Chest
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To describe changes in ICU postoperative management strategies utilized for patients undergoing cardiac surgery. The treatment of these patients serves as a useful illustration of the changing patterns of ICU utilization and care associated with contemporary surgery. ⋯ Despite the paucity of controlled data, rapid recovery, extubation, and discharge from the ICU following cardiac surgery is an approach to care that is growing in acceptance. The goals include reduction in the utilization of resources and costs associated with cardiac surgery and maintenance of quality of care and patient satisfaction. Assessment of outcomes requires a program to monitor outcomes. Success does not appear to be linked to preoperative risk for most patients but does relate directly to the anesthetic management delivered in the operating room. Few adverse consequences from this approach have been reported. Experience to date suggests that programs designed to truncate ICU admission following cardiac surgery can be implemented with the cooperation between the health delivery team including surgeon, anesthesiologist, intensivist where available, nursing, respiratory care, and patient and family. These programs can serve as useful models for reassessing the utilization and role of the ICU in the postoperative treatment of routine surgical patients.
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Randomized Controlled Trial Clinical Trial
Patient satisfaction with conscious sedation for bronchoscopy.
Bronchoscopic technique is not standardized. Controversies exist with regard to premedication with sedatives before the test. To evaluate safety and efficacy of conscious sedation, we studied 100 randomized patients undergoing diagnostic bronchoscopy; patients received premedication with lidocaine spray and atropine sulfate i.m. (nonsedation group; 50 patients) or lidocaine spray, atropine i.m. and diazepam i.v. (sedation group; 50 patients). ⋯ In our study, sedation had a beneficial effect on patient tolerance and rarely induced significant alterations in cardiorespiratory monitoring parameters.
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Pulmonary edema is a known postoperative complication, but the clinical manifestations and danger levels for fluid administration are not known. We studied (1) 13 postoperative patients (11 adult, 2 pediatric) who developed fatal pulmonary edema, and (2) one contemporaneous year of inpatient operations at two university teaching hospitals to determine the clinical manifestations, causes, epidemiology, and guidelines for fluid administration. ⋯ Pulmonary edema can occur within the initial 36 postoperative hours when net fluid retention exceeds 67 mL/kg/d. There are no known predictive warning signs and cardiorespiratory arrest is the most frequent clinical presentation. The monitoring systems currently in use neither detect nor predict impending pulmonary edema, and as yet, there are no known panic values for excessive fluid administration or retention.
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Cost-effective preoperative evaluation can be approached from a variety of methods, educational strategies, and use of data to modify clinical practice. This article focuses on the proposed organizational and clinical changes in the process of preoperative evaluations, the cost-effective outcomes, and the relative merits these changes provide the physicians, operating room nurses, and center administrators.
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Preoperative pulmonary evaluation and preparation involve first identifying patients at risk for complications and then attempting to modify that risk. For most patients without underlying lung disease, a thorough history and physical examination and preoperative instruction in the use of incentive spirometry is sufficient. In patients with known or suspected lung disease, preoperative pulmonary function tests, while unproven as prognostic tools, may reduce risk by aiding in medical management, and in the case of the lung resection candidate, by helping determine very directly his or her viability for the procedure.