Local infusion of bupivacaine combined with intravenous patient-controlled analgesia provides better pain relief than intravenous patient-controlled analgesia alone in patients undergoing minimally invasive cardiac surgery

ObjectiveThis prospective randomized double-blind study examined the effect of local wound infusion of anesthetics on pain control in the thoracotomy wound of patients undergoing minimally invasive cardiac surgery.MethodsPatients who underwent coronary artery bypass grafting or cardiac valvular procedures via a minimally invasive thoracotomy were studied. Patients were enrolled and randomly allocated to two groups with different modalities of postoperative analgesia. The thoracotomy wound infusion group received 0.15% bupivacaine infused continuously at 2 mL/h through a catheter embedded in the wound, as well as intravenous patient-controlled analgesia. The control group had patient-controlled analgesia alone with a sham thoracotomy wound infusion of normal saline. Verbal analog pain scores (0–10 points) and recovery profiles were investigated.ResultsThere were 19 patients in each group for complete data analysis. On the first day after the operation, infusion of local anesthetics significantly reduced the verbal analog pain scores both at rest and during motion (thoracotomy wound infusion vs control). The improved pain relief with thoracotomy wound infusion persisted at day 3 and even at 3 months after the operation. No difference was noted about time to extubation, length of intensive care unit stay, or hospital stay.ConclusionIn this controlled double-blind study, thoracotomy wound infusion and patient-controlled analgesia were superior to patient-controlled analgesia alone in reducing pain at 1, 3, and 90 days after minimally invasive cardiac surgery

Hyperbilirubinemia after Cardiac Operation : Incidence, Risk Factor, and Clinical Significance

　　Three hundred and two consecutive patients who had undergone cardiac operation for various cardiac lesions were studied prospectively to evaluate the incidence, risk factors, and the associated mortality of postoperative hyperbilirubinemia after cardiopulmonary bypass. Concentrations of the serum total (conjugated and unconjugated) bilirubin, alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, alkaline phosphatase, albumin, globulin, and serum haptoglobin were measured before the operation and again on the first, second , and seventh postoperative days. Postoperative hyperbilirubinemia was defined as occurrence of a serum total bilirubin concentration of more than 3 mg/dl in any miasurement during the postoperative period. Logistic regression was done to identify possible risk factors for postoperative hyperbilirubinemia. Overall incidence of postoperative hyperbilirubinemia was 35.1%; the incidence of postoperative hyperbilirubinemia was higher in padtients whose valyes were replaced with mechanical prostdheses than in those without prostheses (p<0.00001). In patients with postoperative hyperbilirubinemia, 70% of the increase of total bilirubin on the first postoperative day came about from an increase in unconjugated bilirubin. Serum haptoglobin decreased significantly at the same time (p <0. 01). Development of the postoperative hyperbilirubinemia was associated with a higher mortality (5.6% versus 0.5%, p <0. 01) and higher frequency of use of intraaortic balloon counterpulsation, especially for patients in whom the highest postoperative total bilirubin occurred after the first 2 days. The numbers of valves replaced, preoperative right atrial pressure, and preoperative total bilirubin concentration are the significant risk factors that, in combination, correctly predict the occurrence of postoperative hyperbilirubinemia in 80% of the patients. We concluded that postoperative hyperbilirubinemia results mainly from and increase in unconjugated bilirubin and is associated with higher mortality, especially for patients in whom highest postoperative total bilirubin occurred late after operatio

Complications of Intraoperative Transesophageal Echocardiography in Adult Cardiac Surgical Patients—Experience of Two Institutions in Taiwan

There is some safety concern about transesophageal echocardiography (TEE) when it is used routinely during cardiac operations. The purpose of this investigation was to study the incidence of intraoperative TEE-associated complications in adult cardiac surgical patients. The study population comprised 6255 consecutive adult cardiac surgical patients with intraoperative TEE examinations. TEE-associated complications occurred in 25 patients (0.4%). Most of these complications consisted of oropharyngeal mucosal bleeding (15/25, 60%). Esophageal perforation occurred in one patient. Two patients experienced upper gastrointestinal bleeding. Seven patients experienced dental injuries, and TEE probe insertion failed in 10 patients. We conclude that intraoperative TEE-associated complications in cardiac operations is very low; the complication rate we found was comparable to previously reported values. [J Formos Med Assoc 2007; 106(1):92-95

Compliance of health care workers with hand hygiene practices: independent advantages of overt and covert observers.

BACKGROUND: Evaluation and feedback of hand hygiene (HH) compliance are important elements of the WHO multimodal strategy for hospital infection control. Overt observation is recommended, but it may be confounded by Hawthorne effect. Covert observation offers the opportunity to decrease observer bias. In this study we conducted a one year hospital-wide HH promotion program that included medical students (MS) as covert observers. METHODS: HH compliance for the five WHO indications was determined by trained and validated observers. The overt observers consisted of eleven infection control nurses (ICNs) and two unit HH ambassadors (UAs) in each of 83 wards. The covert observers consisted of nine MS during their rotating clinical clerkships. Feedback was provided to department heads and staff each quarter. RESULTS: Of the 23,333 HH observations 76.0% were by MS, 5.3% by ICNs and 18.7% by UAs. The annual compliance rates were MS 44.1%, ICNs 74.4% and UAs 94.1%; P<0.001. The MS found significantly lower annual compliance rates for 4/5 HH indications compared to ICNs and UAs; P<0.05. The ICNs reported significantly improvement from the first to the fourth quarter; P<0.001. This was associated with feedback from the MS of very poor compliance by nurses during the first quarter. CONCLUSIONS: Based on these findings we recommend a two-pronged approach to HH programs. The role of ICNs and UAs is to educate, serve as role models, establish, sustain good HH practices and provide direct feedback. The role of the covert observers is to measure compliance and provide independent feedback

Incidence and Significance of Clinically Abnormal Events in a Tertiary Referral Medical Center: Implementation of the Clinical Alert System (CAS)

The prognosis of in-hospital cardiopulmonary arrest remains very poor. Reports have shown patients often have clinically abnormal events prior to arrest. To improve patient outcome and prevent arrest, detection of the abnormal events with early intervention has been advocated. However, the incidence of these events in Taiwan and their clinical significance remain unclear. Methods: We conducted a prospective observational study with the implementation of the clinical alert system (CAS) in a university-affiliated tertiary referral medical center. Clinically abnormal events were detected using the CAS criteria for acute physiologic deterioration, and reported to experienced physicians for management. Patient and report data were retrieved, collected and analyzed. Results: During the 14-month study period, a total of 2050 events were detected in 1640 patients. The estimated incidence of the events was 3.19 per 1000 bed-days, which occurred in 2.14% of admissions. The most common event was abnormal heart rate (36.5%), followed by desaturation (26.7%), abnormal respiratory rate (24.5%), and abnormal blood pressure (23.1%). The majority of the events were reported in the day time, and nurses contributed most of the reports (66.4%). The 30-day and in-hospital mortality rates were 26.3% and 34%, respectively. Multivariate survival analysis showed that desaturation (relative risk [RR] = 1.715; p < 0.001), abnormal respiratory rate (RR = 1.652; p < 0.001), abnormal blood pressure (RR = 1.460; p = 0.001), coma (RR = 1.918; p < 0.001), and oliguria (RR = 1.424; p = 0.0024) were significantly associated with 30-day mortality. Mortality of patients in the last 2 months was significantly lower than that in the first 2 months (20.5% vs. 35.4%; p < 0.001), which suggests the effectiveness of the CAS. Conclusion: The development of clinically abnormal events is associated with poor outcome, which suggests that early detection and timely management of these events is necessary. Implementation of the CAS may improve the in-hospital outcome of these patients

Microcirculatory Response to Changes in Venoarterial Extracorporeal Membrane Oxygenation Pump Flow: A Prospective Observational Study

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) pump flow is crucial for maintaining organ perfusion in patients with cardiogenic shock, but VA-ECMO pump flow optimization remains as a clinical challenge. This study aimed to investigate the response of sublingual microcirculation to changes in VA-ECMO pump flow. Methods: Sublingual microcirculation was measured before and after changing VA-ECMO pump flow according to the treatment plan of ECMO team within 24 h and at 24-48 h after VA-ECMO placement. In clinical events of increasing VA-ECMO pump flow, those events with increased perfused vessel density (PVD) were grouped into group A, and the others were grouped into group B. In clinical events of decreasing VA-ECMO pump flow, those events with increased PVD were grouped into group C, and the others were grouped into group D. Results: Increased PVD was observed in 60% (95% CI, 38.5–81.5%) of the events with increasing VA-ECMO pump flow. The probability of increasing PVD after increasing VA-ECMO pump flow were higher in the events with a PVD < 15 mm/mm 2 at baseline than those with a PVD ≥ 15 mm/mm 2 [100% (95% CI, 54.1–100%) vs. 42.9% (95% CI, 17.7–71.1%), P = 0.042]. Other microcirculatory and hemodynamic parameters at baseline did not differ significantly between group A and B or between group C and D. Conclusion: This study revealed contradictory and non-contradictory responses of sublingual microcirculation to changes in VA-ECMO pump flow. Tandem measurements of microcirculation before and after changing VA-ECMO pump flow may help to ensure a good microcirculation