The incidence and effect of resternotomy following cardiac surgery on morbidity and mortality: a 1-year national audit on behalf of the Association of Cardiothoracic Anaesthesia and Critical Care.

Over 30,000 adult cardiac operations are carried out in the UK annually. A small number of these patients need to return to theatre in the first few days after the initial surgery, but the exact proportion is unknown. The majority of these resternotomies are for bleeding or cardiac tamponade. The Association of Cardiothoracic Anaesthesia and Critical Care carried out a 1-year national audit of resternotomy in 2018. Twenty-three of the 35 centres that were eligible participated. The overall resternotomy rate (95%CI) within the period of admission for the initial operation in these centres was 3.6% (3.37-3.85). The rate varied between centres from 0.69% to 7.6%. Of the 849 patients who required resternotomy, 127 subsequently died, giving a mortality rate (95%CI) of 15.0% (12.7-17.5). In patients who underwent resternotomy, the median (IQR [range]) length of stay on ICU was 5 (2-10 [0-335]) days, and time to tracheal extubation was 20 (12-48 [0-2880]) hours. A total of 89.3% of patients who underwent resternotomy were transfused red cells, with a median (IQR [range]) of 4 (2-7 [1-1144]) units of red blood cells. The rate (95%CI) of needing renal replacement therapy was 23.4% (20.6-26.5). This UK-wide audit has demonstrated that resternotomy after cardiac surgery is associated with prolonged intensive care stay, high rates of blood transfusion, renal replacement therapy and very high mortality. Further research into this area is required to try to improve patient care and outcomes in patients who require resternotomy in the first 24 h after cardiac surgery.

Complications related to peri-operative transoesophageal echocardiography - a one-year prospective national audit by the Association of Cardiothoracic Anaesthesia and Critical Care.

Previous studies on the safety of peri-operative transoesophageal echocardiography seem to suggest a low rate of associated morbidity and mortality. That said, there has been a paucity of prospective multicentre studies in this important area of clinical practice. We carried out a one-year prospective study in 2017, co-ordinated by the Association of Cardiothoracic Anaesthesia and Critical Care, to determine the rate and severity of complications associated with peri-operative transoesophageal echocardiography in anaesthetised cardiology and cardiac surgical patients. With the help of clinicians from 28 centres across the UK and Ireland, we recorded the total number of examinations conducted in anaesthetised patients during the study period. All major complications at each centre were prospectively reported and recorded. Of the 22,314 examinations, there were 17 patients diagnosed with a major complication which caused either palatal injury or gastro-oesophageal disruption. This corresponds to an incidence of 0.08% (95%CI 0.05-0.13%) or approximately 1:1300 examinations. There were seven deaths reported during the study period which were directly attributed to these complications, corresponding to an incidence of 0.03% (95%CI 0.01-0.07%) or approximately 1:3000. These figures are higher than previously reported and suggest a high probability of death following the development of a complication (~40%). Most complications occurred in patients without known risk factors for transoesophageal echocardiography associated gastro-oesophageal injury. We suggest clinicians and departments review their procedural guidelines, especially in relation to probe insertion techniques, together with the information communicated to patients when the risks and benefits of such examinations are discussed.

The ACTA PORT-score for predicting perioperative risk of blood transfusion for adult cardiac surgery.

BACKGROUND: A simple and accurate scoring system to predict risk of transfusion for patients undergoing cardiac surgery is lacking. METHODS: We identified independent risk factors associated with transfusion by performing univariate analysis, followed by logistic regression. We then simplified the score to an integer-based system and tested it using the area under the receiver operator characteristic (AUC) statistic with a Hosmer-Lemeshow goodness-of-fit test. Finally, the scoring system was applied to the external validation dataset and the same statistical methods applied to test the accuracy of the ACTA-PORT score. RESULTS: Several factors were independently associated with risk of transfusion, including age, sex, body surface area, logistic EuroSCORE, preoperative haemoglobin and creatinine, and type of surgery. In our primary dataset, the score accurately predicted risk of perioperative transfusion in cardiac surgery patients with an AUC of 0.76. The external validation confirmed accuracy of the scoring method with an AUC of 0.84 and good agreement across all scores, with a minor tendency to under-estimate transfusion risk in very high-risk patients. CONCLUSIONS: The ACTA-PORT score is a reliable, validated tool for predicting risk of transfusion for patients undergoing cardiac surgery. This and other scores can be used in research studies for risk adjustment when assessing outcomes, and might also be incorporated into a Patient Blood Management programme.

The incidence and importance of anaemia in patients undergoing cardiac surgery in the UK - the first Association of Cardiothoracic Anaesthetists national audit.

The importance and variability of pre-operative anaemia in cardiac surgical patients across the UK is not known, and there is debate about its association with patient outcomes. The Association of Cardiothoracic Anaesthetists carried out its first national audit on anaemia and transfusion, and analysed data from 19,033 patients operated on in 12 cardiac surgical centres between 2010 and 2012; 5895 (31%) had pre-operative anaemia. Centre-specific prevalence of anaemia varied from 23% to 45%; anaemia was associated with older patients, diabetes and surgical risk (EuroSCORE). Nevertheless, controlling for these factors, regional variation remained an independent effect (p < 0.001). Multivariable analysis demonstrated an independent association of anaemia with transfusion (odds ratio (95% confidence interval) 2.75 (2.55-2.95), p < 0.001), mortality (1.42 (1.18-1.71), p < 0.001) and hospital stay (geometric mean ratio (95% confidence interval) 1.15 (1.13-1.17), p < 0.001). Haemoglobin concentration per se was also independently associated with worse outcomes; a 10 g.l(-1) decrease in haemoglobin was associated with a 43% increase (95% confidence interval 40-46%) in the odds of transfusion and a 16% increase (95% confidence interval 10-22%) in the odds of mortality (both p < 0.001). This large UK-wide audit has demonstrated marked regional variation in both anaemia and transfusion, with a consistently high incidence of both. The independent association between pre-operative anaemia and worse outcomes in UK practice has also been confirmed, and robust prospective study of anaemia treatment before cardiac surgery is required; these data will assist in designing such trials.

The contribution of the anaesthetist to risk-adjusted mortality after cardiac surgery.

It is widely accepted that the performance of the operating surgeon affects outcomes, and this has led to the publication of surgical results in the public domain. However, the effect of other members of the multidisciplinary team is unknown. We studied the effect of the anaesthetist on mortality after cardiac surgery by analysing data collected prospectively over ten years of consecutive cardiac surgical cases from ten UK centres. Casemix-adjusted outcomes were analysed in models that included random-effects for centre, surgeon and anaesthetist. All cardiac surgical operations for which the EuroSCORE model is appropriate were included, and the primary outcome was in-hospital death up to three months postoperatively. A total of 110 769 cardiac surgical procedures conducted between April 2002 and March 2012 were studied, which included 127 consultant surgeons and 190 consultant anaesthetists. The overwhelming factor associated with outcome was patient risk, accounting for 95.75% of the variation for in-hospital mortality. The impact of the surgeon was moderate (intra-class correlation coefficient 4.00% for mortality), and the impact of the anaesthetist was negligible (0.25%). There was no significant effect of anaesthetist volume above ten cases per year. We conclude that mortality after cardiac surgery is primarily determined by the patient, with small but significant differences between surgeons. Anaesthetists did not appear to affect mortality. These findings do not support public disclosure of cardiac anaesthetists' results, but substantially validate current UK cardiac anaesthetic training and practice. Further research is required to establish the potential effects of very low anaesthetic caseloads and the effect of cardiac anaesthetists on patient morbidity.

Simulation-based teaching versus point-of-care teaching for identification of basic transoesophageal echocardiography views: a prospective randomised study.

In recent years, the use of transoesophageal echocardiography has increased in anaesthesia and intensive care. We explored the impact of two different teaching methods on the ability of echocardiography-naïve subjects to identify cardiac anatomy associated with the 20 standard transoesophageal echocardiography imaging planes, and assessed trainees' satisfaction with these methods of training. Fifty-two subjects were randomly assigned to one of two groups: a simulation-based and a theatre-based teaching group. Subjects undertook video-based tests comprised of 20 multiple choice questions on echocardiography views before and after receiving echocardiography teaching. Subjects in simulation- and theatre-based teaching groups scored 40% (30-40 [20-50])% and 35% (30-40 [15-55])% in the pre-test, respectively (p = 0.52). Following echocardiography teaching, subjects within both groups improved upon their pre-test knowledge (p < 0.001). Subjects in the simulation-based teaching group significantly outperformed their theatre-based group counterparts in the post-intervention test (p = 0.0002).

A review of echocardiography in anaesthetic and peri-operative practice. Part 2: training and accreditation.

Echocardiography has been widely adopted as a diagnostic and monitoring tool in cardiac anaesthesia and critical care. There is considerable interest in how echocardiography could be used to benefit patients in other areas of anaesthesia and peri-operative practice. The first part of review examines the impact and utility of echocardiography, while this second part is concerned with the matter of training and accreditation. There are a number of existing clinical protocols for the use of transthoracic echocardiography with a focused approach. Some of these, such as Focused Intensive Care Echocardiography in the UK, have been developed into structured accreditation processes with embedded supervision. Learning opportunities are now emerging for anaesthetists who wish to acquire echocardiography skills--these encompass clinical, simulation and online resources. Whilst the roll-out of echocardiography for more widespread use in peri-operative management is a long-term project, it is now an appropriate time to consider how this may be achieved.

A review of echocardiography in anaesthetic and peri-operative practice. Part 1: impact and utility.

Echocardiography is migrating rapidly across speciality boundaries and clinical demand is expanding. Echocardiography shows promise for evolving applications in the peri-operative assessment and therapeutic management of patients undergoing non-cardiac surgery, whether it be elective or emergency. Although evidence is limited with regard to significant impact on outcomes from anaesthesia and surgery, there is little doubt about the validity and power of two-dimensional real-time viewing of cardiac anatomy and function. Echocardiography can be used to assist in decision-making along the entire peri-operative pathway, and is increasingly delivered by the previously referring physicians. The discussion around more widespread incorporation of cardiac ultrasound into anaesthetic practice must take into account competency, training and governance. Failure to do so adequately may mean that the use of echocardiography is poorly applied and costly.

Factor VIII mutation and desmopressin-responsiveness in 62 patients with mild haemophilia A.

Utilization of the synthetic vasopressin analogue (1-deamino-8-D-arginine-vasopressin, DDAVP) in treatment of mild haemophilia A (MHA, specific clotting factor VIII activity level 0.05-0.4 IU mL(-1) ) is convenient and effective for many but not all patients. Genetic testing for patients with MHA is increasingly recognized as providing valuable information for patient care beyond informing reproductive decisions, and as more patients are genotyped, mutation data can be utilized to individualize treatment decisions. To determine if genetic information informs response to DDAVP, a retrospective chart review was performed under Institutional Review Board approval to extract patient data with MHA, genetic mutation results, and response to DDAVP challenge. 62 patients met inclusion criteria. Complete responses (C) presented in mean value IU mL(-1) (range), were recorded for 32 of 62(52%) subjects: pre 0.19(0.04-0.45) and post 0.78(0.5-1.95); partial responses (P) were recorded for 15 of 62(24%) subjects: pre 0.1(0.06-0.15) and post 0.4(0.3-0.47); responses that were not clinically significant (N) were recorded for 15 of 62(24%) subjects: pre 0.17(0.02-0.34) and post 0.25(0.03-0.44). Subjects (related and unrelated) with the same mutation showed a trend towards a similar response to DDAVP. Eight genotypes were common to two or more subjects (n = 26). Two genotypes were concordant in all subjects [p.Ser2192Ile n = 3(C), p.Ala2220Pro n = 2(P)]. Of mutations in the C1 or C2 domains, 13 of 15(87%) subjects responded to DDAVP [C = 9(60%); P = 4(27%); n = 2(13%)]. Baseline FVIII:C did not predict magnitude of response to DDAVP. Genetic mutation results can assist with predicting DDAVP responsiveness, but baseline FVIII:C may not.

The impact of internet and simulation-based training on transoesophageal echocardiography learning in anaesthetic trainees: a prospective randomised study.

With the increasing role of transoesophageal echocardiography in clinical fields other than cardiac surgery, we decided to assess the efficacy of multi-modular echocardiography learning in echo-naïve anaesthetic trainees. Twenty-eight trainees undertook a pre-test to ascertain basic echocardiography knowledge, following which the study subjects were randomly assigned to two groups: learning via traditional methods such as review of guidelines and other literature (non-internet group); and learning via an internet-based echocardiography resource (internet group). After this, subjects in both groups underwent simulation-based echocardiography training. More tests were then conducted after a review of the respective educational resources and simulation sessions. Mean (SD) scores of subjects in the non-internet group were 28 (10)%, 44 (10)% and 63 (5)% in the pre-test, post-intervention test and post-simulation test, respectively, whereas those in the internet group scored 29 (8)%, 59 (10)%, (p = 0.001) and 72 (8)%, p = 0.005, respectively. The use of internet- and simulation-based learning methods led to a significant improvement in knowledge of transoesophageal echocardiography by anaesthetic trainees. The impact of simulation-based training was greater in the group who did not use the internet-based resource. We conclude that internet- and simulation-based learning methods both improve transoesophageal echocardiography knowledge in echo-naïve anaesthetic trainees.

Type A aortic dissection in pregnancy.

Type A aortic dissection is a life-threatening event to both mother and baby, and accounted for 14% of maternal cardiac deaths in the 2006-2008 UK Confidential Enquiries into Maternal Deaths. Difficulty exists in the diagnosis of this rare but potentially curable condition, the mortality of which increases with delay in diagnosis. We present a case of acute type A aortic dissection in a previously well multiparous woman, treated successfully by aortic root repair immediately following caesarean section. The acute presentation of aortic dissection and diagnostic clues that may have expedited the diagnosis are discussed. A brief literature review is presented of the perioperative management of patients undergoing cardiothoracic surgery post-caesarean section and the modifications to standard techniques that are required.

The impact of intraoperative transoesophageal echocardiography on an unselected cardiac surgical population: a review of 2343 cases.

Although intraoperative transoesophageal echocardiography (TOE) has an established role in the management of some cardiac surgical procedures, there is little data on its impact on coronary artery bypass graft (CABG) cases that are stratified for clinical risk. This is a retrospective review of the surgical impact of intraoperative TOE on 2,343 unselected cardiac cases. The surgical impact of TOE findings were rated E (essential)--resulted in changes to the proposed surgical procedure or V (valuable)--the surgical technique for the planned surgery was altered. The surgical impact that routine TOE had on low-, medium- and high-risk CABG cases was also examined. The surgical impact of TOE for the total study population (E + V) was 4.5%. The impact was greatest in combined CABG + mitral valve procedures (18%). The impact in CABG cases was 3.5% overall, with an estimated impact in low-risk patients of 2.8% (95% CI. 2.7-3.0%) versus 6.7% (95% CI. 5.9-7.7%) in high-risk cases. The commonest E-impact in CABG patients was unscheduled valve surgery (2.6% of high-risk patients). The complication rate attributable to TOE was 0.09%. These findings provide indirect evidence for a potential patient benefit from the routine use of TOE in cardiac surgery.

Reversible tetraplegia due to polyneuropathy in a diabetic patient with hyperosmolar non-ketotic coma.

Critical illness polyneuromypathy has not previously been reported as a complication of diabetic coma. We describe a patient with hyperosmolar non-ketotic coma (HONK) complicating gram-negative sepsis in whom persistent coma and profound tetraplegia caused considerable concern. Although, initially, it was feared that the patient had suffered a central neurological complication such as stroke or cerebral oedema, a diagnosis of critical illness motor syndrome (CIMS) was subsequently confirmed neurophysiologically. Profound limb weakness associated with HONK is not necessarily due to a catastrophic cerebral event, rather it may be a result of CIMS, which has an excellent prognosis for full neurological recovery.