472 Accuracy of Documentation and Handover of Surgical Operation Details in Cardiac Surgery

Introduction

GMC Good Medical Practice Guideline states that documentation must be clear, accurate and legible. Accurate documentation of operation notes ensures proper postoperative care and forms important legal documents. This audit aims to assess the accurateness and consistency of recorded operation names throughout patients’ hospital stay following cardiac surgery, as well as the effect of standardisation of operation names to improve the accuracy of documentation.

Method

Patients undergoing cardiac surgery at St. Bartholomew's Hospital from November 29 to December 10, 2021, had data prospectively collected from their electronic patient records, which were compared to the standardised operation name. After the first audit cycle, junior medical staff were educated on the standardisation of operation names. Electronic patient records were reviewed again for patients undergoing cardiac surgery from January 10 to January 20, 2022.

Results

Following intervention, there were significant improvements in the accuracy of documented operation details. Initially, 65% of operation notes were accurately documented, whereas 96% of operation notes were completed to the ideal standard post-intervention. There was a 37% increase in the number of accurate discharge summaries, while inaccuracies and missing operation names were reduced to 0% from the initial 12%.

Conclusions

Accurate documentation of operation details is expected by GMC standards. Poor documentation can hinder the quality-of-care patients receive postoperatively. We have shown variation in descriptions of standard operations and multiple inaccuracies throughout patients’ hospital stay. We suggest agreed standardisation of operation details and education of junior medical staff regarding accuracy of documentation to enhance compliance with the GMC standard.

Systematic review and literature appraisal on methodology of conducting and reporting critical-care echocardiography studies: a report from the European Society of Intensive Care Medicine PRICES expert panel

Background

The echocardiography working group of the European Society of Intensive Care Medicine recognized the need to provide structured guidance for future CCE research methodology and reporting based on a systematic appraisal of the current literature. Here is reported this systematic appraisal.

Methods

We conducted a systematic review, registered on the Prospero database. A total of 43 items of common interest to all echocardiography studies were initially listed by the experts, and other “topic-specific” items were separated into five main categories of interest (left ventricular systolic function, LVSF n = 15, right ventricular function, RVF n = 18, left ventricular diastolic function, LVDF n = 15, fluid management, FM n = 7, and advanced echocardiography techniques, AET n = 17). We evaluated the percentage of items reported per study and the fraction of studies reporting a single item.

Results

From January 2000 till December 2017 a total of 209 articles were included after systematic search and screening, 97 for LVSF, 48 for RVF, 51 for LVDF, 36 for FM and 24 for AET. Shock and ARDS were relatively common among LVSF articles (both around 15%) while ARDS comprised 25% of RVF articles. Transthoracic echocardiography was the main echocardiography mode, in 87% of the articles for AET topic, followed by 81% for FM, 78% for LVDF, 70% for LVSF and 63% for RVF. The percentage of items per study as well as the fraction of study reporting an item was low or very low, except for FM. As an illustration, the left ventricular size was only reported by 56% of studies in the LVSF topic, and half studies assessing RVF reported data on pulmonary artery systolic pressure.

Conclusion

This analysis confirmed sub-optimal reporting of several items listed by an expert panel. The analysis will help the experts in the development of guidelines for CCE study design and reporting.

The role of point-of-care platelet function testing in predicting postoperative bleeding following cardiac surgery: a systematic review and meta-analysis

This systematic review and meta-analysis appraises the utility of point-of-care platelet function tests for predicting blood loss and transfusion requirements in cardiac surgical patients, and analyses whether their use within a transfusion management algorithm is associated with improved patient outcomes. We included 30 observational studies incorporating 3044 patients in the qualitative assessment, and nine randomised controlled trials including 1057 patients in the meta-analysis. Platelet function tests demonstrated significant variability in their ability to predict blood loss and transfusion requirements. Their use within a blood transfusion algorithm demonstrated a reduction in blood loss at longest follow-up (mean difference -102.9 ml (95% CI -149.9 to -56.1 ml), p < 0.001), and transfusion of packed red cells (RR 0.86 (95% CI 0.78-0.94), p = 0.001) and fresh frozen plasma (RR 0.42 (95% CI 0.30-0.59), p < 0.001). Viscoelastic methods used in combination with other platelet function tests achieved greater reduction in blood loss (mean difference -111.8 ml (95% CI -174.9 to -49.1 ml), p = 0.0005) compared with their use alone (mean difference -90.6 ml (95% CI 166.1-15.0 ml), p = 0.02). We conclude that incorporation of point-of-care platelet function tests into transfusion management algorithms is associated with a reduction in blood loss and transfusion requirements in cardiac surgery patients.

Cardiac complications associated with goal-directed therapy in high-risk surgical patients: a meta-analysis

Patients with limited cardiopulmonary reserve are at risk of mortality and morbidity after major surgery. Augmentation of oxygen delivery index (DO2I) with i.v. fluids and inotropes (goal-directed therapy, GDT) has been shown to reduce postoperative mortality and morbidity in high-risk patients. Concerns regarding cardiac complications associated with fluid challenges and inotropes may prevent clinicians from performing GDT in patients who need it most. We hypothesized that GDT is not associated with an increased risk of cardiac complications in high-risk, non-cardiac surgical patients. We performed a systematic search of Medline, Embase, and CENTRAL databases for randomized controlled trials (RCTs) of GDT in high-risk surgical patients. Studies including cardiac surgery, trauma, and paediatric surgery were excluded. We reviewed the rates of all cardiac complications, arrhythmias, myocardial ischaemia, and acute pulmonary oedema. Meta-analyses were performed using RevMan software. Data are presented as odds ratios (ORs), [95% confidence intervals (CIs)], and P-values. Twenty-two RCTs including 2129 patients reported cardiac complications. GDT was associated with a reduction in total cardiovascular (CVS) complications [OR=0.54, (0.38-0.76), P=0.0005] and arrhythmias [OR=0.54, (0.35-0.85), P=0.007]. GDT was not associated with an increase in acute pulmonary oedema [OR=0.69, (0.43-1.10), P=0.12] or myocardial ischaemia [OR=0.70, (0.38-1.28), P=0.25]. Subgroup analysis revealed the benefit is most pronounced in patients receiving fluid and inotrope therapy to achieve a supranormal DO2I, with the use of minimally invasive cardiac output monitors. Treatment of high-risk surgical patients GDT is not associated with an increased risk of cardiac complications; GDT with fluids and inotropes to optimize DO2I during early GDT reduces postoperative CVS complications.

Diffusion of (226)Ra and (40)K radionuclides reproduced in underwater sedimentary columns in laboratory

The potential radiological impact of the increase of radioactive substances in the environment makes interesting the study of the migration of the contaminant radionuclides in soils and sediments, which are the last receiver system of these substances. By using a battery of sedimentary columns controlled in the laboratory, the diffusion of the (226)Ra and (40)K radionuclides has been studied, assessing their respective effective diffusion coefficients in a similar sedimentary medium. A decreasing temporal evolution is obtained, associated to the progressive 'fixation' of the radionuclides by the clay minerals of the sediment, followed by a constant tendency. A timescale of the 'fixation' by the sediment is determined, being of the order of days for (226)Ra and of the order of months for (40)K, so the progressive 'fixation' of (40)K by the clay minerals of the sediments is slower than in the case of (226)Ra.

Comparison of treatment planning dose calculations with measurements and Monte Carlo calculations in a RANDO phantom

Solid tumours are often treated with external beams of photons generated by Bremsstrahlung radiation. These beams are shaped and filtered to optimise the dose to specific regions defined by the treatment plans, which may involve irradiations from multiple angles. It is important that doses to healthy tissue do not exceed tolerance doses and that the dose to the tumour is maximised. To accomplish these objectives, commercially available 3-D treatment planning software is used to calculate doses to healthy tissue and to the tumour. It is generally believed that these commercial software packages calculate doses through the patient to within a few per cent. In order to examine this claim, dose calculations obtained from ADAC software for external beam treatment to the pelvic region of a RANDO phantom are compared with 37 thermoluminescence dosemeters placed into several slices of a RANDO phantom. The phantom was irradiated to obtain a prescription dose of 180 cGy at the tumour location. Data from homogeneous regions agree within several per cent with results obtained from ADAC software, whereas this comparison is less favourable in regions of heterogeneity. Results from Monte Carlo calculations in a homogeneous phantom are comparable to results from ADAC treatment planning software.

Ionotropic glutamate receptor activated by N-methyl-D-aspartate: a key molecule of conscious life

We want to propose that basic stereotyped integrative functions are the result of sequentially built neuronal circuits in the primitive regions of the brain in whose build-up a particular subunit composition iGluR-NMDA would play a central role. iGluR-NMDA is a multiregulated heteromeric glutamate receptor-ion channel found in plasma membranes of neurons and other cells. iGluR-NMDA may be composed of up to five subunits, depending on the type of cell involved and its location. There are three major types of subunits and there are variations within each type allowing for up to 13 possible subunits, at least in the rat, which differ from each other in amino acid sequence and thus, in tertiary structure. The actual iGluR-NMDA heteropolymer involved in a given function may thus have a great number of subunit composition possibilities which would be the result of the particular genes expressed in a given type of cell. The iGluR-NMDA is an ion channel that opens in response to glutamate in a highly regulated fashion in which different molecules and ions present in the interstitial fluid determine whether or not the channel opens upon glutamate binding. The original function of iGluR-NMDA may have been that of allowing calcium influx to cells. As the brain receives external stimuli through the senses, new circuits will be formed stepwise in the neocortex in which a particular subunit composition iGluR-NMDA will be involved. Differentiation between external stimuli generated circuits and those governing internal functions will allow distinction between self and non-self, thus generating conscious awareness. The role of the particular subunit composition iGluR-NMDA proposed would be that of providing a means of calcium influx to the synapses to be formed and, if the same stimulus is forthcoming, allowing permanent synapses formation through the membrane incorporation of calcium dependent adhesion molecules such as cadherins and cytoskeleton reorganization promoted by nectins.

Neurophysiologic assessment of the anal sphincters

One hundred twenty consecutive patients with either fecal incontinence (60 patients), chronic constipation (41 patients), or idiopathic intractable pelvic pain (19 patients) were prospectively assessed. Patients underwent concentric needle electromyography (EMG), bilateral pudendal nerve terminal motor latency evaluation, anorectal manometry, and cinedefecography. The most common EMG finding in patients with fecal incontinence was decreased recruitment of motor units with squeezing and polyphasic motor unit potentials; these are consistent with an injury pattern. The most common EMG finding in the constipated patients was paradoxical puborectalis contraction. This latter abnormality was also a frequent finding in patients with rectal pain, as was prolongation of pudendal nerve latency. Paradoxical puborectalis contraction was diagnosed more frequently with EMG than with cinedefecography. Inter-examination correlation was best in the incontinent group between EMG and manometry. Cinedefecography had poor correlation with EMG in all patient groups but was valuable in the detection of additional pathology such as rectoanal intussusception and anterior rectocele. Electromyography including pudendal nerve terminal motor latency assessment is a valuable adjunct in the evaluation of disorders of evacuation. The information it yields is complementary to that offered by more routine physiologic examinations.

Biphasic effect of fructose 2,6-bisphosphate on the liver fructose-1,6-bisphosphatase: mechanistic and physiological implications

Fructose 2,6-bisphosphate has been claimed to be both a substrate analogue and an allosteric inhibitor of fructose-1,6-bisphosphatase. The results reported here show that fructose 2,6-bisphosphate can be both an inhibitor and an activator of the enzyme, depending on the substrate concentration. This biphasic behaviour at saturating concentrations of substrate can only be due to an allosteric effect. In addition to the mechanistic implication it is possible that this finding may have physiological meaning.

Significance of focal and lateralized beta activity in the EEG

In a group of 16,432 EEGs studied in a five year period, a total of 43 with focal, lateralized or paroxysmal beta activity were noted. The focal beta activity was mainly seen in children suffering from intractable seizures secondary to A-V malformation, porencephalic cysts or tumors. This was practically an epileptiform discharge with a high clinical pathologic correlation. The lateralized beta activity was seen mainly in adults suffering from cerebrovascular disease or tumor. In the cerebrovascular group the lateralized activity was seen on the contra-lateral side of the lesion. The paroxysmal beta activity is a rare phenomenon seen purely as an ictal manifestation, and mainly seen in children with Lennox-Gastaut Syndrome or infantile spasms. The importance of proper technique to record such abnormalities is emphasized.