Changing trends in the use of preoperative carotid arteriography: the community experience.

Between 1 January 1991 and 31 December 1994, 215 carotid endarterectomies were performed at the authors' institution, which utilized a clinical pathway. Prior to May 1992, arteriography was performed routinely. A near perfect correlation was found between the arteriograms and duplex scans when they were compared as part of the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL) vascular laboratory accreditation process. A policy of selective arteriography was instituted in May 1992. Only 11 arteriograms were performed on the next 148 patients (7%) who underwent carotid endarterectomies. Arteriography was performed on two patients with extremely high bifurcations, and five patients when an exact degree of stenosis could not be determined. Two patients with simultaneous mid common carotid and bifurcation stenoses had arteriography to confirm the duplex findings. Arteriography confirmed a long, high-grade internal carotid artery stenosis, which was felt to be operable by duplex, and a simultaneous bifurcation and suspected left common carotid orificial stenosis in one patient each. Arteriograms were performed on three non-operated patients felt to have occluded internal carotid artery on duplex scanning. Two had string-like internal carotid arteries that extended intracranially from the bifurcation, and one patient had an internal carotid artery dissection. Duplex results were grossly confirmed at operation and pathologically. There were no neurological complications in those patients undergoing carotid endarterectomies based on the results of duplex scanning alone. Carotid endarterectomies can be safely performed based on the results of a duplex scan performed in an accredited vascular laboratory. This approach eliminates the risk and cost of arteriography. Approximately 10% of patients will require arteriography if the duplex scan is equivocal or shows disease at other areas than the carotid bifurcation.

Cardiac tamponade from central venous catheters.

BACKGROUND: This retrospective study was undertaken to determine the mechanism by which cardiac tamponade (CT) occurs after placement of central venous catheters (CVC), and to determine if physicians are aware of this potentially lethal complication. MATERIALS AND METHODS: Twenty-five previously unreported cases of CT from CVC were reviewed. The chest radiographs and postmortem records were reviewed when available. Two hundred physicians were interviewed about their knowledge of CT from CVC. They were specifically asked if they had reviewed the three-volume video, "CVC Complications," that was sent by the Food and Drug Administration to all hospitals where CVC are inserted. RESULTS: All postinsertion chest radiographs showed the tip of the catheter to be within the pericardial silhouette. All patients developed unexplained hypotension from hours to 1 week after CVC placement. Eight patients complained of chest tightness, 12 of shortness of breath, and 15 were noted to have air hunger. The electrocardiogram showed inferior wall injury in 7 patients. None of the physicians surveyed had seen the FDA video. CONCLUSIONS: Cardiac tamponade from central venous catheters is preventable if the tip of the catheter is outside the cardiac silhouette on chest radiograph. Any patient with a CVC in place who develops unexplained hypotension, chest tightness, or shortness of breath should have an emergency echocardiogram to rule out cardiac tamponade.

Are preoperative antibiotics administered preoperatively?

Ideally antibiotics should be administered preoperatively within 2 hours of skin incision to ensure adequate tissue concentrations, especially when a vascular prosthesis is used. The quality of patient outcomes may be adversely affected when key processes, by degrees, fail to meet patient care objectives. This study was designed to incorporate the concepts of total quality management to determine how effectively this goal was achieved, and, after review of those measured results, what process improvements could be instituted to meet the established requirements for the administration of antibiotics. The study was then repeated on a yearly basis to determine what effect these improvement measures had on antibiotic administration. Three time periods were established for determining when antibiotics were administered. The "early" period was more than 2 hr preoperatively. "Preoperative" was from 2 hr before surgery until the time of incision and "perioperative" was after the time of incision. Group 1 consisted of the first 100 patients undergoing vascular procedures in 1992. After the data were collected, a multidisciplinary team of nurses, pharmacists, and surgeons was assembled to determine the step by step desired process flow from order received to actual medication administration. The team then reviewed each step of the process to identify variations relative to data obtained. An action plan was developed to implement the agreed upon improvement plan. After improvements were implemented, groups 2, 3, 4, and 5 consisted of the first 100 vascular procedures of 1993, 1994, 1995, and 1996. Group 1 had only 26% of antibiotics administered during the preoperative period and 74% during the perioperative period. Problems identified were: surgeons ordered the antibiotics when the patient was in the operating room, cefamandole and vancomycin required at least 1 hr to infuse, nurses were not aware of the need for preoperative infusion, and the pharmacy did not supply the antibiotics in a timely fashion. Educational inservices were held for all parties involved, and cefazolin was used in place of cefamandole because it could be given as a bolus. Results were: group 1, early, 0%; preoperative, 26%; perioperative, 74%; P = N/A; group 2, early, 0%, preoperative, 90%; perioperative, 10%; group 3, early, 7%; preoperative, 93%; perioperative, 0%; group 4, early 0%; preoperative, 100%; perioperative, 0%; and group 5, early, 0%; preoperative, 100%; perioperative, 0%; P = 0.0001 for groups 2-5 (versus group 1). It was surprising how often antibiotics were administered incorrectly in a busy vascular practice. By focusing on the process of care delivery, a continuous quality improvement team implemented simple changes that resulted in significant improvements. We are now conducting a study to determine what effect these process improvements had on our infection rate.

Fast tracking carotid endarterectomy: practical considerations.

The diagnosis-related groups (DRG) and managed care economics have encouraged physicians to be more cost and resource efficient. In response to this demand, a fast track program for elective carotid endarterectomies has been established at Sewickley Valley Hospital. The essential components of this four-step program are operation based on duplex ultrasonography alone, same-day admission, a short recovery room stay to limit intensive care use, and discharge on the first postoperative day. Overall, 79% of patients for elective carotid endarterectomy successfully completed all four steps of the protocol at our institution. This has resulted in marked cost savings.

Do clinical pathways for major vascular surgery improve outcomes and reduce cost?

PURPOSE: This study was performed to determine whether the implementation of clinical pathways for patients who undergo major vascular procedures in a community hospital would shorten the length of stay and reduce charges when compared with Medicare standards. METHODS: Length of stay, hospital costs, and morbidity, mortality, and readmission rates for the four most common vascular diagnosis-related group (DRG) categories at our institution were compared with Medicare standards. The four categories were DRG 005 (extracranial vascular procedures), DRG 110 (aortic and renal procedures), DRG 478 (leg bypass with comorbidity), and DRG 479 (leg bypass without comorbidity). Between May 1, 1994, and June 30, 1996, 112 patients underwent carotid endarterectomy, 42 patients underwent aortic or renal procedures, and 130 patients underwent lower extremity bypass procedures (68% with comorbidity). Only Medicare patients were included because exact cost/reimbursement data were available. No admissions were excluded. RESULTS: The average length of stay was 1.2 days for DRG 005, 6.9 days for DRG 110, and 3.2 and 2.1 days for DRGs 478 and 479, respectively. The average cost savings when compared with the Medicare reimbursement was $4338 for DRG 005, $7161 for DRG 110, $4108 for DRG 478, and $2313 for DRG 479. Readmission was necessary for 9% of peripheral bypass patients. Ten percent of patients in DRG 005 and 86% of patients in DRG 110 needed intensive care, whereas only 2% of patients who underwent complicated bypass procedures did. Ninety percent of carotid endarterectomy patients and 23% of leg bypass patients were discharged on the first postoperative day. There were two postoperative strokes (2%) after carotid surgery. Thirty-three percent of aortic/renal patients had complications that led to care outside the clinical pathway. Twenty-five percent of leg bypass patients required home care to treat open foot wounds. Total inpatient cost savings were $1,256,000 when compared with Medicare reimbursement. CONCLUSIONS: Clinical pathways significantly improve the length of stay and decrease inpatient charges for major vascular surgical procedures while maintaining high standards of care. Factors that favorably affected the length of stay and hospital charges were outpatient arteriography, same-day admission, early ambulation, physical therapy, home care, use of the intensive care unit on a selective basis, and early discharge. Factors that adversely affected these outcomes were emergency admission, inpatient arteriography, thrombolytic therapy, complications, and the need for dialysis or anticoagulation.

Cardiac tamponade caused by central venous catheter perforation of the heart: a preventable complication.

BACKGROUND: Pericardial tamponade caused by central venous catheter perforation of the heart is a catastrophic complication that can be prevented by attention to proper positioning of the catheter tip proximal to the cardiac silhouette. This study was performed to determine awareness of this potential complication among physicians and to suggest measures to minimize the incidence of this problem. STUDY DESIGN: Clinical and radiologic features of 11 cases were evaluated. House officers and attending staff who frequently pass central venous catheters and train junior physicians to place these catheters were questioned specifically to test their awareness of this complication and their knowledge of optimal catheter tip positioning. Attending radiology staff physicians were questioned similarly. The written protocols of local community hospitals with respect to central venous catheter placement were reviewed to determine their criteria for optimal catheter placement. RESULTS: Ten of the 11 cases reviewed resulted in death; the 11th case resulted in severe anoxic brain insult with a persistent vegetative state. In the ten cases that had radiologic studies available for review, the central venous catheter tip was seen to lie malpositioned within the cardiac silhouette. Questioning of house officers and attending staff as well as attending radiology staff revealed a lack of awareness of this problem generally and a lack of knowledge of optimal catheter tip positioning specifically. The protocols of area hospitals revealed similar findings with respect to this potential complication. CONCLUSIONS: Pericardial tamponade resulting from central venous catheter perforation of the heart can be avoided by adherence to proper technique in the placement of these catheters, ensuring that the catheter tip lies proximal to the cardiac silhouette, optimally in the superior vena cava, 2 cm proximal to the pericardial reflection. Physicians who place these catheters and train others to do so must be aware of this issue and they must educate their trainees as well. Radiologists responsible for interpreting the roentgenographs of the chest obtained after catheter placement should be alert to catheter malposition and communicate this information promptly. Hospital protocols should deal with this issue explicitly and insist on repositioning of catheters if catheter tips are seen to lodge in suboptimal positions.

Are one-day admissions for carotid endarterectomy feasible?

BACKGROUND: In 1990, a clinical pathway for streamlining the care of patients undergoing elective carotid endarterectomy was developed and tested at our institution. This consisted of extensive preoperative patient education in the surgeon's office, outpatient arteriography (now performed only on select patients), same-day admission, regional anesthesia when possible, selective use of the intensive care unit (ICU), and early discharge in the first postoperative day when feasible. PATIENTS AND METHODS: Between January 1, 1991 and June 30, 1994, 186 patients were entered into the protocol. Twenty-six percent of the patients were asymptomatic, while 74% had either transient symptoms or a prior stroke; 13% were operated on under general anesthesia. RESULTS: Three (1.6%) patients developed neurologic complications: 1 minor stroke, 1 transient ischemic attack, and 1 intracerebral hematoma; and 18 (10%) patients required the ICU postoperatively. On the first postoperative day, 157 patients were discharged. Average operative time was 48 minutes (range 39 to 61). Average length of stay (LOS) was 1.27 days. One death occurred on the 28th postoperative day from cardiac causes, and there were no hospital readmissions. Cost savings were over $3,000/patient when compared to the diagnosis-related group reimbursement. Because of the distribution of the data, statistical analysis was not feasible; however, several trends were clear. Neurologic complications, admission to the ICU, and increasing LOS all diminished the cost efficiency of carotid endarterectomy. Type of anesthesia and the use of a shunt or patching did not affect cost. Clearly, increasing the length of operation would also decrease cost efficiency. CONCLUSIONS: Adoption of the clinical pathway presented here is feasible in any institution. One-day admission for patients undergoing carotid endarterectomy has been shown to be safe, highly cost-effective, and results in more efficient use of scarce resources, such as the ICU.

Carotid endarterectomy: a safe cost-efficient approach.

The diagnosis-related groups have encouraged physicians to become more efficient in the care of their patients; often, however, raising the question of safety. For 3 years all patients undergoing carotid endarterectomy at our institution were monitored in the intensive care unit for 24 hours and the majority were discharged on the second postoperative day. After review of these patient's hospital records and direct patient interviews, it was clear that many patients did not require a stay in the intensive care unit and could be discharged on the first postoperative day. In January 1991 a prospective policy was established to evaluate the safety and efficacy of outpatient arteriography, same-day admission, selective use of the intensive care unit, and early discharge on the first postoperative day when feasible. During a 10-month period all patients undergoing carotid endarterectomy at our institution were evaluated (n = 52). Eleven patients had had a prior stroke (21%), 31 had either amaurosis fugax or transient ischemic attacks (60%), and 10 had no symptoms (19%). The arteriogram for 49 of the patients was obtained on an outpatient basis or during a prior admission, and these patients were admitted to the hospital on the day of operation. Nine patients were placed under general anesthesia and had shunting procedures, and 43 patients had cervical block anesthesia, eight of whom had shunting (19%). Only five patients required an intensive care unit stay for either hypertension, hypotension, or neurologic complication (one transient ischemic attack and one minor stroke). Forty-six patients (88%) were discharged on the first postoperative day; average length of stay was 1.29 days/patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Atraumatic vascular anastomoses using a tourniquet.

Because of the occurrence of stenoses just beyond the distal anastomosis, lower leg exsanguination and the use of a mid-thigh tourniquet was adapted. From July 1, 1988 until June 30, 1990, 75 primary operations and 18 secondary operations on failing bypasses were performed using this technique. The primary operations were to the below-knee popliteal (4), anterior tibial (19), posterior tibial (16), peroneal (26), and inframalleolar arteries (10). The proximal anastomoses were also done while the tourniquet was inflated in 11 cases (three tibio-tibial and eight from the popliteal below the knee). Of the secondary procedures, 15 were patch angioplasties and three were distal extensions. The cuff was inflated to 400 mmHg from 22 to 73 minutes. This technique offers numerous advantages: only enough arterial surface is dissected for the anastomoses to be performed. Veins and arterial branches are left intact, thus decreasing the risk of bleeding. The artery is left in its bed to preserve its vasa vasorum. The lumen is not obliterated by clamps assuring the best anastomosis. Since there are no clamps in the field, suturing is less difficult. The tourniquet facilitates a faster, drier operation. No stenoses have been noted in the arteries just distal to the anastomoses on follow-up showing the value of atraumatic occlusion, especially on small vessels. No inflow stenoses occurred in the area under the tourniquet if the artery was patent at the time of operation.

Small bowel lymphoma associated with AIDS.

Patients with the Acquired Immunodeficiency Syndrome (AIDS) are known to be at increased risk for developing malignancy; however, the spectrum that these malignancies encompass has not been fully defined. An unusual case of a 32 year old homosexual male with AIDS who developed two spontaneous small bowel perforations is presented. The diagnosis of primary histiocytic lymphoma of the small intestine was established only after his second operation.

Is percutaneous insertion of the intra-aortic balloon pump through the femoral artery the safest technique?

Between Jan. 1, 1979, and Sept. 30, 1983, 423 intra-aortic balloon pumps (IABPs) were successfully inserted into 400 patients; IABPs could not be inserted in 36 patients (success rate 91.7%). Before 1980 all balloons were inserted surgically through a graft and by 1983 virtually all IABPs were inserted by percutaneous techniques. Infectious complications occurred in 12.3% of IABPs inserted by the open technique and 1.5% of IABPs inserted percutaneously (p less than 0.001). Major ischemic complications were not significantly different between the two groups when all of the patients were analyzed together (p greater than 0.5) and when only the surviving patients were analyzed (p greater than 0.75). However, ischemic complications occurred in 32.9% of women in the study and only 19.7% of the men (p less than 0.005). The percutaneous insertion of the IABP is recommended as the technique of choice because of the ease of insertion, lack of infectious complications, and similar rate of major ischemic complications when compared with IABPs inserted by open surgical means through a graft anastomosed to the common femoral artery.

Small intestinal adenocarcinoma complicating regional enteritis.

Three new cases of small intestinal adenocarcinoma complicating Crohn's disease are reported. Seventy-five other cases have been reported to date. Analysis of these cases in comparison with de novo adenocarcinoma of the small bowel shows that they: (1) occur at a younger age; (2) occur in distal small bowel; (3) show a male predilection; and (4) have a worse prognosis. The increasing number of these cases suggests that small intestinal regional enteritis predisposes to adenocarcinoma. Improved prognosis can only be achieved with earlier diagnosis.

Nonoperative salvage of subcutaneous hemodialysis fistulae.

During a 7-month study period 11 chronic hemodialysis patients presented with thrombosis of their arteriovenous grafts or fistulae. They were prospectively entered in a protocol to evaluate the efficacy of low-dose streptokinase and percutaneous angioplasty for reopening the hemodialysis access. All patients were evaluated with a fistulagram and had local, low-dose streptokinase (10,000 U/h) infused directly into the fistula, until the thrombus dissolved or for 36 h. If repeat fistulagram demonstrated stenoses, percutaneous transluminal angioplasty was attempted. 5 patients were successfully treated, and 4 have remained patent without complication for a minimum follow-up of 9 months. 4 patients had the streptokinase stopped prematurely: 1 died (myocardial infarct), 1 was operated upon (perforated diverticulum), and 2 patients had perigraft complications. There were no major complications, although minor complications were common. Significant systemic effects on the coagulation profile did not occur. The regimen of locally infused, low-dose streptokinase and percutaneous transluminal angioplasty was found to be a safe and effective alternative for the treatment of thrombosed hemodialysis arteriovenous grafts or fistulae. If this regimen is unsuccessful, it does not preclude operative revision.

Cardiac tamponade from central venous catheters. Report of a case and review of the English literature.

A case of acute cardiac tamponade caused by an internal jugular central venous catheter which was successfully treated is reported. The English literature is reviewed and shows that tamponade can occur up to 37 days after insertion and has a 65% mortality. The tamponade is usually caused by the actual infusate and not by blood.

Nontraumatic Clostridium septicum gangrenous myonecrosis.

Nontraumatic Clostridium septicum infections may present as either septicemia or as metastatic myonecrosis. Most of these infections occur in debilitated patients with diabetes who are receiving cancer chemotherapy. The majority have a hematologic abnormality or a carcinoma of the colon. Usually there is an ulcerative lesion of the gastrointestinal tract that serves as the portal of entry. While most of these patients die from overwhelming sepsis, our patient was debrided early and treated promptly with high-dose penicillin therapy as well as hyperbaric oxygen therapy. He fully recovered from C. septicum gas gangrene and underwent resection of a recurrent colonic cancer.

Detection of metastatic disease from carcinoma of the breast: limited value of full lung tomography.

Until now no large prospective study has been made to evaluate the efficacy of full lung tomography in detection of pulmonary metastases from carcinoma of the breast in the presence of a negative chest radiograph. In the current study, 144 patients with proven breast carcinoma and a negative chest radiograph underwent full lung tomography. Nodules were demonstrated in three patients and, in two of them, presumably reflected metastatic disease. Both patients had advanced extrapulmonary metastatic disease at the time of full lung tomography and in neither case did a change in therapy result. One presumed false-positive observation was also made. Because of the low propensity for carcinoma of the breast to metastasize to the lungs, full chest tomography does not appear warranted as a screening procedure in these patients.