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.

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

A comparison of sequential total and activated white cell count in patients undergoing coronary artery bypass grafting, using cardiopulmonary bypass, with and without a white cell filter

Introduction Cardiopulmonary bypass (CPB) has been shown to induce a systemic inflammatory response similar to the local reaction seen after tissue damage [1]. This leads to the release of toxic substances, such as elastase, which cause endothelial damage and may adversely affect outcome [2]. Use of a leucocyte depleting arterial line filter is one of many anti-inflammatory strategies that are undergoing evaluation. Leucocyte depleting filters may be capable of selectively removing activated white cells [3], but this has not been proved in vivo. The aim of the present study was to compare sequential total and activated white cells during CPB, using either a leucocyte depleting or standard arterial line filter. Materials and methods After local ethical committee approval, 20 patients undergoing coronary artery bypass grafting using CPB were prospectively randomly allocated to have either a Leukogard LG–6 (Pall Biomedical, Portsmouth, UK) or a nonleucocyte depleting filter inserted into the arterial line of the CPB circuit. Arterial limb blood samples were taken immediately after institution of CPB (0min) and at 10–min intervals throughout the bypass period. Activated white cells were identified using nitroblue tetrazolium, then both total and activated white cell numbers counted after staining with Leucoplate.Results Table 1 shows the number of white cells counted/1.25 ? l (volume of a single channel of Nageotte counting chamber) using light microscopy (× 25).Conclusion The LG6 leucocyte filter reduces the total white cell count and is capable of selectively removing activated white cells during CPB. The exact relationship between leucocyte depletion and improved patient outcome still remains unclear

History of British Intensive Care, c. 1950–c. 2000

Annotated and edited transcript of a Witness Seminar held on 16 June 2010. Introduction by Professor Sir Ian Gilmore, Royal Liverpool Hospital and University of Liverpool.Annotated and edited transcript of a Witness Seminar held on 16 June 2010. Introduction by Professor Sir Ian Gilmore, Royal Liverpool Hospital and University of Liverpool.Annotated and edited transcript of a Witness Seminar held on 16 June 2010. Introduction by Professor Sir Ian Gilmore, Royal Liverpool Hospital and University of Liverpool.Annotated and edited transcript of a Witness Seminar held on 16 June 2010. Introduction by Professor Sir Ian Gilmore, Royal Liverpool Hospital and University of Liverpool.Annotated and edited transcript of a Witness Seminar held on 16 June 2010. Introduction by Professor Sir Ian Gilmore, Royal Liverpool Hospital and University of Liverpool.Annotated and edited transcript of a Witness Seminar held on 16 June 2010. Introduction by Professor Sir Ian Gilmore, Royal Liverpool Hospital and University of Liverpool.Annotated and edited transcript of a Witness Seminar held on 16 June 2010. Introduction by Professor Sir Ian Gilmore, Royal Liverpool Hospital and University of Liverpool.Annotated and edited transcript of a Witness Seminar held on 16 June 2010. Introduction by Professor Sir Ian Gilmore, Royal Liverpool Hospital and University of Liverpool.Intensive care developed in the UK as a medical specialty as the result of some extraordinary circumstances and the involvement of some extraordinary people. In 1952, the polio epidemic in Copenhagen demonstrated that tracheostomy with intermittent positive pressure ventilation saved lives and those infected with tetanus (common in agricultural areas) soon benefited. War-time developments such as triage, monitoring, transfusion and teamwork, and different specialists such as respiratory physiologists, anaesthetists and manufacturers of respiratory equipment all improved emergency treatment. These advances were rapidly extended to the care of post-operative patients, particularly with developments in cardiac surgery. Dedicated units appeared in the early 1960s in Cambridge, London and Liverpool, and later specialist care units were created for prenatal, cardiac and dialysis patients. The importance of specialist nursing care led to the development of nurse training, education and the eventual appointment of nurse consultants in the NHS in 1999. The specialty of intensive care was granted Faculty status by the GMC in 2010. Introduced by Professor Sir Ian Gilmore, this transcript includes, inter alia, the development of cardiac catheters, monitoring equipment, data collection techniques and the rise of multidisciplinarity, national audit, and scoring systems

Accreditation in Echocardiography: The time to act is now

Accreditation in echocardiography is an important and necessary next step towards raising standards in the practice of all forms of echocardiography in South Africa. A process of planning and in some cases implementing accreditation amongst the various disciplines performing echocardiography in South Africa is now underway but in widely varying stages of progress. Is our discipline leading the way or have we fallen behind?

European Association of Cardiothoracic Anesthesiology and Intensive Care (EACTAIC) Fellowship Curriculum: Second Edition

This document represents the first update of the Cardiothoracic and Vascular Anaesthesia Fellowship Curriculum of the European Association of Cardiothoracic Anaesthesiology and Intensive Care. After obtaining feedback from exit interviews with fellows in training, graduate fellows, and program directors, 2 modified online Delphi procedures with questionnaires were conducted. A consensus was reached when two-thirds of responding committee members gave green or yellow ratings on a traffic light system, and >70% indicated strong agreement or agreement on a 5-point Likert scale. The new regulations include the following: (1) more flexibility in the fellows` rotation, as long as the total number of days, rotations, and cases are completed during the training year; (2) recommendation for strict compliance with national working-time guidelines; (3) no extension of fellowship training to compensate for annual and/or sick leave, unless the required minimum number of cases and rotations are not reached; (4) interruption of fellowship training for >12 months is allowed for personal or medical reasons; (5) introduction of a checklist for quantitative assessment of standard clinical skills; (6) recommendations for a uniform structure of exit interviews; (7) possibility of a 1-month training rotation in a postanesthesia care unit instead of an intensive care unit; and (8) provided all other requirements have been met, the allowance of progression from the basic training year to the advanced fellowship training year without first passing the transesophageal echocardiography examination

European Association of Cardiothoracic Anesthesiology and Intensive Care (EACTAIC) Fellowship Curriculum: Second Edition.

International audienceThis document represents the first update of the Cardiothoracic and Vascular Anaesthesia Fellowship Curriculum of the European Association of Cardiothoracic Anaesthesiology and Intensive Care. After obtaining feedback from exit interviews with fellows in training, graduate fellows, and program directors, 2 modified online Delphi procedures with questionnaires were conducted. A consensus was reached when two-thirds of responding committee members gave green or yellow ratings on a traffic light system, and >70% indicated strong agreement or agreement on a 5-point Likert scale. The new regulations include the following: (1) more flexibility in the fellows` rotation, as long as the total number of days, rotations, and cases are completed during the training year; (2) recommendation for strict compliance with national working-time guidelines; (3) no extension of fellowship training to compensate for annual and/or sick leave, unless the required minimum number of cases and rotations are not reached; (4) interruption of fellowship training for >12 months is allowed for personal or medical reasons; (5) introduction of a checklist for quantitative assessment of standard clinical skills; (6) recommendations for a uniform structure of exit interviews; (7) possibility of a 1-month training rotation in a postanesthesia care unit instead of an intensive care unit; and (8) provided all other requirements have been met, the allowance of progression from the basic training year to the advanced fellowship training year without first passing the transesophageal echocardiography examination

European Association of Cardiothoracic Anesthesiology and Intensive Care Pediatric Cardiac Anesthesia Fellowship Curriculum:First Edition

International audiencePediatric cardiac anesthesia is a subspecialty of cardiac and pediatric anesthesiology dedicated to the perioperative care of patients with congenital heart disease. Members of the Congenital and Education Subcommittees of the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) agreed on the necessity to develop an EACTAIC pediatric cardiac anesthesia fellowship curriculum. This manuscript represents a consensus on the composition and the design of the EACTAIC Pediatric Cardiac Anesthesia Fellowship program. This curriculum provides a basis for the training of future pediatric cardiac anesthesiologists by clearly defining the theoretical and practical requirements for fellows and host centers

Current Anesthetic Care of Patients Undergoing Transcatheter Aortic Valve Replacement in Europe:Results of an Online Survey

Objectives: Transcatheter aortic valve replacement (TAVR) has become an alternative treatment for patients with symptomatic aortic stenosis not eligible for surgical valve replacement due to a high periprocedural risk or comorbidities. However, there are several areas of debate concerning the pre-, intra- and post-procedural management. The standards and management for these topics may vary widely among different institutions and countries in Europe. Design: Structured web-based, anonymized, voluntary survey. Setting: Distribution of the survey via email among members of the European Association of Cardiothoracic Anaesthesiology working in European centers performing TAVR between September and December 2018. Participants: Physicians. Measurements and main results: The survey consisted of 25 questions, including inquiries regarding number of TAVR procedures, technical aspects of TAVR, medical specialities present, preoperative evaluation of TAVR candidates, anesthesia regimen, as well as postoperative management. Seventy members participated in the survey. Reporting members mostly performed 151-to-300 TAVR procedures per year. In 90% of the responses, a cardiologist, cardiac surgeon, cardiothoracic anesthesiologist, and perfusionist always were available. Sixty-six percent of the members had a national curriculum for cardiothoracic anesthesia. Among 60% of responders, the decision for TAVR was made preoperatively by an interdisciplinary heart team with a cardiothoracic anesthesiologist, yet in 5 countries an anesthesiologist was not part of the decision-making. General anesthesia was employed in 40% of the responses, monitored anesthesia care in 44%, local anesthesia in 23%, and in 49% all techniques were offered to the patients. In cases of general anesthesia, endotracheal intubation almost always was performed (91%). It was stated that norepinephrine was the vasopressor of choice (63% of centers). Transesophageal echocardiography guiding, whether performed by an anesthesiologist or cardiologist, was used only Conclusion: The results indicated that requirements and quality indicators (eg, periprocedural anesthetic management, involvement of the anesthesiologist in the heart team, etc) for TAVR procedures as published within the European guideline are largely, yet still not fully implemented in daily routine. In addition, anesthetic TAVR management also is performed heterogeneously throughout Europe. (C) 2020 Elsevier Inc. All rights reserved

Risk factor analysis for fast track protocol failure

Background: The introduction of fast-track treatment procedures following cardiac surgery has significantly shortened hospitalisation times in intensive care units (ICU). Readmission to intensive care units is generally considered a negative quality criterion. The aim of this retrospective study is to statistically analyse risk factors and predictors for re-admission to the ICU after a fast-track patient management program. Methods: 229 operated patients (67 ± 11 years, 75% male, BMI 27 ± 3, 6/2010-5/2011) with use of extracorporeal circulation (70 ± 31 min aortic crossclamping, CABG 62%) were selected for a preoperative fast-track procedure (transfer on the day of surgery to an intermediate care (IMC) unit, stable circulatory conditions, extubated). A uni- and multivariate analysis were performed to identify independent predictors for re-admission to the ICU. Results: Over the 11-month study period, 36% of all preoperatively declared fast-track patients could not be transferred to an IMC unit on the day of surgery (n = 77) or had to be readmitted to the ICU after the first postoperative day (n = 4). Readmission or ICU stay signifies a dramatic worsening of the patient outcome (mortality 0/10%, mean hospital stay 10.3 ± 2.5/16.5 ± 16.3, mean transfusion rate 1.4 ± 1,7/5.3 ± 9.1). Predicators for failure of the fast-track procedure are a preoperative ASA class > 3, NYHA class > III and an operation time >267 min ± 74. The significant risk factors for a major postoperative event (= low cardiac output and/or mortality and/or renal failure and/or re-thoracotomy and/or septic shock and/or wound healing disturbances and/or stroke) are a poor EF (OR 2.7 CI 95% 0.98-7.6) and the described ICU readmission (OR 0.14 CI95% 0.05-0.36). Conclusion: Re-admission to the ICU or failure to transfer patients to the IMC is associated with a high loss of patient outcome. The ASA > 3, NYHA class > 3 and operation time >267 minutes are independent predictors of fast track protocol failure

Postoperative Critical Care: Resource Availability, Patient Risk and Other Factors Influencing Referral and Admission

Although intended for benefit, surgery exposes patients to potential complications. Critical care is thought to protect against the development of these complications, and is recommended for patients at higher risk. However, previous literature suggests that high-risk patients do not consistently receive postoperative critical care. In this PhD thesis, I investigate the supposed misallocation of critical care resources, and seek to answer the following research questions: 1. What is the availability of postoperative critical care? 2. How do clinicians estimate perioperative risk? 3. How accurate are current available risk prediction tools? 4. How do clinicians decide which patients to admit for postoperative critical care? 5. What factors influence their admission? A survey of postoperative critical care availability was conducted in 309 hospitals across the United Kingdom, Australia and New Zealand (NZ). Then, in a subset of 274 of these hospitals, a cohort study enrolling 26,502 patients undergoing inpatient surgery was undertaken. Postoperative critical care availability was found to differ between countries. UK hospitals reported fewer critical care beds per 100 hospital beds (median = 2.7) compared with Australia (median = 3.7) and NZ (median = 3.5). Enhanced care/high-acuity beds used to manage some high-risk patients were identified in around 31% of hospitals. The estimated numbers of critical care beds per 100,000 population were 9.3, 14.1, and 9.1 in the UK, Australia, and NZ, respectively. The estimated per capita high-acuity bed capacities per 100,000 population were 1.2, 3.8, and 6.4 in the UK, Australia, and NZ, respectively. The risk profile of inpatients undergoing inpatient surgery and the incidence of short-term mortality and morbidity outcomes were described. Less than 40% of predicted high-risk patients (defined as having a 5% or higher predicted 30-day mortality) in the cohort were admitted to critical care directly after surgery, regardless of risk model used. Compared with objective risk tools, subjective clinical assessment performed similarly in terms of discrimination, but consistently overpredicted risk. The Area Under the Receiver Operating Characteristic curve (AUROC) for subjective clinical assessment was 0.89, compared to 0.91 for the Surgical Outcome Risk Tool (SORT), the best-performing objective risk tool. However, a model combining information from both objective tools and subjective assessment improved the accuracy and clinical applicability of risk predictions (combined model AUROC = 0.93; continuous Net Reclassification Index [NRI] = 0.347, p <0.001). Associations were identified between patient risk factors (e.g. increased comorbidities, more complex surgery, higher surgical urgency) and the likelihood of being recommended postoperative critical care admission. Increased critical care bed availability had a small but significant association with critical care recommendation (adjusted odds ratio [OR] = 1.05 per empty critical care bed at the time of surgery), suggesting a subtle effect of exogenous influences on clinical decision-making. These results will have value in informing policy around the delivery of postoperative care for high-risk patients undergoing surgery, both at a macroscopic level in planning services, and at a microscopic level in making clinical decisions for individual patients