Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 consecutive cardiac surgical procedures.

OBJECTIVE: To determine the effect of consultant surgeon sleep hours on patient outcomes in cardiac surgery. DESIGN: Prospective observational cohort study. SUBJECTS: Between January 2004 and December 2009, we prospectively collected sleep hours of 6 consultant surgeons, ranging in age from 32 to 55 years, working in a tertiary care academic institution. The prospective study cohort included all patients undergoing coronary artery bypass, valve, combined valve-coronary artery bypass, and aortic surgery. The predicted risk of death and/or any of 10 major complications was calculated using our institutional multivariable model, which was then compared with observed values. Additional prespecified analyses examined the interaction between surgeon age, sleep hours, and postoperative outcomes. This study had more than 90% power to detect a 4% (clinically important) difference in overall complication rates among groups. MAIN OUTCOME MEASURES: Complication and mortality rates in operations performed by surgeons with 0 to 3, 3 to 6, or more than 6 hours' sleep the evening prior to surgery. RESULTS: Of 4047 consecutive surgical procedures, 83 were performed by a consultant with 0 to 3 hours, 1595 with 3 to 6 hours, and 2369 with more than 6 hours of sleep. Rates of mortality (3 [3.6%], 44 [2.8%], and 80 [3.4%], respectively; P = .53) were similar in the 3 groups, as were the observed vs expected ratios of major complications (1.20, 0.95, and 1.07, respectively; P = .25). There was no significant interaction between surgeon age, hours of sleep, and occurrence of death or any of 10 major complications (P = .09). CONCLUSION: This well-powered prospective study showed no evidence that consultant surgeon sleep hours had an effect on postoperative outcomes.

Blood conservation in cardiac surgery: let's get restrictive.

Despite increasing evidence suggesting harmful effects of blood transfusions, physician practices are slow to change. A systematic approach is required to successfully minimize the need for red cell transfusions in the perioperative cardiac surgical patient. This involves preoperative, intraoperative, and postoperative strategies to minimize blood loss and maximize blood conservation. In addition it requires physician education regarding the potential deleterious effects of blood and the more recent evidence that restrictive transfusion strategies are safe and possibly beneficial to postoperative surgical outcomes. In this article, we review the data with respect to blood transfusions in cardiac surgery patients as well as management strategies to minimize the need for blood transfusions in the perioperative period.

Sodium-hydrogen exchange inhibition by cariporide to reduce the risk of ischemic cardiac events in patients undergoing coronary artery bypass grafting: results of the EXPEDITION study.

BACKGROUND: The EXPEDITION study addressed the efficacy and safety of inhibiting the sodium hydrogen exchanger isoform-1 (NHE-1) by cariporide in the prevention of death or myocardial infarction (MI) in patients undergoing coronary artery bypass graft surgery. The premise was that inhibition of NHE-1 limits intracellcular Na accumulation and thereby limits Na/Ca-exchanger-mediated calcium overload to reduce infarct size. METHODS: High-risk coronary artery bypass graft surgery patients (n = 5,761) were randomly allocated to receive either intravenous cariporide (180 mg in a 1-hour preoperative loading dose, then 40 mg per hour over 24 hours and 20 mg per hour over the subsequent 24 hours) or placebo. The primary composite endpoint of death or MI was assessed at 5 days, and patients were followed for as long as 6 months. RESULTS: At 5 days, the incidence of death or MI was reduced from 20.3% in the placebo group to 16.6% in the treatment group (p = 0.0002). Paradoxically, MI alone declined from 18.9% in the placebo group to 14.4% in the treatment group (p = 0.000005), while mortality alone increased from 1.5% in the placebo group to 2.2% with cariporide (p = 0.02). The increase in mortality was associated with an increase in cerebrovascular events. Unlike the salutary effects that were maintained at 6 months, the difference in mortality at 6 months was not significant. CONCLUSIONS: The EXPEDITION study is the first phase III myocardial protection trial in which the primary endpoint was achieved and proof of concept demonstrated. As a result of increased mortality associated with an increase in cerebrovascular events, it is unlikely that cariporide will be used clinically. The findings suggest that sodium hydrogen exchanger isoform-1 inhibition holds promise for a new class of drugs that could significantly reduce myocardial injury associated with ischemia-reperfusion injury.

Does the trainee's level of experience impact on patient safety and clinical outcomes in coronary artery bypass surgery?

BACKGROUND: There is a relative dearth of information on how the resident's level of training affects patient outcomes in cardiac surgery. We designed this study to determine if there were any significant differences in patient demographics and clinical outcomes of coronary artery bypass procedures (CABG) performed by residents of PGY 4/lower, residents of PGY 5/6, fellows, or consultants. METHODS: Standardized preoperative, intraoperative, and postoperative variables were prospectively collected and analyzed on 2906 isolated CABG procedures, performed between July 1999 and March 2006 with the primary surgeon prospectively classified as PGY4/lower, PGY5/6, fellow, and consultant. RESULTS: The number of cases performed by residents of PGY4/lower, PGY5/6, fellows and consultants were 179, 263, 301, and 2163, respectively. Preoperative demographics and comorbidities were similar except PGY4/lower group had more diabetics and consultant group had more patients requiring IABP. More non-LIMA arterial conduits were used in the consultant and fellow groups. However, there were neither significant differences in the mean number of grafts nor in the composite postoperative morbidity, median ICU, and hospital lengths of stay. Observed in-hospital mortality was 2.2%, 1.5%, 1.7%, and 2.7% (p = 0.49), respectively. CONCLUSIONS: Preoperative patient demographics and operative data were similar in all groups except that patients requiring IABP preoperatively were more likely operated on by consultants and arterial revascularization was performed more commonly by consultants and fellows. Postoperative mortality and morbidity rates were similar among all groups, thus demonstrating that with appropriate supervision, trainees of all levels can safely be taught CABG.

Perioperative N-acetylcysteine to prevent renal dysfunction in high-risk patients undergoing cabg surgery: a randomized controlled trial.

CONTEXT: Renal dysfunction is a complication of coronary artery bypass graft (CABG) surgery performed with cardiopulmonary bypass (CPB) that is associated with increased morbidity and mortality. N-acetylcysteine, an antioxidant and vasodilator, counteracts renal ischemia and hypoxia. OBJECTIVE: To determine whether perioperative intravenous (IV) N-acetylcysteine preserves renal function in high-risk patients undergoing CABG surgery with CPB compared with placebo. DESIGN, SETTING, AND PATIENTS: Randomized, quadruple blind, placebo-controlled trial (October 2003-September 2004) in operating rooms and general intensive care units (ICUs) of 2 Ontario tertiary care centers. The 295 patients required elective or urgent CABG and had at least 1 of the following: preexisting renal dysfunction, at least 70 years old, diabetes mellitus, impaired left ventricular function, or undergoing concomitant valve or redo surgery. INTERVENTIONS: Patients received 4 (2 intraoperative and 2 postoperative) doses of IV N-acetylcysteine (600 mg) (n = 148) or placebo (n = 147) over 24 hours. MAIN OUTCOME MEASURES: The primary outcome was the proportion of patients developing postoperative renal dysfunction, defined by an increase in serum creatinine level greater than 0.5 mg/dL (44 micromol/L) or a 25% increase from baseline within the first 5 postoperative days. Secondary outcomes included postoperative interventions and complications, the requirement for renal replacement therapy (RRT), adverse events, hospital mortality, and ICU and hospital length of stay. RESULTS: There was no difference in the proportion of patients with postoperative renal dysfunction (29.7% vs 29.0%, P = .89; relative risk [RR], 1.03 [95% confidence interval {CI}, 0.72-1.46]) in the N-acetylcysteine and placebo groups, respectively. We noted nonsignificant differences in postoperative interventions and complications, the need for RRT (0.7% vs 2.1%; P = .37), total (6.1% vs 9.6%; P = .26) and serious adverse events, hospital mortality (3.4% vs 2.7%; P>.99), and ICU and hospital length of stay between the N-acetylcysteine and placebo groups. A post hoc subgroup analysis of patients (baseline creatinine level >1.4 mg/dL [120 micromol/L]) showed a nonsignificant trend toward fewer patients experiencing postoperative renal dysfunction in the N-acetylcysteine group compared with the placebo group (25.0% vs 37.1%; P = .29). CONCLUSIONS: N-acetylcysteine did not prevent postoperative renal dysfunction, interventions, complications, or mortality in high-risk patients undergoing CABG surgery with CPB. Further research is required to identify CABG patients at risk for postoperative renal events, valid markers of renal dysfunction, and to establish renal thresholds associated with important clinical outcomes.