Background: Mortality through single-ventricle palliation remains high and the effect of the timing of stage 2 palliation (S2P) is not well understood. We investigated current practice patterns in the timing of S2P across two professional societies and compared them to actual practice patterns from two databases of patients who underwent S2P. Methods: A ten-question survey was distributed to the members of the Congenital Heart Surgeons’ Society (CHSS) and the European Congenital Heart Surgeons’ Association (ECHSA). Results were summarized using descriptive statistics. Surgeon-reported preferences were compared to clinical data from the CHSS Critical Left Ventricular Outflow Tract Obstruction (LVOTO) Registry and the Pediatric Heart Network Single Ventricle Reconstruction (SVR) database. Results: Overall, 38% (88 of 232) of surgeons from 74 institutions responded, of which 70% (62 of 88) were CHSS members and 30% (26 of 88) were ECHSA members. Surgeons reported performing S2P at a median of five months after stage 1 (interquartile range [IQR]: 4.5-6), with no difference between CHSS and ECHSA surgeons. Surgeons reported performing nonelective S2P at a median of 4.5 months after stage 1 (IQR: 3.5-5.5), again with no difference by society. No difference existed between the surgeon-reported preferences and patient data in the Critical LVOTO and SVR databases for the timing of elective (5 vs 5.1 vs 5.3 months, P = .19) or nonelective S2P (4.5 vs 4.6 vs 4.2 months, P = .06). Conclusion: There was a remarkable lack of variation in surgeon preferences regarding the timing of S2P. This may represent a natural standardization of practice across congenital heart surgery, which is notable, given the current lack of guidelines regarding the timing of S2P.
We evaluated the effect of patient age and significant residual cardiac lesions on the association between hyperglycemia and adverse outcomes in children after cardiac surgery. The incidence, severity, and duration of hyperglycemia in this patient population and perioperative factors predisposing to hyperglycemia were also delineated.Retrospective, observational cohort study.Eighteen-bed pediatric cardiac critical care unit.Seven hundred seventy-two children undergoing cardiac surgery with cardiopulmonary bypass during 2006 and 2007.None.Postoperative glucose levels were reviewed in all children who underwent cardiac surgery with cardiopulmonary bypass at our institution during 2006 and 2007 who met all inclusion criteria and none of the exclusion criteria (n = 772). The composite morbidity-mortality outcome included hospital death, cardiac arrest, renal/hepatic failure, lactic acidosis, extracorporeal membrane oxygenation use, or infection. Hyperglycemia occurred in 90% of patients and resolved within 72 hrs in most without exogenous insulin. Preoperative factors, including prostaglandins, mechanical ventilation, and cyanosis, were significantly associated with increased odds of significant hyperglycemia (>180 mg/dL for >12 hrs or any level >270 mg/dL) as were increased surgical complexity and perioperative steroid administration. Thirty-one percent of the entire cohort reached the composite outcome and the odds were significantly increased after 54 hrs of mild (elevated, but <180 mg/dL), 12 hrs of moderate (180-270 mg/dL), or any period of severe hyperglycemia (>270 mg/dL). Neonates (<1 month of age) tolerated longer periods of hyperglycemia before showing increased odds of reaching the composite morbidity-mortality end point. In the setting of important residual cardiac lesions, mild or moderate hyperglycemia was not as strongly associated with adverse outcomes.Age and residual cardiac lesions are important modifiers of the association between hyperglycemia and suboptimal outcomes after pediatric cardiac surgery. Use of insulin therapy for glucose control in this patient population may need to be carefully targeted toward high-risk subsets of patients.
The treatment for cervical cancer is a complex, multidisciplinary issue, which applies according to the stage of the disease. The surgical elective treatment of cervical cancer is represented by the radical abdominal hysterectomy. In time, many surgeons perfected this surgical technique; the ones who stood up for this idea were Thoma Ionescu and Ernst Wertheim. There are many varieties of radical hysterectomies performed by using the abdominal method and some of them through vaginal and mixed way. Each method employed has advantages and disadvantages. At present, there are three classifications of radical hysterectomies which are used for the simplification of the surgical protocols: Piver-Rutledge-Smith classification which is the oldest, GCG-EORTC classification and Querlow and Morrow classification. The last is the most evolved and recent classification; its techniques can be adapted for conservative operations and for different types of surgical approaches: abdominal, vaginal, laparoscopic or robotic.
Pediatric cardiac surgery patients commonly suffer from alterations in vascular tone in the early post-operative period. Pharmacologic manipulation of systemic vascular resistance (SVR) can be complex in a variety of special patient situations including extremes of age, presence of left sided valvar lesions and the use of mechanical circulatory support. Familiarity with how these special circumstances alter SVR and the response to pharmacologic intervention will allow for tailored therapy and hopefully, optimized outcomes. This article addresses the eighth topic of the special issue entitled “Pharmacologic strategies with afterload reduction in low cardiac output syndrome after pediatric cardiac surgery”. Keywords: Cardiac surgery, mechanical circulatory support, postoperative management, afterload reduction.Cardiac surgery, mechanical circulatory support, postoperative management, afterload reduction.
Summary Background Transfer of patient care among clinicians (handovers) is a common source of medical errors. While the immediate efficacy of these initiatives is well documented, sustainability of practice changes that results in better processes of care is largely understudied. Aims The objective of the current investigation was to evaluate the sustainability of a protocolized handover process in pediatric patients from the operating room after cardiac surgery to the intensive care unit. Methods This was a prospective study with direct observation assessment of handover performance conducted in the cardiac ICU ( CICU ) of a free‐standing, tertiary care children's hospital in the United States. Patient transitions from the operating room to the CICU , including the verbal handoff, were directly observed by a single independent observer in all phases of the study. A checklist of key elements identified errors classified as: 1) technical, 2) information omissions, and 3) realized errors. Total number of errors was compared across the different times of the study (preintervention, postintervention, and the current sustainability phase). Results A total of 119 handovers were studied: 41 preintervention, 38 postintervention, and 40 in the current sustainability phase. The median [Interquartile range ( IQR )] number of technical errors was significantly reduced in the sustainability phase compared to the preintervention and postintervention phase, 2 (1–3), 6 (5–7), and 2.5 (2–4), respectively P = 0.0001. Similarly, the median ( IQR ) number of verbal information omissions was also significantly reduced in the sustainability phase compared to the preintervention and postintervention phases, 1 (1–1), 4 (3–5) and 2 (1–3), respectively. Conclusions We demonstrate sustainability of an improved handover process using a checklist in children being transferred to the intensive care unit after cardiac surgery. Standardized handover processes can be a sustainable strategy to improve patient safety after pediatric cardiac surgery.
