The average cost of CABG without complication was $36,580. Each additional major complication resulted in an exponential increase in cost. Over the past 10 years, the total cost of complications after isolated CABG was $78.6 million, emphasizing the importance of quality improvement projects to contain costs.
BACKGROUND: Current ex vivo lung perfusion (EVLP) protocols aim to achieve perfusion flows of 40% of cardiac output or more. We hypothesized that a lower target flow rate during EVLP would improve graft function and decrease inflammation of donation after circulatory death (DCD) lungs. METHODS: A porcine DCD and EVLP model was utilized. Two groups (n = 4 per group) of DCD lungs were randomized to target EVLP flows of 40% (high-flow) or 20% (low-flow) predicted cardiac output based on 100 ml/min/kg. At the completion of 4 hours of normothermic EVLP using Steen solution, left lung transplantation was performed, and lungs were monitored during 4 hours of reperfusion. RESULTS: After transplant, left lung−specific pulmonary vein partial pressure of oxygen was significantly higher in the low-flow group at 3 and 4 hours of reperfusion (3-hour: 496.0 § 87.7 mm Hg vs. 252.7 § 166.0 mm Hg, p = 0.017; 4-hour: 429.7 § 93.6 mm Hg vs. 231.5 § 178 mm Hg, p = 0.048). Compliance was significantly improved at 1 hour of reperfusion (20.8 § 9.4 ml/cm H 2 O vs. 10.2 § 3.5 ml/cm H 2 O, p = 0.022) and throughout all subsequent time points in the low-flow group. After reperfusion, lung wet-to-dry weight ratio (7.1 § 0.7 vs. 8.8 § 1.1, p = 0.040) and interleukin-1b expression (927 § 300 pg/ng protein vs. 2,070 § 874 pg/ng protein, p = 0.048) were significantly reduced in the low-flow group. CONCLUSIONS: EVLP of DCD lungs with low-flow targets of 20% predicted cardiac output improves lung function, reduces edema, and attenuates inflammation after transplant. Therefore, EVLP for lung rehabilitation should use reduced flow rates of 20% predicted cardiac output.
Implementation of a prophylactic amiodarone protocol significantly reduced risk-adjusted rates of POAF, with a cost savings of $458 per patient. This analysis demonstrates how rigorous quantitative analysis can evaluate the benefits of quality improvement projects.
Enhanced recovery pathways (ERPs), used across multiple surgical subspecialties, are multidisciplinary approaches to the delivery of perioperative care that are designed to return patients to baseline as quickly as possible. Although small variations exist between programs, core tenets of thoracic surgery ERP have been implemented in several centers over the last few years. Evidence of the benefit of thoracic ERP has started to emerge in terms of clinical outcomes and health care-associated cost.
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