Impact of perioperative transesophageal echocardiography on tetralogy of fallot total repair

IntroductionPrevious studies have suggested that in cardiac surgical patients, TEE provides essential information before and after cardiopulmonary bypass regarding cardiac performance, valve function, and congenital anomalies. Significant residual abnormalities may be missed during TOF surgical repair. The result is often post-operative morbidity and mortality and sometimes the need for reoperation.ObjectivesTo determine impact and accuracy of perioperative TEE in assessment of patients undergoing TOF total repair.MethodsThe study included 50 patients with TOF referred to Cardiothoracic Surgery Department Ain Shams University Hospitals for total repair. Each patient was subjected to history taking, clinical examination, routine preoperative investigations, preoperative TTE, perioperative TEE and Post recovery TTE.ResultsOur study population included 45 (90%) pediatric patients and 5(10%) adults. Youngest was 1year 2 months old and oldest was 25 years old. Their weight ranged from 8 to 85Kg. TEE was feasible in 49 cases (98%) while the pediatric probe failed to be introduced in only one patient. TEE was able to visualize LM coronary artery in 96% of cases, and visualized RCA in 70% of cases. TEE newly detected a case with separate ostea of LAD and LCX. Only one patient developed non sustained runs of SVTThere was significant difference between TEE and TTE as regard IAS visualization (P value <0.0001). All our patients had only subaortic VSD except 4 patients. Three had doubly commited subarterial VSD seen by both TTE and TEE, while one patient had subaortic VSD with inlet extension, which was visualized only by TEE. Postoperative TEE detected residual small VSD in 29 cases of whom 14 cases had the VSD closed spontaneously by the time of TTE. TEE missed small residual VSD in 3 cases. In one case postoperative TEE showed a serpignous mid muscular VSD which was not detected preoperatively.There was moderate agreement between TEE and TTE regarding overriding of aortic valve (weighted Kappa 0.580). There was strong agreement between TTE and TEE in assessment of postoperative PR (r o.8594, P<0.0001).Preoperative TEE showed major impact in 2 cases (4%). In one case total repair was decided instead of shunt operation. While in the other TEE newly detected TV chordae attached to IVS crest with inlet extension of VSD. Preoperative TEE had minor impact in 29 cases (59%) by adding new information which did not alter surgical plan, as visualization of coronaries and IAS.TEE showed major postoperative impact in 2 cases (4%) in the form of second run of CPB and RVOT reconstruction. Minor impact in the form of detection of relieved RVOT obstruction, absence of residual shunts, preserved biventricular function in 47 cases (94%).ConclusionTEE imaging is a safe, feasible, and accurate tool for anatomical, hemodynamic, and functional assessment in patients with TOF during surgical repair. TEE offers the advantage of permitting visualization of the operative procedure in real time and provides guidance for the surgeon in making decisions inside the operating room

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely