Outpatient surgery for the inpatient: an introduction to postacute care.

PURPOSE OF REVIEW: This article considers how postacute care (PAC) facilities such as skilled nursing facilities, inpatient rehabilitation facilities and long-term care hospitals could represent an opportunity for outpatient surgical facilities to improve patient care. In order to understand how these facilities interact with outpatient surgical services, it is first necessary to understand the types of facilities that provide PAC. RECENT FINDINGS: The significant costs associated with PAC have led to some proposed regulatory changes. Evidence examining postacute costs following total joint replacement has indicated that these costs may be decreased with cooperative efforts between perioperative physicians and PAC facilities. However, the lack of currently published data on the interaction between outpatient surgery and inpatient PAC facilities creates a need to explore how greater cooperation between these types of facilities could lead to improvements in patient care. SUMMARY: PAC facilities are inpatient facilities focused on the rehabilitation of patients recovering from an acute illness or surgical intervention. This article seeks to provide ambulatory practitioners a fundamental understanding of PAC as a starting point for future collaborative efforts with PAC facilities; improving care for patients referred to and from PAC facilities for outpatient surgical care.

Excessive Dynamic Airway Collapse: An Unexpected Contributor to Respiratory Failure in a Surgical Patient.

Central airway collapse plays a significant, underrecognized role in respiratory failure after extubation of critically ill patients. Historically, airway collapse has been attributed to tracheomalacia (TM), softening of the cartilage in the trachea and other large airways. More recently, excessive dynamic airway collapse (EDAC) has been described as a distinct process unrelated to a loss of cartilaginous airway support. EDAC is caused by the posterior wall of the trachea bulging forward and causing airway obstruction during exhalation. This process is exaggerated when intrathoracic pressure is increased and results in a clinical picture of coughing, difficulty clearing secretions, dyspnea, and stridor. The increased use of computerized tomography and fiberoptic bronchoscopy has identified varying degrees of EDAC and TM in both symptomatic and asymptomatic individuals. This has led to renewed consideration of airway collapse and the different processes that contribute to it. Here we describe a 43-year-old morbidly obese patient who failed repeated attempts at extubation after elective hysterectomy. We will discuss the processes of EDAC and TM, describe how this condition contributed to this patient's respiratory failure, and review diagnosis and management options.

Echocardiographic assessment for ventricular assist device placement.

While many factors depend on successful implantation and outcome of left ventricular assist devices (LVAD), echocardiography remains an integral part and is vital to the success of this process. Transesophageal echocardiography (TEE) allows interrogation of all the cardiac structures and great vessels. The pre-implantation TEE exam establishes a baseline and may identify potential problems that need palliation. Among these, most significant are aortic insufficiency (AI), intracardiac thrombi, poor right ventricular (RV) function, and intracardiac shunts. The post-implantation exam allows for adequate de-airing of the heart and successful LVAD initiation. The position and flow profiles of the inflow and outflow cannulas of the LVAD may be assessed. Finally, it assists in the astute management and vigilant identification and correction of a number of complications in the immediate post-implantation period. TEE will continue to remain vital to the successful outcomes LVAD patients.