 2 reversal of colostomy). The investigations generated were 48 colonoscopies, 77 flexible sigmoidoscopies, 77 Barium enemas, 2 CT scans and 34 ultrasound scans. A total number of 410 clinic appointments were generated. One year after discharge 134/148 (90.5%) patients were alive. The total cost of this activity was £465263 or 5.3% of the total annual budget for General Surgery. Seventy percent of the cost was bed‐days expenses with ICU hospitalization accounting for 25% of the total cost. Conclusion Diverticular disease is a major cause of morbidity in a large district hospital and a significant burden on resources. More research should be done on prevention of complications and management in the community. The current methods of management do not appear to be cost‐effective and attempts should be made to produce protocols for evidence‐based, cost‐efficient management of the disease. A UK national audit should be undertaken.     

Effect of aprotinin on neutrophil function after major vascular surgery.

High-dose aprotinin reduces blood loss and blood transfusion requirements during liver transplantation and cardiac and vascular surgery. The mechanism of the haemostatic effect of aprotinin is unclear. A general effect on the anti-inflammatory response may be involved. Because leucocyte activation is part of this process, white cell function was measured in patients undergoing aortic surgery who received high-dose aprotinin therapy (n = 10) and was compared with the results from controls who did not (n = 10). The test group received an intravenous bolus (2 x 10(6) kallikrein inhibitor units) of aprotinin after induction of anaesthesia followed by continuous infusion (0.5 x 10(6) kallikrein inhibitor units/h) until the end of the operation. Blood samples were obtained before operation, immediately after surgery, and 1 and 7 days after operation. Aprotinin maintained significantly better postoperative white cell function as measured by bipolar shape formation (P less than 0.001), unstimulated nitroblue tetrazolium (NBT) reduction (P less than 0.001) and chemotaxis (P less than 0.001). Endotoxin-stimulated NBT reduction was similar in both groups, indicating that neutrophils from treated individuals retained the capacity to respond to oxidative stimuli. Aortic surgery activates neutrophils in vivo, as reflected by impaired chemotaxis and increased superoxide production. Aprotinin protects the cells against this potentially deleterious effect without affecting their ability to respond when provoked. Whether this affects leucocyte interaction with coagulation pathways and contributes to the reduction in blood loss remains to be determined.     

The influence of clinical variables on hospital costs after orthotopic liver transplantation

BACKGROUND: The burgeoning influence of managed care in transplantation, coupled with a shrinking health-care dollar, has placed most transplant programs under intense pressure to cut costs. We undertook a retrospective cost-identification analysis to determine what clinical variables influenced financial outcomes after orthotopic cadaver liver transplants (OLTx). METHODS: Fifty patients receiving 53 transplants between April 1995 and November 1996 were reviewed. Clinical data were obtained from our institution's transplant database, and total costs (not charges) for the transplant admission and the 6 months after transplant were obtained with use of an activity-based cost accounting system (HBOC Trendstar, Atlanta, Ga). RESULTS: The average total cost of second transplants (n = 5) was $97,262 greater than for first transplants (n = 48, P < .05). Patients transplanted initially as United Network for Organ Sharing (UNOS) status 2 (n = 20) incurred average costs that were $51,762 higher than for patients transplanted as UNOS status 3 (n = 28, P = .008). Patients with a major bacterial or fungal infection (n = 28) incurred average costs $46,282 higher than recipients who were infection free (n = 22, P = .02). Multivariate analysis demonstrated that only length of stay, retransplantation, and postoperative dialysis were significantly and independently correlated with costs (r2 = .605). When the model was repeated with preoperative variables alone, only UNOS status was significantly correlated with 6-month total costs (P = .006, r2 = .16). CONCLUSIONS: Length of stay is the most important determinant of costs after OLTx. Rational strategies to design cost-effective protocols after OLTx will require further studies to truly define the cost of various morbidities and outcomes after OLTx.     

Respiratory mechanics during and after anaesthesia for major vascular surgery

To evaluate the effects of major vascular surgery on respiratory mechanics, 11 patients undergoing general anaesthesia for abdominal aortic surgery were studied. Before aortic cross-clamping, chest wall elastance and resistance both increased (by 126% and 58%, respectively) when surgical retractors were placed. After aortic cross-clamping, lung elastance increased by 29%, accompanied by a decrease in cardiac index (22%) and an increase in pulmonary (17%) and systemic (15%) vascular resistance. After aortic unclamping, lung elastance decreased, although it remained higher than baseline values (by 12%). All cardiovascular variables returned to the values obtained before aortic cross-clamping.     

Granulocytes in bronchial lavage fluid after major vascular surgery

Increased numbers of polymorphonuclear granulocytes (PMN) in the airways, as measured by PMN content in bronchial lavage fluid (P less than 0.01), were found 3 h postoperatively in ten patients undergoing surgery for lumbar aortic aneurysms. An increase in plasma levels of the complement split product C3dg from 6 (0-19) AU/ml preoperatively to 20 (13-50) AU/ml 3 h after surgery (P less than 0.01), indicates an activation of the complement cascade. These changes were not accompanied by increased elastase activity in the bronchial lavage fluid or by major changes in pulmonary blood gas exchange or vascular resistance, indicating that massive PMN activation, analogous to that proposed in adult respiratory distress syndrome (ARDS) had not taken place. In conclusion, complement system activation and migration of PMN into the airways, as seen in connection with major vascular surgery, does not seem to contribute to ARDS-type pulmonary dysfunction.     

Impact of transfusion policy on acute coronary syndrome after major vascular reconstruction

Objectives

To investigate the impact of a restrictive transfusion approach, as indicated by accepting a perioperative hemoglobin (Hb) level as low as 8 g/dL, on the incidence of acute coronary syndrome (ACS) and mortality after major vascular reconstruction.

Methods

Using a case-control design, 45 patients who underwent vascular reconstruction and developed postoperative ACS were compared with 135 patients treated with similar procedures who did not suffer ACS postoperatively.

Results

A history of CAD was more often present in the ACS group (16% vs 56%) and was an independent predictor of ACS (odds ratio [OR] = 6.62; confidence interval [CI], 3.16-13.88; P < .001) and postoperative death (OR = 5.08; CI, 2.0-12.85; P = .001). Postoperative (Hb) levels as low as 8 g/dL were well tolerated and had no impact on the occurrence of ACS (OR = .61; CI, 0.29-1.26; P = .181) or death (OR = 1.33; CI, 0.52-3.43; P = .547). The presence of CAD for a given Hb level did not increase the odds of either ACS (OR = 3.43; CI, .75-15.6; P = .112) or death (OR = 2.02; CI, .5-19.55; P = .543).

Conclusions

A restrictive transfusion policy is justified in patients undergoing major vascular reconstruction, even in the presence of appropriately managed cad.     

Effects of ephedrine on renal function in patients after major vascular surgery

The haemodynamic and renal effects of ephedrine were studied in 11 mechanically ventilated patients on the first day after major vascular surgery. Ephedrine, a sympathomimetic agent with alpha-1, beta-1, and beta-2 agonistic activity, was infused into 11 patients to achieve a 20% rise in systolic blood pressure. The doses used were 2-6 micrograms/kg/min, and in six of these 11 patients the dose was then doubled, 4-12 micrograms/kg/min for another renal function test. Blood pressure, heart rate, and cardiac output increased at both dose-ranges. Systolic pulmonary arterial pressure increased by 10% at the first dose-range. Systemic vascular resistance was unchanged and plasma catecholamine levels were unaltered in the present study. Plasma renin activity diminished by 18% and 6%, respectively. Clearance of para-aminohippuric acid increased by 20% and 6%, at the two dose-ranges, while clearance of inulin and urine flow rate increased by 24% and 29%, respectively, at the first dose-range, without further increase during the second dose-range. Fractional chloride excretion, and fractional osmolar clearance were unaltered. Fractional Na+ clearance rose by 30% and 36%, respectively. Fractional free water clearance diminished by 8% at the second dose-range. When comparing the two dose-ranges, HR, systolic and mean BP rose by 8%, 13% and 11%, respectively. Fractional K+ excretion diminished by 30%. We conclude that ephedrine given as a continuous infusion seems to have beneficial effects on renal function in patients after elective major vascular surgery.     

Impact of hospital volume on long-term survival after esophageal cancer surgery

HYPOTHESIS: The improved survival after esophageal cancer surgery in Sweden during recent years may be attributable to the increased centralization of such surgery. DESIGN: Population-based study. SETTING: All Swedish residents undergoing esophageal cancer surgery from January 1, 1987, through December 31, 2000, were identified from the inpatient and cancer registers and were followed up until October 18, 2004, through nationwide registers. Hospital, tumor, and patient characteristics and preoperative oncological treatment were assessed through the registers and histopathological records. PATIENTS: Among 4904 patients with esophageal cancer, 1199 patients (24.4%) who underwent resection constituted the study cohort. Main Outcome Measure Survival rates and hazard ratios (HRs) relative to hospital volume. Low-volume hospitals (LVHs) conducted fewer than 10 esophagectomies annually, while high-volume hospitals (HVHs) conducted 10 or more. Hazard ratios were adjusted for several potential confounders. RESULTS: Thirty-day survival was 96% at HVHs and 91% at LVHs (P = .09). Survival rates 1, 3, and 5 years after surgery at HVHs were nonsignificantly higher (58%, 35%, and 27%, respectively) compared with those at LVHs (55%, 30%, and 24%, respectively). The adjusted HR was nonsignificantly 10% decreased at HVHs (HR, 0.90; 95% confidence interval, 0.79-1.04). In an analysis restricted to 764 patients (64%) without preoperative oncological treatment (in which the tumor stage was also adjusted for), survival was similar at HVHs and at LVHs (HR, 0.99; 95% confidence interval, 0.84-1.18). CONCLUSIONS: This study revealed no effect of hospital volume on long-term survival after esophageal cancer surgery. Tumor biology apparently has a greater effect on the chances of long-term survival than hospital volume.