Joseph Alex

Comparison of the immediate postoperative outcome of using the conventional two drains versus a single drain after lobectomy

BACKGROUND We compared the immediate postoperative outcome and cost-effectiveness of using a single chest drain in the midposition to the conventional apical and basal drains after lobectomy. METHODS Of the 120 consecutive patients who underwent thoracotomy and lobectomy for lung cancer at our center between January 2001 and December 2002, 60 had the conventional 28 French apical and basal drains (group A), whereas the remaining 60 had a single 28 French chest drain placed in the midposition before closure (group B). The assessed outcomes included length of stay, amount and duration of drainage, subcutaneous emphysema, postremoval hemothorax and pneumothorax, drain reinsertion, patient controlled analgesia duration, maximum pain scores, and analgesic usage. RESULTS Both groups matched in terms of age (group A vs group B mean, 65 years old vs 66 years old, respectively; p = not significant [NS]) and gender (M:F, 4:1 for group A vs 4:1 for group B). There was no significant difference in the length of stay (mean, 7.7 days for group A vs 7.8 days for group B; p = NS), amount of drainage (mean, 667 mL for group A vs 804 mL for group B; p = NS), duration of drainage (mean, 4 days for group A vs 4.3 days for group B; p = NS), duration of patient controlled analgesia (mean, 3.7 days for group A vs 4.2 days for group B; p = NS) and analgesic combinations used (nonsteroidal antiinflammatory drugs +/- oral opioids +/- paracetamol) between the two groups. There were no clinically significant postdrain removals of hemothorax or pneumothorax in either group. Group A patients had a significantly higher maximum pain score compared with group B patients (mean, 1.4 vs 1.02, respectively; p = 0.02). Cost savings per patient in group B was more than or equal to 55 US dollars, which added up to a total cost savings of approximately more than or equal to 3,300 US dollars. CONCLUSIONS A single chest drain in the midposition is just as effective, significantly less painful, and much more cost effective than the conventional use of two drains after lobectomy.

Surgical nurse assistants in cardiac surgery: a UK trainee's perspective.

OBJECTIVE To assess the impact of surgical nurse assistants on surgical training based on a comparative audit of case-mix and outcome of coronary revascularizations assisted by surgical nurse assistants vs. surgical trainees. METHODS Relevant recent articles on Calman reform of specialist training and European working time directive (EWTD) on junior doctor working hours were reviewed for the discussion. For the audit prospectively entered data of elective and expedite first time coronary artery bypass grafting cases from 2000 to 2003 were analysed. Group A (n=233, Consultant+Surgical nurse assistant), group B (n=1067, Consultant+Junior surgical trainee). Chi-square test, t-test and Fishers test were used as appropriate for statistical analysis. RESULTS Comparative preoperative variables were gender (P=0.8), body mass index (P=0.9), smoking (P=0.3), diabetes mellitus (P=0.2), hypertension (P=1), peripheral vascular disease (P=0.5), previous cerebrovascular accident (CVA)/transient ischemic attack (TIA) (P=0.3), renal dysfunction (P=0.4), preoperative rhythm disturbances (P=0.3), previous Q-wave myocardial infarction (MI) (P=0.4), Canadian Cardiovascular Society angina class (P=0.4), New York Heart Association heart failure class (P=0.4) and left ventricular function (P=0.4). Patients in group B were of higher risk due to age (P=0.01), coronary disease severity (P=0.05), left main stem disease (P=0.001), Parsonnet score (P=0.0001) and Euroscore (P=0.005. Regarding the myocardial protection technique, intermittent cross-clamp fibrillation was used more frequently in group A while antegrade-retrograde cold blood cardioplegia and off-pump coronary artery bypass were used more in group B (P=0.0001). The cross-clamp (P=0.0001) and operation time (P=0.0001) were significantly lower in group A despite a comparable mean number of grafts (P=0.2). There was no significant difference in the immediate postoperative outcome ventilation time (P=0.2), intensive care unit stay, postoperative stay (P=0.2), re-exploration for bleeding (P=0.5), inotrope+intra-aortic balloon pump (P=0.2), postoperative MI (P=0.9), postoperative rhythm disturbances (P=0.9), CVA/TIA (P=0.8), renal dysfunction (P=0.6), wound infection (P=0.7), sternal re-wiring (P=0.2), multi-organ failure (P=0.4) or mortality (P=0.1). CONCLUSIONS Surgical nurse assistants can be used effectively in low-risk cases without compromising postoperative results. However, initiatives to tackle the EWTD should be focused on areas that do not compromise the training needs of junior surgical trainees. An intermediate grade between the present senior house officer and registrar grades could be a way forward.

Comparison of the immediate post-operative outcome of two different myocardial protection strategies: antegrade–retrograde cold St Thomas blood cardioplegia versus intermittent cross-clamp fibrillation

The objective of this study was to compare the immediate post-operative outcome of two myocardial protection strategies. Data of consecutive elective first time coronary artery bypass grafting (CABG) were analysed: Group A (n=671, antegrade-retrograde cold St Thomas blood cardioplegia) and Group B (n=783, intermittent cross-clamp fibrillation). Age, angina class, myocardial infarction (MI), pre-operative rhythm, respiratory disease, smoking, diabetes mellitus (DM), hypertension (HT), renal function, cerebrovascular disease, body mass index (BMI) and Parsonnet score were comparable. Significant differences existed in gender (P=0.02), peripheral vascular disease (PVD) (P=0.04), heart failure class (P=0.0001), left ventricular (LV) function (P=0.01), disease severity (P=0.02), left main stem (LMS) (P=0.02) and preinduction intra-aortic balloon pump(IABP) (P=0.08). Group A had more grafts (P=0.008), longer bypass (P=0.0001) and cross-clamp time (P=0.0001). Post-operative inotrope, MI, arrhythmias, neurological, renal complications, multi-organ failure, sternal re-wiring, ventilation, length of stay and mortality were comparable. There was higher IABP usage and longer intensive therapy unit (ITU) stay (P=0.01) in Group B. Chronic obstructive airway disease (COAD), renal dysfunction, cross-clamp time, bypass time, post-operative inotrope or IABP and re-exploration predicted longer ITU stay. Intermittent cross-clamp fibrillation is a versatile and cost-effective method of myocardial protection, with the immediate post-operative outcome comparable to antegrade-retrograde cold St Thomas blood cardioplegia in elective first-time CABG.

Intensive care unit readmission after elective coronary artery bypass grafting.

Prospective data of 3,120 consecutive patients who had elective coronary artery bypass were analyzed to identify patient profile, cost, outcome and predictors of those readmitted to the intensive care unit. Group A (n = 3,002) had a single intensive care unit admission and group B (n = 118) were readmitted within 30 days after surgery. Parsonnet score, EuroSCORE, age, body mass index, chronic obstructive airway disease, peripheral vascular disease, renal dysfunction, unstable angina, congestive cardiac failure, and poor left ventricular function were higher in group B. Bypass and crossclamp times were longer, and the prevalence of inotropic and balloon pump support, arrhythmias, myocardial infarction, re-exploration, blood loss and transfusion, cerebrovascular accident, wound infection, sternal dehiscence, and multisystem failure were higher in group B. Despite a 4-fold increase in cost of care, the mortality rate (32.4%) of patients readmitted to intensive care was 23-times higher than routine patients (1.4%). Crossclamp time > 80 min, Parsonnet score > 10, EuroSCORE > 9, sternal dehiscence, ventricular arrhythmias, and renal failure predicted readmission.

Systemic inflammatory response after cardiopulmonary bypass: the mediators of leukocyte-endothelial adhesion

Any surgery carries the risk of post-operative systemic inflammatory reaction. However, in cardiac surgery, the use of the bypass machine multiplies the risk many times over. The clinical manifestations can vary from insignificant transient organ dysfunction to life-threatening multi-organ failure. Surgical trauma, contact activation of leukocytes and platelets in the cardiopulmonary bypass circuit, release of activated neutrophils from the pulmonary bed, endotoxins released from the gut, and reperfusion injury have all been implicated as triggering factors. This complex inflammatory response involves the release of initiators from different cascades that activate neutrophils causing them to marginate and adhere to the endolthelium, transmigrate across the endothelial lining and finally degranulate in tissues. Once leukocyte activation and adhesion occurs, transmigration, degranulation and tissue damage become inevitable. The activation and adhesion are two steps where potential therapeutic intervention c...