Remediation: a necessary function for employers to correct incompetence regarding clinical professional registered nurse practice.

Remediation for the professional licensed registered nurse is a topic sparsely written about in the nursing literature. The provision of remediation, however, is a common tool used to address registered nurse practice issues. This article seeks to describe the various stakeholders' roles in remediation and recommends that nurses in management roles should ensure the provision of remediation for registered nurses when warranted.

Nurses' risk without using smart pumps.

Intravenous smart pump devices hold specific medications in electronic libraries. These libraries contain predetermined volumes with corresponding administration rate limits. Smart pumps prevent nurses from engaging in calculations under high-pressure situations and ensure that only therapies available to the nurse are administered to patients. When this technology is available and not utilized, litigation could be successful in finding fault on the nurse. Therefore, nurses should use the available smart pump technology every time when administering intravenous therapy.

Concurrent primary cardiac tumors of differing histology and origin: case report with literature review.

Primary cardiac tumors are rare and are diverse in histology and anatomic origin. Approximately 75% are benign, and nearly 50% of these are myxomas. Herein, we report concurrent myxoma and papillary fibroelastoma, which tumors were found attached to the left atrial septum and aortic valve, respectively. Concurrent primary cardiac tumors of differing histology and origin are rare, and, to our knowledge, this is one of the few such cases reported in the medical literature.

Current results of off-pump coronary artery bypass surgery.

Whether to use or not use cardiopulmonary bypass-cardioplegic arrest to perform coronary artery bypass surgery is the main controversy presently facing our surgical specialty. The reported clinical outcomes are mainly retrospective and highly debatable for conclusiveness regarding the benefits of off-pump surgery. As more centers and larger patient cohorts are analyzed and reported, particularly over the last 2 years, off-pump surgery appears to provide significantly improved outcomes with decreased bleeding and transfusion requirements, less myocardial enzyme release, less ventilatory time, and decreased hospital stay and costs. Reported off-pump benefits for the major outcomes of operative mortality and stroke are encouraging, but less conclusive. From experienced centers, early off-pump angiographic graft patency has been comparable to previously published conventional results. High-risk, elderly patients may benefit the greatest from off-pump surgery. Although in relative technical infancy, off-pump coronary artery bypass grafting has demonstrated enough benefit outcomes that it is no longer an experimental procedure, but a valid surgical revascularization method requiring further investigation and continued usage.

New approaches to redo-coronary bypass grafting.

Patients presenting with recurrent symptoms after coronary artery bypass graft surgery (CABG) continue to be a significant therapeutic challenge for the interventional cardiologist and cardiac surgeon. Percutaneous transcatheter angioplasty and repeat CABG, directed at vein graft degeneration and progression of native atherosclerotic disease, carry substantially worse outcomes than primary procedures. Recent minimally invasive, surgical advances using minimal-access incisions, arterial conduits, and off-pump techniques are demonstrating improved hospital outcomes compared with conventional CABG. These sternotomy-sparing, beating heart surgical approaches combined with recent advances in drug-eluting stents to provide complete revascularization may provide the best cardiac event-free survival for symptomatic CABG patients in the future.

Endoscopic radial artery harvesting: results of first 300 patients.

BACKGROUND: With the expanded use of the radial artery as a bypass conduit in patients undergoing coronary artery bypass grafting, an endoscopic radial artery harvesting method was used to improve esthetics and patient acceptance, and possibly, to decrease hand neurologic complications. METHODS: After informed consent and confirmation of adequate ulnar collateral blood flow, 300 consecutive patients undergoing coronary artery bypass grafting had their nondominant radial artery endoscopically removed through a small 3-cm incision just proximal to the radial styloid prominence. Standard endoscopic vein equipment (30-degree 5-mm endoscope, subcutaneous retractor, and vessel dissector) with ultrasonic harmonic coagulating shears were used. After radial artery isolation, the radial artery was proximally clipped and transected 1 to 2 cm distal to the visualized ulnar artery origin to the inferior end of the wrist incision. RESULTS: The mean age was 62.2 years; 23% of the patients were women, 39% had diabetes mellitus, and 28% had peripheral vascular disease. All 300 endoscopic radial arteries were grossly acceptable and used for grafting. Early in the series, 29 patients (9.7%) required a second 3-cm incision proximally for vascular control. Only one wrist incision was required at the last 200 cases. The conduit length varied between 18 and 24 cm. Occurring early in the series, hospital complications were two tunnel hematomas requiring drainage and one brachial artery clipping repaired primarily without sequela. At 30 days postoperative follow-up, 5 patients (1.6%) had been treated with oral antibiotics for incisional cellulitis and 26 patients (8.7%) had objective dorsal thenar sensory numbness. No ischemic hand complication, perioperative myocardial infarction, reintervention in radial artery graft distribution, or numbness in the lateral forearm occurred. All patients expressed marked satisfaction with the small incision and cosmetic result. CONCLUSIONS: In our initial experience, endoscopic radial artery harvesting can be performed safely, with minor, infrequent complications. A full-length radial artery conduit can be obtained with improved esthetics and patient satisfaction and acceptance. Late dorsal thenar paresthesias, although infrequent, continue to be a problem as with the open method.

Limited-access surgical coronary artery revascularization.

The continued evolution of surgical revascularization has resulted in much less invasive alternatives for patients undergoing coronary artery bypass grafting. In particular, techniques and technologies have been developed to allow for the grafting of coronary arteries through limited access incisions without the circulatory support of cardiopulmonary bypass. The conduits are generally arterial rather than the venous alternatives used originally, and the harvesting of these conduits is performed through limited access incisions described in another article in this review. The result of these efforts is sternal-sparing solutions for the off-pump coronary artery bypass grafting of all the various coronary locations on the heart. This is accomplished through a spectrum of small incisions that can directly expose any specific area of interest for focal bypass grafting. The surgical insult is greatly reduced and the patient's recovery is significantly enhanced. These efforts continue to bring us closer to the ultimate goal of 24-hour hospital stays for coronary artery bypass grafting patients.

Facilitated vascular anastomosis in coronary bypass surgery.

The goal of truly minimally invasive surgical revascularization with 1-day hospital stays is shared by surgeons, patients, and payors alike. However, accomplishing this will involve doing surgery through more limited-access incisions and working within closed spaces. Suture management in this setting is cumbersome, slow, and unreliable. Facilitated anastomotic techniques and technologies are generally believed to be the vehicle that will ultimately allow us to address this. A considerable amount of time and resources has already been expended by many people and companies in this effort, with early clinical progress now being reported. Much more remains to be done, and other new approaches still need to be investigated. This article provides an overview or snapshot of the work and progress to date with facilitated vascular anastomoses along with some of the challenges that have yet to be solved. The achievement of a predictable, reproducible, and reliable technique to accomplish this will significantly and irrevocably reduce the extent of surgery required to revascularize the heart.