Predicting Post-Fontan Length of Stay: The Limits of Measured Variables.

Post-operative length of stay (LOS) is an important metric for both healthcare providers and patients and their families. Predicting LOS is a challenge as it is sensitive to multitudinous patient and system factors. All subjects undergoing a Fontan from 1996-2016 who survived to hospital discharge were included. Details about the pre-operative status, operative conduct, and post-operative course of each patient were obtained. The association between patient characteristics and post-Fontan LOS were determined using stepwise multivariable regression models. Of 320 subjects who underwent a Fontan, 314 (98.1%) survived to hospital discharge. Median age at Fontan was 3.3 years (IQR 2.8, 4.0) and the most common underlying diagnosis was hypoplastic left heart syndrome (106, 33.8%). Median post Fontan LOS was 11 days (IQR 8, 17). Univariable risk factors for longer LOS included number of previous surgeries, post-Glenn LOS, cardiopulmonary bypass time, post-operative chylothorax, and failure to extubate in the operating room (all p < 0.05). In multivariable models, number of previous operations, extubation in the operating room, and postoperative complications predicted LOS (R2 = 0.5185 for full model). The proportion of patients discharged on week days (14.7-18.8% per day) was significantly higher than the proportion discharged on weekend days (5.1-9.9% per weekend day). Pre-operative variables have limited use in predicting post-Fontan length of stay. The most important predictors of post-operative LOS are extubation in the operating room and the occurrence of post-operative complications. However, a significant proportion of variability in LOS was not explained by available measurable variables.

Combined Stump Pressure and Oximetry for Shunt Use During Carotid Endarterectomy.

BACKGROUND: Cross-clamp ischemia during carotid endarterectomy can be prevented with carotid bypass shunts in vulnerable patients identified by cerebral monitoring for ischemia. We compared transcranial cerebral oximetry (TCO) with carotid stump pressure measurements for selective shunt use. METHODS: We prospectively collected data on 300 consecutive patients operated on under general anesthesia between 2009 and 2016. Shunts were inserted for a 10% or greater drop in cerebral saturations and/or a mean stump pressure less than 40 mmHg. RESULTS: Seventy-five patients, 25% of the study population, were shunted. The indication was a combined desaturation and stump pressure in 38 (50% of the shunted group), desaturation alone in 11 patients (15%), and a low stump pressure alone in 26 patients (35%). There were no significant differences in baseline characteristics between those patients who were or were not shunted, except angiographic collateral blood supply, which was more commonly identified in patients who were not shunted. A watershed infarct occurred in just one patient with borderline TCO and stump pressure measurements in whom a shunt was not used. CONCLUSIONS: There was poor concordance between TCO and stump pressures, but using both in determining the need for shunt use almost eliminated cross-clamp ischemia in this series of 300 carotid endarterectomy patients.

Fast-track extubation after modified Fontan procedure.

OBJECTIVE: In 2007, we introduced a policy to plan to extubate all patients after a modified Fontan procedure in the operating room. Our objective was to review the feasibility, safety, and clinical outcomes of this approach. METHODS: Patients who underwent a modified Fontan operation between May 2004 and May 2010 were reviewed. RESULTS: Ninety-seven patients underwent a modified Fontan operation (mean age, 3.9 ± 2.2 years; mean weight, 15.1 ± 5.0 kg); 46 patients (47%) were extubated in the operating room (group A). Nineteen patients were extubated in the intensive care unit within 24 hours (group B), and 32 patients had delayed extubation (group C). The 3 groups were not significantly different with respect to preoperative characteristics. Twenty-four hours postoperatively, group A had a lower mean central venous pressure compared with patients in group B or C (13 vs 14 vs 17 mm Hg, respectively, P < .001); a higher base excess (0.4 vs -1.3 vs -3.4, P < .001); a lower fluid balance (234 vs 514 vs 730 mL, P < .001); and a lower inotrope score (4.6 vs 6.7 vs 10.8, P < .001). Group C had a longer median intensive care unit length of stay (2 vs 3 vs 6 nights, P = .01), kept their chest tubes longer (8 vs 9 vs 15 days, P = .001), and had a longer median hospital length of stay (9 vs 11 vs 21 days, P = .001). CONCLUSIONS: Extubation in the operating room after a modified Fontan procedure seems feasible. This approach is associated with improved early postoperative hemodynamics, earlier time to chest tube removal, and shorter intensive care unit and hospital lengths of stay.

Carotid revascularization: an update.

Symptomatic extracranial internal carotid artery stenosis poses a high short-time risk of ischemic cerebral stroke, as high as 20% to 30% in the first three months. Timely performed carotid endarterectomy (CEA) has been shown to be highly effective in reducing this risk although, in recent years, there has been great interest in replacing this procedure with less invasive carotid angioplasty and stenting (CAS). In this update we review recent studies and provide recommendations regarding the indications, methods and timing of surgical intervention as well as the anaesthetic management of CEA, and we report on recently published randomized controlled trials comparing CEA to CAS. We also provide recommendations regarding the sometime neglected but important medical management of patients undergoing carotid intervention, including antithrombotic and antihypertension therapy, lipid lowering agents, assistance with smoking cessation, and diabetes control.

Carotid endarterectomy: a review.

BACKGROUND: Since the validation of carotid endarterectomy (CEA) as an effective means of stroke prevention, there has been renewed interest in its best indications and methods, as well as in how it compares to carotid angioplasty and stenting (CAS). This review examines these topics, as well as the investigation of carotid stenosis and the role of auditing and reporting CEA results. INVESTIGATION: Brain imaging with CT or MRI should be obtained in patients considered for CEA, in order to document infarction and rule out mass lesions. Carotid investigation begins with ultrasound and, if results agree with subsequent, good-quality MRA or CT angiography, treatment can be planned and catheter angiography avoided. An equally acceptable approach is to proceed directly from ultrasound to catheter angiography, which is still the gold-standard in carotid artery assessment. INDICATIONS: Appropriate patients for CEA are those symptomatic with transient ischemic attacks or nondisabling stroke due to 70-99% carotid stenosis; the maximum allowable stroke and death rate being 6%. Uncertain candidates for CEA are those with 50-69% symptomatic stenosis, and those with asymptomatic stenosis > or = 60% but, if selected carefully on the basis of additional risk factors (related to both the carotid plaque and certain patient characteristics), some will benefit from surgery. Asymptomatic patients will only benefit if surgery can be provided with exceptionally low major complication rates (3% or less). Inappropriate patients are those with less than 50% symptomatic or 60% asymptomatic stenosis, and those with unstable medical or neurological conditions. TECHNIQUES: Carotid endarterectomy can be performed with either regional or general anaesthesia and, for the latter, there are a number of monitoring techniques available to assess cerebral perfusion during carotid cross-clamping. While monitoring cannot be considered mandatory and no single monitoring technique has emerged as being clearly superior, EEG is most commonly used. "Eversion" endarterectomy is a variation in surgical technique, and there is some evidence that more widely practiced patch closure may reduce the acute risk of operative stroke and the longer-term risk of recurrent stenosis. CAROTID ANGIOPLASTY AND STENTING: Experience with this endovascular and less invasive procedure grows, and its technology continues to evolve. Some experienced therapists have reported excellent results in case series and a number of randomized trials are now underway comparing CAS to CEA. However, at this time it is premature to incorporate CAS into routine practice replacing CEA. AUDITING: It has been shown that auditing of CEA indications and results with regular feed-back to the operating surgeons can significantly improve the performance of this operation. Carotid endarterectomy auditing is recommended on both local and regional levels.

Reoperation for acute hemispheric stroke after carotid endarterectomy: is there any value?

OBJECTIVE: Because the clinical benefit of urgent investigation and carotid re-repair for acute stroke complicating carotid endarterectomy (CEA) is uncertain, the results of this approach were examined in a large series of patients. METHODS: In a consecutive series of 700 CEAs, 24 patients (3.4%) had a postoperative stroke. Thirteen of these 24 patients experienced major hemispheric deficits (hemiplegia with or without aphasia, forced eye deviation, and decreased consciousness) that prompted either immediate surgical reexploration or cerebral angiography with reoperation on the basis of angiogram results; these 13 patients are the subject of this report. Neurological improvement was attributed to carotid reopening when affected muscle strength increased to antigravity power within 6 hours of reoperation. RESULTS: Of the 13 patients with severe postoperative deficits, 5 (38%) had the deficits when they awakened, 7 deficits occurred within 12 hours of surgery, and the only intracerebral hemorrhage in this series occurred 8 days after surgery. Five patients underwent urgent reoperation without angiography, and carotid occlusions were found and repaired in two patients. In another patient, the carotid was patent, and an intra-arterial injection of tissue plasminogen activator (20 mg) was given. In the seven patients who underwent cerebral angiography as the first step, two carotid occlusions and one residual stenosis with thrombus were found and repaired on an urgent basis. Surgical reopening of occluded arteries was followed by improvement in two of four patients, and early improvement was noted in one patient with a stenosis correction as well as in the patient who received intraoperative tissue plasminogen activator. Four patients who underwent urgent reoperation did not demonstrate a benefit soon after surgery. Two patients died, two were left with major deficits and five with moderate deficits, and four patients eventually had good recovery at a minimum of 6 months of follow-up. CONCLUSION: In this series, approximately one-half of hemispheric strokes complicating CEA had an underlying correctable lesion (occlusion or stenosis), and these patients typically had delayed-onset strokes. Approximately one-half of these patients improved early as a result of reopening, although computed tomography revealed new infarcts in most of them. Urgent carotid repair may benefit a minority of selected patients who have a major stroke after CEA.