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Fletcher CM, Hinton JV, Xing Z, Perry LA, Greifer N, Karamesinis A, Shi J, Penny-Dimri JC, Ramson D, Liu Z, Williams-Spence J, Segal R, Smith JA, Coulson TG, Bellomo R. Platelet Transfusion in Cardiac Surgery: An Entropy-Balanced, Weighted, Multicenter Analysis. Anesth Analg 2024; 138:542-551. [PMID: 37478047 DOI: 10.1213/ane.0000000000006624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
Abstract
BACKGROUND Platelet transfusion is common in cardiac surgery, but some studies have suggested an association with harm. Accordingly, we investigated the association of perioperative platelet transfusion with morbidity and mortality. METHODS We conducted a retrospective analysis of prospectively collected data from the Australian Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database. We included consecutive adults from 2005 to 2018 across 40 centers. We used inverse probability of treatment weighting via entropy balancing to investigate the association of perioperative platelet transfusion with our 2 primary outcomes, operative mortality (composite of both 30-day and in-hospital mortality) and 90-day mortality, as well as multiple other clinically relevant secondary outcomes. RESULTS Among 119,132 eligible patients, 25,373 received perioperative platelets and 93,759 were considered controls. After entropy balancing, platelet transfusion was associated with reduced operative mortality (odds ratio [OR], 0.63; 99% confidence interval [CI], 0.47-0.84; P < .0001) and 90-day mortality (OR, 0.66; 99% CI, 0.51-0.85; P < .0001). Moreover, it was associated with reduced odds of deep sternal wound infection (OR, 0.57; 99% CI, 0.36-0.89; P = .0012), acute kidney injury (OR, 0.84; 99% CI, 0.71-0.99; P = .0055), and postoperative renal replacement therapy (OR, 0.71; 99% CI, 0.54-0.93; P = .0013). These positive associations were observed despite an association with increased odds of return to theatre for bleeding (OR, 1.55; 99% CI, 1.16-2.09; P < .0001), pneumonia (OR, 1.26; 99% CI, 1.11-1.44; P < .0001), intubation for longer than 24 hours postoperatively (OR, 1.13; 99% CI, 1.03-1.24; P = .0012), inotrope use for >4 hours postoperatively (OR, 1.14; 99% CI, 1.11-1.17; P < .0001), readmission to hospital within 30 days of surgery (OR, 1.22; 99% CI, 1.11-1.34; P < .0001), as well as increased drain tube output (adjusted mean difference, 89.2 mL; 99% CI, 77.0 mL-101.4 mL; P < .0001). CONCLUSIONS In cardiac surgery patients, perioperative platelet transfusion was associated with reduced operative and 90-day mortality. Until randomized controlled trials either confirm or refute these findings, platelet transfusion should not be deliberately avoided when considering odds of death.
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Affiliation(s)
- Calvin M Fletcher
- From the Department of Anaesthesiology and Perioperative Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jake V Hinton
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Zhongyue Xing
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Luke A Perry
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia
| | - Noah Greifer
- Harvard University Institute for Quantitative Social Science, Cambridge, Massachusetts
| | - Alexandra Karamesinis
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Jenny Shi
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Jahan C Penny-Dimri
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Dhruvesh Ramson
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Zhengyang Liu
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Jenni Williams-Spence
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Reny Segal
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia
| | - Julian A Smith
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Tim G Coulson
- From the Department of Anaesthesiology and Perioperative Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Escalante GO, Sun J, Schnell S, Guderian E, Mack CA, Argenziano M, Kurlansky P. Hospital characteristics associated with failure to rescue in cardiac surgery. JTCVS Open 2023; 16:509-521. [PMID: 38204725 PMCID: PMC10775121 DOI: 10.1016/j.xjon.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 09/25/2023] [Accepted: 10/11/2023] [Indexed: 01/12/2024]
Abstract
Objective The study objective was to examine the association between hospital processes of care and failure to rescue in a diverse, multi-institutional cardiac surgery network. Methods Failure to rescue was defined as an operative mortality after 1 or more of 4 complications: prolonged ventilation, stroke, renal failure, and unplanned reoperation. Society of Thoracic Surgeons data from 20,950 consecutive patients in the Columbia HeartSource network who underwent 1 of 7 cardiac operations-coronary artery bypass grafting, aortic valve replacement ± coronary artery bypass grafting, mitral valve repair or replacement ± coronary artery bypass grafting-were analyzed to calculate failure to rescue rates. Hospital-specific characteristics were ascertained by survey method. Multivariable mixed-effects logistic models assessed the association of these hospital characteristics with failure to rescue while adjusting for patient-related factors known to be associated with mortality. Results Failure to rescue rates at affiliate hospitals ranged from 5.45% to 21.74% (median, 12.5%; interquartile range, 6.9%). When controlling for Society of Thoracic Surgeons-predicted risk of mortality with hospital as a random effect, 4 hospital characteristics were found to be associated with lower failure to rescue rates; the presence of cardiac-trained anesthesiologists (odds ratio, 0.41; CI, 0.31-0.55, P < .001), availability of extracorporeal membrane oxygenation mechanical circulatory support (odds ratio, 0.41; CI, 0.31-0.54, P < .001), ratio of intensive care unit beds to intensivists (odds ratio, 0.87; CI, 0.76-0.99, P = .039), and total number of intensive care unit beds (odds ratio, 0.97; CI, 0.96-0.99, P = .002). Conclusions In a diverse multi-institutional cardiac surgical network, we were able to identify specific hospital processes of care associated with failure to rescue, even when adjusting for patient-related predictors of operative mortality.
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Affiliation(s)
| | - Jocelyn Sun
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University New York, New York, NY
| | - Susan Schnell
- Division of Cardiac, Thoracic and Vascular Surgery, Columbia University, New York, NY
| | - Emily Guderian
- Division of Cardiac, Thoracic and Vascular Surgery, Columbia University, New York, NY
| | - Charles A. Mack
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Michael Argenziano
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University New York, New York, NY
- Division of Cardiac, Thoracic and Vascular Surgery, Columbia University, New York, NY
| | - Paul Kurlansky
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University New York, New York, NY
- Division of Cardiac, Thoracic and Vascular Surgery, Columbia University, New York, NY
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Kunst G, Agarwal S. Fitter, better, sooner: prehabilitation and clinical outcomes in cardiac surgery. Anaesthesia 2023; 78:1438-1441. [PMID: 37855196 DOI: 10.1111/anae.16146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 10/20/2023]
Affiliation(s)
- G Kunst
- Department of Anaesthetics and Pain Therapy, King's College Hospital NHS Foundation Trust, London, UK
- Department of Cardiovascular Anaesthesia, School of Cardiovascular and Metabolic Medicine and Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - S Agarwal
- Department of Anaesthesia, Manchester University Hospitals NHS Trust, Manchester, UK
- Manchester University, Manchester, UK
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Abbasciano RG, Tomassini S, Roman MA, Rizzello A, Pathak S, Ramzi J, Lucarelli C, Layton G, Butt A, Lai F, Kumar T, Wozniak MJ, Murphy GJ. Effects of interventions targeting the systemic inflammatory response to cardiac surgery on clinical outcomes in adults. Cochrane Database Syst Rev 2023; 10:CD013584. [PMID: 37873947 PMCID: PMC10594589 DOI: 10.1002/14651858.cd013584.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
BACKGROUND Organ injury is a common and severe complication of cardiac surgery that contributes to the majority of deaths. There are no effective treatment or prevention strategies. It has been suggested that innate immune system activation may have a causal role in organ injury. A wide range of organ protection interventions targeting the innate immune response have been evaluated in randomised controlled trials (RCTs) in adult cardiac surgery patients, with inconsistent results in terms of effectiveness. OBJECTIVES The aim of the review was to summarise the results of RCTs of organ protection interventions targeting the innate immune response in adult cardiac surgery. The review considered whether the interventions had a treatment effect on inflammation, important clinical outcomes, or both. SEARCH METHODS CENTRAL, MEDLINE, Embase, conference proceedings and two trial registers were searched on October 2022 together with reference checking to identify additional studies. SELECTION CRITERIA RCTs comparing organ protection interventions targeting the innate immune response versus placebo or no treatment in adult patients undergoing cardiac surgery where the treatment effect on innate immune activation and on clinical outcomes of interest were reported. DATA COLLECTION AND ANALYSIS Searches, study selection, quality assessment, and data extractions were performed independently by pairs of authors. The primary inflammation outcomes were peak IL-6 and IL-8 concentrations in blood post-surgery. The primary clinical outcome was in-hospital or 30-day mortality. Treatment effects were expressed as risk ratios (RR) and standardised mean difference (SMD) with 95% confidence intervals (CI). Meta-analyses were performed using random effects models, and heterogeneity was assessed using I2. MAIN RESULTS A total of 40,255 participants from 328 RCTs were included in the synthesis. The effects of treatments on IL-6 (SMD -0.77, 95% CI -0.97 to -0.58, I2 = 92%) and IL-8 (SMD -0.92, 95% CI -1.20 to -0.65, I2 = 91%) were unclear due to heterogeneity. Heterogeneity for inflammation outcomes persisted across multiple sensitivity and moderator analyses. The pooled treatment effect for in-hospital or 30-day mortality was RR 0.78, 95% CI 0.68 to 0.91, I2 = 0%, suggesting a significant clinical benefit. There was little or no treatment effect on mortality when analyses were restricted to studies at low risk of bias. Post hoc analyses failed to demonstrate consistent treatment effects on inflammation and clinical outcomes. Levels of certainty for pooled treatment effects on the primary outcomes were very low. AUTHORS' CONCLUSIONS A systematic review of RCTs of organ protection interventions targeting innate immune system activation did not resolve uncertainty as to the effectiveness of these treatments, or the role of innate immunity in organ injury following cardiac surgery.
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Affiliation(s)
| | | | - Marius A Roman
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Angelica Rizzello
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Suraj Pathak
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Joussi Ramzi
- Leicester Medical School, University of Leicester, Leicester, UK
| | - Carla Lucarelli
- Department of Cardiac Surgery, University of Verona, Verona, Italy
| | - Georgia Layton
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Ayesha Butt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Florence Lai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Tracy Kumar
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Marcin J Wozniak
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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Walsh B, Mueller B, Roche SL, Alonso-Gonzalez R, Somerset E, Sano M, Villagran Schmidt M, Hickey E, Barron D, Heggie J. Impact of a quality improvement initiative with a dedicated anesthesia team on outcomes after surgery for adult congenital heart disease. JTCVS Open 2023; 14:188-204. [PMID: 37425473 PMCID: PMC10329027 DOI: 10.1016/j.xjon.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 03/23/2023] [Accepted: 03/24/2023] [Indexed: 07/11/2023]
Abstract
Objectives A quality improvement initiative was introduced to the adult congenital cardiac surgery program at Toronto General Hospital in January 2016. A dedicated Adult Congenital Anesthesia and intensive care unit team was introduced within the cardiac group. The use of factor concentrates was introduced. The study compares perioperative mortality, adverse events, and transfusion burden before and after this process change. Methods We performed a retrospective analysis of all adult congenital cardiac surgeries from January 2004 to July 2019. Two groups were analyzed: patients undergoing operation before and after 2016. The primary outcome was in-hospital mortality. One-year mortality and prevalence of key morbidities were analyzed as secondary outcomes. A separate analysis looked at patients who had and had not attended an anesthesia-led preassessment clinic. Results In-hospital mortality was significantly reduced in patients undergoing operation after 2016 (1.1% vs 4.3%, P = .003) despite a higher risk profile. One-year mortality (1.3% vs 5.8%, P = .003) and ventilation times (5.5 hours [3.4-13.0] vs 6.3 hours [4.2-16.2], P = .001) were also reduced. The incidence of stroke and renal failure was similar between groups. Blood product exposure was comparable, but the incidence of chest reopening decreased (1.8% vs 4.8%, P = .022), despite more patients with multiple previous chest wall incisions, on anticoagulation, and with more complex cardiac anatomy. There were no significant outcome differences between those who did or did not attend the preassessment clinic. Conclusions Both in-hospital and 1-year mortality were significantly reduced after the introduction of a quality improvement program, despite a higher risk profile. Blood product exposure remained unchanged, but there were less chest reopenings.
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Affiliation(s)
- Bill Walsh
- Department of Anesthesia and Pain Medicine, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Brigitte Mueller
- Ted Rogers Computational Program, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - S. Lucy Roche
- Division of Cardiology, Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Rafael Alonso-Gonzalez
- Division of Cardiology, Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Emily Somerset
- Ted Rogers Computational Program, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Minako Sano
- Department of Anesthesia and Pain Medicine, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Milca Villagran Schmidt
- Department of Anesthesia and Pain Medicine, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Edward Hickey
- Division of Cardiac Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
- Division of Cardiac Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - David Barron
- Division of Cardiac Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
- Division of Cardiac Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jane Heggie
- Department of Anesthesia and Pain Medicine, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
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Guinot PG, Andrei S, Durand B, Martin A, Duclos V, Spitz A, Berthoud V, Constandache T, Grosjean S, Radhouani M, Anciaux JB, Nguyen M, Bouhemad B. Balanced Nonopioid General Anesthesia With Lidocaine Is Associated With Lower Postoperative Complications Compared With Balanced Opioid General Anesthesia With Sufentanil for Cardiac Surgery With Cardiopulmonary Bypass: A Propensity Matched Cohort Study. Anesth Analg 2023; 136:965-974. [PMID: 36763521 DOI: 10.1213/ane.0000000000006383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
BACKGROUND There are no data on the effect of balanced nonopioid general anesthesia with lidocaine in cardiac surgery with cardiopulmonary bypass. The main study objective was to evaluate the association between nonopioid general balanced anesthesia and the postoperative complications in relation to opioid side effects. METHODS Patients undergoing cardiac surgery with cardiopulmonary bypass between 2019 and 2021 were identified. After exclusion of patients for heart transplantation, left ventricular assistance device, and off-pump surgery, we classified patients according to an opioid general balanced anesthesia or a nonopioid balanced anesthesia with lidocaine. The primary outcome was a collapsed composite of postoperative complications that comprise respiratory failure and confusion, whereas secondary outcomes were acute renal injury, pneumoniae, death, intensive care unit (ICU), and hospital length of stay. RESULTS We identified 859 patients exposed to opioid-balanced general anesthesia with lidocaine and 913 patients exposed to nonopioid-balanced general anesthesia. Propensity score matching yielded 772 individuals in each group with balanced baseline covariates. Two hundred thirty-six patients (30.5%) of the nonopioid-balanced general anesthesia versus 186 patients (24.1%) presented postoperative composite complications. The balanced lidocaine nonopioid general anesthesia group was associated with a lower proportion with the postoperative complication composite outcome OR, 0.72 (95% CI, 0.58-0.92; P = .027). The number of patients with acute renal injury, death, and hospital length of stay did not differ between the 2 groups. CONCLUSIONS A balanced nonopioid general anesthesia protocol with lidocaine was associated with lower odds of postoperative complication composite outcome based on respiratory failure and confusion.
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Affiliation(s)
- Pierre-Grégoire Guinot
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
- Department of Anaesthesiology and Intensive Care Medicine, University of Burgundy and Franche-Comté, Dijon, France
| | - Stefan Andrei
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Bastien Durand
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Audrey Martin
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Valerian Duclos
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Alexandra Spitz
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Vivien Berthoud
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Tiberiu Constandache
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Sandrine Grosjean
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Mohamed Radhouani
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Jean-Baptiste Anciaux
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Maxime Nguyen
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
- Department of Anaesthesiology and Intensive Care Medicine, University of Burgundy and Franche-Comté, Dijon, France
| | - Belaid Bouhemad
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
- Department of Anaesthesiology and Intensive Care Medicine, University of Burgundy and Franche-Comté, Dijon, France
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White SM, Tedore T, Shelton CL. There is (probably) no (meaningful) difference in (most) outcomes between 'spinal' and 'general' anaesthesia for hip fracture surgery: time to move forward. Br J Anaesth 2023; 130:385-389. [PMID: 36801101 DOI: 10.1016/j.bja.2023.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/12/2023] [Accepted: 01/14/2023] [Indexed: 02/18/2023] Open
Abstract
A meta-analysis influenced by two recent large randomised controlled trials (REGAIN and RAGA) concluded that little, if any, difference in commonly measured outcomes exists between patients administered spinal or general anaesthesia for their hip fracture surgery. We explore whether there is genuinely no difference, or what the methodological problems in research might be that prevent any real difference from being observed. We also discuss the need for greater nuance in future research to determine how anaesthetists might deliver perioperative care towards improving postoperative recovery trajectories in patients following hip fracture.
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Affiliation(s)
- Stuart M White
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK.
| | - Tiffany Tedore
- Weill Cornell Medical College, NewYork-Presbyterian Hospital/Weill Cornell, New York, NY, USA
| | - Clifford L Shelton
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK; Lancaster Medical School, Lancaster University, Lancaster, UK
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Balan C, Tomescu DR, Bubenek-Turconi SI. Nociception Control of Bilateral Single-Shot Erector Spinae Plane Block Compared to No Block in Open Heart Surgery-A Post Hoc Analysis of the NESP Randomized Controlled Clinical Trial. Medicina (Kaunas) 2023; 59. [PMID: 36837467 DOI: 10.3390/medicina59020265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/24/2023] [Accepted: 01/27/2023] [Indexed: 01/31/2023]
Abstract
Background and Objectives: The erector spinae plane block (ESPB) is an analgesic adjunct demonstrated to reduce intraoperative opioid consumption within a Nociception Level (NOL) index-directed anesthetic protocol. We aimed to examine the ESPB effect on the quality of intraoperative nociception control evaluated with the NOL index. Materials and Methods: This is a post hoc analysis of the NESP (Nociception Level Index-Directed Erector Spinae Plane Block in Open Heart Surgery) randomized controlled trial. Eighty-five adult patients undergoing on-pump cardiac surgery were allocated to group 1 (Control, n = 43) and group 2 (ESPB, n = 42). Both groups received general anesthesia. Preoperatively, group 2 received bilateral single-shot ESPB (1.5 mg/kg/side 0.5% ropivacaine mixed with dexamethasone 8 mg/20 mL). Until cardiopulmonary bypass (CPB) was initiated, fentanyl administration was individualized using the NOL index. The NOL index was compared at five time points: pre-incision (T1), post-incision (T2), pre-sternotomy (T3), post-sternotomy (T4), and pre-CPB (T5). On a scale from 0 (no nociception) to 100 (extreme nociception), a NOL index > 25 was considered an inadequate response to noxious stimuli. Results: The average NOL index across the five time points in group 2 to group 1 was 12.78 ± 0.8 vs. 24.18 ± 0.79 (p < 0.001). The NOL index was significantly lower in the ESPB-to-Control group at T2 (12.95 ± 1.49 vs. 35.97 ± 1.47), T3 (13.28 ± 1.49 vs. 24.44 ± 1.47), and T4 (15.52 ± 1.49 vs. 34.39 ± 1.47) (p < 0.001) but not at T1 and T5. Compared to controls, significantly fewer ESPB patients reached a NOL index > 25 at T2 (4.7% vs. 79%), T3 (0% vs. 37.2%), and T4 (7.1% vs. 79%) (p < 0.001). Conclusions: The addition of bilateral single-shot ESPB to general anesthesia during cardiac surgery improved the quality of intraoperative nociception control according to a NOL index-based evaluation.
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Schnelle C, Jones MA. Characteristics of exceptionally good Doctors-A survey of public adults. Heliyon 2023; 9:e13115. [PMID: 36718151 PMCID: PMC9883187 DOI: 10.1016/j.heliyon.2023.e13115] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 01/17/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023] Open
Abstract
Background Systematic reviews have found that doctors can have a substantial effect on patients' physical health, beyond what can be explained by known factors. In a previous qualitative study, 13 medical doctors were interviewed on their experiences of exceptionally good doctors, and all had met at least one such doctor. Objective To determine how common it is for exceptionally good doctors to be encountered by patients and what are the characteristics of exceptionally good doctors. Design Mixed methods cross-sectional survey of 580 Amazon Mechanical Turk participants. Questions included doctor and participant demographics, and 34 Likert questions on characteristics of exceptionally good and average doctors. Free-text questions allowed participants to describe exceptional doctors, record their experience, and provide survey feedback. Stratified sampling ensured gender parity and 33% of participants aged ≥55 years. Analysis included descriptive statistics, statistical modelling of associations between Likert scale scores and patient demographics, and factor analysis. Results Of 580 responses, 505 (86%) were included in the analysis. Factor analysis confirmed internal validity. Most respondents (86%) had met at least two exceptionally good doctors, of whom 55% were specialists. 58% of respondents regarded doctors as exceptional based on an overall impression with multiple reasons. Doctors were most commonly considered exceptional based on one or more of their personality, diagnostic, or intervention ability. Respondents who reported the doctors "willingly listened to them to the end" scored their doctors higher on 33 of 34 Likert questions, except for popularity. They also rated average doctors lower throughout. Conclusions Exceptionally good doctors appear to be commonly encountered by the adult public. Listening to patients willingly to the end is a highly rated and influential characteristic, suggesting that listening could be targeted for quality improvement.
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Gerritsen JKW, Rizopoulos D, Schouten JW, Haitsma IK, Eralp I, Klimek M, Dirven CMF, Vincent AJPE. Impact of dedicated neuro-anesthesia management on clinical outcomes in glioblastoma patients: A single-institution cohort study. PLoS One 2022; 17:e0278864. [PMID: 36512593 DOI: 10.1371/journal.pone.0278864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 11/25/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Glioblastomas are mostly resected under general anesthesia under the supervision of a general anesthesiologist. Currently, it is largely unkown if clinical outcomes of GBM patients can be improved by appointing a neuro-anesthesiologist for their cases. We aimed to evaluate whether the assignment of dedicated neuro-anesthesiologists improves the outcomes of these patients. We also investigated the value of dedicated neuro-oncological surgical teams as an independent variable in both groups. METHODS A cohort consisting of 401 GBM patients who had undergone resection was retrospectively investigated. Primary outcomes were postoperative neurological complications, fluid balance, length-of-stay and overall survival. Secondary outcomes were blood loss, anesthesia modality, extent of resection, total admission costs, and duration of surgery. RESULTS 320 versus 81 patients were operated under the anesthesiological supervision of a general anesthesiologist and a dedicated neuro-anesthesiologist, respectively. Dedicated neuro-anesthesiologists yielded significant superior outcomes in 1) postoperative neurological complications (early: p = 0.002, OR = 2.54; late: p = 0.003, OR = 2.24); 2) fluid balance (p<0.0001); 3) length-of-stay (p = 0.0006) and 4) total admission costs (p = 0.0006). In a subanalysis of the GBM resections performed by an oncological neurosurgeon (n = 231), the assignment of a dedicated neuro-anesthesiologist independently improved postoperative neurological complications (early minor: p = 0.0162; early major: p = 0.00780; late minor: p = 0.00250; late major: p = 0.0364). The assignment of a dedicated neuro-oncological team improved extent of resection additionally (p = 0.0416). CONCLUSION GBM resections with anesthesiological supervision of a dedicated neuro-anesthesiologists are associated with improved patient outcomes. Prospective evidence is needed to further investigate the usefulness of the dedicated neuro-anesthesiologist in different settings.
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11
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Schnelle C, Clark J, Mascord R, Jones MA. Is There a Doctors' Effect on Patients' Physical Health, Beyond the Intervention and All Known Factors? A Systematic Review. Ther Clin Risk Manag 2022; 18:721-737. [PMID: 35903086 PMCID: PMC9314759 DOI: 10.2147/tcrm.s372464] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/11/2022] [Indexed: 01/10/2023] Open
Abstract
Purpose Despite billions of doctor visits worldwide each year, little is known on whether doctors themselves affect patients’ physical health after accounting for intervention and confounders such as patients’ and doctors’ data, hospital effects, nor how strong that doctors’ effect is. Knowledge of surgeons’ and psychotherapists’ effects exists, but not for 102 other medical specialties notwithstanding the importance of such knowledge. Methods Eligibility Criteria: Randomized controlled trials (RCTs), case-control, and cohort studies including medical doctors except surgeons for any intervention, reporting the proportion of variance in patients’ outcomes owing to the doctors (random effects), or the fixed effects of grading doctors by outcomes, after multivariate adjustment. Exclusions: studies of <15 doctors or solely reporting doctors’ effects for known variables. Sources Medline, Embase, PsycINFO, inception to June 2020. Manual search for papers referring/referred to by resulting studies. Risk of Bias Using Newcastle–Ottawa scale. Results Despite all medical interventions bar surgery being eligible, only thirty cohort papers were found, covering 36,239 doctors, with 10 specialties, 21 interventions, 60 outcomes (17 unique). Studies reported doctors’ effects by grading doctors from best to worst, or by diversely calculating the doctor-attributed percentage of patients’ outcome variation, ie the intra-class correlation coefficient (ICC). Sixteen studies presented fixed effects, 18 random effects, and 3 another approach. No RCTs found. Thirteen studies reported exceptionally good and/or poor performers with confidence intervals wholly outside the average performance. ICC range 0 to 33%, mean 3.9%. Highly diverse reporting, meta-analysis therefore not applicable. Conclusion Doctors, on their own, can affect patients’ physical health for many interventions and outcomes. Effects range from negligible to substantial, even after accounting for all known variables. Many published cohorts may reveal valuable information by reanalyzing their data for doctors’ effects. Positive and negative doctor outliers appear regularly. Therefore, it can matter which doctor is chosen. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/uXjR7VOXTwQ
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Affiliation(s)
- Christoph Schnelle
- Institute of Evidence-Based Healthcare, Bond University, Robina, Queensland, Australia
| | - Justin Clark
- Institute of Evidence-Based Healthcare, Bond University, Robina, Queensland, Australia
| | - Rachel Mascord
- General Dentist, BMA House, Sydney, New South Wales, Australia
| | - Mark A Jones
- Institute of Evidence-Based Healthcare, Bond University, Robina, Queensland, Australia
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12
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Schnelle C, Jones MA. The Doctors' Effect on Patients' Physical Health Outcomes Beyond the Intervention: A Methodological Review. Clin Epidemiol 2022; 14:851-870. [PMID: 35879943 PMCID: PMC9307914 DOI: 10.2147/clep.s357927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 06/22/2022] [Indexed: 01/02/2023] Open
Abstract
Background Previous research suggests that when a treatment is delivered, patients’ outcomes may vary systematically by medical practitioner. Objective To conduct a methodological review of studies reporting on the effect of doctors on patients’ physical health outcomes and to provide recommendations on how this effect could be measured and reported in a consistent and appropriate way. Methods The data source was 79 included studies and randomized controlled trials from a systematic review of doctors’ effects on patients’ physical health. We qualitatively assessed the studies and summarized how the doctors’ effect was measured and reported. Results The doctors’ effects on patients’ physical health outcomes were reported as fixed effects, identifying high and low outliers, or random effects, which estimate the variation in patient health outcomes due to the doctor after accounting for all available variables via the intra-class correlation coefficient. Multivariable multilevel regression is commonly used to adjust for patient risk, doctor experience and other demographics, and also to account for the clustering effect of hospitals in estimating both fixed and random effects. Conclusion This methodological review identified inconsistencies in how the doctor’s effect on patients’ physical health outcomes is measured and reported. For grading doctors from worst to best performances and estimating random effects, specific recommendations are given along with the specific data points to report. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/rvHjVIEPVhI
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Affiliation(s)
- Christoph Schnelle
- Institute of Evidence-Based Healthcare, Bond University, Robina, QLD, 4226, Australia
| | - Mark A Jones
- Institute of Evidence-Based Healthcare, Bond University, Robina, QLD, 4226, Australia
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13
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Schnelle C, Clark J, Mascord R, Jones MA. Is There a Surgeons’ Effect on Patients’ Physical Health, Beyond the Intervention, That Requires Further Investigation? A Systematic Review. Ther Clin Risk Manag 2022; 18:467-490. [PMID: 35502434 PMCID: PMC9056050 DOI: 10.2147/tcrm.s357934] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 04/04/2022] [Indexed: 12/23/2022] Open
Abstract
Objective To find and review published papers researching surgeons’ effects on patients’ physical health. Clinical outcomes of surgery patients with similar prognoses cannot be fully explained by surgeon skill or experience. Just as there are “hospital” and “psychotherapist” effects, there may be “surgeons” effects that persist after controlling for known variables like patient health and operation riskiness. Methods Cohort studies and randomized controlled trials (RCTs) of any surgical intervention, which, after multivariate adjustment, either showed proportion of variance in patients’ physical health outcomes due to surgeons (random effects) or graded surgeons from best to worst (fixed effects). Studies with <15 surgeons or only ascribing surgeons’ effects to known variables excluded. Medline, PubMed, Embase, and PsycINFO were used for search until June 2020. Manual search for papers referring/referred by resulting studies. Risk of bias assessed by Cochrane risk-of-bias tool and Newcastle–Ottawa Scale. Results Included studies: 52 cohort studies and three RCTs of 52,436+ surgeons covering 102 outcomes (33 unique). Studies either graded surgeons from best to worst or calculated the intra-class correlation coefficient (ICC), the percentage of patients’ variation due to surgeons, in diverse ways. Sixteen studies showed exceptionally good and/or bad performers with confidence intervals wholly above or below the average performance. ICCs ranged from 0 to 47%, median 4.0%. There are no well-established reporting standards; highly heterogeneous reporting, therefore no meta-analysis. Discussion Interpretation: There is a surgeons' effect on patients’ physical health for many types of surgeries and outcomes, ranging from small to substantial. Surgeons with exceptional patient outcomes appear regularly even after accounting for all known confounding variables. Many existing cohort studies and RCTs could be reanalyzed for surgeons’ effects especially after methodological reporting guidelines are published. Conclusion In terms of patient outcomes, it can matter which surgeon is chosen. Surgeons with exceptional patient outcomes are worth studying further. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/pL-eGyAGhSk
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Affiliation(s)
- Christoph Schnelle
- Institute for Evidence-Based Healthcare, Bond University, Robina, Queensland, Australia
- Correspondence: Christoph Schnelle, Institute for Evidence-Based Healthcare, Bond University, Robina, Queensland, Australia, Email
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Bond University, Robina, Queensland, Australia
| | - Rachel Mascord
- General Dentist, BMA House, Sydney, New South Wales, Australia
| | - Mark A Jones
- Institute for Evidence-Based Healthcare, Bond University, Robina, Queensland, Australia
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14
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Chen L, He Y, Song K, Zhang B, Liu L. Preoperative Creatinine Clearance and Mortality of Elective Cardiac Surgery in Hospitalization: A Secondary Analysis. Front Cardiovasc Med 2022; 8:712229. [PMID: 35155591 PMCID: PMC8830902 DOI: 10.3389/fcvm.2021.712229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 12/29/2021] [Indexed: 12/02/2022] Open
Abstract
Objective It has been reported that poor renal function before surgery is related to poor prognosis. However, there is no specific discussion on the ideal value of preoperative creatinine clearance. Consequently, our primary goal is to explore the correlation between baseline creatinine clearance and short-term mortality after cardiac surgery. Methods We conducted a secondary data analysis based on a French cardiac surgery cohort. The cohort included 6,889 participants in a Paris university hospital from December 2005 to December 2012. The exposure variable and outcome variable used in this secondary analysis were the preoperative creatinine clearance rate and postoperative hospital mortality. Multivariate logistic regression and generalized additive models were employed. Results The nonlinear relationship between the preoperative creatinine clearance rate and postoperative death was observed in this study. The preoperative creatinine clearance rate was negatively correlated with postoperative mortality in the range of 8.9–78.5 in patients younger than 80 years old (odds ratio = 0.98, 95% confidence interval 0.97–0.98, in Cockcroft Gault formulae). However, this effect characteristics reaches saturation after the preoperative creatinine clearance rate exceeds 78.5 (odds ratio = 0.99, 95% confidence interval 0.98–1.00, CG). In patients with history of thromboembolic event and coronary artery disease, the saturation effect were 30.8 mL.min−1 (CG) and 56.6 mL.min−1(CG). Conclusion In the range of 8.9–78.5 (Cockcroft), an increase in preoperative creatinine clearance is associated with a decrease in postoperative mortality with patients younger than 80 years old. In patients with a history of embolism and coronary artery disease, the cut-off points of the reduction in preoperative creatinine clearance associated with a increase in postoperative mortality are 30.8 mL.min−1 and 56.6 mL.min−1.
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Affiliation(s)
- Lu Chen
- Department of Clinical Trials Centre, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Yan He
- Department of Clinical Trials Centre, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
- *Correspondence: Yan He
| | - Kai Song
- The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Bingqian Zhang
- The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Lin Liu
- The Affiliated Hospital of Guizhou Medical University, Guiyang, China
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Affiliation(s)
- W J Fawcett
- Department of Anaesthesia, Royal Surrey County NHS Foundation Trust, Guildford, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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16
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Kamenetsky E, Hogue CW. Is a Mean Arterial Pressure Less Than 65 mm Hg an Appropriate Indicator of the Quality of Anesthesia Care? Anesth Analg 2021; 132:942-5. [PMID: 33723192 DOI: 10.1213/ANE.0000000000005281] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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17
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Mccallister D, Malone B, Hanna J, Firstenberg MS. Variability in Anesthesia Models of Care in Cardiac Surgery. Surgeries 2021; 2:1-8. [DOI: 10.3390/surgeries2010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The operating room in a cardiothoracic surgical case is a complex environment, with multiple handoffs often required by staffing changes, and can be variable from program to program. This study was done to characterize what types of practitioners provide anesthesia during cardiac operations to determine the variability in this aspect of care. A survey was sent out via a list serve of members of the cardiac surgical team. Responses from 40 programs from a variety of countries showed variability across every dimension requested of the cardiac anesthesia team. Given that anesthesia is proven to have an influence on the outcome of cardiac procedures, this study indicates the opportunity to further study how this variability influences outcomes and to identify best practices.
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Abstract
As mortality is now low for many cardiac surgical procedures, there has been an increasing focus on patient centered outcomes such as recovery and quality of life. The Enhanced Recovery After Surgery (ERAS) cardiac society recently published the first set of guidelines for cardiac surgery which will be useful as a starting point to help translate this philosophy for the benefit of those undergoing cardiac surgery. At the same time there are many advances in other areas such as mechanical circulation, diagnostics and quality metrics. We intend here to present a balanced and evidenced based review of selected aspects of current practice, encompassing both UK and international perioperative care with a focus on recent advances. For the convenience of the reader we will adopt the conventional perioperative preoperative, intraoperative and postoperative phases of care. The focus of cardiac surgical practice needs to evolve from mortality to recovery. Those specialists who work in cardiac anaesthesia and critical care are well placed to contribute to these changes. Accompanying this work is the development of technologies to improve recognition of and intervention to prevent early organ dysfunction. Measuring, benchmarking and publishing quality outcomes from cardiac surgical centres is likely to improve services and benefit our patients.
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Affiliation(s)
| | | | | | - Nick Fletcher
- St Georges University Hospitals, London, UK.,Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, UK
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19
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Del Rio JM, Abernathy JJ, Taylor MA, Habib RH, Fernandez FG, Bollen BA, Lauer RE, Nussmeier NA, Glance LG, Petty JV, Mackensen GB, Vener DF, Kertai MD. The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes. Anesth Analg 2020; 131:1383-1396. [PMID: 33079860 DOI: 10.1213/ane.0000000000005093] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- J Mauricio Del Rio
- From the Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - James Jake Abernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark A Taylor
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert H Habib
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | - Felix G Fernandez
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Bruce A Bollen
- International Heart Institute of Montana, Missoula Anesthesiology, PC, Missoula, Montana
| | - Ryan E Lauer
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California
| | - Nancy A Nussmeier
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Joseph V Petty
- CHI Health Clinic Physician Enterprise Anesthesia, CHI Health Nebraska Heart, Omaha, Nebraska
| | - G Burkhard Mackensen
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, Washington
| | - David F Vener
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Del Rio JM, Jake Abernathy J, Taylor MA, Habib RH, Fernandez FG, Bollen BA, Lauer RE, Nussmeier NA, Glance LG, Petty JV, Mackensen GB, Vener DF, Kertai MD. The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes. J Cardiothorac Vasc Anesth 2020; 35:22-34. [PMID: 33008722 DOI: 10.1053/j.jvca.2020.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The Society of Cardiovascular Anesthesiologists, in partnership with The Society of Thoracic Surgeons, has developed the Adult Cardiac Anesthesiology Section of the Adult Cardiac Surgery Database. The goal of this landmark collaboration is to advance clinical care, quality, and knowledge, and to demonstrate the value of cardiac anesthesiology in the perioperative care of cardiac surgical patients. Participation in the Adult Cardiac Anesthesiology Section has been optional since its inception in 2014 but has progressively increased. Opportunities for further growth and improvement remain. In this first update report on quality and outcomes of the Adult Cardiac Anesthesiology Section, we present an overview of the clinically significant anesthesia and surgical variables submitted between 2015 and 2018. Our review provides a summary of quality measures and outcomes related to the current practice of cardiothoracic anesthesiology. We also emphasize the potential for addressing high-impact research questions as data accumulate, with the overall goal of elucidating the influence of cardiac anesthesiology contributions to patient outcomes within the framework of the cardiac surgical team.
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Affiliation(s)
- J Mauricio Del Rio
- Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - James Jake Abernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark A Taylor
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert H Habib
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | - Felix G Fernandez
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Bruce A Bollen
- International Heart Institute of Montana, Missoula Anesthesiology, PC, Missoula, Montana
| | - Ryan E Lauer
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California
| | - Nancy A Nussmeier
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Joseph V Petty
- CHI Health Clinic Physician Enterprise Anesthesia, CHI Health Nebraska Heart, Omaha, Nebraska
| | - G Burkhard Mackensen
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, Washington
| | - David F Vener
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
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21
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Del Rio JM, Abernathy JJ, Taylor MA, Habib RH, Fernandez FG, Bollen BA, Lauer RE, Nussmeier NA, Glance LG, Petty JV, Mackensen GB, Vener DF, Kertai MD. The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes. Ann Thorac Surg 2020; 110:1447-1460. [PMID: 33008569 DOI: 10.1016/j.athoracsur.2020.05.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 10/23/2022]
Abstract
The Society of Cardiovascular Anesthesiologists, in partnership with The Society of Thoracic Surgeons, has developed the Adult Cardiac Anesthesiology Section of the Adult Cardiac Surgery Database. The goal of this landmark collaboration is to advance clinical care, quality, and knowledge, and to demonstrate the value of cardiac anesthesiology in the perioperative care of cardiac surgical patients. Participation in the Adult Cardiac Anesthesiology Section has been optional since its inception in 2014 but has progressively increased. Opportunities for further growth and improvement remain. In this first update report on quality and outcomes of the Adult Cardiac Anesthesiology Section, we present an overview of the clinically significant anesthesia and surgical variables submitted between 2015 and 2018. Our review provides a summary of quality measures and outcomes related to the current practice of cardiothoracic anesthesiology. We also emphasize the potential for addressing high-impact research questions as data accumulate, with the overall goal of elucidating the influence of cardiac anesthesiology contributions to patient outcomes within the framework of the cardiac surgical team.
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Affiliation(s)
- J Mauricio Del Rio
- Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - James Jake Abernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark A Taylor
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert H Habib
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | - Felix G Fernandez
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Bruce A Bollen
- International Heart Institute of Montana, Missoula Anesthesiology, PC, Missoula, Montana
| | - Ryan E Lauer
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California
| | - Nancy A Nussmeier
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Joseph V Petty
- CHI Health Clinic Physician Enterprise Anesthesia, CHI Health Nebraska Heart, Omaha, Nebraska
| | - G Burkhard Mackensen
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, Washington
| | - David F Vener
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
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Kendall S, O'Keeffe N. Strategies to eradicate resternotomy after cardiac surgery from clinical practice. Anaesthesia 2020; 76:3-5. [PMID: 32683678 DOI: 10.1111/anae.15182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2020] [Indexed: 11/29/2022]
Affiliation(s)
- S Kendall
- Department of Cardiothoracic Surgery, James Cook University Hospital, Society for Cardiothoracic Surgery Great Britain, and Ireland, Middlesbrough, UK
| | - N O'Keeffe
- Department of Anaesthesia and Intensive Care, Manchester Royal Infirmary, Association for Cardiothoracic Anaesthesia and Critical Care, Manchester, UK
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Abbasciano RG, Roman MA, Rizzello A, Pathak S, Ramzi J, Lucarelli C, Layton G, Lai F, Kumar T, Wozniak MJ, Murphy G. Effects of interventions targeting the systemic inflammatory response to cardiac surgery on clinical outcomes in adults. Hippokratia 2020. [DOI: 10.1002/14651858.cd013584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
| | - Marius A Roman
- Department of Cardiothoracic Surgery / Cardiovascular Sciences; University Hospitals of Leicester / University of Leicester; Leicester UK
| | - Angelica Rizzello
- Department of Cardiovascular Sciences; University of Leicester; Leicester UK
| | - Suraj Pathak
- Department of Cardiothoracic Surgery; Glenfield Hospital; Leicester UK
| | - Joussi Ramzi
- Leicester Medical School; University of Leicester; Leicester UK
| | - Carla Lucarelli
- Department of Cardiac Surgery; University of Verona; Verona Italy
| | - Georgia Layton
- University Hospitals of Leicester NHS Trust; Leicester UK
| | - Florence Lai
- Leicester Clinical Trials Unit; University of Leicester, Glenfield Hospital; Leicester UK
| | - Tracy Kumar
- Department of Cardiovascular Sciences; University of Leicester; Leicester UK
| | - Marcin J Wozniak
- Department of Cardiovascular Sciences; University of Leicester; Leicester UK
| | - Gavin Murphy
- Department of Cardiovascular Sciences; University of Leicester; Leicester UK
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Pisano A, Torella M, Yavorovskiy A, Landoni G. The Impact of Anesthetic Regimen on Outcomes in Adult Cardiac Surgery: A Narrative Review. J Cardiothorac Vasc Anesth 2020; 35:711-729. [PMID: 32434720 DOI: 10.1053/j.jvca.2020.03.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/18/2020] [Accepted: 03/29/2020] [Indexed: 11/11/2022]
Abstract
Despite improvements in surgical techniques and perioperative care, cardiac surgery still is burdened by relatively high mortality and frequent major postoperative complications, including myocardial dysfunction, pulmonary complications, neurologic injury, and acute kidney injury. Although the surgeon's skills and volume and patient- and procedure-related risk factors play a major role in the success of cardiac surgery, there is growing evidence that also optimizing perioperative care may improve outcomes significantly. The present review focuses on the aspects of perioperative care that are strictly related to the anesthesia regimen, with special reference to volatile anesthetics and neuraxial anesthesia, whose effect on outcome in adult cardiac surgery has been investigated extensively.
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Affiliation(s)
- Antonio Pisano
- Department of Critical Care, Cardiac Anesthesia and Intensive Care Unit, AORN Dei Colli, Monaldi Hospital, Naples, Italy
| | - Michele Torella
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Andrey Yavorovskiy
- Department of Anesthesiology and Intensive Care, First Moscow State Medical University, Moscow, Russia
| | - Giovanni Landoni
- Vita-Salute San Raffaele University, Milan, Italy; Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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Affiliation(s)
- N Fletcher
- St. George's Hospital, London, UK.,Institute of Critical Care and Anaesthesia, Cleveland Clinic London, UK
| | - D T Engelman
- Department of Surgery, University of Massachusetts-Baystate, Baystate Medical Center, Springfield, MA, USA
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Krichevskiy LA, Dzybinskaya EV. Fifteen Years of Transesophageal Echocardiography in Cardiac Anesthesia in Russia. J Cardiothorac Vasc Anesth 2019; 33:3375-3382. [PMID: 31253523 DOI: 10.1053/j.jvca.2019.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/24/2019] [Accepted: 06/04/2019] [Indexed: 12/16/2022]
Abstract
Transesophageal echocardiography was first introduced in Russia as a component of anesthesiology monitoring in 2003 following its successful implementation in the practice of cardiac anesthesia in the United States and Western Europe. This novel opportunity for perioperative hemodynamic evaluation was enthusiastically adopted at several cardiac surgical clinics despite the presence of critical barriers. The most important of these were the lack of certification programs for anesthesiologists, limited equipment, and a lack of understanding of the responsibility of the anesthesiologist as the coordinator of perioperative therapeutic decisions. Although intraoperative transesophageal echocardiography as a part of the anesthesiology protocol has been introduced in less than 10% of Russian cardiac surgery clinics, a group of interested anesthesiologists has formed over the last 15 years. Both the technical conditions and professional mentality of anesthesiologists need to be changed substantially for successful further development of intraoperative echocardiography. This review aims to highlight the milestones, successes, and challenges in the implementation of intraoperative echocardiography in the practice of cardiac anesthesiology in Russia, which may be interesting to a wide range of cardiac anesthesiologists.
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Affiliation(s)
- Lev A Krichevskiy
- City Clinical Hospital n.a. S.S.Yudin, Department of Health of Moscow, Department of Anesthesiology and Intensive Care, Moscow, Russia.
| | - Elena V Dzybinskaya
- National Medical Research Center of Cardiology, Ministry of Health of the Russian Federation, Department of Anesthesiology and Intensive Care, Moscow, Russia
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Jubber I, Pang KH, Groves R, Reed O, Noon AP, Catto JWF, Cumberbatch MG. Impact of Anaesthetist Volume on Radical Cystectomy Outcomes. Eur Urol Focus 2019; 7:117-123. [PMID: 31072807 DOI: 10.1016/j.euf.2019.04.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/30/2019] [Accepted: 04/24/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Radical cystectomy (RC) is a gold standard treatment for aggressive bladder cancer. Higher surgical volumes through centralisation are associated with improved RC outcomes. The impact of anaesthetist experience and RC volume on outcomes is less clear. OBJECTIVE We sought to examine RC outcomes stratified by anaesthetist volume using a contemporary homogenous series. DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis of a prospectively collected, single-surgeon database of RC patients over a 10-yr period. INTERVENTION Four hundred and fifty-three consecutive patients underwent RC, including 430 (95%) with anaesthetist annotation. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Anaesthetists were stratified into low- (<10 cases) and high-volume (≥10 cases) classes. Primary outcomes were blood loss, transfusion rates, length of stay (LOS), and postoperative mortality. RESULTS AND LIMITATIONS In total, 63 anaesthetists were included for analysis (median two RCs per anaesthetist). Of 63 anaesthetists, 56 (88.9%) and seven (11.1%) were classified, respectively, into low and high volume, and these provided cover for 110 (25.6%) and 320 (74.4%) patients, respectively. When comparing high- versus low-volume anaesthetists, there were shorter LOS (median [interquartile range {IQR}]: 10 [6-14] vs 12 [7-19] d, p = 0.008), lower blood loss (median [IQR]: 600 [384-1000] vs 800 [500-1275] ml, p<0.001), and lower transfusion rate (23/320, 7.2% vs 22/110, 20%; p < 0.001). There was no difference in disease-specific mortality, overall mortality, or readmission rates. In multivariable analysis, a high anaesthetist volume was independently associated with transfusion rate (odds ratio 0.24 [0.07-0.83], p = 0.02). CONCLUSIONS Higher-volume anaesthetists have lower transfusion rates for RC patients. Whilst LOS and blood loss may also differ with experience, there is no difference in mortality after RC. PATIENT SUMMARY Radical cystectomy is a major operation. Experienced anaesthetists give fewer blood products to patients undergoing this operation. They may also help reduce blood loss and speed recovery. However, all other recovery measures were similar.
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Affiliation(s)
- Ibrahim Jubber
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Karl H Pang
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Ruth Groves
- Department of Anaesthetics, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Oliver Reed
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Aidan P Noon
- Department of Urology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - James W F Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK.
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Soppa G, Theodoropoulos P, Bilkhu R, Harrison DA, Alam R, Beattie R, Bleetman D, Hussain A, Jones S, Kenny L, Khorsandi M, Lea A, Mensah K, Hici TN, Pinho-Gomes AC, Rogers L, Sepehripour A, Singh S, Steele D, Weaver H, Klein A, Fletcher N, Jahangiri M. Variation between hospitals in outcomes following cardiac surgery in the UK. Ann R Coll Surg Engl 2019; 101:333-341. [PMID: 30854865 PMCID: PMC6513373 DOI: 10.1308/rcsann.2019.0029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2019] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION We examine the influence of variations in provision of cardiac surgery in the UK at hospital level on patient outcomes and also to assess whether there is an inequality of access and delivery of healthcare. Cardiothoracic surgery has pioneered the reporting of surgeon-specific outcomes, which other specialties have followed. We set out to identify factors other than the individual surgeon, which can affect outcomes and enable other surgical specialties to adopt a similar model. MATERIALS AND METHODS A retrospective analysis of prospectively collected data of patient and hospital level factors between 2013 and 2016 from 16 cardiac surgical units in the UK were analysed through the Society for Cardiothoracic Surgery of Great Britain and Ireland and the Royal College of Surgeons Research Collaborative. Patient demographic data, risks factors, postoperative complications and in-hospital mortality, as well as hospital-level factors such as number of beds and operating theatres, were collected. Correlation between outcome measures was assessed using Pearson's correlation coefficient. Associations between hospital-level factors and outcomes were assessed using univariable and multivariable regression models. RESULTS Of 50,871 patients (60.5% of UK caseload), 25% were older than 75 years and 29% were female. There was considerable variation between units in patient comorbidities, bed distribution and staffing. All hospitals had dedicated cardiothoracic intensive care beds and consultants. Median survival was 97.9% (range 96.3-98.6%). Postoperative complications included re-sternotomy for bleeding (median 4.8%; range 3.5-6.9%) and mediastinitis (0.4%; 0.1-1.0%), transient ischaemic attack/cerebrovascular accident (1.7%; range 0.3-3.0%), haemofiltration (3.7%; range 0.8-6.8%), intra-aortic balloon pump use (3.3%; range 0.4-7.4%), tracheostomy (1.6%; range 1.3-2.6%) and laparotomy (0.3%; range 0.2-0.6%). There was variation in outcomes between hospitals. Univariable analysis showed a small number of positive associations between hospital-level factors and outcomes but none remained significant in multivariable models. CONCLUSIONS Variations among hospital level factors exists in both delivery of, and outcomes, following cardiac surgery in the UK. However, there was no clear association between these factors and patient outcomes. This negative finding could be explained by differences in outcome definition, differences in risk factors between centres that are not captured by standard risk stratification scores or individual surgeon/team performance.
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Affiliation(s)
- G Soppa
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - P Theodoropoulos
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - R Bilkhu
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - DA Harrison
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - R Alam
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - R Beattie
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - D Bleetman
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - A Hussain
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - S Jones
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - L Kenny
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - M Khorsandi
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - A Lea
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - Ka Mensah
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - TN Hici
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - AC Pinho-Gomes
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - L Rogers
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - A Sepehripour
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - S Singh
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - D Steele
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - H Weaver
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - A Klein
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - N Fletcher
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
| | - M Jahangiri
- Department of Cardiothoracic Surgery, St. George’s Hospital, London, UK
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Shelley BG, McCall PJ, Glass A, Orzechowska I, Klein AA. Association between anaesthetic technique and unplanned admission to intensive care after thoracic lung resection surgery: the second Association of Cardiothoracic Anaesthesia and Critical Care (ACTACC) National Audit. Anaesthesia 2019; 74:1121-1129. [PMID: 30963555 DOI: 10.1111/anae.14649] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2019] [Indexed: 12/19/2022]
Abstract
Unplanned intensive care admission is a devastating complication of lung resection and is associated with significantly increased mortality. We carried out a two-year retrospective national multicentre cohort study to investigate the influence of anaesthetic and analgesic technique on the need for unplanned postoperative intensive care admission. All patients undergoing lung resection surgery in 16 thoracic surgical centres in the UK in the calendar years 2013 and 2014 were included. We defined critical care admission as the unplanned need for either tracheal intubation and mechanical ventilation or renal replacement therapy, and sought an association between mode of anaesthesia (total intravenous anaesthesia vs. volatile) and analgesic technique (epidural vs. paravertebral) and need for intensive care admission. A total of 253 out of 11,208 patients undergoing lung resection in the study period had an unplanned admission to intensive care in the postoperative period, giving an incidence of intensive care unit admission of 2.3% (95%CI 2.0-2.6%). Patients who had an unplanned admission to intensive care unit had a higher mortality (29.00% vs. 0.03%, p < 0.001), and hospital length of stay was increased (26 vs. 6 days, p < 0.001). Across univariate, complete case and multiple imputation (multivariate) models, there was a strong and significant effect of both anaesthetic and analgesic technique on the need for intensive care admission. Patients receiving total intravenous anaesthesia (OR 0.50 (95%CI 0.34-0.70)), and patients receiving epidural analgesia (OR 0.56 (95%CI 0.41-0.78)) were less likely to have an unplanned admission to intensive care after thoracic surgery. This large retrospective study suggests a significant effect of both anaesthetic and analgesic technique on outcome in patients undergoing lung resection. We must emphasise that the observed association does not directly imply causation, and suggest that well-conducted, large-scale randomised controlled trials are required to address these fundamental questions.
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Affiliation(s)
- B G Shelley
- University of Glasgow Academic Unit of Anaesthesia, Pain and Critical Care Medicine, Glasgow, UK
| | - P J McCall
- University of Glasgow Academic Unit of Anaesthesia, Pain and Critical Care Medicine, Glasgow, UK
| | - A Glass
- University of Glasgow Academic Unit of Anaesthesia, Pain and Critical Care Medicine, Glasgow, UK
| | - I Orzechowska
- London School of Hygiene and Tropical Medicine, London, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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Coulson TG, Karalapillai D. Providence, patient or provider? Looking for truth in retrospective database studies. Anaesthesia 2019; 74:424-426. [DOI: 10.1111/anae.14573] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2018] [Indexed: 11/29/2022]
Affiliation(s)
- T. G. Coulson
- The Austin Hospital; Melbourne Vic. Australia
- Monash University; Melbourne Vic. Australia
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Coulson TG, Mullany DV, Reid CM, Bailey M, Pilcher D. Measuring the quality of perioperative care in cardiac surgery. Eur Heart J Qual Care Clin Outcomes 2018; 3:11-19. [PMID: 28927188 DOI: 10.1093/ehjqcco/qcw027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Indexed: 11/13/2022]
Abstract
Quality of care is of increasing importance in health and surgical care. In order to maintain and improve quality, we must be able to measure it and identify variation. In this narrative review, we aim to identify measures used in the assessment of quality of care in cardiac surgery and to evaluate their utility. The electronic databases Pubmed/MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, and CINAHL were searched for original published studies using the terms 'cardiac surgery' and 'quality or outcome or process or structure' as either keywords in the title or text or MeSH terms. Secondary searches and identification of references from original articles were carried out. We found a total of 54 original articles evaluating measurements of quality. While structure, process, and outcome indicators remain the mainstay of quality measurement, new and innovative methods of risk assessment have improved reliability and discrimination. Continuous assessment provides a promising method of both maintaining and improving quality of care. Future studies should focus on long-term and patient-centred outcomes, such as quality-of-life measures.
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Affiliation(s)
- Tim G Coulson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Daniel V Mullany
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Michael Bailey
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Pilcher
- Department of Intensive Care, The Alfred Hospital, 55 Commercial Rd, Melbourne, Victoria 3004, Australia.,ANZICS Centre for Outcome and Resource Evaluation, Ievers Terrace, Carlton, Melbourne, Victoria, Australia
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Papachristofi O, Klein AA, Mackay J, Nashef S, Fletcher NS, Sharples LD. Does the "Weekend Effect" for Postoperative Mortality Stand Up to Scrutiny? Association for Cardiothoracic Anesthesia and Critical Care Cohort Study of 110,728 Cardiac Surgical Patients. J Cardiothorac Vasc Anesth 2018; 32:2178-2186. [PMID: 29753669 DOI: 10.1053/j.jvca.2018.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Ongoing debate focuses on whether patients admitted to the hospital on weekends have higher mortality than those admitted on weekdays. Whether this apparent "weekend effect" reflects differing patient risk, care quality differences, or inadequate adjustment for risk during analysis remains unclear. This study aimed to examine the existence of a "weekend effect" for risk-adjusted in-hospital mortality after cardiac surgery. DESIGN Retrospective analysis of prospectively collected cardiac registry data. SETTING Ten UK specialist cardiac centers. PARTICIPANTS A total of 110,728 cases, undertaken by 127 consultant surgeons and 190 consultant anesthetists between April 2002 and March 2012. INTERVENTIONS Major risk-stratified cardiac surgical operations. MEASUREMENTS AND MAIN RESULTS Crude in-hospital mortality rate was 3.1%. Multilevel multivariable models were employed to estimate the effect of operative day on in-hospital mortality, adjusting for center, surgeon, anesthetist, patient risk, and procedure priority. Weekend elective cases had significantly lower mortality risk compared to Monday elective cases (odds ratio [OR] 0.64, 95% confidence interval [CI] 0.42, 0.96) following risk adjustment by the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) and procedure priority; differences between weekend and Monday for urgent and emergency/salvage cases were not significant (OR 1.12, 95% CI 0.73, 1.72, and 1.07, 95% CI 0.79, 1.45 respectively). Considering only the logistic EuroSCORE but not procedure priority yielded 29% higher odds of death for weekend cases compared to Monday operations (OR 1.29, 95% CI 1.08, 1.54). CONCLUSIONS This study suggests that undergoing cardiac surgery during the weekend does not affect negatively patient survival, and highlights the importance of comprehensive risk adjustment to avoid detecting spurious "weekend effects."
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Affiliation(s)
- Olympia Papachristofi
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK.
| | - Andrew A Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - John Mackay
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - Samer Nashef
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Nick S Fletcher
- Department of Anaesthesia and Intensive Care, St George's Hospital, London, UK
| | - Linda D Sharples
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
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Fierro MA, Bartz RR, Bennett-Guerrero E. Cardiothoracic Surgery in the United Kingdom: Operating Without a Weekend Effect? J Cardiothorac Vasc Anesth 2018; 32:2187-2189. [PMID: 30251644 DOI: 10.1053/j.jvca.2018.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Michael A Fierro
- Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Raquel R Bartz
- Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
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Poulton TE, Salih T, Martin P, Rojas-garcia A, Raine R, Moonesinghe SR. Systematic review of the influence of socioeconomic deprivation on mortality after colorectal surgery. Br J Surg 2018; 105:959-70. [DOI: 10.1002/bjs.10848] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 01/25/2018] [Accepted: 02/02/2018] [Indexed: 01/12/2023]
Abstract
Abstract
Background
Socioeconomic deprivation is a potentially important factor influencing surgical outcomes. This systematic review aimed to summarize the evidence for any association between socioeconomic group and mortality after colorectal surgery, and to report the definitions of deprivation used and the approaches taken to adjust for co-morbidity in this patient population.
Methods
MEDLINE, Embase, the Cochrane Library and Web of Science were searched for studies up to November 2016 on adult patients undergoing major colorectal surgery, which reported on mortality according to socioeconomic group. Risk of bias and study quality were assessed by extracting data relating to study size, and variations in inclusion and exclusion criteria. Quality was assessed using a modification of a previously described assessment tool.
Results
The literature search identified 59 studies published between 1993 and 2016, reporting on 2 698 403 patients from eight countries. Overall findings showed evidence for higher mortality in more deprived socioeconomic groups, both in the perioperative period and in the longer term. Studies differed in how they defined socioeconomic groups, but the most common approach was to use one of a selection of multifactorial indices based on small geographical areas. There was no consistent approach to adjusting for co-morbidity but, where this was considered, the Charlson Co-morbidity Index was most frequently used.
Conclusion
This systematic review suggests that socioeconomic deprivation influences mortality after colorectal surgery.
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White SM, Altermatt F, Barry J, Ben-David B, Coburn M, Coluzzi F, Degoli M, Dillane D, Foss NB, Gelmanas A, Griffiths R, Karpetas G, Kim JH, Kluger M, Lau PW, Matot I, McBrien M, McManus S, Montoya-Pelaez LF, Moppett IK, Parker M, Porrill O, Sanders RD, Shelton C, Sieber F, Trikha A, Xuebing X. International Fragility Fracture Network Delphi consensus statement on the principles of anaesthesia for patients with hip fracture. Anaesthesia 2018; 73:863-874. [DOI: 10.1111/anae.14225] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2018] [Indexed: 01/16/2023]
Affiliation(s)
- S. M. White
- Brighton and Sussex University Hospitals NHS Trust; Brighton East Sussex UK
| | - F. Altermatt
- División de Anestesiología; Escuela de Medicina; Pontificia Universidad Católica de Chile; Santiago Chile
| | - J. Barry
- Cairns Hospital; Queensland Australia
| | - B. Ben-David
- University of Pittsburgh Medical Centre; Pittsburgh PA USA
| | - M. Coburn
- Medical Faculty; RWTH Aachen University; Aachen Germany
| | - F. Coluzzi
- Department Medical and Surgical Sciences and Biotechnologies; Sapienza University of Rome; Latina Italy
| | - M. Degoli
- Ospedale Civile di Baggiovara; Azienda Ospedaliero Universitaria di Modena; Modena Italy
| | - D. Dillane
- Anesthesiology and Pain Medicine; University of Alberta; Canada
| | - N. B. Foss
- Department of Anaesthesiology and Intensive Care Medicine; Hvidovre University Hospital; Hvidovre Denmark
| | - A. Gelmanas
- Hospital of Lithuanian University of Health Sciences Kauno klinikos; Lithuania
| | - R. Griffiths
- Peterborough and Stamford Hospitals NHS Trust; Peterborough UK
| | - G. Karpetas
- General University Hospital of Patras; Rio Greece
| | - J.-H. Kim
- Korea University College of Medicine; Seoul South Korea
| | | | - P.-W. Lau
- University of Hong Kong; Hong Kong China
| | - I. Matot
- Critical Care and Pain; Tel Aviv Medical Center; Sackeler School of Medicine; Tel Aviv Israel
| | | | | | - L. F. Montoya-Pelaez
- Department of Anaesthesia and Perioperative Medicine; Groote Schuur Hospital; University of Cape Town; Cape Town South Africa
| | - I. K. Moppett
- Anaesthesia and Critical Care Section; Division of Clinical Neuroscience; Queen's Medical Centre Campus; Nottingham University Hospitals NHS Trust; University of Nottingham; Nottingham UK
| | - M. Parker
- Peterborough and Stamford Hospitals NHS Trust; Peterborough UK
| | - O. Porrill
- New Somerset Hospital; University of Cape Town; South Africa
| | | | - C. Shelton
- Lancaster Medical School and Wythenshawe Hospital; Manchester UK
| | - F. Sieber
- Johns Hopkins Bayview Medical Center; Baltimore MD USA
| | - A. Trikha
- All India Institute of Medical Sciences; New Delhi India
| | - X. Xuebing
- University of Hong Kong-Shenzhen Hospital; Shenzhen China
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Papachristofi O, Klein AA, Mackay J, Nashef S, Fletcher N, Sharples LD. Effect of individual patient risk, centre, surgeon and anaesthetist on length of stay in hospital after cardiac surgery: Association of Cardiothoracic Anaesthesia and Critical Care (ACTACC) consecutive cases series study of 10 UK specialist centres. BMJ Open 2017; 7:e016947. [PMID: 28893748 PMCID: PMC5595188 DOI: 10.1136/bmjopen-2017-016947] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To determine the relative contributions of patient risk profile, local and individual clinical practice on length of hospital stay after cardiac surgery. DESIGN Ten-year audit of prospectively collected consecutive cardiac surgical cases. Case-mix adjusted outcomes were analysed in models that included random effects for centre, surgeon and anaesthetist. SETTING UK centres providing adult cardiac surgery. PARTICIPANTS 10 of 36 UK specialist centres agreed to provide outcomes for all major cardiac operations over 10 years. After exclusions (duplicates, cases operated by more than one consultant, deaths and procedures for which the EuroSCORE risk score for cardiac surgery is not appropriate), there were 107 038 cardiac surgical procedures between April 2002 and March 2012, conducted by 127 consultant surgeons and 190 consultant anaesthetists. MAIN OUTCOME MEASURE Length of stay (LOS) up to 3 months postoperatively. RESULTS The principal component of variation in outcomes was patient risk (represented by the EuroSCORE and remaining patient heterogeneity), accounting for 95.43% of the variation for postoperative LOS. The impact of the surgeon and centre was moderate (intra-class correlation coefficients ICC=2.79% and 1.59%, respectively), whereas the impact of the anaesthetist was negligible (ICC=0.19%). Similarly, 96.05% of the variation for prolonged LOS (>11 days) was attributable to the patient, with surgeon and centre less but still influential components (ICC=2.12% and 1.66%, respectively, 0.17% only for anaesthetists). Adjustment for year of operation resulted in minor reductions in variation attributable to surgeons (ICC=2.52% for LOS and 2.23% for prolonged LOS). CONCLUSIONS Patient risk profile is the primary determinant of variation in LOS, and as a result, current initiatives to reduce hospital stay by modifying consultant performance are unlikely to have a substantial impact. Therefore, substantially reducing hospital stay requires shifting away from a one-size-fits-all approach to cardiac surgery, and seeking alternative treatment options personalised to high-risk patients.
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Affiliation(s)
- Olympia Papachristofi
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Andrew A Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - John Mackay
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - Samer Nashef
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Nick Fletcher
- Department of Anaesthesia and Intensive Care, St George’s Hospital, London, UK
| | - Linda D Sharples
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
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Guida P, Iacoviello M, Passantino A, Scrutinio D. Early mortality following percutaneous coronary intervention and cardiac surgery: Correlations within providers and operators. Int J Cardiol 2017; 240:97-102. [DOI: 10.1016/j.ijcard.2017.04.106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 03/31/2017] [Accepted: 04/30/2017] [Indexed: 11/23/2022]
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Coulson TG, Bailey M, Reid CM, Tran L, Mullany DV, Smith JA, Pilcher D. The association between peri-operative acute risk change (ARC) and long-term survival after cardiac surgery. Anaesthesia 2017; 72:1467-1475. [DOI: 10.1111/anae.13967] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2017] [Indexed: 01/23/2023]
Affiliation(s)
- T. G. Coulson
- Department of Epidemiology and Preventive Medicine; School of Public Health and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - M. Bailey
- Department of Epidemiology and Preventive Medicine; School of Public Health and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - C. M. Reid
- Department of Epidemiology and Preventive Medicine; School of Public Health and Preventive Medicine; Monash University; Melbourne Victoria Australia
- School of Public Health; Curtin University; Perth Western Australia Australia
| | - L. Tran
- Department of Epidemiology and Preventive Medicine; School of Public Health and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - D. V. Mullany
- Critical Care Research Group; University of Queensland; Brisbane Queensland Australia
| | - J. A. Smith
- Department of Surgery; Monash University; Melbourne Victoria Australia
| | - D. Pilcher
- Department of Epidemiology and Preventive Medicine; School of Public Health and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Department of Intensive Care; The Alfred Hospital; Melbourne Victoria Australia
- ANZICS Centre for Outcome and Resource Evaluation; Carlton, Melbourne Victoria Australia
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Greenberg S, Shear T, Mascha E. Is Experience a Surrogate for Expertise? Anesth Analg 2017; 125:5-7. [DOI: 10.1213/ane.0000000000001895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Bomberg H, Klingele M, Wagenpfeil S, Spanuth E, Volk T, Sessler DI, Schäfers H, Groesdonk HV. Presepsin (sCD14-ST) Is a Novel Marker for Risk Stratification in Cardiac Surgery Patients. Anesthesiology 2017; 126:631-42. [DOI: 10.1097/aln.0000000000001522] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Abstract
Background
Presepsin (soluble cluster-of-differentiation 14 subtype [sCD14-ST]) is a humoral risk stratification marker for systemic inflammatory response syndrome and sepsis. It remains unknown whether presepsin can be used to stratify risk in elective cardiac surgery. The authors therefore determined the usefulness of presepsin for risk stratification in patients having elective cardiac surgery.
Methods
Eight hundred fifty-six cardiac surgical patients were prospectively studied. Preoperative plasma concentrations of presepsin, procalcitonin, N-terminal pro–hormone natriuretic peptide, cystatin C, and the additive European System of Cardiac Operative Risk Evaluation 2 were compared to mortality at 30 days (primary outcome), 6 months, and 2 yr. Discrimination was assessed with C statistic. Logistic regression analysis was used to calculate univariable and multivariable odds ratios.
Results
Thirty-day mortality was 3.2%, 6-month mortality was 6.1%, and 2-yr mortality was 10.4% across the population. Median preoperative presepsin concentrations were significantly greater in 30-day nonsurvivors than in survivors: 842 pg/ml (interquartile range, 306 to 1,246) versus 160 pg/ml (interquartile range, 122 to 234); difference, 167 pg/ml (interquartile range, 92 to 301; P < 0.001). The results were similar for 6-month and 2-yr mortality. Compared to the European System of Cardiac Operative Risk Evaluation 2, presepsin concentration provided better discrimination for postoperative mortality at all follow-up periods, including 30 days (C statistic 0.88 vs. 0.74), 6 months (0.87 vs. 0.76), and 2 yr (0.81 vs. 0.74). Presepsin also provided better discrimination than cystatin C, N-terminal pro–hormone natriuretic peptide, or procalcitonin. Elevated presepsin remained an independent risk predictor after adjustment for potential confounding factors.
Conclusions
Elevated preoperative plasma presepsin concentration is an independent predictor of postoperative mortality in elective cardiac surgery patients and is a stronger predictor than several other commonly used assessments.
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Miles LF, Marchiori P, Falter F. Pilot validation of an individualised pharmacokinetic algorithm for protamine dosing after systemic heparinisation for cardiopulmonary bypass. Perfusion 2017; 32:481-488. [PMID: 28820026 DOI: 10.1177/0267659117695881] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION This manuscript represents a pilot study assessing the feasibility of a single-compartment, individualised, pharmacokinetic algorithm for protamine dosing after cardiopulmonary bypass. METHODS A pilot cohort study in a specialist NHS cardiothoracic hospital targeting patients undergoing elective cardiac surgery using cardiopulmonary bypass. Patients received protamine doses according to a pharmacokinetic algorithm (n = 30) or using an empirical, fixed-dose model (n = 30). Categorical differences between the groups were evaluated using the Chi-squared test or Fisher's exact test. Continuous data was analysed using a paired Student's t-test for parametric data and the paired samples Wilcoxon test for non-parametric data. RESULTS Patients who had protamine dosing according to the algorithm demonstrated a lower protamine requirement post-bypass relative to empirical management as measured by absolute dose (243 ± 49mg vs. 305 ± 34.7mg; p<0.001) and the heparin to protamine ratio (0.79 ± 0.12 vs. 1.1 ± 0.15; p<0.001). There was no difference in the pre- to post-bypass activated clotting time (ACT) ratio (1.05 ± 0.12 vs. 1.02 ± 0.15; p=0.9). Patients who received protamine according to the algorithm had no significant difference in transfusion requirement (13.3% vs. 30.0%; p=0.21). CONCLUSIONS This study showed that an individualized pharmacokinetic algorithm for the reversal of heparin after cardiopulmonary bypass is feasible in comparison with a fixed dosing strategy and may reduce the protamine requirement following on-pump cardiac surgery.
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Affiliation(s)
- Lachlan F Miles
- 1 Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | | | - Florian Falter
- 3 Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, UK
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Gerstein NS, Petersen TR, Ramakrishna H. Evaluating the Cardiac Anesthesiologist’s Role in Surgical Outcomes—A Reappraisal Based on Recent Evidence. J Cardiothorac Vasc Anesth 2017; 31:283-290. [DOI: 10.1053/j.jvca.2016.06.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Indexed: 11/11/2022]
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Shahin J, Ferrando-Vivas P, Power GS, Biswas S, Webb ST, Rowan KM, Harrison DA. The Assessment of Risk in Cardiothoracic Intensive Care (ARCtIC): prediction of hospital mortality after admission to cardiothoracic critical care. Anaesthesia 2016; 71:1410-1416. [PMID: 27667471 DOI: 10.1111/anae.13624] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2016] [Indexed: 01/09/2023]
Abstract
The models used to predict outcome after adult general critical care may not be applicable to cardiothoracic critical care. Therefore, we analysed data from the Case Mix Programme to identify variables associated with hospital mortality after admission to cardiothoracic critical care units and to develop a risk-prediction model. We derived predictive models for hospital mortality from variables measured in 17,002 patients within 24 h of admission to five cardiothoracic critical care units. The final model included 10 variables: creatinine; white blood count; mean arterial blood pressure; functional dependency; platelet count; arterial pH; age; Glasgow Coma Score; arterial lactate; and route of admission. We included additional interaction terms between creatinine, lactate, platelet count and cardiac surgery as the admitting diagnosis. We validated this model against 10,238 other admissions, for which the c index (95% CI) was 0.904 (0.89-0.92) and the Brier score was 0.055, while the slope and intercept of the calibration plot were 0.961 and -0.183, respectively. The discrimination and calibration of our model suggest that it might be used to predict hospital mortality after admission to cardiothoracic critical care units.
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Affiliation(s)
- J Shahin
- Department of Medicine, Respiratory Division, Department of Critical Care, McGill University, Montreal, Quebec, Canada
| | | | - G S Power
- Intensive Care National Audit and Research Centre, London, UK
| | - S Biswas
- Respiratory Epidemiology and Clinical Research Unit, McGill University, Montreal, Quebec, Canada
| | - S T Webb
- Papworth Hospital, Cambridge, UK
| | - K M Rowan
- Intensive Care National Audit and Research Centre, London, UK
| | - D A Harrison
- Intensive Care National Audit and Research Centre, London, UK
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Affiliation(s)
- N Fletcher
- Cardiothoracic Intensive Care and Cardiac Anaesthesia St Georges University Hospitals Foundation Trust, London, UK
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Affiliation(s)
- F. Sanfilippo
- St. Georges Healthcare NHS Foundation Trust; London UK
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Glance LG, Hannan EL, Fleisher LA, Eaton MP, Dutton RP, Lustik SJ, Li Y, Dick AW. Feasibility of Report Cards for Measuring Anesthesiologist Quality for Cardiac Surgery. Anesth Analg 2016; 122:1603-13. [DOI: 10.1213/ane.0000000000001252] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Affiliation(s)
- N. Levy
- Department of Anaesthesia; West Suffolk Hospital; Bury St Edmunds Suffolk UK
| | - P. Mills
- Department of Anaesthesia; West Suffolk Hospital; Bury St Edmunds Suffolk UK
| | - M. Mythen
- University College London Hospitals; NIHR Biomedical Research Centre; London UK
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Mackay JH, Nashef SAM, Klein AA, Papachristofi O, Sharples LD, Fletcher SN. Anaesthetist contribution to mortality after cardiac surgery - a reply. Anaesthesia 2016; 71:599-601. [PMID: 27072767 DOI: 10.1111/anae.13475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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