Clinical and nonclinical indicators of performance in thoracic surgery

One of the most important steps in the entire process of monitoring and improving quality of care is to identify the proper quality measures. This may be challenging from the outset since no single indicator can fully comprehend the entire concept of quality of care, which is multidimensional by nature. Ideally, multiple indicators should be used at the same time to obtain a more precise assessment of the quality of care. The quality of care can be measured by observing its structure, its processes, and its outcomes. Each indicator may reflect different aspects of quality and may be of particular interest to different audiences (providers, consumers, regulators, purchasers). The selection of one or the other may depend on the objectives of the analysis and the target audience. Although outcomes represent the ultimate product of health care, if the focus is on identifying and remedying apparent variations in performance, it is often preferable to measure not only outcomes but also the desirable processes of care. From a performance management perspective, the key issue is that a desirable process should be unambiguously associated with improved patient health outcomes. Monitoring the process can then be a substitute for measuring the outcome. Unlike outcome indicators, process measures have the potential to identify for clinicians exactly which processes they followed or did not follow that had the potential to affect patient outcomes. Process indicators provide information that is actionable. Finally, thoracic surgeons should take the lead in the managerial approach to the evaluation of performance, preventing administrative personnel unfamiliar with our multifaceted clinical world from judging our practice through imprecise instruments. We, as physicians, must absolutely improve our skill and confidence in risk analysis, outcome-evaluation methods, and process-based assessment of our practice.     

Fire during thoracic surgery.

A 67-year-old male with bilateral lung lesions presented for median sternotomy. One-lung ventilation was complicated by arterial desaturation. Continuous positive airway pressure with oxygen was applied to the non-ventilated lung to relieve the hypoxaemia. However, the cotton gauze packed inside the operative site was ignited by the electrocautery. The burning gauze was immediately removed without any complication. We report a case of electrocautery-induced fire during thoracic surgery done in supine position and discuss its implication on the choice of oxygen enrichment therapy during one-lung ventilation.     

全电视胸腔镜下肺叶切除术

目的总结探讨全电视胸腔镜肺叶切除的安全手术方法。方法在自2008年7月至2010年3月以来共完成全电胸腔镜下肺叶切除57例,男34例,女23例,年龄45～78岁。临床诊断支气管扩张症3例,肺曲菌球病2例,肺硬化性血管瘤2例,慢性肺部炎症1例,肺癌49例。腋中线第7或第8肋间作镜孔（1.5～2cm）,肩胛下角线第7或第8肋间作操作孔（1.5～2cm）,腋前线与锁骨中线间第4肋间（上中叶切除）或第5肋间（下叶切除）作一长约4～6cm辅助切口,便于游离肺门血管和取出被切肺叶。术中应用血管切割缝合器处理血管、支气管。结果切除左肺上叶12例,左肺下叶13例,右肺上叶11例,右肺中叶5例,右肺下叶16例。术后平均胸管引流量50～150ml/d。平均住院时间10.5d。全组无死亡病例。结论全电视胸腔镜肺叶切除具有出血少、疼痛小、住院时间短和病程恢复快等优点。胸外科医师经过相关训练完全能掌握这项微创技术进行安全手术。     

Epidural anesthesia in awake thoracic surgery.

Despite the indisputable and well-known advantages of general anesthesia in thoracic surgery, this can trigger some adverse effects including an increased risk of pneumonia, impaired cardiac performance, neuromuscular problems, mechanical ventilation-induced injuries, which include barotrauma, volotrauma, atelectrauma, and biotrauma. In order to reduce the adverse effects of general anesthesia, thoracic epidural anesthesia has been recently employed to perform awake thoracic surgery procedures including coronary artery bypass, management of pneumothorax, resection of pulmonary nodules and solitary metastases, lung volume reduction surgery, and even transsternal thymectomy. The results achieved in this early series have been encouraging, although indications and many pathophysiologic aspects remain to be elucidated. In this review we have tried to provide a first-step analysis of the anecdotal reports available in the literature on this topic. We also desired to provide insights into the main physiologic effects of awake thoracic surgery with epidural anesthesia, with particular attention to the several issues raised by its application in patients with chronic obstructive pulmonary disease, which can represent one of the most stimulating challenges in this setting.     

Clinical experience with fibrin gluing in general and thoracic surgery

Fibrin sealing was applied in 615 cases to patients in the Surgery I Department of Salzburg County Hospitals, between April 1st, 1978 and April 30th, 1985. Fibrin glue Tissucol (Immuno, Vienna) was used in all cases. Need for additional sealing of sutures and anastomoses (n = 331), haemostasis and wound dressing on parenchymatous organs (n = 125), and glueing of skin grafts (n = 97) were the most common indications. Postoperative complications occurred to eight cases (6.4 per cent) in the wake of haemostatic glueing of parenchymatous organs, with lethality being 1.6 per cent (n = 2). One of the patients had to be relaparotomised. Fistulation, following additional sealing of anastomoses and sutures, was recorded from 4.9 per cent of the patients, with the rate of lethality being 0.6 per cent. Inadequate healing of skin grafts was observed in eleven per cent of all cases. Side effects of the fibrin sealant, say, hepatitis, were not observed at all.     

Continuous intercostal blockade with lidocaine after thoracic surgery. Clinical and pharmacokinetic study

The efficacy and the side effects of a continuous infusion of lidocaine in the fifth intercostal space for the management of postoperative pain after lateral thoracotomy were evaluated in 20 adults. An indwelling catheter was inserted in the appropriate intercostal space before thoracotomy closure. After recovery from general anesthesia, a loading dose of 3 mg/kg of 1.5% lidocaine with epinephrine 1:160,000 was injected through the catheter, followed by a continuous infusion of 1% lidocaine without epinephrine at a rate of 1 mg.kg-1.h-1 for 54 h. In seven patients pharmacokinetic data were obtained. Pain, assessed by visual continuous analog scale, decreased from a median score of 8 (range, 7-10) to a score of 5 (range, 2-7) 20 min after the loading dose of lidocaine and continued to decrease until the end of the study (P = 0.0001). Complete cutaneous analgesia, assessed by pinprick test, was seen in a median of three thoracic spinal segments (range, 0-6) with partial cutaneous analgesia in seven segments (range, 6-9) 40 min after the loading dose, and levels that remained unchanged for 54 h (P = 0.0001). Peak lidocaine serum concentrations, 1.9 +/- 0.7 micrograms/mL, were present 9 +/- 3 min after injection of the loading dose. Serum concentrations of lidocaine under steady state conditions averaged 4.8 +/- 0.9 micrograms/mL (range, 3.5-5.8 micrograms/mL). This level under steady state conditions, though below the toxic level, suggests that additional bolus injection of lidocaine during the course of infusion might result in potentially toxic serum levels of lidocaine.(ABSTRACT TRUNCATED AT 250 WORDS)     

The practice of thoracic surgery in Canada.

The objective of the consensus conference of the Canadian Association of Thoracic Surgeons (CATS) was to define the scope of thoracic surgery practice in Canada, to develop standards of practice, to define training and resource requirements for the practice of thoracic surgery in Canada and to determine appropriate waiting times for thoracic surgery care. A meeting of the CATS membership was held in September 2001 to address issues facing thoracic surgeons practising in Canada. The discussion was facilitated by an expert panel of surgeons and supplemented by a survey. At the end of the meeting, consensus was reached by the membership regarding the issues outline above. The membership agreed that the scope of practice includes diagnosis and management of conditions of the lungs, mediastinum, pleura and foregut. They agreed that appropriate training in thoracic surgery included completion and certification in general or cardiac surgery prior to completing a 2-year program in thoracic surgery. The membership supported the Canadian Society of Surgical Oncology recommendations for management of cancer patients that new patients should be seen within 2 weeks of referral and cancer therapy initiated within 2 weeks of consultation. Thoracic surgical care is best delivered by 2 or 3 fully certified thoracic surgeons, in regional centres linked to a cancer centre and trauma unit. The establishment of a critical mass of thoracic surgeons in each centre would lead to improved quality and delivery of care and allow for adequate coverage for on-call and continuing medical education.