The association between preoperative patient characteristics and both clinical and economic outcomes after abdominal aortic surgery

Efecto de la adscripción de internistas a un servicio quirúrgico

BACKGROUND AND OBJECTIVE

Although surgical units commonly request the collaboration of internists via medical consultation, the efficiency of this system is low and expensive. We studied the effect of the integration of full-time internists in a surgical department.

PATIENTS AND METHOD

The study group consisted of the patients admitted during intervention in the Orthopedic Surgery and Traumatology Department. Those patients admitted during the same period of the previous year made up the control group. We analyzed pre-surgical stay, post-surgical stay and total stay. We also studied in-hospital mortality, re-admissions and those patients who were not submitted to surgery (NSS). Control variables were age, sex, type of admission (programmed/emergency) and main diagnosis.

RESULTS

1,216 patients were included, 599 in the control group and 617 in the study group, 48.0% were emergency admissions and 11.7% NSS patients. Study of programmed patients did not suggest any differences between both groups in any of the analyzed variables. In emergency patients, the total stay was decreased in 18.2%, and it was reduced in 40.2% of the NSS. The distribution of the re-admissions was similar in both study and control groups. We observed a decrease in the NSS and a 50% decrease in the deaths of the study group. The obtained saving was 329,170 Euros.

CONCLUSIONS

The adscription of full-time internists to a surgical service clearly improves the quality of the service it provides, with important hospital savings.

Preoperative preparation of patients with advanced liver disease

OBJECTIVE

To review the characteristic features of patients with advanced liver disease that may lead to increased perioperative morbidity and mortality rates.

DESIGN

Literature review.

RESULTS

Patients with end-stage liver disease are at high risk of major complications and death following surgery. The most common complications are secondary to acute liver failure and include severe coagulopathy, encephalopathy, adult respiratory distress syndrome, acute renal failure, and sepsis. The degree of malnutrition, control of ascites, level of encephalopathy, prothrombin time, concentration of serum albumin, and concentration of serum bilirubin predict the risk of complications and death following surgery. Other determinants of adverse outcome include emergency surgery, advanced age, and cardiovascular disease. Portal hypertension is a prominent feature of advanced liver disease, and it predisposes the patient to variceal hemorrhage, hepatorenal syndrome, hepatopulmonary syndrome, and uncontrolled ascites. Portal hypertension can be ameliorated by percutaneous or surgical portasystemic shunting procedures. If well-defined contraindications are not present, patients with advanced liver disease should be evaluated for orthotopic liver transplantation from a cadaver donor or possible living-related liver transplantation.

CONCLUSIONS

Optimal preparation, which addresses the common features of advanced liver disease, may decrease the risk of complications or death following surgery. Preparation should include correcting coagulopathy, minimizing preexisting encephalopathy, preventing sepsis, and optimizing renal function.

Opening of a new postanesthesia care unit: impact on critical care utilization and complications following major vascular and thoracic surgery

STUDY OBJECTIVES

To assess the impact of a new postanesthesia care unit (PACU) on intensive care unit (ICU) utilization, hospital length of stay, and complications following major noncardiac surgery.

DESIGN

Observational study.

SETTING

University hospital.

PATIENTS AND MEASUREMENTS

From 1992 to 1999, 915 patients underwent either abdominal aortic reconstruction (n = 448) or lung resection for cancer (n = 467). Demographic, clinical, surgical, and anesthetic data, as well as perioperative complications, were abstracted from two institutional databases.

INTERVENTIONS

Patients were divided in two study periods, before and after the opening of a new PACU (period 1992-1995 and period 1996-1999).

MAIN RESULTS

Utilization of ICU decreased from 35% to 16% for vascular patients and from 57% to less than 4% for thoracic patients during the second period. Readmission to the ICU, perioperative mortality, and respiratory complications were comparable between the two periods. Patients with congestive heart failure, chronic obstructive pulmonary disease, or renal insufficiency were more likely to be admitted to the ICU than the PACU. Following vascular surgery the frequency of cardiac complications decreased from 10.6% in 1992-1995 to 5.2% in 1996-1999 (p < 0.005), as well as the need for postoperative mechanical ventilation (25% vs. 12%; P < 0.05).

CONCLUSIONS

Increased availability of PACU beds resulted in reduced utilization of ICU resources without compromising patient care after major noncardiac surgery.

Cost Containment in Vascular Surgery

In the last decade, the delivery of health care and the role of the physician have undergone radical change. With the ad vent of managed care and the tightening of restrictions by Medicare and insurance companies, physicians have been required to review, re-engineer, and revitalize their role. Increasing financial pressures at the hospital level have caused administrators to cut costs at all levels. It is imper ative that physicians take an active role in cost containment so that the quality of care is not sacrificed. Cost containment in vascular surgery is an urgent priority in health care. Copyright © 2000 by W.B. Saunders Company.

The future of anesthesiology is perioperative medicine

Anesthesiology faces many challenges in the years ahead. To meet these challenges, the author hypothesizes that perioperative medicine, which includes the spectrum of care from preoperative assessment to postoperative care, offers the best chance for the specialty to survive and prosper. The history of perioperative medicine is reviewed and a discussion of how such change will benefit anesthesiology is included. Implementation may be difficult and the author explores how a transition from traditional procedure-focused anesthesiology to a broader based specialty may be accomplished. The special needs of perioperative medicine and how they differ from anesthesiology are also presented.