Same day admission for elective cardiac surgery: how to improve outcome with satisfaction and decrease expenses

Admission on the day of surgery for elective cardiac and non-cardiac surgery has been established as a prevalent, critical practice. This approach realizes medical, logistical, psychological and fiscal benefits, and its success is predicated on an effective outpatient pre-operative evaluation. The establishment of a highly functional pre-operative clinic with a comprehensive set-up and efficient logistical pathways is invaluable. This notion has been expanded in recent years to include the entire peri-operative period and the concept of a ‘peri-operative anesthesia/surgical home’ is gaining popularity and support. Evaluating patients prior to admission for surgery, anesthesiologists can place themselves at the forefront of reducing unnecessary pre-operative hospital admissions, excess lab tests, unneeded consultations, and ultimately decrease the cancellations on the day of surgery. Furthermore, by taking a leadership role in the pre-operative clinic, anesthesiologists place themselves squarely at the forefront of the burgeoning movement for the peri-operative surgical home and continue to cement the indispensability of the anesthesiologist during the entire peri-operative course. The authors present this review as a follow-up describing the successful implementation of a pre-operative same-day cardiac surgery clinic and offer these experiences over the last 8 years as a guide to helping other anesthesiologists do the same.     

Even a “pigtail” distal end catheter can enter the epidural space after continuous paravertebral block

A woman with a medical history of breast cancer presented with chronic pain of the right hemithorax. To alleviate pain, a continuous paravertebral block was performed using a pigtail end catheter, introduced using ultrasound visualization (transversal technique at the inferior articular process of T6). Complete pain relief was observed. A few hours later, urinary retention was diagnosed and discharge from the ambulatory setting was canceled. On the following day, a new injection of local anesthetics through the catheter triggered paresthesia in the contralateral leg and a new urinary retention was diagnosed. A CT scan confirmed the epidural misplacement of the catheter. The latter was withdrawn, and the patient was released to home after the complete disappearance of her neurological symptoms. This case report highlights the risk of inadvertently misplacing the catheter into the epidural space during thoracic paravertebral block, even with a “pigtail” distal end type of catheter.     

Novel microvascular anastomosis between a single vessel and two downstream vessels

Microsurgeons rarely encounter a situation that includes multiple downstream arteries requiring reperfusion with only one feeding artery being available. To cope with the difficulty of such a case, a unique microvascular anastomosis is described. This surgical technique is based on the assumption of the presence of a single large outflowing vessel and two small downstream vessels. The axial incisions were made on the cut end of the two small vessels. The ends of the two small vessels were sutured side-to-side and remodeled as one vessel. The partially coalesced small vessels were then anastomosed with the outflowing large vessel in an end-to-end fashion. Case presentation: a crush injury of the foot required reconstruction of the blood flow. The first dorsal metatarsal artery (FDMA) was damaged and occluded by thrombosis. The first and second toes had no blood supply. The original plan was simply to remove the damaged area of the FDMA and replace it with a straight vein graft, as the bifurcation to the two digital arteries appeared to be intact. At the time of microvascular anastomosis, however, the FDMA was found to still be damaged, and it required additional debridement. As a suboptimal method, the vein graft and the two digital arteries were anastomosed by the above-described atypical method. The digits all survived, and the patient subsequently returned to work, with no complications as of 10 months postoperatively. This atypical microvascular anastomosis is not an established method, but it has potential utility in similar situations.Level of Evidence: Level V, therapeutic study.     

Banking a fillet flap to aid in reconstruction following a hindquarter amputation

A hindquarter amputation and hemipelvectomy for recurrent malignancy presents a reconstructive challenge to the plastic surgeon. Tumour resection leaves a considerable defect, with exposure of bone, neurovascular structures, pelvic and abdominal organs. A free lower leg fillet flap is a recognised method of providing soft tissue coverage, but ischaemic time is often lengthy as described in the literature. We present a unique method of providing soft tissue coverage using a free lower leg fillet flap, and minimising ischaemic time by banking the flap on the ulnar artery during the hindquarter amputation and tumour resection.Level of Evidence: Level V, therapeutic study.