Seminars in pediatric surgery
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Semin. Pediatr. Surg. · Dec 2015
Patient-centered care and quality: Activating the system and the patient.
Patient-centered care is an expectation in our current environment, yet it is only one of the six domains that the Institute of Medicine has described as critical in redesigning the architecture of a medical system. Patients requiring long-term feeding tube access represent a particularly complex group of patients who stress the mechanisms placed within a healthcare system to optimize quality and safety. We describe the implementation of a new approach to this patient population that serves as an example of redesigning a system of care to optimize safety using the principles of patient-centered care while delivering safe, effective, timely, efficient, and equitable care.
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Craniopagus twins are rare and account for up to 6% of all conjoined twins. No hospital will encounter many such twins and the opportunity to develop expertise is limited. ⋯ We believe that detailed imaging allows precise delineation of the anatomy and facilitates detailed planning of the surgery. When venous drainage from the 2 brains is connected, we believe that staged separation is preferable as gradual alteration of hemodynamics may be safer than a single-stage procedure.
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The management of anaesthesia for conjoined twins poses unique anatomical, physiological and logistic challenges. Although many possible configurations of union exist and each is unique, we describe the principles of anaesthesia for conjoined twins drawing on our institutional experience of managing 26 sets for a variety of procedures including separation.
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All good intensive care requires attention to detail of the routine elements of care. These include staffing and monitoring, drug prescription and administration, feeding and fluid balance, analgesia and sedation, organ support and reducing the risk of healthcare-associated infection. Doing this well requires an understanding of the relevant physiology and an awareness of the limited evidence base. ⋯ This is especially true following separation of conjoined twins. Despite the sophisticated imaging and multi-disciplinary planning that precede elective separation, the acute physiological changes in each twin cannot always be predicted reliably. In this article, we review briefly each element of peri-operative care and how this might vary in conjoined twins.
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Semin. Pediatr. Surg. · Jun 2015
ReviewSurgical innovation and quality assurance: Can we have both?
Innovation is the major force for progress in pediatric surgery. Most of the progress in surgery has evolved secondary to novel approaches developed by surgeons confronted with difficult pathologic conditions. Up to the present time, most surgical innovation has been practiced with few rules for guidance. ⋯ There is a significant potential for autonomous surgical innovators to clash with well-meaning proponents of quality improvement. A suggested remedy to encourage surgical innovators while protecting patients from unintended harm is for institutions to develop Surgical Innovation Committees to evaluate and give oversight to the early application of new techniques and devices. Scientific evaluation under the auspices of an IRB should follow when feasible.