RESUMEN
Implementing a new technical process demands a complex preparation. In cardiac surgery this complex preparation is often reduced to visiting a surgeon who is familiar with a technique. The science of learning has identified that several steps are needed towards a successful implementation. The first step is the creation of a complete conceptual approach; this demands the deposit in writing of the actions and reactions of every involved party in this new approach. By definition a successful implementation starts with the creation of a group of involved individuals willing to collaborate towards a new goal. Then every teachable component, described in this concept, needs to be worked out in simulation training, from the smallest manual step to complete scenario training for complex situations. Finally, optimal organisational learning needs to have an existing database of the previous situation, a clear goal and objective and a new database where every new approach is restudied versus the previous one, using appropriate methods of corrections for variability. A complete implementation will always be more successful versus a partial one, due to the habit in partial implementation to return to the previous routines.
RESUMEN
BACKGROUND: To investigate the predictive value of S100 (biochemical marker of neuroglial injury) for the occurrence of postoperative delirium (POD) in patients undergoing off-pump coronary artery bypass (OPCAB)-surgery. METHODS: We enrolled 92 patients older than 18 years undergoing elective OPCAB-surgery. Serum-levels of S100 were determined at baseline (BL), end of surgery (EOS) and on the first postoperative day (PD1). Postoperatively, all-patients were evaluated daily until PD5 for the presence of POD using the confusion assessment method (CAM) or the confusion assessment method for the intensive care unit (CAM-ICU) for patients in the intensive care unit (ICU). RESULTS: The overall incidence of POD was 21%. S100-values on PD1 significantly predicted the occurrence of POD during the later hospital stay [area under the curve (AUC)=0.724 (95% confidence interval (CI): 0.619-0.814); p=0.0001] with an optimal cut-off level of 123 pg mL-1 (sensitivity 100%, specificity 44%). Below this value, the absence of POD was predicted correctly in 43.66% of patients without POD [negative predictive value (NPV) of 100% (95%CI: 88.8%-100.0%) - positive predictive value of 29.8% (95%CI: 18.4%-43.4%) and likelihood ratio (LR) of the negative result of 0.0]. CONCLUSIONS: S100-levels <123 pg mL-1 measured on PD1 reliably rule out the development of POD after elective OPCAB-surgery. This finding warrants testing whether S100-levels could be used for a risk stratification of cardiac surgical patients and for the initiation of preventive measures against POD in patients with high postoperative S100-levels.
Asunto(s)
Biomarcadores/sangre , Enfermedades Cardiovasculares/cirugía , Puente de Arteria Coronaria Off-Pump/efectos adversos , Delirio/diagnóstico , Complicaciones Posoperatorias , Proteínas S100/sangre , Adulto , Anciano , Anciano de 80 o más Años , Delirio/sangre , Delirio/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios ProspectivosRESUMEN
OBJECTIVES: The purpose of this study was to examine the influence of material variables on needle-hole bleeding in vascular anastomoses. Material variables include suture size, needle-tip geometry and diameter, needle coating, suture material and coating and swage area. We attempted to determine whether particular suture material and a reduced needle-to-suture ratio (N:S ratio) could reduce the vessel wall defect and reduce needle-hole bleeding, without changing the suture diameter used for the anastomosis. METHODS: A comparative analysis was made of the needle-hole leak rate in end-to-end anastomoses of an ePTFE®-ePTFE® vascular graft with a PROLENE® polypropylene suture with HEMO-SEAL™ technology (HS, 1.84:1 N:S ratio), standard PROLENE® polypropylene suture (polypropylene 1, 2.41:1 N:S ratio), an alternate standard PROLENE® polypropylene suture (polypropylene 2, 2.06:1 N:S ratio) and a GORE-TEX™ ePTFE® suture (ePTFE® suture, 1.4:1 N:S ratio) in an ex vivo cardiopulmonary bypass pulsatile flow loop model using heparinized porcine blood. Testing was completed within the model with an activated clotting time between 250 and 500 s, at near normothermia (33-35°C) and at normotensive pressure levels (120/80 mmHg). A sample size of n = 20 was completed for each group. RESULTS: The average total sample leak rate was 19.8 ± 4.5 ml/min for the HS suture, 57.2 ± 7.2 ml/min for polypropylene 1, 33.8 ± 4.1 ml/min for polypropylene 2 and 46.5 ± 10.3 ml/min for the ePTFE suture. The average needle-hole leak rates were 0.63 ± 0.13 ml/min for the HS suture, 1.94 ± 0.23 ml/min for polypropylene 1, 1.14 ± 0.14 ml/min for polypropylene 2 and 1.56 ± 0.34 ml/min for the ePTFE® suture. A two-sided 95% confidence interval for the difference in leak rates showed that there were significant differences (44-67% reduction) in favour of the HS suture when compared with the alternative needles with the same suture material and different N:S ratios, and also a reduction (59%) compared with the sample with smaller N:S ratios but different suture material. CONCLUSIONS: The N:S ratio as well as the physical characteristics of the suture material are important factors in reducing needle-hole bleeding in vascular anastomoses.
Asunto(s)
Prótesis Vascular , Agujas/efectos adversos , Hemorragia Posoperatoria/etiología , Técnicas de Sutura/instrumentación , Suturas , Anastomosis Quirúrgica/efectos adversos , Animales , Modelos Animales de Enfermedad , PorcinosAsunto(s)
Competencia Clínica/estadística & datos numéricos , Evaluación de Procesos, Atención de Salud/estadística & datos numéricos , Indicadores de Calidad de la Atención de Salud/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Competencia Clínica/normas , Interpretación Estadística de Datos , Bases de Datos Factuales , Humanos , Modelos Estadísticos , Evaluación de Procesos, Atención de Salud/normas , Indicadores de Calidad de la Atención de Salud/normas , Reproducibilidad de los Resultados , Medición de Riesgo , Factores de Riesgo , Procedimientos Quirúrgicos Operativos/efectos adversos , Procedimientos Quirúrgicos Operativos/mortalidad , Procedimientos Quirúrgicos Operativos/normas , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: Bilateral internal thoracic artery (BITA) grafting is extensively underused in coronary artery bypass graft surgery and it is mostly preserved for patients under the age of 70. The purpose of the present study was to compare outcomes in propensity score-matched patients aged 70 years or greater using a BITA, with patients using a single internal thoracic artery (SITA) graft. METHODS: Among 18 761 patients operated on in our unit until December 2006, we selected 3496 patients aged 70 years or greater; of these, 1328 received a BITA (BITA group) and 2168 received a SITA (SITA group). Propensity score matching was used to reduce the preoperative patient variability. The 3-month and 10-year survival, stroke, myocardial infarction and sternal wound complication rate (defined as sternal instability or need for refixation) were compared between the two groups. RESULTS: After the correction, 892 patients per group were selected. Survival at 3 months was 90.6% in the SITA group and 91.6% in the BITA group (P = 0.34) and at 10 years was 38.9 and 57.5% (P = 0.02), respectively. The rates of stroke (1.01 vs 1.12%, P = 1), myocardial infarction (1.91 vs 2.13%, P = 0.86) and sternal wound complications (3.30 vs 5.42%, P = 0.17) were all similar between the SITA and BITA groups, respectively. CONCLUSIONS: The use of BITA grafting in elderly patients improves the 10-year survival rate, with similar postoperative morbidity. Thus, using adequate selection criteria, this technique should be routinely extended also to patients older than 70 years.
Asunto(s)
Puente de Arteria Coronaria/mortalidad , Puente de Arteria Coronaria/métodos , Arterias Mamarias/cirugía , Anciano , Puente de Arteria Coronaria/estadística & datos numéricos , Femenino , Humanos , Masculino , Estudios Retrospectivos , Análisis de SupervivenciaRESUMEN
OBJECTIVE: Training in cardiothoracic surgery across Europe remains diverse and variable despite the ever closer integration of European countries at all levels and in all areas of life. Coupled with the increasing ease of movement across Europe, the need for uniform training programmes has arisen to allow for equivalent accreditation and certification. METHODS: We review the current training paradigms within the specialty across the world and in Europe and also explore the concept of competence. RESULTS: There are diverse training systems across the world and in Europe in particular. Competence-based training is the new model of training; however, competence remains difficult to define and measure. We propose a European Training Programme in Cardiothoracic Surgery that aims to standardize training across the European countries. CONCLUSIONS: The difficulties in unifying training across Europe are numerous, but it is time to implement a European Training System in Cardiothoracic Surgery that will deliver a competence-based curriculum.
Asunto(s)
Competencia Clínica/normas , Educación de Postgrado en Medicina/métodos , Cirugía Torácica/educación , Acreditación , Educación Basada en Competencias , Curriculum , Europa (Continente) , Humanos , Enseñanza/métodos , Cirugía Torácica/normasRESUMEN
OBJECTIVES: The use of off-pump coronary artery bypass grafting (OPCAB) has been associated with similar or even worse results vs on-pump coronary artery bypass graft (CABG). Different production processes demand re-engineering, operational learning and quality loops to study and reduce negative learning curves. This analysis studies and quantifies the impact of these processes on the early mortality of continued re-engineering and quality loops within the OPCAB patient group. METHODS: We re-engineered CABG towards OPCAB in October 1999. A consecutive cohort of 3054 patients, representing 92.3% (ranging from 90% in 2000 to 99% in 2001 and later) of all primary and redo isolated CABG from that same period, was divided into three consecutive cohorts of 1018 patients. An anniversary follow-up at 3 months was complete for 100% of the patients. The 1- and 3-month survivals are studied using saturated propensity score matching and stratification for cohort variability (area under the curve = 0.82). RESULTS: Despite a progressively worsening risk profile (history of vascular disease, stroke and diabetes; main stem stenosis; left ventricular dysfunction), a survival improvement was shown between the consecutive cohorts. This improvement remained valid after the propensity stratification and propensity matching at 1 (97.6 vs 99.3%, P < 0.001) and at 3 months (96.7 vs 98.8%, P < 0.001). CONCLUSIONS: OPCAB re-engineering, followed by operational learning, improved the early survival even in the presence of a worsening risk profile.
Asunto(s)
Enfermedades Cardiovasculares/cirugía , Puente de Arteria Coronaria Off-Pump/educación , Puente de Arteria Coronaria Off-Pump/mortalidad , Anciano , Bélgica/epidemiología , Enfermedades Cardiovasculares/mortalidad , Distribución de Chi-Cuadrado , Estudios de Cohortes , Comorbilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de RiesgoRESUMEN
BACKGROUND: We evaluated the process of changing from conventional coronary artery bypass grafting (CABG) to totally arterial off-pump coronary artery bypass (TOPCAB) at a single heart center in Germany. METHODS: We (1) used multivariate statistical methods to assess real-time monitoring of OPCAB effects, (2) conducted a case review to assess preventable deaths and identify areas of improvement, (3) conducted a team survey, and (4) evaluated benchmarking results. RESULTS: All surgeons and assistants (n = 18) at this center were involved and were guided by the department head and one of the consultants, who was trained in this procedure in 2004 at the Leuven OPCAB school. The frequency of OPCAB operations increased abruptly in 2005 from 5% to 43% and then increased gradually to 67% (n = 546) by 2008 (total, 1781 OPCAB cases and 1563 on-pump cases). The in-hospital and 30-day mortality rates for OPCAB surgeries (n = 10 [0.6%] and 21 [1.2%], respectively) were lower than for on-pump surgeries (n = 27 [1.7%] and 26 [1.7%], respectively). Stroke rates were also lower for OPCAB surgeries (7 cases [0.4%] versus 15 cases [1%]). The lower risk of stroke in the OPCAB group was significant (P < .05) after risk adjustment. Monitoring curves and case reviews demonstrated a preventable death percentage of at least 30%. The attitude of the team was mostly positive because of the promising results (eg, fewer strokes, increasing TOPCAB popularity, and a top national rank). CONCLUSIONS: The change from conventional CABG to TOPCAB was effective in decreasing the incidence and severity of stroke, in developing a team routine and a positive team attitude, and in producing excellent benchmarking results. The presence of a training and communication deficiency at the beginning of the study suggested an area for further improvement. After 6 years TOPCAB had largely replaced conventional CABG.
Asunto(s)
Puente de Arteria Coronaria/efectos adversos , Innovación Organizacional , Accidente Cerebrovascular/etiología , Anciano , Instituciones Cardiológicas/estadística & datos numéricos , Puente de Arteria Coronaria/métodos , Puente de Arteria Coronaria/estadística & datos numéricos , Puente de Arteria Coronaria Off-Pump/efectos adversos , Puente de Arteria Coronaria Off-Pump/métodos , Puente de Arteria Coronaria Off-Pump/estadística & datos numéricos , Femenino , Alemania/epidemiología , Indicadores de Salud , Humanos , Incidencia , Masculino , Análisis Multivariante , Puntaje de Propensión , Factores de Riesgo , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/enfermería , Accidente Cerebrovascular/prevención & controlRESUMEN
Since 1998, a large body of literature regarding off-pump coronary bypass surgery has been published, although varying techniques and outcomes likely have led to its inconsistent application. One approach has been developed and standardized at the University Hospitals Leuven, Campus Gasthuisberg, Leuven, Belgium. This approach is straightforward and can be replicated without need for conversion toward cardiopulmonary bypass. The patient is 'conditioned' before and during the procedure. Both mammary arteries are harvested through a standard median sternotomy. The anterior surface of the heart is exposed with a horizontal line of left-sided pericardial stitches, just above the level of the heart. The anterior coronary vessels are anastomosed after routine shunting. The lateral and inferior aspects of the heart are exposed without deforming the atrio-ventricular axis. This is performed in a stepwise manner. The first step is anchoring a sling into the posterior pericardium under the roof of the left atrium. Second, this sling is gradually pulled upwards, supporting the heart as a cradle. Once the heart is exposed towards the zenith, an apical suction device stabilizes, reformats and exposes the ventricle. The lateral and inferior walls are then revascularized. As a strict no-touch aorta technique is used, free grafts are anastomosed to in-situ arterial grafts.