HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Search for Related Content

Ann Thorac Surg 1995;60:132
© 1995 The Society of Thoracic Surgeons

Discussion

	Introduction

Top Introduction

 
See also page 127.

DR J. MARK WILLIAMS (Greenville, NC): Our group actually became interested in this issue of early extubation about 6 or 7 years ago. Because of resource limitations at that time, inability to extubate patients early and transfer them from the intensive care unit delayed or cancelled the cardiac cases the following day. The variable that had the greatest impact on early intubation in our group was the nurse who took care of the patient that evening. I noticed that this was not a variable in your analysis.

The aggressive nurse who was giving diuretics early, more rigidly following our protocol, and aggressively weaning the patient from the ventilator always resulted in early extubation. The amount or type of anesthesia given, the surgeon, or the length of the pump run did not prove to be as great a factor as the nurse taking care of the patient that evening after operation. I would suggest that you look at the nurse as one issue that can have a great impact on early extubation.

DR AROM: I am sorry I did not go through the last slide as well as I could have because I ran out of time. You may not have seen it either, because it went so fast. What I wanted to say with that slide is that early extubation requires education, leadership, and cooperation between the nursing personnel, anesthesiologist, respiratory technician, and the surgeon.

Our continuous quality improvement team and clinical pathway committee, which includes all the involved personnel, have met regularly every month for the past 4 to 5 years. Having everyone involved in the education and sitting down together every month has helped us solve the problems that you are having.

DR CLINTON E. BAISDEN (Temple, TX):I enjoyed your talk very much. We also are interested in this particular subject and just finished a prospective, randomized study looking at different methods of keeping our patients warm after returning them to the intensive care unit after an open heart operation. Something that was very interesting that fell out of the data and was highly statistically significant was seen. We found that for each kilogram of weight gain (which would be equivalent to 1,000 mL of fluid), there was an additional 45 minutes required on the ventilator and 2 hours in the intensive care unit. We now are reviewing these cases to determine whether some of the patients received excessive fluid from the anesthesiologist, the perfusionist, or the nurses in the intensive care unit. We are looking for methods to limit weight gain to see if that would allow the patients to come off the ventilator sooner.

I enjoyed your presentation very much.

DR AROM: I agree with you wholeheartedly and am amazed that some of us at our own institution have not caught on to this real phenomenon yet. When the patient goes to the intensive care unit, it is much easier for the nursing personnel to take care of the patient when the tank is full and the pressure then is less fluctuating. They will go ahead and give 1,000 to 2,000 mL of Hespan almost routinely to everyone who has a low central venous pressure.

We try very hard not to use blood or blood products in the operating room. When the patient goes to the intensive care unit with a hemoglobin level of 9 g/dL and receives 2 L of fluid, the next morning the hemoglobin level will be down to 7 g/dL. The cardiologist comes by and gives two units of packed cells. Therefore, we had to pay for 2 L of Hespan, we had to pay for more diuretics, and we had to pay for packed cells. All of this increased the cost of operation, besides defeating the purpose of not using blood or blood products. So, I believe the key is that we have to educate those people. As long as the patient is nice and warm, has good urine output, and has adequate systemic blood pressure, we need not treat low central venous pressure. If the blood pressure is too low, then alpha agonist should be tried first.

Doctor Baisden, the study you have mentioned should be very beneficial to many of us, and hopefully we will hear from you soon about this. Thanks again for your discussion.

DR FREDERICK L. GROVER (Denver, CO): We have had a similar experience in Denver and have done an in-depth review of this. We have implemented the fast track with critical pathways similar to Dr Dick Engelman and the Bay State group. This has resulted in a 50% reduction in our lengths of stay in the surgical intensive care unit and 27% and 28% reductions in costs and charges, respectively, for DRGs 106 and 107. At our Veterans Affairs hospital, where we also have implemented this, one of our nurses has done a study demonstrating a significant decrease in the incidence of nosocomial infections in our postoperative heart patients with the shortening of the postoperative intubation period.

Have you also observed any similar improvements in quality of care in addition to improved cost effectiveness?

DR AROM: Yes, absolutely. The incidences of pneumonia and nosocomial infection are, indeed, much less than they used to be.

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Search for Related Content