The implementation of a pectus bar insertion enhanced recovery after surgery pathway: A quality improvement initiative.

BACKGROUND: Pectus excavatum repair is associated with significant discomfort, and pain is a primary contributor to postoperative hospital length of stay. Recent advances in postoperative pain control include the use of intercostal cryoablation techniques that may now make it possible to discharge patients on the day of surgery. Unnecessary variation in patient care and noncompliance with care bundles may be a factor in extended length of stay. The global aim of this quality improvement initiative was to successfully implement an enhanced recovery after surgery (ERAS) pathway on patients undergoing pectus excavatum repair. The SMART aim was to have a greater than 70% compliance for the perioperative bundle elements within 1 year of the pathway implementation. METHODS: Multiple Plan-Do-Study-Act (PDSA) cycles were designed to create and implement an ERAS pathway for patients undergoing a pectus bar insertion procedure. This multidisciplinary pathway was designed, managed, and implemented with key stakeholders from the Departments of Evidence Based Practice, Surgery, Anesthesiology, and Perioperative Nursing. Patient characteristics, outcomes, and compliance with elements of the pathway were measured for analysis for both the baseline and post-intervention groups with monthly automated reports. RESULTS: After implementation of the ERAS pathway, data on the first 50 patients showed a 90% compliance with the perioperative bundle elements. Mean length of stay was significantly decreased from 33 h (95% CI [28.76, 37.31]) to 18 h (95% CI [14.54, 21.70]). There were zero readmissions within 24 hours for patients who were discharged on the day of surgery. CONCLUSION: Employing a multidisciplinary approach in both planning and execution that standardized clinician practices and minimized unnecessary variation in patient care, an ERAS pathway for pectus bar insertion has been successfully established at our institution.

Vaping Associated Cardiac Arrest at School in a Teenager with Anomalous Left Coronary Artery.

The prevalence of electronic cigarette use is increasing at an astonishing pace, particularly in the teenage population. While at school, a healthy 13-year-old male experienced a sudden cardiac arrest after vaping multiple times throughout the day. Workup revealed an anomalous left coronary artery originating from the right sinus of Valsalva. Given this patient's underlying anomalous left coronary artery, we suspect that sympathoexcitatory and arrhythmogenic effects of high dose nicotine from vaping led to his cardiovascular collapse. This is the first published case report of a vaping associated cardiac arrest in a patient of this age.

Trimmed central venous catheters in pediatric cardiac surgery: Does height or weight correlate with the amount trimmed?

BACKGROUND: Due to excess catheter length, pediatric patients undergoing cardiac surgery frequently have the tip of the central venous catheter trimmed while on bypass to obtain optimal catheter positioning. AIMS: We sought to determine if there is a correlation between the patient's height or weight and the length of catheter removed. Our secondary aim compared the instances of central line-associated bloodstream infections and venous thromboembolisms between the trimmed and untrimmed catheters. METHODS: This retrospective study included patients having undergone cardiac surgery over a 3-year period who had an 8 cm central venous catheter placed in the right internal jugular vein. Hospital lists of central line-associated bloodstream infections and venous thromboembolisms that occurred were cross referenced with our study patients. RESULTS: There were 147 cases where the 8 cm central venous catheter was trimmed, which represents 35% of the cases. Of the catheters that were cut, on average 2.17 cm was removed. There is negligible correlation between the length of catheter removed and patient height (r = -.19, p = .021). There is negligible correlation between the length of catheter removed and patient weight (r = -.17, p = .039). There were no instances of central line-associated bloodstream infections or venous thromboembolisms attributed to the trimmed catheters. Of the 273 untrimmed catheters, there were no instances of an infection and one instance of a venous thromboembolism. CONCLUSION: Right internal jugular 8 cm central venous catheters are trimmed during pediatric cardiac surgery, and there is minimal correlation between the length removed and the patient height or weight. Due to the difficulty in estimating the proper length of a central venous catheter in smaller pediatric patients, placing an 8 cm long catheter in these patients and then trimming the distal tip while on bypass may be the most accurate way to properly position a catheter.