Vascular Surgery Ward Research Articles

A pilot survey of dietitian services carried out in a vascular surgery ward in Helsinki University Hospital

A pilot survey of dietitian services carried out in a vascular surgery ward in Helsinki University Hospital

VALIDAÇÃO DE WEBSITE PARA IMPLANTAÇÃO DO PROTOCOLO PERIOPERATÓRIO NA PROFILAXIA DE TROMBOEMBOLISMO VENOSO

Introduction: Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is the leading cause of preventable postoperative deaths. Identifying risk factors based on Virchow’s Triad (blood stasis, hypercoagulability, and endothelial injury) is crucial. Approximately 20% of surgical patients develop VTE, with 7% resulting in fatal PE. The Caprini risk score, used to assess VTE risk, is complex and has limited adherence despite its validation across various specialties. Methodology: The applied research developed the application of a perioperative protocol for VTE prophylaxis in the Vascular Surgery ward of the Hospital Municipal de Marabá. The descriptive and quantitative study was structured via website. The 2013 version of the Caprini score was adopted for risk stratification. Validation of the tool involved 16 experts with inclusion criteria focused on doctors and nurses with experience in the area, where everyone responded to the Likert scale that evaluated 2 major domains of the tool: usability and functionality. Results: Among the 16 evaluators, 56,3% were male and 43,8% female, with an average age of 32,4 years and 7,6 years of experience. The system’s functionality received 97,5% approval, 96,3% of reliability, and 91,3% regarding interface and usability. The utility was well-rated, with 98,8% approving the professional facilitation. Chi-square tests indicated that functionality perception did not vary between physicians and nurses, but utility was significantly influenced by profession. Cronbach’s alpha coefficients indicated high internal consistency: 0,85 for functionality and 0,77 for utility. Discussion: The diverse profiles of the evaluators enriched the website’s validation. Functionality was consistently positively rated, while utility varied by professional role. High internal consistency suggests that the questionnaire is reliable for measuring website performance perceptions. Conclusion: The inclusion of the Caprini protocol in the Tupan Health website demonstrated good performance and high reliability among professionals, facilitating protocol adherence and the prevention of perioperative complications.

Is It Still Time for Safety Walkaround? Pilot Project Proposing a New Model and a Review of the Methodology.

Background and Objectives: Healthcare facilities are complex systems due to the interaction between different factors (human, environmental, management, and technological). As complexity increases, it is known that the possibility of error increases; therefore, it becomes essential to be able to analyze the processes that occur within these contexts to prevent their occurrence, which is the task of risk management. For this purpose, in this feasibility study, we chose to evaluate the application of a new safety walkaround (SWA) model. Materials and Methods: A multidisciplinary working group made up of experts was established and then the subsequent phases of the activity were divided into three stages, namely the initial meeting, the operational phase, and the final meeting, to investigate knowledge regarding patient safety before and subsequently through visits to the department: the correct compilation of the medical record, adherence to evidence-based medicine (EBM) practices, the overall health and the degree of burnout of the various healthcare professionals, as well as the perception of empathy of staff by patients. Results: This working group chose to start this pilot project in the vascular surgery ward, demonstrating the ability of the tool used to capture the different aspects it set out to collect. In detail, the new version of SWA proposed in this work has made it possible to identify risk situations and system vulnerabilities that have allowed the introduction of corrective tools; detect adherence to existing company procedures, reschedule training on these specific topics after reviewing, and possibly update the same procedures; record the patient experience about the doctor-patient relationship and communication to hypothesize thematic courses on the subject; evaluate workers' perception of their health conditions about work, and above all reassure operators that their well-being is in the interest of the management of the healthcare company, which is maintained. Conclusions: Therefore, the outcome of the present study demonstrates the versatility and ever-present usefulness of the SWA tool.

Mealtimes in single-room accommodation: The patients’ perspective

Aim: To investigate how patients admitted to single-room accommodation experience mealtime situations. Methods: The study employed an ethnographical phenomenological design using the go-along method. From April to September 2022, 40 hours of meal-related observations and informal conversations with ten patients were completed in a Danish cardiac medicine ward and a vascular surgery ward. Data were analysed using a Ricoeur-inspired method. Results: Admission to a single-room is not unequivocally excellent or wrong with respect to the patients’ experiences of the meal or their perceived appetite. Nevertheless, meals were often referred to as the highlights of the day. Patients were positive about their own influence on their food choices, but they needed to experience professionals talking to them about healthy nutrition. Privacy was greatly emphasised, and most patients chose to eat alone because of their condition. Therefore, eating in the common dining room was seldom chosen. The results are presented in two themes: 1) Beyond the tray: Understanding the significance of meals for patients in single-rooms, and 2) Alone – but not lonely. Conclusions: Single-rooms allow for privacy during illness and recovery and make it possible to have private conversations about adequate nutrition. Clear professional responsibility needs to be assigned for the meal in single-room accommodation. Relevance to clinical practice: Knowledge of patients’ perspectives may guide nurses’ approaches to communicating with patients about the importance of the meal.

Implementation of an antimicrobial stewardship program in the Vascular Surgery ward of a university tertiary care hospital in Pavia, Northern Italy

PurposeThe commitment of multidisciplinary teams in antimicrobial stewardship programs (ASPs) is often inadequately considered, especially in surgical wards. We wanted to evaluate clinical, microbiological, and pharmacological outcomes before and after the implementation of an ASP in the Vascular Surgery ward of Fondazione IRCCS Policlinico San Matteo, a tertiary care hospital in Pavia, Italy.MethodsThis was a quasi-experimental quality-improvement study. The antimicrobial stewardship activity was conducted twice a week for 12 months and consisted of both prospective audit and feedback of all the ongoing antimicrobial prescriptions by the infectious diseases’ consultants and educational meetings for the healthcare workers of the Vascular Surgery ward. For comparison between the study periods, Student t test (Mann–Whitney test for skewed distributions) was used for quantitative variables (ANOVA or Kruskall-Wallis for > 2 groups respectively), and Pearson’s chi-squared test (Fisher exact test where appropriate) for categorical variables. 2-tailed tests were used. P-value significance cut-off was 0.05.ResultsDuring the 12-month intervention period, among a total number of 698 patients, 186 prescriptions were revised, mostly leading to de-escalating an ongoing antimicrobial therapy (39, 20.97%). A statistically significant reduction in isolates of carbapenem-resistant Pseudomonas aeruginosa (p-value 0.003) and the absence of Clostridioides difficile infections were reported. No statistically significant changes were observed in terms of length of stay and all-cause in-hospital mortality. A significant decrease in the administration of carbapenems (p-value 0.01), daptomycin (p-value < 0.01) and linezolid (p-value 0.43) was registered. A significant reduction in antimicrobial costs was also observed.ConclusionsThe implementation of a 12-month ASP brought significant clinical and economic results, highlighting the benefits of a multidisciplinary teamwork.

Perioperative variable rate intravenous insulin infusion: a quality improvement project on a vascular surgery ward

AimsVariable rate intravenous insulin infusion (VRIII) is used perioperatively to maintain normoglycaemia in patients with diabetes who are undergoing surgery. The aims of this project were as follows: (1) to...

948. Impact of a Multi-pronged Approach to Antimicrobial Stewardship on the Vascular Ward at a Tertiary Hospital

Abstract Background Up to 50% of inpatient antibiotic use may be inappropriate, and guideline concordance for antibiotic prescribing in surgical wards tends to be lower than medical wards. As such, our study describes a multi-pronged approach to antimicrobial stewardship (AMS) targeting a vascular ward and its impact on improving antibiotic use. Methods This is a quality improvement study at a tertiary hospital in British Columbia, Canada. All patients admitted to the vascular surgery ward for any vascular related issues and who received piperacillin-tazobactam or a carbapenem were included. Patients were excluded if admitted to the ward for &amp;lt; 48 hours. The primary outcome is appropriateness of carbapenem and piperacillin-tazobactam use in concordance with local policies. Secondary outcome is consumption of these agents. The pre-intervention period was March 2020 to June 2020. The AMS team prospectively reviewed included patients to establish the baseline level of appropriate antibiotic use. The intervention period was from July 2020 to February 2021. Aside from presentations to surgeons, the main intervention was regular audit and feedback to a nurse practitioner who rounds with the surgeons. Mandatory ID consultation for carbapenems was the last resort if AMS recommendations were not accepted. Results During the pre-intervention period, 19 out of 25 prescriptions (76%), either carbapenem or piperacillin-tazobactam, had appropriate indications. In the intervention period, 121 prescriptions were reviewed and the appropriateness level increased to 87% (Figure 1). Eleven mandatory ID consultations were generated. The mean days of therapy (DOT) per 1000 patient-days for carbapenem decreased from 94.6 to 56.6 for pre- and intervention periods, respectively. For piperacillin-tazobactam, the mean DOT per 1000 patient-days decreased from 209.9 to 138.5 for pre- and intervention periods. The reduced usage of piperacillin-tazobactam remained sustainable post-intervention (Figure 2). Figure 1:Summary of patient characteristics and outcomes during intervention period (July 2020 to February 2021)Figure 2:Usage of piperacillin-tazobactam from June 2019 to June 2021 Conclusion A multi-pronged approach, consisting of education, prospective audit and feedback to the surgical team, and mandatory ID consult in selected cases, is effective in decreasing inappropriate broad-spectrum antibiotic use on the vascular ward at a tertiary centre. Disclosures All Authors: No reported disclosures.

Effect of Music on Pain, Anxiety and Physiological Parameters among Postoperative Sternotomy Patients: A Randomized Controlled Trial.

Introduction: Music is a non-invasive, inexpensive and non-pharmacological nursing intervention that has no side effects and can be effective when provided alongside the routine care in cardiothoracic and vascular surgery (CTVS) ward and intensive care unit (ICU). The objective of the study was to assess the effect of music on pain, anxiety and physiological parameters among the post-operative sternotomy patients from CTVS ward and ICU in Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India. Methods: A randomized controlled trial research design was used to conduct the study among 70 post-operative sternotomy patients. The pain score, and anxiety level were recorded using Numerical Pain Rating Scale (NPRS) and post-operative anxiety scale, with the physiological parameters recorded for both groups before the music intervention, after the first post-operative day, and after the intervention on seventh post-operative day. Data were analyzed by SPSS software version 23. Results: There was a marked reduction in the mean score of pain, anxiety, systolic and diastolic blood pressure (SBP & DBP), heart rate and respiratory rate in the study group as compared to the control group. There was a significant difference between the mean score of pain, anxiety, SBP, DBP, heart rate, respiratory rate and oxygen saturation in both groups after the intervention. Conclusion: Music was found to be effective on pain, anxiety, diastolic blood pressure, heart rate and oxygen saturation among post-operative sternotomy patients. Thus, it is essential to include music as a tool in post-operative care.

Imaging myocardial perfusion with [99mTc] Tc-HMPAO: Fiction or reality? – Preliminary results

Introduction and objectives: [ 99mTc] Tc-HMPAO, developed for brain imaging, is taken up by the heart, but never used to study it. We aimed to compare cardiac images with [99mTc] Tc-HMPAO and [ 99mTc] Tc-Tetrofosmin, using imaging techniques. Materials and methods: Cardiac gated SPECTs with [99mTc] Tc-HMPAO were compared with myocardial perfusion scintigraphies (MPS) with [99mTc] Tc-Tetrofosmin in three inpatients, from the vascular surgery ward. We developed algorithms in MATLAB R2016 to compare the [99mTc] Tc-Tetrofosmin/ [99mTc] Tc-HMPAO images. Pixel-wise correlations for slices, reversibility, and polar maps were obtained. Results: Correlations of both radiotracers’ myocardial images were as high as 0.93. Polar maps correlations were 0.93-0.95 (for both stress and rest) and 0.62-0.90 (reversibility). One of the patients (smoker) had significant lung [99mTc] Tc-HMPAO uptake. Conclusions: Cardiac SPECT with [99mTc] Tc-HMPAO might be a screening method for myocardial ischemia in non-smoking patients with epilepsy suspected of having heart changes, and who need to perform a brain perfusion SPECT. Keywords: myocardial perfusion scintigraphy; epilepsy; HMPAO; myocardial SPECT.

Lessons Learned from the Impact of the COVID-19 Pandemic in a Vascular Surgery Department and Preparation for Future Outbreaks

ObjectivesThis study aims to report the changes and adaptations of a vascular tertiary center during a global pandemic and the impact on its activity and patients.MethodsWe conducted a retrospective cohort study within the Vascular Surgery ward in Centro Hospitalar Universitário Lisboa Norte, Portugal. All data from surgical, inpatient and outpatient activity were collected from February to June 2020 and compared to the same 5-month period in 2018 and 2019. We ran a descriptive analysis of all data and performed statistical tests for the variation of procedures and admissions between February and June 2018 and the same time period in 2020.ResultsDuring the outbreak, our staff had to be readapted. Six nurses were transferred to COVID-19 units (out of a total of 33 nurses) while 1 of the 7 residents was transferred to an intensive care unit and 1 senior surgeon was put on prophylactic leave. In the outpatient clinic, there was an increase in the number of telemedicine consultations with a greater focus on first-time referrals and urgent cases. There was a significant increase in the total number of elective admissions whereas there were significantly less admissions from an emergency setting (+57% and −54%, respectively, P < 0.001). The vascular surgery team performed a total number of 584 procedures between February and June 2020 (−17.8% compared to 2018 and 2019), with a significant increase in the number of endovascular procedures (P < 0.001) and in the use of local and regional anesthesia (P < 0.001), especially in the Angio Suite (+600%, P < 0.001). Comparing with 2018 and 2019, the surgical team performed less outpatient procedures in early 2020. We reported a significant increase in the total number of procedures for patients with a chronic limb-threatening ischemia (CLTI) diagnosis (+21%, P < 0.001). We did not report significant changes in the proportion of other vascular conditions. Regarding mortality, we observed a 16% decrease in the intraoperative mortality (P 0.67).ConclusionsIn this study, we assessed the impact of the COVID-19 outbreak in daily activity during the contingency period. During the outbreak, there was an overall decline in outpatient clinics and inpatient admissions. Nevertheless, and despite the restrictions imposed by the pandemic and health authorities, we managed to maintain most procedures for most vascular diseases, particularly for CLTI urgent cases, without a significant increase in the mortality rate. Stringent protective measures for patient and staff or higher use of endovascular techniques and local anesthesia are some of the successful changes implemented in the department. These learned lessons are to be pursued as the pandemic evolves with future outbreaks of COVID-19, such as the current second outbreak currently spreading through Europe.

On the question of determining a necessity to use conduits of biological origin in reconstructive surgical interventions in acute arterial insufficiency

Objective: to determine a necessity to use grafts of biological origin in patients with acute arterial insufficiency.Material and methods. A retrospective analysis of 212 medical records of patients with acute arterial insufficiency of the lower limbs undergoing in-patient treatment at the Vascular Surgery Ward of the institution «Gomel Regional Clinical Cardiology Center» from 2007 to 2019 has been carried out. Statistical processing of the study results has been performed using GoogleSheet, Statskingdom. Differences between groups were considered to be statistically significant at p &lt; 0.05.Results. Surgical interventions were performed on the arteries of the lower limbs in 22.4 % of patients having acute thrombosis in their medical history. In 97.1 % of the cases, repeated surgery was required on the arteries of the same lower limb. Autologous veins were used as conduits in 26.3 % of the cases, and synthetic explants were used in 73.7 % of the patients. Among the total number of surgeries, autologous materials were used as plastic material in 40 % of bypasses, and synthetic explants were used in 60 % of the cases.Conclusion. The study has shown the necessity to use materials of biological origin as plastic material for the treatment of acute arterial insufficiency.

Multidisciplinary quality improvement programme for older patients admitted to a vascular surgery ward.

Older vascular surgical patients are at high risk of hospital-associated complications and prolonged stays. To implement a multidisciplinary co-management model for older vascular patients and evaluate impact on length of stay (LOS), delirium incidence, functional decline, medical complications and discharge destination. Prospective pre-post evaluation of a quality improvement intervention, enrolling pre-intervention (August 2012-January 2013) and post-intervention cohort (September 2013-March 2014). Participants were consenting patients aged 65 years and over admitted to the vascular surgical ward of a metropolitan teaching hospital for at least 3 days. Intervention was physician-led co-management plus a multidisciplinary improvement programme targeting delirium and functional decline. Primary outcomes were LOS, delirium and functional decline. Secondary outcomes were medical complications and discharge destination. Process measures included documented consultation patterns. Administrative data were also compared for all patients aged 65 and older for 12 months pre- and post-intervention. We enrolled 112 participants pre-intervention and 123 participants post-intervention. LOS was reduced post-intervention (geometric mean 7.6 days vs 9.3 days; ratio of geometric means 0.82 (95% confidence interval CI0.68-1.00), P = 0.04). There was a trend to less delirium (18 (14.6%) vs 24 (21.4%), P = 0.17) and functional decline (18 (14.6%) vs 27 (24.3%), P = 0.06), with greatest reductions in the urgently admitted subgroup. Administrative data showed reduced median LOS (5.2 days vs 6 days, P = 0.03) and greater discharge home (72% vs 50%, P < 0.01). Physician-led co-management plus a multidisciplinary improvement programme may reduce LOS and improve functional outcomes in older vascular surgical patients.

Persuasive antimicrobial stewardship intervention in the context of a KPC outbreak: a controlled interrupted time series analysis

IntroductionAntimicrobial resistance is a major public health threat. Antimicrobial stewardship (AMS) is one of the key strategies to overcome resistance, but robust evidence on the effect of specific interventions is lacking. We report an interrupted time series (ITS) analysis of a persuasive AMS intervention implemented during a KPC producing Klebsiella pneumoniae outbreak.MethodsA controlled ITS for carbapenem consumption, total antibiotic consumption and antibiotic-free days, between January 2012 and May 2018 was performed, using segmented regression analysis. The AMS intervention was implemented in the Vascular Surgery ward starting on April 2016 in the context of a KPC outbreak. The General Surgery ward was taken as a control group. Data were aggregated by month for both wards, including 51 pre-intervention and 26 intervention points.ResultsThe AMS intervention produced a level change in carbapenem consumption of − 11.14 DDDs/100 patient-days accompanied by a decreasing trend of total antibiotic consumption and stable rate of antibiotic-free days in Vascular Surgery ward. These differences were not apparent in the control group. No differences in mortality or readmission rates between pre-intervention and intervention periods were noticed in any of the groups.ConclusionPersuasive AMS interventions on top of previously implemented restrictive interventions can reduce carbapenem consumption without increasing total antibiotic consumption. Starting persuasive AMS interventions in an outbreak setting does not compromise the sustainability of the intervention.

Risk factors for impaired wound healing and prolonged hospitalization in patients after amputation of the lower limb above the knee joint.

A retrospective analysis was performed using the database of the General and Vascular Surgery Ward of the Nikolay Pirogov Regional Specialist Hospital in Łódź. Patients who underwent lower limb amputation at the transfemoral level in 2017 were analyzed. 92 patients undergoing surgery were qualified for the study. Patients were divided into two groups: those with no healing complications and those with stump healing complications. Medical records of both groups were analyzed for risk factors for impaired healing. The obtained data were subjected to statistical analysis. Patients with impaired stump healing most often had minimal bleeding and higher ASA scores compared to patients without healing complications. No differences between the two groups were found for the remaining parameters. Patients with complications needed an average of 28 days to heal the wound and spent an average of 40 days in hospital, compared to 14 and 21 days, respectively, for patients without complications. The percentage of deaths in the group of patients with complications was also significantly higher (35%) than in the group of patients without complications (5%). Statistically significant factors increasing the risk of impaired stump healing include high ASA scale and minimal muscle bleeding during surgery. Patients who experienced this complication are at greater risk of prolonged hospitalization and death in the postoperative period. This study showed statistically significant risk factors for impaired stump healing following amputation and confirmed the negative impact of this complication on the length of hospitalization and risk of death.

La valutazione delle ulcere vascolari degli arti inferiori attraverso la Wound Trend Scale: l’esperienza dell’Azienda USL di Piacenza/Assessment of vascular ulcers of the lower limbs through the Wound Trend Scale: the experience of the LHA of Piacenza

Le ulcere cutanee vascolari degli arti inferiori, siano esse di origine venosa, arteriosa o mista, rappresentano una patologia diffusa che colpisce dallo 0,3 al 5% della popolazione, consumando fra l'1 ed il 3% del fondo sanitario Nazionale. La cura delle persone con questo tipo di lesioni deve avvalersi di strumenti idonei alla valutazione delle caratteristiche delle ulcere in modo che possa innescare il trattamento clinico/assistenziale più adeguato. Il presente studio intende verificare l'appropriatezza nella descrizione delle lesioni e la capacità predittiva sull’evoluzione delle stesse della Wound Trend Scale (WTS). La ricerca è stata condotta presso l’unità operativa di chirurgia vascolare e nell’ambulatorio di vulnologia dell’Azienda USL di Piacenza; ha coinvolto 11 pazienti con 12 lesioni vascolari degli arti inferiori. Il campione di convenienza utilizzato era composto per la maggior parte da pazienti di sesso femminile (73%) con un’età media di 79,2 anni (DS±0,7). È emersa una maggiore frequenza di ulcere venose (58%) prevalentemente localizzate in sede perimalleolare (50%). La WTS composta da 14 items, oltre ad informare rispetto alle caratteristiche delle lesioni, permette di indicare l’evoluzione delle stesse attraverso tre misurazioni seriate con intervalli stabiliti in base alla gravità della ferita. Dallo studio è emerso che l’83% delle ulcere ha mostrato un’evoluzione verso la guarigione, mentre il restante 17% è stato connotato da un peggioramento della lesione. La WTS si pone come un valido strumento per la descrizione delle ulcere con caratteristiche di predittività rispetto all’evoluzione delle stesse ma necessita di maggiori approfondimenti per testarne l’appropriatezza.&#x0D; Vascular ulcers of the lower limbs, be they venous, arterial or mixed, represent a widespread pathology affecting from 0,3 to 5% of the population, consuming between 1 and 3% of the National health fund. The care of people with this type of injury must use tools that are suitable for assessing the characteristics of ulcers so that it can trigger the most appropriate care treatment. The present study intends to verify the appropriateness in the description of the lesions and the predictive ability on the evolution of the same ones of the Wound Trend Scale (WTS). The research was conducted at the vascular surgery ward and in the volnology service of the Health Authority of Piacenza; involved 11 patients with 12 lower limb vascular ulcers. The convenience sample used was mostly composed of female patients (73%) with a mean age of 79,2 years (DS±0.7). A greater frequency of venous ulcers (58%) has emerged, mainly located in the perimalleolar site (50%). The WTS consists of 14 items, in addition to informing the characteristics of the lesions, premise to indicate the evolution of the same through three measurements with intervals established based on the severity of the wound. The study found that 83% of ulcers showed an evolution towards healing, while the remaining 17% was characterized by a worsening of the lesion. The WTS stands as a valid tool for the description of ulcers with predictive characteristics with respect to their evolution but needs more in-depth analysis to test their appropriateness.

Post-carotid Endarterectomy Hypertension. Part 2: Association with Peri-operative Clinical, Anaesthetic, and Transcranial Doppler Derived Parameters

The first paper in this series observed that pre-operative baroreceptor dysfunction and poorly controlled hypertension were independently predictive for identifying patients who went on to require treatment for post-endarterectomy hypertension (PEH). The second paper examines the influence of intra-operative patient, transcranial Doppler (TCD) ultrasound, and anaesthetic variables on the incidence of PEH. In total, 106 patients underwent carotid endarterectomy (CEA) under general anaesthesia. Systolic blood pressure (SBP) changes, anaesthetic and vasoactive agents, analgesia, and post-operative pain scores, as well as TCD derived changes in middle cerebral artery (MCA) velocity during surgery were recorded. Patients who met pre-existing unit criteria for treating PEH after CEA (SBP>170mmHg without symptoms or SBP>160mmHg with headache/seizure/neurological deficit) were treated according to an established and validated protocol. In total, 40/106 patients (38%) required treatment for PEH following CEA (26 in theatre recovery [25%], 27 back on the vascular surgery ward [25%]), whereas seven (7%) had SBP surges>200mmHg on the ward. Patients requiring treatment for PEH had significantly higher pre-induction SBP (174±21mmHg vs. 153±21mmHg; p<.001), the greatest decreases in SBP after induction of anaesthesia (median decrease 100±32mmHg vs. 83±24mmHg; p=.01) and were significantly more likely to experience moderate/severe pain scores post-operatively (p=.003). Logistic regression analysis of the pre- and intra-operative data revealed that higher pre-induction mean SBP and lower pre-operative (impaired) BRS were the only independent predictors of PEH. This analysis of intra-operative variables has demonstrated that patients with poorly controlled and/or labile hypertension at induction of general anaesthesia were those at greatest risk of requiring treatment for PEH in the post-operative period after CEA. No other variables, including use of vasopressors, treatment of hypotension, anaesthetic agents, or changes in MCA velocity after clamp release and restoration of flow were able to predict who might go on to require treatment for PEH. Identification of at-risk individuals and aggressive blood pressure control in the post-operative period remains the mainstay of treatment.

Lymphoscintigraphic abnormalities in the contralateral lower limbs of patients with unilateral lymphedema.

The contralateral limbs of patients with unilateral lymphedema in the lower limbs (LLs) can exhibit abnormal lymphatic circulation, even in the absence of lymphedema. This idea is based on a number of reports that have studied isolated cases using lymphoscintigraphy. It is likely that these patients previously had some form of lymphopathy, and the lymphedema arose after the action of some external factor. However, there are no studies in the literature that adequately assess the asymptomatic contralateral limbs of these patients or address the prevalence and characteristics of the abnormal lymphatic circulation in these limbs. The aim of this study was to assess the prevalence of abnormal lymphatic circulation in the asymptomatic contralateral limbs of patients with unilateral lymphedema of the LL. Forty-three patients from the angiology and vascular surgery ward of the Hospital das Clínicas da Universidade Federal de Pernambuco with unilateral lymphedema of the LL underwent lymphoscintigraphy. All patients received a subcutaneous injection of 0.2 mL (74 MBq) of a solution of dextran 70 labeled with technetium Tc 99m in the first interdigital space of each foot. Images were obtained on two occasions: 10 minutes and 1 hour after the injection. The study design was transversal prospective. Among the 43 asymptomatic LLs, 30 (70%) showed abnormal lymphatic circulation. The lymphoscintigraphic abnormalities found were the following: reduced visualization of the lymphatic vessels and lymph nodes during 1 hour (83%), collateral circulation (30%), visualization of the inguinal and pelvic lymph nodes after at least 1 hour (30%), visualization of the popliteal lymph nodes (20%), dilation and lymphatic tortuosity (20%), and dermal backflow (10%). In this study,70% of the patients with unilateral lymphedema of the LL had some form of lymphopathy in the contralateral limb during the lymphoscintigraphic examination. These findings could favor the early treatment of these patients to prevent the disease from progressing to its most severe stage.

Health Care Professionals' Opinions and Expectations of Clinical Pharmacy Services on a Surgical Ward.

Pharmacists have made significant contributions to patient care and have been recognized as integral members of the interprofessional team. Health care professionals differ in their opinions and expectations of clinical pharmacy services. Very little has been published about health care professionals' perspectives on advanced clinical pharmacy roles, such as prescriptive authority or administration of vaccines. In 2013, clinical pharmacy services were introduced in a vascular and general surgery ward where a pharmacist had not previously been assigned. To explore surgical nurses' and physicians' opinions and expectations of clinical pharmacy services and to determine how these views changed over time; to compare pharmacists' views of clinical pharmacy services with those of nurses and physicians; and to develop validated survey tools. Three survey tools were created and validated, one for each profession. Surveys were distributed to nurses and physicians assigned to the general and vascular surgery ward before introduction of clinical pharmacy services and 8 months after implementation. Hospital pharmacists were invited to complete the survey at one time point. Differences existed in the opinions of nurses, physicians, and pharmacists about some traditional activities. Nurses and physicians indicated stronger agreement with pharmacists participating in medication reconciliation activities than did pharmacists (p < 0.001), whereas a greater proportion of pharmacists felt that they were the most appropriate health care professionals to provide medication discharge counselling, relative to nurses and physicians (p = 0.001). Respondents supported advanced roles for pharmacists, such as collaborative practice agreements, but there was less support for prescribing, physical assessments, and administration of vaccines. Nurses indicated the strongest agreement with pharmacist prescribing (82% versus 69% among pharmacists and 27% among physicians; p < 0.001). Nurses and physicians expressed strong endorsements of clinical pharmacy services in the surveys' comment sections. The introduction of clinical pharmacy services to a surgical health care team resulted in high levels of satisfaction among nurses and physicians who responded to this survey. Differences in perceptions of traditional clinical pharmacy service activities and advanced practice roles need to be studied in more depth to better understand the factors influencing health care professionals' views.

Delayed discharges at a major arterial centre: a 4-month cross-sectional study at a single specialist vascular surgery ward

ObjectivesDelayed discharges are a significant problem for the National Health Service. The objectives of this study were to determine the prevalence and impact of delayed discharge at a single specialist...

Current Factors of Fragility and Delirium in Vascular Surgery

Vascular surgery patients are frequently deemed to be in a frail clinical condition and at risk for delirium. Therefore, we evaluated the incidence and independent perioperative risk factors for delirium. In addition, we describe factors on frailty in the various vascular disease groups in current practice. This observational longitudinal study included 206 selected patients who were referred to a vascular surgery ward of a large-sized teaching hospital (Amphia Hospital, Breda, The Netherlands) for critical limb ischemia (n = 80), diabetic foot ulcers (n = 27), abdominal aortic aneurysm (AAA) (n = 62), and carotid surgery (n = 37) between April 2013 and December 2013. Data on factors that characterize frailty were collected. Delirium was scored using the Delirium Observation Screening Scale. Multivariable logistic regression analysis was performed to find independent risk factors for delirium. Delirium was present in 24% of the critical limb ischemia patients, in 19% of the patients with a diabetic foot ulcer, in 7% of the patients with an AAA, and in 8% of the patients undergoing carotid surgery (P > 0.05). Of the patients with critical limb ischemia and a delirium, 53% were octogenarians. Multivariable stepwise logistic regression analysis revealed that history of delirium and nurse help at patient's home were independently associated with delirium. Patients with critical limb ischemia scored worse on factors related to frailty compared with the other disease groups in our current clinical practice on vascular surgery. Delirium is a frequent complication in vascular surgery clinical practice, especially in the elderly. Nurse visits at patients' homes and the Amphia Risk Score for delirium were independent risk factors for delirium in our study population. In this study, we identified patients with critical limb ischemia as the most frail and vulnerable.