Failure to Rescue as a Quality Metric in Congenital Heart Surgeries in a High-Complexity Service Provider Institution Located in a Middle-Income Country

Background:Failure to rescue has been an effective quality metric in congenital heart surgery.Conversely,mor-bidity and mortality depend greatly on non-modifiable individual factors and have a weak correlation with better-quality performance.We aim to measure the complications,mortality,and risk factors in pediatric patients undergoing congenital heart surgery in a high-complexity institution located in a middle-income country and compare it with other institutions that have conducted a similar study.Methods:A retrospective observational study was conducted in a high-complexity service provider institution,in Cali,Colombia.All pediatric patients undergoing any congenital heart surgery between 2019 and 2022 were included.The main outcomes evaluated in the study were complication,mortality,and failure to rescue rate.Univariate and multivariate logistic regression analysis was performed with mortality as the outcome variable.Results:We evaluated 308 congenital heart sur-geries.Regarding the outcomes,201(65%)complications occurred,23(7.5%)patients died,and the FTR of the entire cohort was 11.4%.The presence of a postoperative complication(OR 14.88,CI 3.06–268.37,p=0.009),age(OR 0.79,CI 0.57–0.96,p=0.068),and urgent/emergent surgery(OR 8.14,CI 2.97–28.66,p<0.001)were the most significant variables in predicting mortality.Conclusions:Failure to rescue is an effective and comparable quality measure in healthcare institutions and is the major contributor to postoperative mortality in congenital heart surgeries.Despite our higher mortality and complication rate,we obtained a comparable failure to rescue rate to high-income countries’health institutions.

Acute kidney injury in severely injured patients admitted to the Intensive Care Unit

Background:Our objective was to identify possible associations between clinical and laboratory variables and the risk of developing acute kidney injury(AKI)in severely injured patients admitted to the Intensive Care Unit(ICU)for whom creatine kinase(CK)levels were available.Methods:For this retrospective observational study,we analyzed adult trauma patients admitted to the ICU from 2011 to 2015 at Fundación Valle del Lili(FVL)University Hospital.Our primary outcome was the incidence of AKI.Multivariate regression analysis was used to assess risk factors for this outcome.Results:A total of 315 patients were included.The trauma mechanisms were blunt(n=130),penetrating(n=66)and blast(n=44)trauma.The median[interquartile range,(IQR)of injury severity score(ISS)was 21(16–29).AKI developed in 75 patients(23.8%).Multivariate regression analysis revealed that the thoracic abbreviated injury scale(AIS)value(median(IQR)in the AKI group:3(0–4)],Acute Physiology and Chronic Health Evaluation(APACHE Ⅱ)score[median(IQR)in the AKI group:18(10–27)],CK greater than 5000 U/L,lactic acid concentration at admission,and dobutamine administration were independently associated with AKI.Conclusions:We found that age,APACHE Ⅱ score,thoracic trauma,lactic acidosis,and dobutamine administration were independently associated with AKI.Trauma surgeons need to be aware of the increased odds of AKI if one of these factors is identified during the evaluation and treatment of injured patients.

Fear is the Path to the Dark Side:Unsafe Delivery,One of the Consequences of Fear of the SARS-CoV-2 Pandemic,A Case Report

Indirect effects of the severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)pandemic are difficult to calculate.Fear of intrahospital infection has led to a decrease in the use of emergency services and the performance of elective procedures.Several low-and middle-income countries have seen the number of institutional deliveries reduced,even in the absence of a follow-up program for home births.We present the case of a patient with adequate prenatal care and an institutional delivery plan who,due to the SARS-CoV-2 pandemic,chose to have a home delivery with unsafe conditions.The lack of supervision by health personnel and the absence of an immediate consultation plan facilitated the presentation of postpartum hemorrhage and poor neonatal results.Little attention has been paid during the pandemic to pregnant women who decide to have their birth at home.A broad discussion is necessary in this regard,to regain the confidence of the population and strengthen institutional births,or to strengthen midwifeassisted home births programs.Patients’fear to acquiring SARS-CoV-2 infection inside hospitals is a factor that must be taken into account in prenatal care programs.

How Learning from Trauma Benefits the Obstetric Population?Damage Control Surgery

The recent implementation of trauma-validated damage control strategies in severe postpartum hemorrhage proves the importance of interdisciplinary management in the obstetric patient.Massive hemorrhage control techniques and damage control surgery are clear examples of how learning from trauma can benefit the obstetric population.Currently,most obstetric programs do not include training in this type of interventions.Nevertheless,it has been shown that these interventions are useful in the management of severe postpartum hemorrhage.The aim of this article is to introduce the application of damage control surgery principles in the management of massive obstetric hemorrhage.We propose to include appropriate training and the implementation of damage control surgery in obstetric management protocols.The prompt application of damage control principles can be considered in patients with persistent hemodynamic instability despite control of the source of bleeding.

Maternal Diaphragmatic Hernia Correction During Pregnancy

Congenital diaphragmatic hernia consists of a defect in the embryonic development of the diaphragm that allows the passage of the abdominal viscera into the thoracic cavity,its diagnosis during pregnancy is quite rare.We present the case of a 31-year-old woman,with 23 weeks of gestation,who consulted for epigastric pain,nausea,and repetitive emetic episodes,without improvement with the medication provided.Due to the intense abdominal pain,a computed tomography of the abdomen and thorax was performed where the 28 mm defect was found at the left diaphragmatic level with protrusion of the gastric fundus to the thoracic cavity.She was taken to surgical management by laparoscopy with abdominal and thoracic approach,with a successful result and without maternal perinatal complications.Although the integrity of the diaphragmatic suture could be feared in relation to the increase in intraabdominal pressure due to uterine growth,the evolution of our patient and previous reports show that postoperative complications are not frequent.Successful vaginal delivery has even been described in some reports.Diaphragmatic hernias diagnosed during pregnancy are quite rare.We suggest that the optimal management of them during pregnancy is immediate surgical correction in case of persistent symptoms,more studies are needed to establish firm recommendations on the management of this pathology.

Ligation or Occlusion of the Internal Iliac Arteries for the Treatment of Placenta Accreta Spectrum:Why Is This Technique Still Performed?

Introduction The major complication of placenta accreta spectrum(PAS)disorder is massive bleeding;therefore,multiple vascular interventions have been described to prevent or treat pelvic bleeding.Ligature of the internal iliac arteries(IIAs)was published more than 130 years ago,and although research relating to the physiology of this procedure has demonstrated poor vascular control over the last few decades,2-this technique has evolved into an established technique known as endovascular IIA balloon occlusion.

Cesarean Scar Pregnancy with Iniencephaly and Progression to Placenta Accreta Due to Early Management Rejection

To editor:Cesarean scar pregnancy(CSP)is a rare pathology,with an increasingly clear association with morbidly adherent placenta(MAP).1 Although the most recommended treatment is pregnancy termination by cesarean section and scar resection shortly after diagnosis.2 The final decision regarding management depends on the patient's choice,medical advice,the fertility desire,and the social,religious and emotional background that should also be taken into account.

Application of the Modified Early Obstetric Warning System in Three Patients with Obstetric Sepsis Through a Telemedicine System

To editor:Maternal sepsis represents the third cause of maternal mortality worldwide and the diagnosis delay portrays a great contribution due to its high lethality.The Modified Early Obstetric Warning System is an early detection tool validated in maternal sepsis scenarios.

Extrauterine Causes of Severe and Concealed Postpartum Bleeding: Clinical Aspects and Challenges

Objective To describe the challenges in diagnosing concealed postpartum bleeding,a rare but potentially life-threatening condition,and to highlight key factors in identifying and managing this condition.Methods We reviewed clinical cases and diagnostic approaches where concealed postpartum bleeding was suspected,focusing on the role of imaging,serologic markers,and angiography.We examined instances of hemodynamic instability,the utility of pelvic space analysis via computed tomography,and the limitations of digital angiography,particularly in identifying bleeding sources in the posterior iliac internal artery division.Results Concealed postpartum bleeding often originates from venous damage or,less commonly,arterial injury.Hemodynamic instability was noted to occur periodically,despite negative findings on vaginal examination and ultrasound,leading to diagnostic delays.Digital angiography often yields negative results when the focus is limited to the anterior division of the internal iliac artery.Bleeding typically arises from damage to the vaginal muscular layer or levator ani muscle,both supplied by branches of the internal pudendal artery(posterior iliac division).In some cases,laparotomy also failed to locate the source due to the bleeding being in the subperitoneal spaces.Conclusion Concealed postpartum bleeding presents a diagnostic challenge due to intermittent hemodynamic instability and often negative imaging results.A detailed pelvic space analysis and awareness of posterior iliac internal artery involvement are crucial.Advanced expertise,along with serologic markers of hidden bleeding,is essential for timely diagnosis and management.