Relationship between processes of care and coronary bypass operative mortality and morbidity

BACKGROUND: Information is limited regarding the effects of processes of care on cardiac surgical outcomes. Correspondingly, many recommended cardiac surgical processes of care are derived from animal experiments or clinical judgment. This report from the VA Cooperative Study in Health Services, "Processes, Structures, and Outcomes of Cardiac Surgery," focuses on the relationships between 3 process groups (preoperative evaluation, intraoperative care, and supervision by senior physicians) and a composite outcome, perioperative mortality and morbidity. METHODS: Data on 734 risk, process, and structure variables were collected prospectively on 3,988 patients who underwent coronary artery bypass grafting at 14 VA medical centers between 1992 and 1996. Data reduction was accomplished by examining data completeness and variation across sites and surgeon, using previously published data and clinical judgment. We then applied multivariable logistic regression to the 39 remaining processes of care to determine which were related to the composite outcome after adjusting for 17 patient-related risk factors and controlling for intraoperative complications. RESULTS: Our first analysis showed several measures of operative duration, the use of inotropic agents, transesophageal echo, lowest systemic temperature, and hemoconcentration/ultrafiltration, to be powerful predictors of the composite outcome. Because the use of inotropic agents and operative duration may be related to an intermediate outcome (eg, intraoperative complications), we performed a second analysis omitting these processes. The use of intraoperative transesophageal echo and hemoconcentration/ultrafiltration remained significantly associated with an increased risk of an event (odds ratios 1.60 and 1.36, respectively). CONCLUSIONS: Our results viewed in the context of past studies suggest the possibility that inotropic use, TEE, and hemoconcentration/ultrafiltration may have adverse effects on operative outcome. Further evaluation of these processes of care using observational data, as well as randomized trials when feasible, would be of interest.     

How not to do it: restrictive thoracic dystrophy after pectus excavatum repair

The purpose of our paper is to call attention to acquired restrictive thoracic dystrophy (ARTD), an iatrogenic disease. The condition may occur following correction of pectus excavatum in young patients and is characterized by a reduced and restricted rib cage, usually with some recurrence of the deformity. The authors personal experience with five such patients includes analysis of their operative notes, radiographs, and long-term follow up. These, as well as literary, data indicate that the cause of ARTD is not that the operation is performed at an early age, but that inappropriate surgical technique was performed that may include radical chondrocostal resection, extirpation of growth centers, and suturing together of the perichondrial strips retrosternally, consequentially causing cartilaginous growth behind the sternum. A well-designed, conservative operation may be safely performed at any age, including in children less than 4 years old.     

Follow-up results of surgical correction of ocular ischemic syndrome

The influence of surgeries in the carotid arteries produced on the visual functions and ocular blood circulation was studied in patients with ocular ischemic syndrome (OIS) during the remote postoperative period. A total of 180 patients with OIS (including 104 patients with an acute OIS clinical course and 76 patients with primary chronic clinical course) and with a pronounced stenosis of the carotid arteries were examined preoperatively and postoperatively within 1 or 2 years. A reliably improved visual acuity (preoperatively -0.37 +/- 0.05; and postoperatively -0.52 +/- 0.07; p < 0.01), positive dynamics in the electric sensitivity threshold and in a lability of the optic nerve were observed in patients with the acute OIS clinical course after reconstructive surgeries in the carotid arteries. An increase in contrast sensitivity of the visual analyzer was detected in 28.8% of patients with the acute clinical course and in 10.5% of patients with the chronic OIS clinical course. An improved blood circulation through the ocular artery was stated in patients of both groups. Reconstructive surgeries in the carotid arteries are most effective in correcting the acute OIS clinical variation.     

Blood flow in ocular vessels in 2 types of ocular ischemic syndrome

Ultrasonic triplex scanning of the orbit (gray scale two-dimensional ultrasonic examination, color Doppler mapping (CDM), and dopplerography) was carried out in 148 patients with ocular ischemic syndrome (OIS) aged 35-70 years, 104 of these with acute and 44 with primary chronic course. Signs of disordered bloodflow in the orbital and central retinal arteries were detected in patients with acute disease: 2-fold decreased maximum systolic bloodflow velocity, 5-fold decreased end diastolic bloodflow velocity, and 1.5 times increased resistance index in comparison with the norm. Chronic course of OIS was characterized by decreased maximum systolic velocity (by 1.5 times) and end diastolic bloodflow velocity (3-fold) in comparison with the norm in both arteries. Studies of ocular bloodflow by CDM timely detected angiological disorders in OIS and help define (in cooperation with angiosurgeon) the indications for angioreconstructive operations.     

Incidence of red cell antibodies after multiple blood transfusion

A retrospective study was performed to estimate the frequency of alloimmunization against red cell (RBC) antigens in a multiply transfused group. Patients (n = 186) were studied who had received at least six blood transfusions during a period of at least 3 months. Some 6944 units of blood were transfused. One hundred forty patients had hematologic disorders. The patients' sera were investigated every 3 months with indirect antiglobulin tests and enzyme-treated RBCs. Twenty-two patients (11.8%) made 33 antibodies. Seven patients made more than one antibody. Eight of the 22 patients (36.4%) made their first antibody before or at the 10th transfusion. The risk of immunization increased with the number of transfusions. Influence of gender and age was not demonstrable. Nor was a relationship demonstrated between blood transfusion reactions and RBC antibody formation; no delayed hemolytic transfusion reactions occurred. Anti-E was demonstrated in 12 patients and anti-K in 15. When the gene frequencies were taken into account, it appeared that anti-E was made by 11.5 percent of E-negative patients, most of whom were immunized after an estimated three transfusions with E-positive blood. Anti-K was made by 8.7 percent of the K-negative patients, after an estimated 2.1 units of K-positive blood. It might be desirable to match red cell units for the E and K antigens in patients at relatively high risk. These are primarily patients who have already formed an antibody and are going to receive many transfusions and women of childbearing age who are to receive more than 4 units of blood.